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Galvin D, O'Reilly B, Greene R, O'Donoghue K, O'Sullivan OE. A national survey on the impact of the coronavirus pandemic on gynecologic surgical training. Int J Gynaecol Obstet 2024. [PMID: 38958460 DOI: 10.1002/ijgo.15761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 06/04/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE The objective of this study was to assess the impact of the coronavirus pandemic on gynecology surgical training. METHODS A national cross-sectional online survey was distributed to all trainees and trainers in the higher specialist training program for obstetrics and gynecology in Ireland. The survey consisted of questions on topics which included: the volume of surgical procedures performed before and since the pandemic, confidence in performing various gynecologic procedures before and since the pandemic and questions regarding the impact of the pandemic on wellbeing and work practices. RESULTS Trainers and trainees experienced a significant reduction in operative volumes for most procedure types. Analysis showed a significant reduction in the number of minor procedures performed by trainees (z = -2.7, P = 0.007) and a significant reduction in the number of all procedure types performed by trainers (minor procedures z = -3.78, P = <0.001; intermediate procedures z = -4.48, P = < 0.001; major procedures z = -3.69, P = < 0.001). Respondents reported they had less time for research and audit, were less able to attend courses or conferences and worried about the impact of their work on their families. CONCLUSIONS In conclusion, this study has highlighted the current difficulties facing surgical trainees in gynecology because of the COVID-19 pandemic. These challenges have compounded an already challenging training environment for gynecology trainees. Efforts must be made to continue to provide high-quality tailored training to ensure the development of the next generation of gynecologic surgeons.
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Affiliation(s)
- Daniel Galvin
- Department of Obstetrics and Gynecology, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Barry O'Reilly
- Department of Obstetrics and Gynecology, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Richard Greene
- Department of Obstetrics and Gynecology, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Keelin O'Donoghue
- Department of Obstetrics and Gynecology, College of Medicine and Health, University College Cork, Cork, Ireland
- INFANT Research Center, University College Cork, Cork, Ireland
| | - Orfhlaith E O'Sullivan
- Department of Obstetrics and Gynecology, College of Medicine and Health, University College Cork, Cork, Ireland
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2
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Ewies AAA. Gynaecological surgery between generalists and high-volume specialists. J OBSTET GYNAECOL 2023; 43:2286743. [PMID: 38070125 DOI: 10.1080/01443615.2023.2286743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Ayman A A Ewies
- Pan Birmingham Gynaecological Cancer Centre, Birmingham City Hospital, Birmingham, UK
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3
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Tummers FHMP, Peltenburg SI, Metzemaekers J, Jansen FW, Blikkendaal MD. Evaluation of the effect of previous endometriosis surgery on clinical and surgical outcomes of subsequent endometriosis surgery. Arch Gynecol Obstet 2023; 308:1531-1541. [PMID: 37639036 PMCID: PMC10520192 DOI: 10.1007/s00404-023-07193-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/13/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE Patients often undergo repeat surgery for endometriosis, due to recurrent or residual disease. Previous surgery is often considered a risk factor for worse surgical outcome. However, data are scarce concerning the influence of subsequent endometriosis surgery. METHODS A retrospective study in a centre of expertise for endometriosis was conducted. All endometriosis subtypes and intra-operative steps were included. Detailed information regarding surgical history of patients was collected. Surgical time, intra-operative steps and major post-operative complications were obtained as outcome measures. RESULTS 595 patients were included, of which 45.9% had previous endometriosis surgery. 7.9% had major post-operative complications and 4.4% intra-operative complications. The patient journey showed a median of 3 years between previous endometriosis surgeries. Each previous therapeutic laparotomic surgery resulted on average in 13 additional minutes (p = 0.013) of surgical time. Additionally, it resulted in more frequent performance of adhesiolysis (OR 2.96, p < 0.001) and in a higher risk for intra-operative complications (OR 1.81, p = 0.045), however no higher risk for major post-operative complications (OR 1.29, p = 0.418). Previous therapeutic laparoscopic endometriosis surgery, laparotomic and laparoscopic non-endometriosis surgery showed no association with surgical outcomes. Regardless of previous surgery, disc and segmental bowel resection showed a higher risk for major post-operative complications (OR 3.64, p = 0.017 respectively OR 3.50, p < 0.001). CONCLUSION Previous therapeutic laparotomic endometriosis surgery shows an association with longer surgical time, the need to perform adhesiolysis, and more intra-operative complications in the subsequent surgery for endometriosis. However, in a centre of expertise with experienced surgeons, no increased risk of major post-operative complications was observed.
