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Danilyants N, MacKoul P, van der Does L, MacKoul M, Kazi N. 60 A retroperitoneal approach to endometriosis excision: Surgical outcomes & 7-year follow-up. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2021.04.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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MacKoul P, Danilyants N, Touchan F, van der Does LQ, Haworth LR, Kazi N. Laparoscopic-assisted myomectomy with uterine artery occlusion at a freestanding ambulatory surgery center: a case series. ACTA ACUST UNITED AC 2020; 17:7. [PMID: 32565764 PMCID: PMC7296894 DOI: 10.1186/s10397-020-01075-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/02/2020] [Indexed: 12/17/2022]
Abstract
Background Non-hysteroscopic myomectomy is infrequently performed in a freestanding ambulatory setting, in part due to risks of intraoperative hemorrhage. There are also concerns about increased surgical risks for morbidly obese patients in this setting. The purpose of this study is to report the surgical outcomes of a series of laparoscopic-assisted myomectomy (LAM) cases at a freestanding ambulatory surgery center (ASC), including a comparative analysis of outcomes in morbidly obese patients (BMI > 40 kg/m2). Methods A retrospective comparative analysis was performed of 969 women, age 18 years or older, non-pregnant, who underwent LAM by one of two high volume, laparoscopic gynecologic surgical specialists at a freestanding ambulatory surgery center serving the Washington, DC area, between October 2013 and February 2019. Reversible occlusion was performed laparoscopically by placing a latex-based rubber catheter as a tourniquet around the isthmus of the uterus, causing a temporary occlusion of the bilateral uterine arteries. Permanent occlusion was performed laparoscopically via retroperitoneal dissection and uterine artery ligation at the origin of the anterior branch of the internal iliac artery. Minilaparotomy was performed for specimen removal in all cases. No power morcellation was used. Postoperative complications were graded using the Clavien-Dindo Classification system. Outcomes were compared across BMI categories using Pearson Chi-Square. Results Average myoma weight and size were 422.7 g and 8.3 cm, respectively. Average estimated blood loss (EBL) was 192.1 mL; intraoperative and grade 3 postoperative complication rates were 1.4% and 1.6%, respectively. While EBL was significantly higher in obese and morbidly obese patients, this difference was not clinically meaningful, with no significant difference in blood transfusion rates. There were no statistically significant intraoperative or postoperative complication rates across BMI categories. There was a low rate of hospital transfers (0.7%) for all patients. Conclusion Laparoscopic-assisted myomectomy can be performed safely in a freestanding ambulatory surgery setting, including morbidly obese patients. This is especially important in the age of COVID-19, as elective surgeries have been postponed due to the 2020 pandemic, which may lead to a dramatic and permanent shift of outpatient surgery from the hospital to the ASC setting.
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Affiliation(s)
- Paul MacKoul
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Natalya Danilyants
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Faraj Touchan
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Louise Q van der Does
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Leah R Haworth
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Nilofar Kazi
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
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Mackoul P, Danilyants N, van der Does L, Haworth L, Kazi N. 22: Laparoscopic-assisted myomectomy with uterine artery occlusion in morbidly obese patients at a freestanding ambulatory surgery center. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Danilyants N, Mamik MM, MacKoul P, van der Does LQ, Haworth L. Laparoscopic-assisted myomectomy: Surgery center versus outpatient hospital. J Obstet Gynaecol Res 2020; 46:490-498. [PMID: 31997510 PMCID: PMC7065249 DOI: 10.1111/jog.14197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/31/2019] [Indexed: 11/30/2022]
Abstract
Aim To compare the safety protocols and operative outcomes of women undergoing laparoscopic‐assisted myomectomy (LAM) by the same surgeons at a freestanding ambulatory surgery center (ASC) versus a hospital outpatient setting. Methods Retrospective chart review of all women ≥18 years old with symptomatic leiomyoma, who underwent LAM with uterine artery occlusion or ligation for blood loss control, at a freestanding ASC between 2013 and 2017, and an outpatient hospital setting between 2011 and 2013, both serving the metropolitan Washington, DC area. The procedures were performed by two minimally invasive gynecologic surgical specialists from a single practice. The safety protocols of each setting were reviewed to identify similarities and differences. Results A total of 816 LAM cases were analyzed (ASC = 588, hospital = 228). The rate of complications was comparable across settings, as was the average myoma weight (ASC = 396.2 g; hospital = 461.5 g; P = 0.064). Operative time was significantly shorter at the ASC: 68 min (95% CI 66–70) versus 80 min at hospital (95% CI 76–84), P < 0.0001. Ambulatory surgery center and hospital protocols differed in limits of preoperative hemoglobin (minimum 9.0 g/dL, 7.5 g/dL respectively), lower nurse/patient ratio in PACU, and were similar in intraoperative surgical safety standards. Conclusion Laparoscopic‐assisted myomectomy can be performed safely and effectively by skilled surgeons at a freestanding ASC, even in patients with morbid obesity or large leiomyoma.
