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Kohn JR, Frost AS, Tambovtseva A, Hunt M, Clark K, Wilson C, Borahay MA. Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors. Int J Gynaecol Obstet 2023; 161:616-623. [PMID: 36436911 PMCID: PMC10121734 DOI: 10.1002/ijgo.14593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/28/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy. METHODS The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates. RESULTS A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges. CONCLUSION Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.
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Affiliation(s)
- Jaden R. Kohn
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anja S. Frost
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Megan Hunt
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Mostafa A. Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
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2
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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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3
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AlAshqar A, Wildey B, Yazdy G, Goktepe ME, Kilic GS, Borahay MA. Predictors of same-day discharge after minimally invasive hysterectomy for benign indications. Int J Gynaecol Obstet 2021; 158:308-317. [PMID: 34674257 DOI: 10.1002/ijgo.13992] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To identify predictors of same-day discharge after benign minimally invasive hysterectomy. METHODS In this retrospective cohort study, we identified women (n = 1084) undergoing benign minimally invasive hysterectomy from 2009 to 2016. Multivariate logistic regression was used to examine demographic, operative, and surgeon factors associated with discharge on postoperative day 0. RESULTS In our study population, 238 women (22%) were discharged on the same day. Robotic hysterectomy (risk ratio [RR] 2.24; 95% confidence interval [CI] 1.13-4.44), shorter operative time (lowest quartile; RR 5.28; 95% CI 2.66-10.46), and minimal blood loss (lowest quartile; RR 3.01; 95% CI 1.68-6.23) were associated with higher same-day discharge likelihood whereas later procedure start time (2-5 pm; RR 0.38; 95% CI 0.17-0.85) and postoperative complications (RR 0.19; 95% CI 0.06-0.55) significantly decreased its likelihood. The strongest predictor was surgeon's number of years in practice, with recently graduated surgeons more likely to discharge their patients on the same day (RR 3.15; 95% CI 2.09-4.77). CONCLUSION Same-day discharge after minimally invasive hysterectomy is determined by several patient, operative, and surgeon factors that can be incorporated into an implementation plan to promote earlier discharge. Most especially, scheduling patients based on perceived case complexity and targeted surgeon education can qualify a larger cohort for same-day discharge.
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Affiliation(s)
- Abdelrahman AlAshqar
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Obstetrics and Gynecology, Kuwait University, Kuwait City, Kuwait
| | - Brian Wildey
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Golsa Yazdy
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Metin E Goktepe
- The University of Texas Medical Branch, Galveston, Texas, USA
| | - Gokhan S Kilic
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Mostafa A Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
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Klapczynski C, Sallée C, Tardieu A, Peschot C, Boutot M, Mohand N, Lacorre A, Margueritte F, Gauthier T. Training for next generation surgeons: a pilot study of robot-assisted hysterectomy managed by resident using dual console. Arch Gynecol Obstet 2020; 303:981-986. [PMID: 33180173 DOI: 10.1007/s00404-020-05870-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/31/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To assess feasibility of a standardized robot-assisted hysterectomy managed by resident and supervised by senior surgeon using dual-console on a 21-step grid (max score = 42) assessing resident autonomy. METHODS A total of seven patients managed between September 2019 and March 2020 by six residents in gynecology and obstetrics were included. Standardized robot-assisted hysterectomy for endometrial cancer or adenomyosis was performed. RESULTS No conversion to laparotomy, no intra- or post-operative incidents were reported. Mean score on the evaluation scale was 29.8 out of 42 (SD = 7.3). Mean operative time was 104 min (SD = 23). Mean average suturing time was, respectively, 335 s (SD = 57 s) and 270 s (SD = 53 s) for the first and the fourth knot. There was a 65 s improvement between the first and the fourth intracorporeal knot (p = 0.043). The perceived workload evaluated with the NASA TLX score showed a low level of stress (Temporal demand = 1.6 /10), and a low level of frustration (Frustration level = 3.6/10). Experience gained during the surgery was felt to be important (Commitment = 8.6/10). CONCLUSION Standardized robot-assisted hysterectomy managed by a resident supervised by a senior surgeon using the dual-console seems feasible. This tool could be useful to assess residents' surgical skills.
