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Objective: To assess whether a superior hypogastric plexus block performed during laparoscopic hysterectomy reduces postoperative pain., Methods: We conducted a multicenter, randomized, single-blind, controlled trial of superior hypogastric plexus block at the start of laparoscopic hysterectomy. Women undergoing a laparoscopic hysterectomy for any indication and with any other concomitant laparoscopic procedure were eligible. Standardized preoperative medications and incisional analgesia were provided to all patients. Our primary outcome was the proportion of patients with a mean visual analog scale (VAS) pain score lower than 4 within 2 hours postoperatively. Patients but not surgeons were blinded to the treatment group. Twenty-nine patients per group was estimated to be sufficient to detect a 38% absolute difference in the proportion of patients with a VAS score lower than 4 at 2 hours postoperatively, with 80% power and an α of 0.05. To account for loss to follow-up and potential imbalances in patient characteristics, we planned to enroll 50 patients per group. All analyses were intention to treat., Results: Between January 2018 and February 2019, 186 patients were eligible; 100 were randomized and analyzed. Demographic and clinical characteristics were similar between the two groups. There was no significant difference in the proportion of patients with a mean VAS score lower than 4 within 2 hours postoperatively between patients who received a superior hypogastric plexus block (57%) and patients who did not (43%) (odds ratio 1.63, 95% CI 0.74-3.59; adjusted odds ratio 1.84, 95% CI 0.75-4.51)., Conclusion: Among patients undergoing laparoscopic hysterectomy with standardized enhanced perioperative recovery pathways, superior hypogastric plexus block did not significantly reduce postoperative pain., Clinical Trial Registration: ClinicalTrials.gov, NCT03283436., Competing Interests: Financial Disclosure Michelle Louie disclosed receiving funds from Hologic. Gaby Moawad reports receiving funds from Intuitive Surgical outside the submitted work. Sarah Cohen was an Advisory Board Member for Myovant (2020) and Boston Scientific (2018). Erin Carey reports money was paid to her institution for expert testimony and money was paid to her from Med IQ and Teleflex Surgical. The other authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Although uterine size has been a previously cited barrier to minimally invasive hysterectomy, experienced gynecologic surgeons have been able to demonstrate that laparoscopic and vaginal hysterectomy is feasible with increasingly large uteri. By demonstrating that minimally invasive hysterectomy continues to have superior outcomes even with increased uterine weights, opportunity exists to meaningfully decrease morbidity, mortality, and cost associated with abdominal hysterectomy., Objective: We sought to determine if there is an association between uterine weight and posthysterectomy complications and if differences in that association exist across vaginal, laparoscopic, and abdominal approaches., Study Design: We conducted a cohort study of prospectively collected quality improvement data from the American College of Surgeons National Surgical Quality Improvement Program database, composed of patient information and 30-day postoperative outcomes from >500 hospitals across the United States and targeted data files, which includes additional data on procedure-specific risk factors and outcomes in >100 of those participating hospitals. We analyzed patients undergoing hysterectomy for benign conditions from 2014 through 2015, identified by Current Procedural Terminology code. We excluded patients who had cancer, surgery by a nongynecology specialty, or missing uterine weight. Patients were compared with respect to 30-day postoperative complications and uterine weight, stratified by surgical approach. Bivariable tests and multivariable logistic regression were used for analysis., Results: In all, 27,167 patients were analyzed. After adjusting for potential confounders, including medical and surgical variables, women with 500-g uteri were >30% more likely to have complications compared to women with uteri ≤100 g (adjusted odds ratio, 1.34; 95% confidence interval, 1.17-1.54; P < .0001), women with 750-g uteri were nearly 60% as likely (adjusted odds ratio, 1.58; 95% confidence interval, 1.37-1.82; P < .0001), and women with uteri ≥1000 g were >80% more likely (adjusted odds ratio, 1.85; 95% confidence interval, 1.55-2.21; P < .0001). The incidence of 30-day postsurgical complications was nearly double in the abdominal hysterectomy group (15%) compared to the laparoscopic group (8%). Additionally, for each stratum of uterine weight, abdominal hysterectomy had significantly higher odds of any complication compared to laparoscopic hysterectomy, even after adjusting for potential demographic, medical, and surgical confounders. For uteri <250 g, abdominal hysterectomy had twice the odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.80-2.33), and among women with uteri between 250-500 g, abdominal hysterectomy was associated with an almost 80% increase in odds of any complication (adjusted odds ratio, 1.76; 95% confidence interval, 1.41-2.19). Even among women with uteri >500 g, abdominal hysterectomy was still associated with a >30% increased odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 1.35; 95% confidence interval, 1.07-1.71)., Conclusion: We found that while uterine weight was an independent risk factor for posthysterectomy complications, abdominal hysterectomy had higher odds of any complication, compared to laparoscopic hysterectomy, even for markedly enlarged uteri. Our study suggests that uterine weight alone is not an appropriate indication for abdominal hysterectomy. We also identified that it is safe to perform larger hysterectomies laparoscopically. Patients may benefit from referral to experienced surgeons who are able to offer laparoscopic hysterectomy even for markedly enlarged uteri., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills., Recent Findings: Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes., Summary: Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeon's career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.