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Affiliation(s)
| | - Mamta M Mamik
- Albert Einstein College of Medicine, New York, New York, USA
| | - Paul MacKoul
- The Center for Innovative GYN Care, Rockville, Maryland, USA
| | | | - Leah Haworth
- The Center for Innovative GYN Care, Rockville, Maryland, USA
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Mackoul P, Danilyants N, Sarfoh V, van der Does L, Haworth L, Kazi N. 2111 Case Series: Potential Link between the use of Celecoxib and Postoperative Hemorrhage Following Gynecological Surgery. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Touchan F, Mamik M, Sarfoh V, Mackoul P, Danilyants N, van der Does L, Haworth L. 2948 Prospective, Single-Blinded Pilot Study: Bimanual Pelvic Examination Versus Pelvic Ultrasound Results in Symptomatic Women. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mamik M, Touchan F, Kazi N, Sarfoh V, Haworth L, Van Der Does L, Danilyants N, Mackoul P. Risk factors for coexistent leiomyoma and adenomyosis compared to coexistent leiomyoma and endometriosis in patients with symptomatic leiomyoma requiring myomectomy. Fertil Steril 2019. [DOI: 10.1016/j.fertnstert.2019.07.994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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MacKoul P, Danilyants N, Sarfoh V, van der Does L, Kazi N. A Retrospective Review of Vaginal Cuff Dehiscence: Comparing Absorbable and Nonabsorbable Sutures. J Minim Invasive Gynecol 2019; 27:122-128. [PMID: 30853572 DOI: 10.1016/j.jmig.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To compare the rate of spontaneous and complete vaginal cuff dehiscence (VCD) using absorbable versus nonabsorbable sutures for vaginal cuff closure. DESIGN Retrospective comparative cohort design. SETTING Freestanding ambulatory surgery center in suburban Maryland. PATIENTS Women age >18 years old who underwent hysterectomy for benign conditions between October 2013 and April 2018. INTERVENTION Laparoscopic retroperitoneal hysterectomy was performed by 2 gynecologic surgical specialists. Transvaginal cuff closure was performed using either absorbable Vicryl (polyglactin 910) sutures (n = 881) or nonabsorbable Ethibond (polyester) sutures (n = 574). The nonabsorbable sutures were surgically removed after 90 days. MEASUREMENTS AND MAIN RESULTS No statistically significant differences in age, race, weight, body mass index, parity, uterine weight, or number of comorbidities were noted between the nonabsorbable and absorbable suture groups. Spontaneous vaginal cuff dehiscence (VCD) occurred in 3 patients (0.52%) in the nonabsorbable group and in 12 patients (1.4%) in the absorbable group (p = .183). Eleven of the 12 cases of VCD in the absorbable group were precipitated by intercourse and occurred within 90 days of surgery. CONCLUSION Our data suggest that use of a nonabsorbable suture may be an effective approach to prevent spontaneous VCD, but the benefits should be weighed against the inherent risk associated with a second procedure to remove sutures.
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Mackoul P, Danilyants N, van der Does L, Haworth L, Kazi N. 70: Laparoscopic-assisted myomectomy with reversible uterine artery occlusion: outcomes from a series of 404 cases. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2019.01.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mackoul P, Danilyants N, van der Does L, Haworth L, Kazi N. 67: Laparoscopic-assisted myomectomy with uterine artery ligation at the origin: outcomes from a series of 184 cases. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2019.01.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Danilyants N, MacKoul P, Baxi R, van der Does LQ, Haworth LR. Value-based assessment of hysterectomy approaches. J Obstet Gynaecol Res 2019; 45:389-398. [PMID: 30402927 PMCID: PMC6587959 DOI: 10.1111/jog.13853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 10/08/2018] [Indexed: 11/30/2022]
Abstract
AIM By evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin. METHODS Retrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high-volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH. RESULTS Total vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic-assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest. CONCLUSION Understanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality-cost framework, the LRH approach as performed by high-volume laparoscopic specialists emerged as having the highest calculated value.