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Affiliation(s)
| | - Sophie I Peltenburg
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Metzemaekers
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Mathijs D Blikkendaal
- Endometriosis Center, Haaglanden Medical Center, The Hague, The Netherlands
- Nederlandse Endometriose Kliniek, Reinier de Graaf Hospital, Delft, The Netherlands
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4
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Sears S, Rhodes S, McBride C, Shoag J, Sheyn D. Complications following retropubic versus transobturator midurethral synthetic sling placement. Int Urogynecol J 2023; 34:2389-2397. [PMID: 37133561 DOI: 10.1007/s00192-023-05553-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/29/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Transobturator slings (TOS) are inferior to retropubic slings (RPS) based on long-term outcomes; data on complications is critical for patient counseling. We hypothesized rates of urinary retention would be higher for RPS, while pain and repeat sling surgery would be higher for TOS. METHODS Using the Premier healthcare database we identified encounters for patients undergoing a midurethral sling procedure between 2010 and 2020. Patients were stratified by sling type, either RPS or TOS. The primary outcome was the difference in the composite complication rate between groups within 12 months. Statistical analysis was performed using Kruskal Wallis test for continuous variables and χ2-test for categorical variables. Multivariable logistic regression was used to determine risk factors for complications and risk of specific complications after sling placement. RESULTS 36,991 patients were included in the RPS group and 16,371 in the TOS group. 7,880 patients (14.8%) had at least one sling specific complication. On multivariable logistic regression, RPS patients were more likely to have urinary retention (OR 1.29, 95%CI 1.16-1.43), sling lysis/excision (OR 1.29, 95%CI 1.10-1.53), and hematoma/hemorrhage (OR 1.82, 95%CI 1.16-2.86); they were less likely to have a UTI (OR 0.88, 95%CI 0.82-0.96) or repeat sling (OR 0.60, 95%CI 0.46-0.78). In patients with urinary retention, RPS patients were more likely to undergo sling lysis than TOS (p = 0.012). CONCLUSIONS Significant complications after midurethral synthetic sling are overall rare. RPS are associated with a higher rate of perioperative bleeding and sling lysis/excision due to urinary retention, but less likely to be associated with UTI and treatment failure.
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Affiliation(s)
- Sarah Sears
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Stephen Rhodes
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Cathryn McBride
- Lincoln Memorial University DeBusk College of Osteopathic Medicine, Knoxville, TN, USA
| | - Jonathan Shoag
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - David Sheyn
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
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5
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Antoun L, Middleton L, Smith P, Saridogan E, Cooper K, Brocklehurst P, McKinnon W, Bevan S, Woolley R, Jones L, Fullard J, Morgan M, Roberts T, Clark TJ. LAparoscopic Versus Abdominal hysterectomy (LAVA): protocol of a randomised controlled trial. BMJ Open 2023; 13:e070218. [PMID: 37669836 PMCID: PMC10481847 DOI: 10.1136/bmjopen-2022-070218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/27/2023] [Indexed: 09/07/2023] Open
Abstract
