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OBJECTIVE To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P

Objective: The aim of this research was to review preoperative and intraoperative findings in patients with rectus muscle endometriosis (RME) and to describe the current authors' novel technique of...

Abdominal wall endometriosis (AWE) is a rare type of endometriosis defined as endometrial glands and stroma located within the abdominal wall. Patients with a history of prior abdominal surgery classically present with cyclic abdominal pain and a palpable mass. Definitive diagnosis is made by pathologic tissue examination, but preoperative imaging with ultrasonography or MRI helps narrow the differential and informs surgical management. Surgical management is traditionally via an open approach; however, laparoscopic removal of AWE is recommended for subfascial or rectus lesions. Following surgical excision, more than 90% of patients experience complete symptom relief.

Objective To demonstrate a laparoscopic approach to managing a colo-ovarian fistula. Design Narrated video outlining surgical technique. Setting Colo-ovarian fistulas are a rare entity with a lack of systematized evidence to guide surgical treatment.1-3 Available case reports describe open en-bloc resection of the colon and adnexal organs with colorectal anastomosis.3 We present a case of a colo-ovarian fistula managed laparoscopically with discoid resection of the fistulous tract, a technique used for rectosigmoid endometriosis.4 Intervention A 51-year-old G0 presented with fevers, leukocytosis, and CT imaging showing a peripherally-enhancing adnexal complex highly suspicious for tubo-ovarian abscess that was refractory to antibiotics and interventional-radiology guided drainage. The patient elected for definitive surgery with hysterectomy, bilateral salpingo-oophorectomy, and indicated procedures. Preoperatively, there was no evidence of gastrointestinal tract involvement but intraoperatively, a colo-ovarian fistula was discovered. General surgery was consulted for en-bloc resection, but given the small size of the fistula and absence of acute inflammation, a discoid resection was deemed a possible alternative. This video highlights: 1. Lysis of adhesions to restore normal anatomy 2. Identification of avascular spaces to secure uterine arteries at the origin 3. Excision of the fistula with an advanced bipolar device enabling surgeon control of energy dispersed prior to cutting 4. Two-layer closure reapproximating bowel with bubble-test to ensure airtight repair Postoperatively, there were no complications. The final pathology confirmed tubo-ovarian abscess, endometriosis, and a fistulous tract. Conclusion Colo-ovarian fistulas are rare with little to guide surgical treatment. This video demonstrates a laparoscopic alternative to open en-bloc resection of the colon and adnexa.

The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8 mmHg. Continuous variables were compared using analysis of variance and χ

Fibroid tissue extraction during hysterectomy and myomectomy has become increasingly controversial. A wave of research has tried to clarify difficult questions around the prevalence of occult malignancies, the effect of morcellation on cancer outcomes, proper informed consent, and surgical options for tissue extraction. This review examines the history of these controversies and discusses tissue extraction techniques and continued areas of debate in the field.

Study Objective To determine whether two-layer laparoscopic vaginal cuff closure during laparoscopic hysterectomies is associated with lower postoperative complications compared to standard one-layer closure. Design Retrospective cohort study. Setting Academic tertiary care center. Patients or Participants 2,973 patients. Interventions During a 6-year period, 1760 (59.2%) and 1213 (40.8%) patients underwent single (1-LVC) vs. two-layer (2-LVC) laparoscopic vaginal cuff closure, respectively. Factors influencing laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, immunosuppressant medications, and sexual activity were recorded. We compared total postoperative complications including visceral injury, blood transfusion, hematoma, thromboembolism, infection, and cuff complications. The latter were further examined for cuff dehiscence, mucosal separation, hematoma, cellulitis/abscess, granulation tissue and persistent vaginal bleeding. Statistical analyses included Chi-square and Wilcoxon rank sum testing. Measurements and Main Results 2-LVC closure was associated with decreased total postoperative complications (2-LVC: 3.38% vs. 1-LVC: 5.57%; p=0.006) without impacting intraoperative complications (1.40% vs. 1.25%; p=0.721) or emergency room/hospital readmissions (11.05% vs. 12.67%; p=0.181). 2.44% of 1-LVC patients experienced postoperative cuff complications compared to only 0.74% women in the 2-LVC group (p=0.002). No subjects in the 2-LVC cohort experienced a vaginal cuff dehiscence or mucosal separation compare to 0.63% and 0.23% of patients in the 1-LVC group, respectively. Granulation tissue (1-LVC: 0.40% vs. 2-LVC: 0.16%), persistent vaginal bleeding (0.57% vs. 0.16%), and cuff cellulitis (0.51% vs. 0.33%) were also more common in the 1-LVC cohort. Univariate analysis of total postoperative cuff complications revealed that a 2-LVC closure was protective of postoperative complications (OR=0.37, 95% CI: 0.188-0.712). Conclusion Although postoperative problems linked to laparoscopic hysterectomies are already exceptionally low, the added use of a 2-LVC closure further lowers postoperative total and vaginal cuff complications.

