Costs and charges associated with three alternative techniques of hysterectomy

Decreasing Utilization of Vaginal Hysterectomy in the United States: An Analysis by Candidacy for Vaginal Approach

INTRODUCTION AND HYPOTHESIS

The objective was to assess trends in hysterectomy routes by patients who are likely and unlikely candidates for a vaginal approach.

METHODS

We performed a retrospective cohort study of patients who underwent vaginal, abdominal, or laparoscopic/robotics-assisted laparoscopic hysterectomy between 2017 and 2020 using the National Surgical Quality Improvement Program database. Patients undergoing hysterectomy for a primary diagnosis of benign uterine pathology, dysplasia, abnormal uterine bleeding, or pelvic floor disorders were eligible for inclusion. Patients who were parous, had no history of pelvic or abdominal surgery, and had a uterine weight ≤ 280 g on pathology were considered likely candidates for vaginal hysterectomy based on an algorithm developed to guide the surgical approach. Average annual changes in the proportion of likely vaginal hysterectomy candidates and route of hysterectomy were assessed using logistic regression.

RESULTS

Of the 77,829 patients meeting the inclusion criteria, 13,738 (17.6%) were likely vaginal hysterectomy candidates. Among likely vaginal hysterectomy candidates, the rate of vaginal hysterectomy was 34.5%, whereas among unlikely vaginal hysterectomy candidates, it was 14.1%. The overall vaginal hysterectomy rate decreased -1.2%/year (p < 0.01). This decreasing trend was nearly twice as rapid among likely vaginal hysterectomy candidates (-1.9%/year, p < .01) compared with unlikely vaginal hysterectomy candidates (-1.1%/year, P < 0.01); the difference in trends was statistically significant (p < 0.01).

CONCLUSIONS

The rate of vaginal hysterectomy performed for eligible indications decreased between 2017 and 2020 in a national surgical registry. This negative trend was more pronounced among patients who were likely candidates for vaginal hysterectomy based on favorable parity, surgical history, and uterine weight.

Laparoscopic-Assisted Vaginal Hysterectomy With Dense Bladder Adhesions and Absent Cervix: A Case Report With a Descriptive Video of the Entire Procedure

Hysterectomy is one of the most frequently performed surgical procedures in the United States. Hysterectomy for benign gynecological reasons can be performed through several approaches: abdominal, laparoscopic, laparoscopically assisted vaginal, robotic-assisted, and vaginal natural orifice hysterectomy. The choice of approach is strongly influenced by factors such as previous procedures, safety, and recovery process. Currently, vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH), assisted vaginal hysterectomy, and robotic-assisted vaginal hysterectomy are considered minimally invasive approaches with multiple benefits to the patient such as less trauma, shorter operative time, and shorter postoperative period. However, in patients with pelvic adhesions, adhesions within the abdominal cavity, especially omental adhesions to the abdominal wall, and adhesions between the uterus and the bladder caused by multiple cesarian sections or prior surgery on the cervix, these minimally invasive approaches are problematic. In this report, we describe in detail our approach to LAVH in a patient with severe abdominal adhesions and an absent cervix. We believe that our approach is safe and relatively fast compared to an open abdominal procedure and, therefore, it may help gynecologic surgeons-in-training nationwide.

Perioperative Outcomes for Same- Versus Next-Day Discharge After Benign Vaginal Hysterectomy

IMPORTANCE

While same-day discharge (SDD) after laparoscopic hysterectomy is well supported, studies for vaginal hysterectomy (VH) are lacking.

OBJECTIVE

The aim of the study was to compare 30-day complications for SDD versus next-day discharge (NDD) after benign VH.

STUDY DESIGN

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Vaginal hysterectomy with or without urogynecology procedures was identified by Current Procedural Terminology codes. The primary outcome was 30-day composite complications of SDD versus NDD after VH. Secondary outcomes compared reoperations rates, time to and reasons for reoperation, and complications between the groups. Composite complications included death, major infection or wound complication, thromboembolism, transfusion, cardiopulmonary complication, renal insufficiency/failure, stroke, or reoperation. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analysis.

RESULTS

Of 24,277 people included, 4,073 (16.8%) were SDD, which were more likely to be younger ( P < 0.001), less likely to have hypertension (23.4 vs 18.3%, P < 0.0001) or diabetes (4.5 vs 3.3%, P = 0.001), and had shorter surgical procedures (100.7 ± 47.5 vs 111.2 ±57.5 minutes, P < 0.0001). There was no difference in composite complications after SDD versus NDD and this remained true in multivariate analysis (2.0 vs 2.3%, P = 0.30, SDD; adjusted odds ratio, 0.9; 95% confidence interval, 0.7-1.1). There was no difference in reoperation rates (0.9 vs 0.9%, P = 0.94) or reasons for reoperation. Time to first complication was shorter for SDD versus NDD (11 vs 13 days, P = 0.47).

CONCLUSION

In our cohort of low-risk patients, SDD after VH with or without urogynecology procedures did not have an increased odds of 30-day composite complications.

A randomized control trial comparing vaginal and laparoscopically-assisted vaginal hysterectomy in the absence of uterine prolapse in a South African tertiary institution

OBJECTIVES

The primary objectives of this study were to estimate blood loss, operation time and cost differences in patients undergoing vaginal hysterectomy (VH) versus laparoscopically-assisted vaginal hysterectomy (LAVH). The secondary objectives were to determine differences in hospital stay, need for postoperative analgesia, intra- and immediate post-operative complications, and the rate of conversion to laparotomy. VH was hypothesized to be the preferred route for hysterectomy for benign uterine conditions.