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Affiliation(s)
- Clémence Klapczynski
- Department of Gynecology, University Hospital of Rouen, 1 rue de Germont Rouen University Hospital, 76000, Rouen, France
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - Camille Sallée
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - Antoine Tardieu
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - Clémence Peschot
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - Manon Boutot
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - Nadia Mohand
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - Aymeline Lacorre
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - François Margueritte
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France
| | - Tristan Gauthier
- Department of Gynecology, University Hospital of Limoges, Mother and child hospital, 8 avenue Dominique Larrey, 87000, Limoges, France.
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AlAshqar A, Goktepe ME, Kilic GS, Borahay MA. Predictors of the cost of hysterectomy for benign indications. J Gynecol Obstet Hum Reprod 2020; 50:101936. [PMID: 33039600 DOI: 10.1016/j.jogoh.2020.101936] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Hysterectomy is a commonly performed procedure with widely variable costs. As gynecologists divert from invasive to minimally invasive approaches, many factors come into play in determining hysterectomy cost and efforts should be sought to minimize it. Our objective was to identify the predictors of hysterectomy cost. MATERIALS AND METHODS This was a retrospective cohort study where women who underwent hysterectomy for benign conditions at the University of Texas Medical Branch from 2009 to 2016 were identified. We obtained and analyzed demographic, operative, and financial data from electronic medical records and the hospital finance department. RESULTS We identified 1,847 women. Open hysterectomy was the most frequently practiced (35.8 %), followed by vaginal (23.7 %), laparoscopic (23.6 %), and robotic (16.9 %) approaches. Multivariate regression demonstrated that hysterectomy charges can be significantly predicted from surgical approach, patient's age, operating room (OR) time, length of stay (LOS), estimated blood loss, insurance type, fiscal year, and concomitant procedures. Charges increased by $3,723.57 for each day increase in LOS (P <0.001), by $76.02 for each minute increase in OR time (P <0.001), and by $48.21 for each one-year increase in age (P 0.037). Adjusting for LOS and OR time remarkably decreased the cost of open and robotic hysterectomy, respectively when compared with the vaginal approach. CONCLUSION Multiple demographic and operative factors can predict the cost of hysterectomy. Healthcare providers, including gynecologists, are required to pursue additional roles in proper resource management and be acquainted with the cost drivers of therapeutic interventions. Future efforts and policies should target modifiable factors to minimize cost and promote value-based practices.
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Affiliation(s)
- Abdelrahman AlAshqar
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, United States; Department of Obstetrics and Gynecology, Kuwait University, Kuwait City, Kuwait
| | - Metin E Goktepe
- Medical Student, The University of Texas Medical Branch in Galveston, TX, United States
| | - Gokhan S Kilic
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch in Galveston, TX, United States
| | - Mostafa A Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, United States.
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Development and Validation of a Vaginal Anterior Repair Simulation Model for Surgical Training. Female Pelvic Med Reconstr Surg 2020; 27:e290-e294. [DOI: 10.1097/spv.0000000000000905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Ensuring patient safety and optimizing outcomes in obstetrics and gynecology through improving technical skills, enhancing team performance, and decreasing medical errors has resulted in significant interest in incorporating drills and simulation into medical training, continuing education, and multidisciplinary team practice. Drills and simulations are ideal because of their wide range of application with various learners and settings. They provide a safe space to learn and maintain technical skills and to improve knowledge, confidence, communication, and teamwork behaviors, particularly for less common, high-stakes clinical scenarios.
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Affiliation(s)
- Jean-Ju Sheen
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th Street PH 16, New York, NY 10032, USA
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th Street PH 16, New York, NY 10032, USA.