Study Objective This objective of this video is to describe several tips and tricks to help familiarize residents with the Fundamentals of Laparoscopic Surgery (FLS) tasks and to improve their technical skills and efficiency. In part 1 of this 2-part series, we provide specific strategies for the peg board, circle cut, and ligating loop tasks. Design Educational instructional video. Setting N/A Patients or Participants N/A Interventions FLS uses five simulation stations to assess basic laparoscopic surgery skills. It is a reliable and valid curriculum which has been shown to improve intraoperative trainee performance. It was developed in 2004, and since 2009 has been a requirement to qualify for the American Board of Surgery board certification. In 2018, the American Board of Obstetrics and Gynecology (ABOG) announced that FLS will be a prerequisite for specialty board certification for obstetrics and gynecology residents graduating after May 2020. ABOG states that this will “ensure that diplomates possess critical skills for the contemporary practice of obstetrics and gynecology.” Measurements and Main Results N/A Conclusion FLS is now a requirement for all OB/GYN residencies. Mastering the skills requires time and effort on the part of the learners but using these pro tips can help gain confidence and improve efficiency.

Study Objective To examine Fundamentals of Laparoscopic Surgery® (FLS) scores and career choices in obstetrics and gynecology residents. Design Retrospective cohort study. Setting Academic obstetrics and gynecology residency program. Patients or Participants Residents in obstetrics and gynecology who took the FLS exam prior to graduation. Interventions N/A Measurements and Main Results Between 2010 – 2020, 94 residents completed the FLS examination, 77.7% in their third year and 22.3% in their fourth year. 92 (97.9%) passed the skills examination and 88 (96.3%) passed the written examination on their first attempt. 75% (6/8) of failures occurred during the first 2 years the test was administered at the program. Mean skills scores did not differ between residents matching into a gynecologic surgery fellowship (gynecologic oncology, urogynecology, minimally invasive gynecologic surgery) and those not matching into a surgical fellowship (543.85 vs 514.13; p=0.095). Median written scores also did not differ between these groups (580 vs 560; p=0.121). Residents who matched into a surgical fellowship were not more likely to pass the written or skills exam compared to those not pursuing these careers. Third year residents scored higher than fourth year residents on the written exam (p=0.002) however there were no significant differences in manual skills scores between the two years (p = 0.276). Resident year did not impact test failure for either the written or skills portion of the FLS exam. Conclusion Obstetrics and gynecology residents matching into a gynecologic surgery fellowship did not perform better than their peers on the written or skills portion of the FLS exam.

This article was migrated. The article was not marked as recommended. Background Competency in surgical scrubbing, gowning and gloving (scrubbing-in) procedures is necessary to participate in surgery, but difficult for trainees to learn due to the fast pace of the operating room and limited availability of experts to provide training. Current methods of scrubbing-in procedures are antiquated. Simulation-based education aligns with the paradigm shift occurring in medical education as we transition from passive models. This study utilized the Delphi technique to identify necessary items to include in a scrubbing-in checklist that can be used in future simulation and assessment tools.MethodsSurgeon experts participated in three rounds of a Delphi process. The panel consisted of surgical specialty residents, fellows and attending surgeons from gynecology, urology, general surgery, plastic, orthopedic and neurosurgery.ResultsFrom January 2018 to September 2018, 39 experts from 6 different surgical subspecialties participated in three Delphi survey rounds. Of the 43 items identified during the first round, 30 (70%) resulted with an importance rating > 4.0. During the final round, a consensus of > 85% was reached for 22 total items (73%).ConclusionWe developed a 22-step checklist for scrubbing-in procedures utilizing the Delphi technique. This checklist will enhance undergraduate medical education simulation curriculums and assessments.

Study Objective To determine if patients with gynecologic pain are more likely than patients without gynecologic pain to use social media to learn about or manage their condition. Design Comparative prospective patient survey. Setting Six hospital systems across country, university-based and community-based. Patients or Participants 497 patients who presented to an FMIGS-affiliated clinic and consented to participate in the survey. Interventions Subjects self-determined if their gynecologic visit was related to pain. Those with pain were in the Study group. Those without pain were in the Control group. Subjects independently completed a survey regarding their internet and social media use in relation to their gynecologic care. The minimum number of subjects needed to detect a 10% difference in the primary outcome was 471 subjects. Fisher's exact test was used to test for significance at a power of 80% and an alpha of .05. Measurements and Main Results 497 subjects enrolled in the study. 459 of 497 (92.4%) of enrolled subjects completed the study survey, 321 (69.6%) with pain (Study group) and 138 (30.1%) without pain (Control group). The median age of participants was 39 years (IQR 29-55) in the Pain group and 42 years (IQR 31-54) in the Control group. 119/321 (37.1%) subjects in the Pain group and 27/138 (19.6%) of subjects in the Control group reported using social media to learn about or manage their gynecologic condition; this difference was statistically significant (p Conclusion Patients with gynecologic pain were more likely than those without pain to use social media to learn about or manage their condition.

Conventional taste-masking strategies are used to overcome the bitter taste perception of pharmaceuticals by coating the drug particles and/or adding flavoring agents. However, for certain product categories such as rapid dissolve sublingual tablets, taste-masking is challenging. Programs exploring such formulation strategies in the LO-CS phase or post CS phase possess very little toxicological information available in order to conduct human taste panel studies. The potential of a bitter taste perception can present a significant business risk. The objective of the study was to validate a rat behavioral avoidance model that identifies bitter-tasting compounds. Most classic bitter substances elicit a response in the micromolar concentration range while most drugs elicit a response in the millimolar range, hence a validation exercise was conducted to examine if the existing biological model was sensitive enough to identify known bitter tasting drugs as such. Five compounds: ergotamine tartrate, fluoxetine, sucrose, sumatriptan and povidone were chosen to represent a spectrum of compounds. The bitter tasting compounds were identified as such in the model. Based on these results, the assay may serve as a useful surrogate test to identify compounds that may have bitter taste issues.