INTRODUCTION There is uncertainty about the advantages and disadvantages of laparoscopic hysterectomy compared with abdominal hysterectomy, particularly the relative rate of complications of the two procedures. While uptake of laparoscopic hysterectomy has been slow, the situation is changing with greater familiarity, better training, better equipment and increased proficiency in the technique. Thus, a large, robust, multicentre randomised controlled trial (RCT) is needed to compare contemporary laparoscopic hysterectomy with abdominal hysterectomy to determine the safest and most cost-effective technique. METHODS AND ANALYSIS A parallel, open, non-inferiority, multicentre, randomised controlled, expertise-based surgery trial with integrated health economic evaluation and an internal pilot with an embedded qualitative process evaluation. A within trial-based economic evaluation will explore the cost-effectiveness of laparoscopic hysterectomy compared with open abdominal hysterectomy. We will aim to recruit 3250 women requiring a hysterectomy for a benign gynaecological condition and who were suitable for either laparoscopic or open techniques. The primary outcome is major complications up to six completed weeks postsurgery and the key secondary outcome is time from surgery to resumption of usual activities using the personalised Patient-Reported Outcomes Measurement Information System Physical Function questionnaire. The principal outcome for the economic evaluation is to be cost per QALY at 12 months' postsurgery. A secondary analysis is to be undertaken to generate costs per major surgical complication avoided and costs per return to normal activities. ETHICS AND DISSEMINATION The study was approved by the West Midlands-Edgbaston Research Ethics Committee, 18 February 2021 (Ethics ref: 21/WM/0019). REC approval for the protocol version 2.0 dated 2 February 2021 was issued on 18 February 2021.We will present the findings in national and international conferences. We will also aim to publish the findings in high impact peer-reviewed journals. We will disseminate the completed paper to the Department of Health, the Scientific Advisory Committees of the RCOG, the Royal College of Nurses (RCN) and the BSGE. TRIAL REGISTRATION NUMBER ISRCTN14566195.
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Affiliation(s)
- Lina Antoun
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Lee Middleton
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Paul Smith
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - Ertan Saridogan
- Department of Gynaecology, University College London Hospitals, London, UK
| | - Kevin Cooper
- Aberdeen Royal Infirmary, Aberdeen, UK
- University of Aberdeen, Aberdeen, UK
| | | | | | | | - Rebecca Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Public Health, Epidemiology & Biostatistics, University of Birmingham, Birmingham, UK
| | | | | | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - T Justin Clark
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
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6
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Mura G, Sechi C, Vismara L, Moi V, Neri M, Paoletti AM. Mental health in women undergoing gynecological surgery at risk of infertility. Health Care Women Int 2023; 44:440-456. [PMID: 34919020 DOI: 10.1080/07399332.2021.2009832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Surgery for benign gynecologic conditions may lead to infertility complications. In a cross-sectional study we investigated depressive and anxiety symptoms, Quality of Life (QoL), and coping strategies in women with benign gynecologic conditions undergoing surgical treatment (G1, N = 45) compared with women that did not need surgery (G2, N = 43), through the Patient's Health Questionnaire, the Short Form Health Survey-12 items, the Self-Rating Anxiety State, and the Brief COPE. Statistical analyses showed that women in G1 had significant higher depressive (p=.04) and anxiety (p=.03) symptoms, and lower QoL (p=.01), than did those in G2. Moreover, women with more depressive or anxiety symptoms in both groups were more likely to present maladaptive coping modalities. A careful evaluation of the mental health of women undergoing gynecological surgery at risk of infertility should be included in the care for benign gynecologic conditions, in order to prevent psychosocial distress and alleviate the burden on QoL.