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8
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Chen R, Rodrigues Armijo P, Krause C, Siu KC, Oleynikov D. A comprehensive review of robotic surgery curriculum and training for residents, fellows, and postgraduate surgical education. Surg Endosc 2019; 34:361-367. [PMID: 30953199 DOI: 10.1007/s00464-019-06775-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/28/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND In 2017, the utilization of robotic-assisted surgery had grown 10-40-fold relative to laparoscopic surgery in common general surgery procedures. The rapid rise in the utilization of robotic-assisted surgery has necessitated a standardized training curriculum. Many curricula are currently being developed and validated. Additionally, advancements in virtual reality simulators have facilitated their integration into robotic-assisted surgery training. This review aims to highlight and discuss the features of existing curricula and robotic-assisted surgery training simulators and to provide updates on their respective validation process. MATERIALS AND METHODS A literature review was conducted using PubMed from 2000-2019 and commercial websites. Information regarding availability, content, and status of validation was collected for each current robotic-assisted surgery curriculum. This review did not qualify as human subjects research, so institutional review board approval was not required. RESULTS The daVinci Technology Training Pathway and Fundamentals of Robotic Surgery are purely web-based and self-paced robotic-assisted surgery training. The Society of American Gastrointestinal and Endoscopic Surgeon Robotic Masters Series, Fundamental Skills of Robot-Assisted Surgery training program, and the Robotics Training Network curriculum require trainees to be on site in order to provide expert feedback on surgical techniques and robot maintenance. Currently, there are few virtual reality simulators for robotic-assisted surgical training available on the market. CONCLUSIONS Didactic courses are available in all of these training programs, but their contents are inconsistent. Furthermore, the availability and nature of hands-on training offered by these curriculums are widely variable.
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Affiliation(s)
- Richard Chen
- College of Medicine, University of Nebraska Medical Center, Nebraska Medical Center, 986245, Omaha, NE, 68198-6245, USA
| | - Priscila Rodrigues Armijo
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, Nebraska Medical Center, 986246, Omaha, NE, 68198-6246, USA
| | - Crystal Krause
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, Nebraska Medical Center, 986246, Omaha, NE, 68198-6246, USA
| | | | - Ka-Chun Siu
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, Nebraska Medical Center, 986246, Omaha, NE, 68198-6246, USA.,College of Allied Health Professions, University of Nebraska Medical Center, Nebraska Medical Center, 984420, Omaha, NE, 68198-4420, USA
| | - Dmitry Oleynikov
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, Nebraska Medical Center, 986246, Omaha, NE, 68198-6246, USA. .,Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, 986245, Omaha, NE, 68198-6245, USA.
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9
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Tam V, Borrebach J, Dunn SA, Bellon J, Zeh HJ, Hogg ME. Proficiency-based training and credentialing can improve patient outcomes and decrease cost to a hospital system. Am J Surg 2018; 217:591-596. [PMID: 30098709 DOI: 10.1016/j.amjsurg.2018.07.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND While proficiency-based robotic training has been shown to enhance skill acquisition, no studies have shown that training leads to improved outcomes or quality measures. METHODS Board-certified general surgeons participated in an optional proficiency-based robotic training curriculum and outcomes from robotic hernia cases were analyzed. Multivariable analysis was performed for operative times to adjust for patient and surgical variables. RESULTS Six out of 16 (38%) surgeons completed training and 210 robotic hernia cases were analyzed. Longer operative times were associated with bilateral repairs (observed-to-expected operative time ratio [OTR] = 1.41, p < 0.001) and incarceration (OTR = 1.24, p = 0.006), while female patients (OTR = 0.87, p = 0.001) and increasing chronologic case order (OTR = 0.94, p < 0.001) were associated with shorter operative times. Surgeons who completed robotic training achieved shorter OTRs than those who did not (p = 0.03). Comparing non-risk adjusted hospital costs, trainees had an average of $1207 in savings (20% reduction) per robotic hernia case. CONCLUSIONS A structured proficiency-based robotics training curriculum is an effective way to reduce operative times and costs.
