Increasing Utilization of Minimally Invasive Hysterectomy

Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score

INTRODUCTION AND HYPOTHESIS

We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model.

METHODS

We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic.

RESULTS

For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all).

CONCLUSIONS

A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Management of advanced prolapse including a bowel obstruction: expanding the role of transvaginal surgery

INTRODUCTION AND HYPOTHESIS

We reviewed a case of concomitant advanced pelvic organ prolapse and partial small bowel obstruction managed via transvaginal small bowel resection and native tissue prolapse repair.

METHODS

The patient is an 82-year-old woman with a history of a radical cystectomy and ileal conduit 2 years prior for bladder cancer that was transferred from an outside hospital for incarcerated prolapse including a small bowel obstruction with transition point inside the prolapse. She had previously unsuccessfully tried several pessaries for her prolapse. She was widowed and not sexually active. After conservative management of her bowel obstruction was unsuccessful, she was taken to the operating room for transvaginal prolapse repair. Intraoperatively, we encountered an isolated area of indurated bowel adherent to the prolapse. Colorectal surgery performed a transvaginal small bowel resection with stapled anastomosis, and a modified LeFort colpocleisis was performed to address her prolapse. Her postoperative course was uncomplicated, and at 6 months, she reported normal bowel function and had no evidence of prolapse recurrence.

CONCLUSION

We present a case of incidental bowel pathology during vaginal prolapse surgery, requiring a small bowel resection. This case demonstrates the feasibility of this procedure when working with a multi-disciplinary team and localized bowel pathology.

Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018

BACKGROUND

There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women.

OBJECTIVE

This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience.

STUDY DESIGN

A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time.

RESULTS

A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications.

CONCLUSION

This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times.

Variation in the utilization of robotic surgical operations

The appropriate use of the robot in surgery continues to evolve. Robotic operations (RO) are particularly advantageous for deep pelvic and retroperitoneal procedures, but the implementation of RO is unknown. We aimed to examine regional variation for the most commonly performed RO in general, gynecologic, and urologic surgery. A three-state inpatient database from 2008 to 2011 was used. Nine common robotic inpatient general, gynecologic and urologic surgery procedures were analyzed. States were divided into hospital service areas (HSAs). The percentage of RO was calculated for each operation. Hospital service areas that had < 50% or > 150% of the RO average were outliers. Hospital service areas were compared based on demographics, patterns of adoption, variation in usage, and association with population, physician and hospital density. Hysterectomies were the procedure that was performed most often robotically. Over 50% of radical prostatectomies were performed robotically. Procedures with the highest rate of RO performance were performed with the least variation. Characteristics that were significantly correlated with RO included provider and hospital density. Variation in the utilization of RO is common and differs by operation. Physician density impacts access to care and is associated with the variation in use of RO depending on procedure type. Further research is needed to understand the causes of variation and adoption of RO.