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Affiliation(s)
- Gioia Mura
- Department of Pedagogy, Psychology, Philosophy, University of Cagliari, Cagliari, Italy
| | - Cristina Sechi
- Department of Pedagogy, Psychology, Philosophy, University of Cagliari, Cagliari, Italy
| | - Laura Vismara
- Department of Pedagogy, Psychology, Philosophy, University of Cagliari, Cagliari, Italy
| | | | - Manuela Neri
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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Rushton T, Satin AJ, Fader AN. Engendered Perceptions About Surgeon Gender and Patient Outcomes After Cesarean Delivery. JAMA Surg 2023; 158:282-283. [PMID: 36696122 DOI: 10.1001/jamasurg.2022.7078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Tullia Rushton
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland.,The Kelly Gynecologic Oncology Service, Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Andrew J Satin
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland.,Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amanda N Fader
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland.,The Kelly Gynecologic Oncology Service, Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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8
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Mikhail E. Gynecologic Surgical Training: Current and Future Perspectives. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Emad Mikhail
- Division of Gynecologic Subspecialties, Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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9
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Sawangkum P, Lockwood C, Brown HL, Louis J, Hoffman MS. The Role of Gynecologic Surgical Training for the Practicing Obstetrician. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Peeraya Sawangkum
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Charles Lockwood
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Haywood L. Brown
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Judette Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Mitchel S. Hoffman
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- MCC GYN Program, Moffitt Cancer Center, Tampa, Florida, USA
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10
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Youssef Y, Afaneh H, Borahay MA. Strategies for Cost Optimization in Minimally Invasive Gynecologic Surgery. JSLS 2022; 26:JSLS.2022.00015. [PMID: 36071991 PMCID: PMC9385110 DOI: 10.4293/jsls.2022.00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Cost and quality are important, complex, and intertwined surgical outcomes. Evidence suggests that major cost drivers include operating room time, length of stay, re-admission, surgical complications, and quality of pre-operative and operative care in general. Our practices shape both costs and quality of gynecologic surgery. Various factors are explored in this review article to present and identify ways to implement cost-effective change that also improve quality of patient care. Database: We searched MEDLINE and PubMed databases for relevant articles. Discussion: Clinical preferences and decisions, surgeon experience, trainee education, and defensive medicine can influence cost. In addition, an incongruent physician-administration relationship may impact decisions across the healthcare system. The accelerating adoption of minimally invasive surgery, particularly the robotic approach, presents both an opportunity and a challenge. An example of practices that improve outcomes, patient satisfaction, and cut cost is pre-operative optimization, enhanced recovery after surgery, and the growing adoption of outpatient hysterectomy. The identification of cost-drivers and finding strategies to improve them would simultaneously improve quality and patient outcomes while reducing costs in minimally invasive gynecologic surgery.
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Affiliation(s)
- Youssef Youssef
- Department of Obstetrics and Gynecology, Hurley Medical Center/Michigan State University College of Human Medicine, Flint, MI
| | - Huda Afaneh
- Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mostafa A Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
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11
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Development and validation of a simulation model for laparoscopic myomectomy. Am J Obstet Gynecol 2022; 227:304.e1-304.e9. [PMID: 35489440 DOI: 10.1016/j.ajog.2022.04.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/14/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Simulation is an important adjunct to traditional surgical training, allowing for repetitive practice of new skills without compromising patient safety. Although several simulation models have been described and evaluated for gynecologic procedures, there is a lack of such models for laparoscopic myomectomy. OBJECTIVE This study aimed to design a low-cost, low-fidelity laparoscopic myomectomy simulation model and to assess the model's validity as a training tool. STUDY DESIGN The model was constructed using a "cup turner" foam cylinder, felt, a 2-inch stress ball, self-adhesive bandage wrap, multipurpose sealing wrap, red marker, and hook-and-loop fastener. Participants were recruited at a quaternary care academic center and at the Society for Gynecologic Surgeons Annual Scientific Meeting. The simulation task involved the following 2 steps: fibroid enucleation and hysterotomy repair. Validity evidence was collected by comparing expert and novice simulation task performances. Video recordings were scored by 2 blinded reviewers using the Global Operative Assessment of Laparoscopic Skills scale (5-20 points) and a modified Global Operative Assessment of Laparoscopic Skills scale (5-35 points), incorporating 3 novel domains specific to laparoscopic myomectomy. The Mann-Whitney U test was used to compare the task completion times and performance scores. Interrater reliability of scoring was assessed using the interclass correlation coefficient. Validity was also assessed with a post-task survey regarding the model's realism, utility, and educational effect. RESULTS The total cost to construct each model was under $5. A 3:1 ratio was used to recruit 15 novices and 5 experts. The median time to task completion was shorter for experts than for novices (11.8 vs 20.1 minutes; P=.004). The experts scored higher than the novices on both the Global Operative Assessment of Laparoscopic Skills scale (median 19 [range 13-20] vs 10 [6-17.5]; P=.007) and the modified Global Operative Assessment of Laparoscopic Skills scale (31.5 [21.5-33.5] vs 18.5 [13.5-32]; P=.009). The interclass correlation coefficient was 0.95 for the Global Operative Assessment of Laparoscopic Skills scores and 0.96 for the modified Global Operative Assessment of Laparoscopic Skills scores. Most of the participants agreed that the model closely approximated the feel of fibroid enucleation (70% [14/20]) and suturing the uterus (80% [16/20]). All the participants agreed that the model was useful for learning or teaching laparoscopic myomectomy. CONCLUSION This study demonstrates evidence supporting the validity of a novel, low-cost laparoscopic myomectomy model and a novel assessment scale for laparoscopic myomectomy training. This simulation model provides a targeted training tool that allows learners to focus on the key aspects of laparoscopic myomectomy and may improve readiness for the operating room.