Objective: To determine the clinical utility of hemoglobin level testing in guiding postoperative care following total laparoscopic hysterectomies performed for benign indications., Study Design: Retrospective cohort study., Results: A total of 629 women underwent total laparoscopic hysterectomies during the 24 month study period. Only 16 (2.5%) developed symptoms and/or signs suggestive of hemodynamic compromise. When compared to asymptomatic patients, symptomatic patients had a larger decrease in postoperative hemoglobin level (2.66 vs 1.80g/dL, P = .007) and were more likely to undergo blood transfusion, pelvic imaging or reoperation (P < .001). Women with a smaller body mass index and/or higher intraoperative intravenous fluid volume were more likely to have a larger decrease in postoperative hemoglobin level (P < .05). Past surgical history, duration and complexity of the hysterectomy, estimated surgical blood loss, uterine weight, and perioperative use of intravenous ketorolac were not associated with a greater decrease in postoperative hemoglobin (P > .05). Using the University of Pittsburgh Medical Center's annual laparoscopic hysterectomy rate and insurance companies' reimbursement for blood hemoglobin testing, we estimated the national annual cost for hemoglobin testing following total laparoscopic hysterectomy to be $2,804,662., Conclusion: Hemoglobin level testing has little clinical benefit following elective total laparoscopic hysterectomy and should be reserved for patients who develop signs or symptoms suggestive of acute anemia. Heath care cost savings can be substantial if this test is no longer routinely requested following total laparoscopic hysterectomies., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: This research was conducted to investigate the effect of morcellation method and site on perioperative outcomes in patients with class 3 obesity (body mass indices [BMI] ≥40). Materials and Methods: This was a retrospective cohort study of 159 patients with BMI ≥40 who underwent laparoscopic hysterectomy requiring morcellation from January 2006 to October 2019 at an academic tertiary care center. Morcellation method (manual or electromechanical) and morcellation site (vaginal or abdominal) were analyzed. The primary outcome was 30-day perioperative complications. Results: Thirty-three (21%) patients underwent electromechanical morcellation while 126 (79%) underwent manual morcellation. Of manual morcellation cases, 46 (37%) underwent vaginal morcellation, while 80 (63%) underwent abdominal morcellation. There were no significant differences in age, BMI, parity, prior surgery, or medical comorbidities among the groups. Median specimen weight was larger for patients with abdominal versus vaginal morcellation (808 g versus 455 g; p < 0.01), without a difference in operative time (274 versus 246 minutes; p = 0.06). There were no differences in the incidence of perioperative complications between electromechanical versus manual (36.4% versus 31.8%; p = 0.61) and vaginal versus abdominal (37.0% versus 28.8%; p = 0.34) morcellation. After controlling for potential confounders, there was no difference in complications between electromechanical versus manual (adjusted odds ratio [aOR]: 2.28; 95% confidence interval [CI]: 0.76–6.84) and vaginal versus abdominal (aOR: 1.72; 95% CI: 0.72–4.13) morcellation. Conclusions: In women with BMI ≥40, abdominal morcellation was associated with significantly larger specimen sizes, compared to vaginal morcellation, without an increase in perioperative complications or operative time. Manual and electromechanical morcellation had similar perioperative complication frequencies. (J GYNECOL SURG 37:491) [ABSTRACT FROM AUTHOR]

Study Objective: To compare intraoperative and 30-day posthysterectomy outcomes between patients who had bariatric surgery before hysterectomy and patients with a body mass index (BMI) >40 kg/m2 without a history of bariatric surgery.Design: A retrospective cohort study.Setting: A tertiary-care, academic medical center.Patients: Patients with a history of bariatric surgery and patients with BMI >40 kg/m2 and no previous bariatric surgery who underwent any route of hysterectomy between January 1, 2000, and March 1, 2018.Interventions: After exclusion of patients with gynecologic malignancy and bariatric surgery reversal, 223 patients with a history of bariatric surgery were matched at a 1:2 ratio by year of hysterectomy to 446 randomly selected patients with a BMI >40 kg/m2 and no bariatric surgery before hysterectomy. Demographics, medical comorbidities, and surgical characteristics were collected by a manual chart review. Chi-square or Fisher's exact tests were used to compare the incidence of intraoperative and 30-day postoperative complications. Polytomous logistic regression was used to estimate the odds of major and minor postoperative complications. Binary logistic regression was used to estimate the odds of any intra- or postoperative complications.Measurements and Main Results: The mean BMI in the bariatric surgery group was 35.2 ± 7.9 kg/m2, compared with 46.3 ± 5.6 kg/m2 in the control group (p <.01). Fewer patients in the bariatric surgery group had obesity-related comorbidities than the group with no previous bariatric surgery (p <.01). There were lower odds of any intraoperative complication in the bariatric surgery group than in the group with no bariatric surgery (adjusted odds ratio, 0.32; 95% confidence interval [CI], 0.13-0.77), after adjusting for relevant confounding factors between groups. However, there was no difference in overall postoperative complications between women who had bariatric surgery and those who did not (adjusted odds ratio, 1.25; 95% CI, 0.82-1.91). When analyzed individually, a higher proportion of patients in the bariatric surgery group had postoperative cuff separation or dehiscence (1.4% [3/223], p = .04) and urinary retention (5.8% [13/223], p <.01). Combining all perioperative complications, we found no significant difference in minor complications, defined as Clavien-Dindo Grade 1 or 2 (adjusted odds ratio, 1.04; 95% CI, 0.68-1.60), major complications, defined as Clavien-Dindo Grade 3 or higher (adjusted odds ratio, 1.25; 95% CI, 0.61-2.54), or combined major and minor perioperative complications (adjusted odds ratio, 0.96; 95% CI, 0.63-1.44) between patients with a history of bariatric surgery and morbidly obese patients with no bariatric surgery before hysterectomy, after adjusting for relevant confounding factors between groups.Conclusion: Compared with women who had a BMI >40 kg/m2, patients with a history of bariatric surgery before hysterectomy had a lower odds of complications during hysterectomy. However, despite lower BMI and fewer obesity-related medical comorbidities, there was no significant difference in posthysterectomy complications and no significant differences in overall major and minor complications. [ABSTRACT FROM AUTHOR]