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Affiliation(s)
- Vernissia Tam
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Jeffrey Borrebach
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | | | - Johanna Bellon
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Herbert J Zeh
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Borahay MA, Tapısız ÖL, Alanbay İ, Kılıç GS. Outcomes of robotic, laparoscopic, and open hysterectomy for benign conditions in obese patients. J Turk Ger Gynecol Assoc 2018; 19:72-77. [PMID: 29699956 PMCID: PMC5994808 DOI: 10.4274/jtgga.2018.0018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective: To compare outcomes of robotic-assisted (RAH), total laparoscopic hysterectomy (LH), and total abdominal hysterectomy (TAH) for benign conditions in obese patients. Material and Methods: Retrospective cohort (Class II-2) analysis. All obese patients who underwent RAH, LH or TAH for benign conditions by a single surgeon at the University of Texas Medical Branch between January 2009 and December 2011 were identified and their charts reviewed. The patients’ characteristics, operative data, and post-operative outcomes were collected and statistically analyzed. Results: A total of 208 patients who underwent RAH (n=51), LH (n=24) or TAH (n=133) were analyzed. There were no significant differences among the groups in demographic characteristics, indications for surgery or pathologic findings. RAH and LH were associated with lower estimated blood loss (EBL) (p<0.001) and shorter length of hospital stay (LOS) (p<0.001) compared with TAH. In addition, RAH and LH had lower intraoperative and early postoperative (≤6 weeks) complications compared with TAH (p=0.002). However, the procedure time was longer in RAH and LH (p<0.001). No significant differences were noted among the groups for late post-operative complications (after 6 weeks) or unscheduled post-operative visits. Conclusion: Minimally invasive hysterectomy appears to be safe in obese patients with the advantages of less EBL, fewer intraoperative complications, and shorter LOS.
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Affiliation(s)
- Mostafa A Borahay
- Department of Obstetrics and Gynecology, Johns Hopkins University, Maryland, USA,Department of Obstetrics and Gynecology, University of Texas Medical Branch, Texas, USA
| | - Ömer Lütfi Tapısız
- Department of Obstetrics and Gynecology, University of Health Sciences, Etlik Zübeyde Hanım Women’s Diseases Training and Research Hospital, Ankara, Turkey
| | - İbrahim Alanbay
- Department of Obstetrics and Gynecology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Gökhan Sami Kılıç
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Texas, USA
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11
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O'Leary MP, Ayabe RI, Dauphine CE, Hari DM, Ozao-Choy JJ. Building a Single-Site Robotic Cholecystectomy Program in a Public Teaching Hospital: Is It Safe for Patients and Feasible for Residents to Participate?. Am Surg 2018. [DOI: 10.1177/000313481808400223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Single-site robotic cholecystectomy (SSRC) accounts for most of the robotic surgery cases performed by general surgeons at our institution since acquiring the da Vinci Si Surgical SystemTM (Intuitive Surgical, Inc., Sunnyvale, CA) in 2014. We sought to determine whether a SSRC program is safe to start in a public teaching hospital and to determine whether resident participation in this procedure is feasible. Data on age, gender, race, BMI, total operative time, length of stay, comorbidities, and conversion from laparoscopic to open surgery were examined for elective SSRC and laparoscopic cholecystectomies (LCs) performed by two faculty surgeons between February 2015 and August 2015. Thirty-eight patients underwent elective SSRC, whereas 27 patients underwent LC. Residents participated as operating surgeons for some portion of the case in 15 SSRC cases and in all LC cases. There were no significant differences in operative time, length of stay, or 30-day readmission rates, regardless of resident involvement. Patients in the SSRC group had a significantly lower BMI (25.8 vs 33.7, P = 0.008). This study suggests that resident participation does not increase complications or total operative time and that SSRC is a safe procedure to start in a public teaching hospital after proper faculty and resident training.
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Affiliation(s)
- Michael P. O'Leary
- Department of Surgery, Division of Surgical Oncology, Harbor UCLA Medical Center, Torrance, California
| | - Reed I. Ayabe
- Department of Surgery, Division of Surgical Oncology, Harbor UCLA Medical Center, Torrance, California
| | - Christine E. Dauphine
- Department of Surgery, Division of Surgical Oncology, Harbor UCLA Medical Center, Torrance, California
| | - Danielle M. Hari
- Department of Surgery, Division of Surgical Oncology, Harbor UCLA Medical Center, Torrance, California
| | - Junko J. Ozao-Choy
- Department of Surgery, Division of Surgical Oncology, Harbor UCLA Medical Center, Torrance, California
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