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12
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Wright KN, Truong M, Siedhoff MT. Residency Training in Gynecologic Surgery: Where Do We Go from Here? J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kelly N. Wright
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mireille Truong
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew T. Siedhoff
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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13
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Gender Equity in Gynecologic Surgery: Lessons from History, Strengthening the Future. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00307-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Correlation of surgical case volume and fellowship training with performance on simulated procedural tasks. Am J Obstet Gynecol 2021; 225:548.e1-548.e10. [PMID: 34147495 DOI: 10.1016/j.ajog.2021.06.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND High-volume and fellowship-trained surgeons have superior outcomes. However, in gynecology, a large proportion of cases are performed by low-volume surgeons. Simulation has been shown to be useful in assessing surgical skill and may be a useful tool in hospital credentialing and maintenance of privileges. OBJECTIVE To determine the correlation between a surgical case volume and fellowship training with performance on simulated procedural tasks. STUDY DESIGN A total of 108 obstetricians and gynecologists with laparoscopic privileges at 2 academic institutions completed a pre-test survey and performed 3 tasks on the LapSim laparoscopic virtual reality simulator. The pre-test survey inquired about the monthly laparoscopic case volume and prior training. Simulations included a basic skills task (peg transfer) followed by a procedural task (salpingectomy) of 2 difficulty levels (low and moderate). Spearman correlation and Wilcoxon tests were used to determine correlations between the survey responses and performance metrics. RESULTS Participants included 67 generalists (62%) and 41 fellowship-trained specialists (38%). There was an observed weak correlation among surgical volume (more than 6 cases per month), time to completion, and the amount of blood loss when performing the low-difficulty level salpingectomy (r=-0.32, P=.0007 and r=-0.29, P=.002, respectively). The economy of movement (instrument path length) was correlated to high surgical volume (r=-0.35, P=.0002). Compared with generalists, surgeons with fellowship training performed tasks faster (410.8 seconds [interquartile range, 309.7-595.2]) vs 530.2 seconds (interquartile range, 406.2-605.0; P=.0009), more efficiently at 6.1 m (interquartile range, 4.8-7.3) vs 8.1 m (interquartile range, 5.8-10.7; P=.0003), and with less blood loss at 21.7 mL (interquartile range, 11.8-37.7) vs 42.9 mL (interquartile range, 18.1-70.6; P=.002). Regarding the case volume and fellowship background, there was no difference in ovarian diathermy damage. In addition, there was no difference among most performance parameters for the peg transfer task and the moderate-difficulty salpingectomy procedure. CONCLUSION Surgical experience obtained through higher case volume and fellowship training correlate with higher performance scores during simulated procedural tasks. In a previous study, we found a similar correlation with simulated basic skills tasks. The current study is a continuation of an ongoing quality initiative to establish a summative assessment of laparoscopic surgical skills using virtual reality simulator for the maintenance of credentials among obstetrical and gynecologic surgeons. Future studies will compare the performance metrics from laparoscopic procedures performed on virtual reality simulator with the performance in the operating room and clinical outcomes.
