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To analyze hysterectomy trends and vaginal cuff dehiscence (VCD) rates by mode of surgery at a tertiary care medical center and to describe characteristics of VCD cases. Observational retrospective cohort study. Large academic hospital and affiliated community hospital. 4722 patients who underwent hysterectomy at Columbia University Irving Medical Center between January 2010 and August 2021. Current Procedural Terminology and International Classification of Diseases codes identified hysterectomies and VCD cases. Hysterectomy trends and VCD rates were calculated by mode of surgery. Relative risks of VCD for each mode were compared with total abdominal hysterectomy (TAH). Clinical characteristics of VCDs were reviewed. There were 4059 total hysterectomies. Laparoscopic hysterectomies, including total laparoscopic hysterectomies (TLHs), laparoscopic-assisted vaginal hysterectomies, and robot-assisted TLHs (RA-TLHs), increased from 41.9% in 2010 to 65.9% in 2021 (p <.001). RA-TLH increased from 5.7% in 2010 to 40.2% in 2021. Supracervical hysterectomies followed similar trends and were excluded from VCD analysis. There were 15 VCDs (overall rate 0.37%). VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66–9.00) and after TLH was 1.18 (95% confidence interval 0.24–5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8–145 days). The most common trigger event was coitus (41%). VCD rates were low (<1%) for all modes of hysterectomy, and rates after robotic and laparoscopic hysterectomy were much lower than previously reported. Although VCD rates trended higher after robotic and laparoscopic hysterectomy compared with abdominal hysterectomy, the difference was not significant. It is difficult to determine whether this finding represents true lack of difference vs a lack of power to detect a significant difference given the rarity of VCD. [ABSTRACT FROM AUTHOR]

Study Objective: To gather validity evidence for and determine acceptability of Surgical Science-Simbionix Hysterectomy Modules for the DaVinci Xi console simulation system (software; 3D Systems by Simbionix [now Surgical Science-Simbionix], Littleton, CO, and hardware; Intuitive Surgical, Inc., Sunnyvale, CA) and evaluate performance benchmarks between novice and experienced or expert surgeons.Design: Prospective education study (Messick validity framework).Setting: Multicenter, academic medical institutions.Participants: Residents, fellows, and faculty in obstetrics and gynecology were invited to participate at 3 institutions. Participants were categorized by experience level: fewer than 10 hysterectomies (novice), 10 to 50 hysterectomies (experienced), and more than 50 hysterectomies (expert). A total of 10 novice, 10 experienced, and 14 expert surgeons were included.Interventions: Participants completed 4 simulator modules (ureter identification, bladder flap development, colpotomy, complete hysterectomy) and a qualitative survey. Simulator recordings were reviewed in duplicate by educators in minimally invasive gynecologic surgery using the Modified Global Evaluative Assessment of Robotic Skills (GEARS) rating scale.Measurements and Main Results: Most participants felt that the simulator realistically simulated robotic hysterectomy (64.7%) and that feedback provided by the simulator was as or more helpful than feedback from previous simulators (88.2%) but less helpful than feedback provided in the operating room (73.5%). Participants felt that this simulator would be helpful for teaching junior residents. Simulator-generated metrics correlated with GEARS performance for the bladder flap and ureter identification modules in multiple domains including total movements and total time for completion. GEARS performance for the bladder flap module correlated with experience level (novice vs experienced/expert) in the domains of interest and total score but did not consistently correlate for the other procedural modules. Performance benchmarks were evaluated for the bladder flap module for each GEARS domain and total score.Conclusion: The modules were well received by participants of all experience levels. Individual simulation modules appear to better discriminate between novice and experienced/expert users than overall simulator performance. Based on these data and participant feedback, the use of individual modules in early residency education may be helpful for providing feedback and may ultimately serve as 1 component of determining readiness to perform robotic hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: To compare the surgical outcomes and costs of robotic-assisted hysterectomy with the single-site (RSSH) or multiport approach (RH).Design: A retrospective analysis of a prospectively collected database (Canadian Task Force classification II1).Setting: A university hospital.Patients: Consecutive women who underwent robotic-assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for the treatment of benign gynecologic diseases.Interventions: Data on surgical approach, surgical outcomes, and costs were collected in a prospective database and retrospectively analyzed.Measurements and Main Results: The total operative time, console time, docking time, estimated blood loss, conversion rate, and surgical complications rate were compared between the 2 study groups. Cost analysis was performed. One hundred four patients underwent total robotic-assisted hysterectomy and bilateral salpingo-oophorectomy (45 RSSH and 59 RH). There was no significant difference in the indications for surgery and in the characteristics of the patients between the 2 study groups. There was no significant difference between the single-site and multiport approach in console time, surgical complication rate, conversion rate, and postoperative pain. The docking time was lower in the RH group (p = .0001). The estimated blood loss and length of hospitalization were lower in the RSSH group (p = .0008 and p = .009, respectively). The cost analysis showed significant differences in favor of RSSH.Conclusion: RSSH should be preferred to RH when hysterectomy is performed for benign disease because it could be at least as equally effective and safe with a potential cost reduction. However, because of the high cost and absence of clear advantages, the robotic approach should be considered only for selected patients. [ABSTRACT FROM AUTHOR]

Study Objective: The aim of this study was to evaluate the surgical and oncologic outcomes of robotic hysterectomy with or without or less pelvic and aortic lymphadenectomy in severely obese patients (body mass index [BMI] ≥ 40 kg/m(2)) with endometrial cancer.Material and Methods: Between August 2010 and November 2014, patients with histologically confirmed endometrial cancer and BMI ≥40 kg/m(2) were deemed eligible for the study and underwent RH with or without pelvic and aortic lymphadenectomy.Results: Seventy patients were divided into 3 groups according to their BMI: group A, BMI between 40 and 45 kg/m(2) (50 patients); group B, BMI between 45 and 50 kg/m(2) (10 patients); and group C, BMI above 50 kg/m(2) (10 patients). No significant statistical differences were found between the 3 groups in terms of operation time, blood loss, hospital stay, and oncologic results. Pelvic lymphadenectomy was performed in 42%, 30%, and 20% of patients in groups A, B, and C, respectively. An intraoperative complication occurred in 1 patient in group A, early postoperative complications in 4 patients in group A and in 1 patient in group C, and a late postoperative complication occurred in 1 patient in group A. No conversions to laparotomy were necessary; however, 3 patients underwent conversions to laparoscopy in group A and 1 patient in both groups B and C.Conclusion: Our study showed that robotic surgery in severely obese patients with endometrial cancer is safe and feasible. Moreover, it seems that an increase in BMI does not change the surgical and oncologic outcomes. However, randomized controlled trials are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Study Objective To compare the change from pre- to postoperative total vaginal length (TVL) in women who underwent either a total vaginal hysterectomy (TVH) with uterosacral ligament suspension (USLS) or a robotic hysterectomy (RH) with colpopexy (SCP). Secondary objectives included comparing sexual function, pelvic floor function, and prolapse recurrence between routes of surgery. Design This was a retrospective cohort study (Canadian Task Force classification II-2). Setting This was conducted at 1 tertiary academic medical center over a 2-year period. Patients Women who underwent either TVH/USLS or RH/SCP. Interventions Baseline and postoperative POP-Q Pelvic Organ Prolapse Quantification exams were recorded as well as postoperative validated questionnaires. Twenty-nine subjects were needed in each group to detect a 1.5-cm difference in TVL. Measurements and Main Results There were 38 TVH/USLS and 46 RH/SCP participants. RHs were either total (28/46 [61%]) or supracervical (18/46 [39%]). The mean postoperative follow-up was 9.5 ± 3.1 months. For the primary outcome, women in the TVH/USLS group had a decrease in TVL, whereas women in the RH/SCP group had an increase in TVL (−0.6 ± 1.0 cm vs 0.5 ± 0.8 cm, p < .001). Among sexually active women (55/84, 65.5%), there was no difference in postoperative sexual function between groups based on Pelvic Organ Prolapse/Urinary incontinence Sexual Function Questionnaire short form scores, with good sexual function in both groups (32.6 ± 6.2 TVH/USLS vs 35.1 ± 7.3 RH/SCP, p = .22). Although both groups showed good postoperative apical support, the TVH/USLS group had a slightly lower mean C point compared with the RH/SCP group (−6.8 ± 1.2 vs −7.7 ± 1.8, p = .02). Both groups showed good postoperative pelvic floor function, with no difference in mean postoperative Pelvic Organ Prolapse Distress Inventory scores (42.2 ± 45.4 vs 52.7 ± 46.6, p = .44). Recurrent prolapse (defined as any prolapse at or beyond the hymen) was not different between groups (13.2% for TVH/USLS vs 6.5% for RH/SCP, p = .46). Conclusion Vaginal length decreased after vaginal hysterectomy with pelvic support surgery compared with RH with pelvic support surgery, with no differences in postoperative sexual function or pelvic floor function between groups. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: To estimate whether a new surgical technique is associated with lower incidence of postoperative breakdown of the vaginal cuff after laparoscopic hysterectomy or trachelectomy, compared with previous methods of closure. Design: Retrospective cohort study, Canadian Task Force Classification II-3. Setting: Tertiary-care university-based teaching hospital. Patients: Patients who underwent laparoscopic vaginal closure after removal of the uterus and/or cervix by members of a subspecialty gynecologic laparoscopy division from January 2007 to January 2010 (n = 387). Interventions: Use of bidirectional barbed suture for laparoscopic vaginal cuff closure. Measurements and Main Results: A total of 387 patient records were reviewed. The incidence of vaginal cuff dehiscence among those with other methods of closure was 4.2%, while there were no cases of dehiscence among those who had closure with bidirectional barbed suture (p = .008). Postoperative bleeding (OR 2.3, 95% C.I. 1.3–3.9), presence of granulation tissue (OR 1.9, 95% C.I. 0.92–3.9), and cellulitis (OR 4.6, 95% C.I. 1.0–21.1) all occurred more frequently in patients without barbed suture closure. Conclusion: Dehiscence of the vaginal cuff after laparoscopic closure is a rare but important complication in gynecologic surgery. Use of bidirectional barbed suture eliminated the problem in our first year of experience with the technique. We also observed a decreased incidence of other common problems of the vaginal cuff. This method is easy to learn and inexpensive and does not require advanced skills such as laparoscopic knot-tying. [Copyright &y& Elsevier]

Abstract: Until the late 1930s, the standard type of abdominal hysterectomy was subtotal, leaving the cervix behind to decrease the risk of peritonitis with its attendant high mortality. With the discovery of antibiotics, careful attention to antisepsis, and other medical and surgical advances, this method was gradually replaced by total abdominal hysterectomy in the United States and the United Kingdom, although the subtotal approach still remained popular, in particular in Scandinavian countries. With the advent of laparoscopic hysterectomy, many surgeons, wanting a simpler approach and for a variety of other reasons, have returned to performance of subtotal hysterectomy. The objectives of the present article is to review the development of the operation from a historical perspective, and to attempt to answer some of the dilemmas posed when choosing between a total and subtotal procedure, using results from evidence-based research when possible. [Copyright &y& Elsevier]

Study Objective: Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m2 undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP.Design: A retrospective cohort study.Setting: An academic teaching hospital.Patients: A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m2) undergoing robotic hysterectomy.Interventions: The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls.Measurements and Main Results: Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room).Conclusion: The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates. [ABSTRACT FROM AUTHOR]