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Affiliation(s)
| | - Paul MacKoul
- The Center for Innovative GYN CareRockvilleMarylandUSA
| | - Rupen Baxi
- The Center for Innovative GYN CareRockvilleMarylandUSA
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Abstract
BACKGROUND AND OBJECTIVE Compare operative outcomes of laparoscopic hysterectomy in an outpatient hospital setting versus freestanding ambulatory surgery center. METHODS Retrospective cohort study of two groups in an outpatient hospital surgery department and freestanding ambulatory surgical center, both serving the Washington, DC area. Women, 18 years or older, who underwent laparoscopic hysterectomy for benign conditions in an outpatient hospital setting between 2011 and 2014 (n = 821), and at an ambulatory surgery center between 2013 and 2017 (n = 1210). Laparoscopic hysterectomy with retroperitoneal dissection and early ligation of the uterine arteries at the origin, performed by gynecologic surgical specialists from a single practice. Patient characteristics, medical history, uterine weight, pathology, operating times, estimated blood loss, and complications were analyzed. RESULTS The mean uterine size between settings was not significantly different (Ambulatory Surgery Center, 349.4 g; Hospital, 329.7 g). The largest uteri removed at the surgery center was 3500 g; at the hospital it was 2489 g. The surgery center had a shorter average operating time than the hospital (53.7 and 61.3 minutes, respectively; P < .001). Intraoperative and postoperative complication rates were not significantly different between settings (2.7% and 3.7%, surgery center; 2.1% and 4.8%, hospital). There were two hospital transfers from the surgery center: 1 for blood transfusion, and 1 for low oxygen saturation. Same-day discharge occurred in 99.8% of surgery center patients versus 88% hospital patients. CONCLUSIONS Laparoscopic hysterectomy can be performed safely and effectively by skilled surgeons at a freestanding ambulatory surgery center, even in complex cases with large uteri.
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Affiliation(s)
- Paul MacKoul
- The Center for Innovative GYN Care, Rockville, MD 20852, USA
| | | | - Rupen Baxi
- The Center for Innovative GYN Care, Rockville, MD 20852, USA
| | | | - Leah Haworth
- The Center for Innovative GYN Care, Rockville, MD 20852, USA
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Baxi R, MacKoul P, Danilyants N, van der Does L, Haworth L, Kazi L, Kazi N. Laparoscopic-Assisted Myomectomy with Reversible Uterine Artery Occlusion: Outcomes from a Series of 404 Cases. J Minim Invasive Gynecol 2018. [DOI: 10.1016/j.jmig.2018.09.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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MacKoul P, Baxi R, Danilyants N, van der Does LQ, Haworth LR, Kazi N. Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation. J Minim Invasive Gynecol 2018; 26:856-864. [PMID: 30170179 DOI: 10.1016/j.jmig.2018.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 07/31/2018] [Accepted: 08/23/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE Conventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal myomectomy (AM) is associated with increased complications and morbidity. Here we evaluated the surgical outcomes of these myomectomy techniques compared with those of laparoscopic-assisted myomectomy (LAM), a hybrid approach that combines laparoscopy and minilaparotomy with bilateral uterine artery occlusion or ligation to control blood loss. DESIGN Retrospective chart review (Canadian Task Force classification II-1). SETTING Suburban community hospital. PATIENTS Women age ≥18 years with nonmalignant indications. INTERVENTION A total of 1313 consecutive CLMs, RAMs, AMs, and LAMs performed between January 2011 and December 2013. MEASUREMENTS AND MAIN RESULTS Our review included 163 CLMs (12%), 156 RAMs (12%), 686 AMs (52%), and 308 LAMs (23%). Although the average number, size, and total weight of leiomyomas removed were comparable in the LAM and AM groups (9.1, 8.13 cm, and 391 g, respectively, vs 9.0, 7.5 cm, and 424 g; p < .0001), the number and weight of myomas were significantly greater in those 2 groups compared with the CLM and RAM groups (2.9 and 217 g, respectively, and 2.9 and 269 g; p < .0001). The intraoperative complication rate was highest in the RAM group, and the postoperative complication rate was highest in the AM group, both of which were approximately 3 times greater than the rates in the LAM group. There was no statistically significant difference in postoperative complication rates between the CLM and LAM groups. CONCLUSION LAM with uterine artery occlusion/ligation is a viable approach for removing large tumor loads while minimizing blood loss and precluding the need for power morcellation.
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Affiliation(s)
- Paul MacKoul
- Center for Innovative GYN Care, Rockville, Maryland (all authors)
| | - Rupen Baxi
- Center for Innovative GYN Care, Rockville, Maryland (all authors)
| | | | | | - Leah R Haworth
- Center for Innovative GYN Care, Rockville, Maryland (all authors)
| | - Nilofar Kazi
- Center for Innovative GYN Care, Rockville, Maryland (all authors)
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Baxi R, MacKoul P, Danilyants N, van der Does L, Haworth L. Can Conversion to Laparotomy Be Prevented During Laparoscopic Hysterectomy? J Minim Invasive Gynecol 2017. [DOI: 10.1016/j.jmig.2017.08.427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Baxi R, Danilyants N, MacKoul P, van der Does L, Haworth L. Vaginal Cuff Dehiscence after Laparoscopic Assisted Vaginal Hysterectomy: Comparing Absorbable to Nonabsorbable Sutures. J Minim Invasive Gynecol 2017. [DOI: 10.1016/j.jmig.2017.08.485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Danilyants N, MacKoul P, Baxi R, van der Does L, Haworth L. Comparison of Clinical Outcomes of Laparoscopic Hysterectomy in an Ambulatory Surgery Center Versus Outpatient Hospital Setting. J Minim Invasive Gynecol 2017. [DOI: 10.1016/j.jmig.2017.08.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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