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15
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Tummers FHMP, Hoebink J, Driessen SRC, Jansen FW, Twijnstra ARH. Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect? Acta Obstet Gynecol Scand 2021; 100:2082-2090. [PMID: 34490608 DOI: 10.1111/aogs.14242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/13/2021] [Accepted: 08/08/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques. MATERIAL AND METHODS A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012. RESULTS The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year. CONCLUSIONS The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.
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Affiliation(s)
| | - Jasmin Hoebink
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sara R C Driessen
- Department of Gynecology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Bio Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
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16
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Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care. Obstet Gynecol 2021; 137:657-661. [PMID: 33706362 DOI: 10.1097/aog.0000000000004309] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/17/2020] [Indexed: 11/27/2022]
Abstract
In this commentary, we describe historical and other influences that drive "double discrimination" in gynecologic surgery-lower pay in the area of surgery that boasts the largest proportion of female surgeons and is focused on female patients and explore how it results in potentially lower quality care. Insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity. The wage gap created by lower reimbursement rates disproportionately affects female surgeons, who are disproportionately represented among gynecologic surgeons. This contributes to a large wage gap in surgery for women. Finally, poor reimbursement for gynecologic surgery pushes many obstetrics and gynecology surgeons to preferentially perform obstetric services, resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates. Creating equity in reimbursement for gynecologic surgery is one important and ethically required step forward to gender equity in medicine for patients and surgeons.
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Sharma RK, Lee J, Liou R, McManus C, Lee JA, Kuo JH. Optimal surgeon-volume threshold for neck dissections in the setting of primary thyroid malignancies. Surgery 2021; 171:172-176. [PMID: 34266647 DOI: 10.1016/j.surg.2021.04.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/11/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although the surgeon-volume relationship is well documented for thyroidectomy, less is known about central neck and lateral neck dissections. The aim of this study was to evaluate and determine the surgeon-volume threshold for central neck and lateral neck dissections for thyroid cancer. METHODS A retrospective analysis of patients with thyroid malignancies who received a central or lateral neck dissection in the New York Statewide Planning and Research Cooperative System was performed (2007-2017). Demographic variables included age, sex, race, and a Charlson Comorbidity Score. Thirty-day complications were identified using International Classification of Diseases (ICD) codes for central neck, lateral neck, and other surgical complications. Optimal surgeon-volume threshold was estimated using a change-point logistic regression. Using the identified threshold, surgeons were then classified to low versus high volume surgeons. Logistic regression analysis was conducted to examine the effect of high-volume status on outcomes. RESULTS In total, 3,808 patients who underwent neck dissections (3,485 central neck dissections and 977 lateral neck dissections) were analyzed. Surgeon-volume threshold to distinguish high volume surgeons for central neck dissections and lateral neck dissections was 7.0 (95% bootstrap confidence interval 1.3-7.5) and 3.3 (1.2-4.8) neck dissections/year, respectively. For central neck dissection, high volume surgeons were associated with a lower rate of vocal cord paralysis (odds ratio 0.45 [0.24-0.82]), hypocalcemia (0.31 [0.14-0.65]), and all-cause complications (0.42 [0.29-0.59]). For lateral neck dissection, high volume surgeons were associated with a lower odds all-cause complications (0.42 [0.23-0.74]) but not lateral neck specific complications (0.18 [0.01-1.07]). CONCLUSION A threshold of 7.0 central neck dissections and 3.3 lateral neck dissections for thyroid cancer per year improves outcomes. Guidelines for training and centralization of care can be guided by these results to reduce complications.
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Affiliation(s)
- Rahul K Sharma
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY. https://twitter.com/RKSharma0407
| | - Jihui Lee
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Rachel Liou
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY
| | - Catherine McManus
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY
| | - James A Lee
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY
| | - Jennifer H Kuo
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY.
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Brunes M, Forsgren C, Warnqvist A, Ek M, Johannesson U. Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden. Acta Obstet Gynecol Scand 2021; 100:1730-1739. [PMID: 33895985 DOI: 10.1111/aogs.14166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume. MATERIAL AND METHODS All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses. RESULTS TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9). CONCLUSIONS RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.
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Affiliation(s)
- Malin Brunes
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Södersjukhuset, Stockholm, Sweden
| | - Catharina Forsgren
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Danderyd Hospital, Stockholm, Sweden
| | - Anna Warnqvist
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marion Ek
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Södersjukhuset, Stockholm, Sweden
| | - Ulrika Johannesson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology at Danderyd Hospital, Stockholm, Sweden
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Chen AH, Robertson MW. Route of Hysterectomy: Robotic. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anita H. Chen
- Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, Florida, USA
| | - Matthew W. Robertson
- Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, Florida, USA
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Feasibility and safety of total laparoscopic hysterectomy for uteri weighing from 1.5 kg to 11.000 kg. Arch Gynecol Obstet 2020; 303:169-179. [PMID: 32949285 DOI: 10.1007/s00404-020-05799-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess the feasibility and safety of total laparoscopic hysterectomy (TLH) for uteri ≥ 1.5 kg. METHODS We prospectively evaluated all elective TLHs (with or without adnexectomy) performed for fibromatous uteri between August 2009 and August 2019 in the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and the Department of Gynecologic Oncology, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari. Patients with large myomatous uteri (uterine weight ≥ 1.5 kg on pathology reports) were included in the analysis. We examined all procedures and collected data about intra- and post-operative short-term and long-term complications, intraoperative blood loss, operative time, hospital stay, and time to achieve well-being. RESULTS Seventy-eight patients were included. The median weight was 2,000 g (range 1,500-11,000 g), estimated blood loss was 100 mL (range 10-700 mL), operating time was 135 min (range 60-300 min), and hospital stay was 2 days (range 2-5 days). Conversion to laparotomy occurred in 4 patients (5.1%) with uterine weight ranging from 3 to 5.5 kg, due to severe adherence syndrome or inadequate visualization. As for intraoperative complications, 1 patient (who had the largest removed uterus weighing 11,000 g) experienced an intraoperative ureteral injury (grade III). No major postoperative complications occurred. CONCLUSIONS This study provides the largest case series of TLH for fibromatous uteri > 1.5 kg and includes some of the largest uteri reported to date in the literature (weighing 5,320, 5,720, and 11,000 g, respectively). The study reaffirms the feasibility and safety of a minimally invasive hysterectomy even in the case of abnormally large uteri.
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Das D, Sinha A, Yao M, Michener CM. Trends and Risk Factors for Vaginal Cuff Dehiscence after Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2020; 28:991-999.e1. [PMID: 32920145 DOI: 10.1016/j.jmig.2020.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/15/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVE The primary objective was to assess the effect of the route of closure of the vaginal cuff on the incidence of vaginal cuff dehiscence (VCD) in laparoscopic hysterectomy (LH). The secondary objective was to assess patient- and surgical-risk factors associated with VCD, rate of perioperative complications by route of closure, and impact of surgeon volume on complications. DESIGN Retrospective chart review with case-control component. SETTING Tertiary care center (main hospital and regional hospitals). PATIENTS A total of 1278 women underwent LH or robot-assisted hysterectomy in 2016, and met the inclusion criteria. Independently, 26 cases of VCD were identified from 2009 through 2016. INTERVENTIONS A retrospective comparison of patients with vaginal cuff closure and laparoscopic cuff closure (LCC) undergoing LH or robot-assisted hysterectomy in 2016. Patients with VCD from 2009 through 2016 (n = 26) were matched by route of cuff closure to the next 7 patients who underwent hysterectomies (n = 182), who became controls. MEASUREMENTS AND MAIN RESULTS In 2016, there were 9 cases of VCD (0.70%). There was no significant difference in VCD between LCC (8/989; 0.81%) and vaginal cuff closure (1/289; 0.35%; p = .41). Seven VCD cases were performed by high-volume surgeons (>30 hysterectomies per year) who were more likely to perform LCC and use barbed suture. There were no significant differences in the rates of perioperative complications or surgeon volume between routes of cuff closure. The case-control patients differed in smoking status (p = .010) and history of prior laparotomy (p = .017). Logistic regression showed that increasing age (odds ratio 0.95; 95% confidence interval, 0.91-0.99) and increasing body mass index (odds ratio 0.98; 95% confidence interval, 0.83-0.97) were protective for VCD. CONCLUSION VCD is a rare but serious complication of LH. Despite previous studies, we did not find a significant difference in VCD or intra- and perioperative complications by route of cuff closure or surgeon volume. Given the lack of evidence favoring one route of cuff closure, we recommend that, to optimize patient outcomes, surgeons employ the closure technique that they are best accustomed to.
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Affiliation(s)
- Deepanjana Das
- Department of Obstetrics and Gynecology, Women's Health Institute (Drs. Das, Sinha, and Michener).
| | - Annika Sinha
- Department of Obstetrics and Gynecology, Women's Health Institute (Drs. Das, Sinha, and Michener)
| | - Meng Yao
- Department of Quantitative Health Sciences (Mr. Yao), Cleveland Clinic, Cleveland, Ohio
| | - Chad M Michener
- Department of Obstetrics and Gynecology, Women's Health Institute (Drs. Das, Sinha, and Michener)
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Patient and Hospital Characteristics Associated with Minimally Invasive Hysterectomy: Evidence from 143 Illinois Hospitals, 2016 to 2018. J Minim Invasive Gynecol 2020; 27:1337-1343. [DOI: 10.1016/j.jmig.2020.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 12/19/2022]
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Traylor J, Friedman J, Runge M, Tsai S, Chaudhari A, Milad MP. Factors that Influence Applicants Pursuing a Fellowship in Minimally Invasive Gynecologic Surgery. J Minim Invasive Gynecol 2020; 27:1070-1075. [DOI: 10.1016/j.jmig.2019.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 01/28/2023]
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Comparing Surgical Experience and Skill Using a High-Fidelity, Total Laparoscopic Hysterectomy Model. Obstet Gynecol 2020; 136:97-108. [DOI: 10.1097/aog.0000000000003897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Klebanoff JS, Marfori CQ, Vargas MV, Amdur RL, Wu CZ, Moawad GN. Ob/Gyn resident self-perceived preparedness for minimally invasive surgery. BMC MEDICAL EDUCATION 2020; 20:185. [PMID: 32503585 PMCID: PMC7275515 DOI: 10.1186/s12909-020-02090-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Very little is known regarding the readiness of senior U.S. Ob/Gyn residents to perform minimally invasive surgery. This study aims to evaluate the self-perceived readiness of senior Ob/Gyn residents to perform complex minimally invasive gynecologic surgery as well as their perceptions of the minimally invasive gynecologic surgery subspecialty. METHODS We performed a national survey study of 3rd and 4th year Ob/Gyn residents. A novel 58-item survey was developed and sent to residency program directors and coordinators with the request to forward the survey link along to their senior residents. RESULTS We received 158 survey responses with 84 (53.2%) responses coming from 4th year residents and 74 (46.8%) responses from 3rd year residents. Residents who train with graduates of a fellowship in minimally invasive gynecologic surgery felt significantly more prepared to perform minimally invasive surgery compared to residents without this exposure in their training. The majority of senior residents (71.5%) feel their residency training adequately prepared them to be a competent minimally invasive gynecologic surgeon. However, only 50% feel prepared to perform a laparoscopic hysterectomy on a uterus greater than 12 weeks size, 29% feel prepared to offer a vaginal hysterectomy on a uterus 12-week size or greater, 17% feel comfortable performing a laparoscopic myomectomy, and 12% feel prepared to offer a laparoscopic hysterectomy for a uterus above the umbilicus. CONCLUSIONS The majority of senior U.S. Ob/Gyn residents feel prepared to provide minimally invasive surgery for complex gynecologic cases. However, surgical confidence in specific procedures decreases when surgical complexity increases.
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Affiliation(s)
- Jordan S Klebanoff
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA.
| | - Cherie Q Marfori
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Maria V Vargas
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Richard L Amdur
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Catherine Z Wu
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
| | - Gaby N Moawad
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C, USA
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