STUDY DESIGN

A randomized control study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital and included the women admitted between January 2017 and December 2019 for hysterectomy due to benign conditions, meeting the inclusion criteria (vaginally accessible uterus, estimated uterine size ≤ 12 weeks of gestation or ≤ 280 g on ultrasound examination and pathology confined to the uterus). Surgical procedures were performed by the residents in training under the supervision of specialists with large experience. The patient demographic characteristics, uterine weight, operative time, estimated blood loss(expressed as the difference between preoperative and postoperative day one serum haemoglobin),direct surgery-associated costs, intra- and immediate post-operative complications and the length of hospital stay were recorded and comparatively analysed among patients randomly placed in VH and LAVH group.

RESULTS

A total of 227 women were included (151 patients underwent VH and 76 LAVH, upon 2:1 randomization, performed on this way to reflect the previous pattern of operating of the unit). The patients were matched with respect to age, parity and body mass index. No significant differences between two groups were found in mean uterine weight and also in mean serum haemoglobin shift, intra- and immediate post-operative complications, and convalescence period duration. There were statistically significant differences in operating time and in cost between the two procedures. On average, LAVH took longer than VH to be performed (62.8 ± 9.3 vs 29.9 ± 6.6 min, p < 0.0001) and it was more costly, mainly due to the longer operating time and required disposables. An amount of 15698.20 South African Rand (ZAR) or 1145.85 United States Dollar (USD) more were needed to perform LAVH in comparison to VH. All VHs and LAVHs were successfully accomplished without major complications or conversation to laparotomy.

CONCLUSION

Our data indicate that VH is a feasible and safe alternative for a large group of women with benign pathology and non-prolapsed uteri, being a faster and less costly procedure than LAVH.

Therapeutic approach of uterine leiomyoma; choosing the most appropriate surgical option

The most common benign pelvic tumor in young women is uterine leiomyoma. It is often asymptomatic, but can cause symptoms such as pelvic-abdominal pain, vaginal bleeding, urinary and intestinal transit disorders. If there is a suspicion of malignancy, it is necessary to perform fractional uterine curettage to establish the histopathological diagnosis.The surgical treatment of uterine leiomyoma includes several procedures: myomectomy, subtotal or total hysterectomy. The procedure will be chosen depending on the patient's particularities: BMI, uterine size, leiomyoma location, surgical history or other associated pathologies.Laparoscopic hysterectomy has a 45-minute shorter duration of intervention than vaginal hysterectomy, and the conversion rate to the open procedure is lower.Laparoscopically treated cases have fewer postoperative complications compared to other surgical procedures and have a shorter hospitalization and recovery time.The recurrence rate of uterine leiomyoma is similar for both laparoscopic and open abdominal approach, and the frequency of long-term complications such as adhesion syndrome or pelvic pain is higher after the latter.

The effect of plantain syrup on heavy menstrual bleeding: A randomized triple blind clinical trial

Given the importance of heavy menstrual bleeding (HMB), we investigated the effect of plantain syrup on HMB. This randomized clinical trial was performed on 68 women with HMB who were referred to the traditional medicine clinics of Mashhad University of Medical Sciences. The intervention group received placebo capsule and plantain syrup, whereas the control group received mefenamic acid capsule and placebo syrup in the first 5 days of menstruation for three menstruation cycles. Patients were asked to complete pictorial blood assessment chart one cycle before the intervention and three intervention cycles. Hemoglobin was measured at the beginning and at the end of the study. The results showed that the bleeding duration and severity diminished in both groups. No significant difference was observed between two groups in severity of bleeding after intervention (Cohen's d = .24), but duration of bleeding in mefenamic acid group was reduced significantly in comparison with plantain group (Cohen's d = .57). Although mean hemoglobin alterations in mefenamic acid group had a significant difference before and after the intervention, there was no significant difference between the two groups in mean hemoglobin alterations postintervention. Plantain syrup could be suggested as a complementary treatment for HMB, but further studies are required.

Feasibility of early discharge following vaginal hysterectomy with a bipolar electrocoagulation device

OBJECTIVE

To evaluate the safety and efficacy of vaginal hysterectomy for benign conditions (excluding prolapse) using the BiClamp (Erbe Elektromedizin, Tübingen, Germany) bipolar electrocoagulation system.

METHODS

The present study was a prospective audit of a consecutive case series of patients who underwent vaginal hysterectomy for benign conditions, performed using the BiClamp between March 1, 2015, and June 30, 2016, at Norfolk and Norwich University Hospital, Norwich, UK. Surgeries performed for benign conditions were eligible, excluding prolapse; severe endometriosis with pelvic adhesions was an exclusion criterion. Patient demographics and past history were recorded, along with intraoperative findings and adverse events. Follow-up data were obtained via telephone interviews 24 hours after surgery and a nurse-led postoperative clinic 8 weeks postoperatively.

RESULTS

The series included 75 patients; 32 (43%) were discharged on the same day as surgery and 70 (93%) within 23 hours. There were two patients who experienced vault hematomas and remained admitted for more than 24 hours. There was one intraoperative bladder injury that was repaired vaginally. No delayed adverse events occurred within 8 weeks. No patient required patient-controlled analgesia or an epidural injection for postoperative analgesia.

CONCLUSION

Patients experienced low postoperative pain following BiClamp treatment and 93% were was discharged within 23 hours.

Perioperative outcomes of robotic hysterectomy with mini-laparotomy versus open hysterectomy for uterus weighing more than 250 g

To compare perioperative outcomes in patients undergoing robotic hysterectomy and extraction of specimen via mini-laparotomy (RHML) versus open hysterectomy (OH) when uterus weighs more than 250 g. To study the factors determining the length of hospital stay in 2 groups. A retrospective analysis of all hysterectomies performed for uterus weighing more than 250 g from the year 2012 to 2015 was conducted. A total of 140 patients were divided into 2 groups based on the type of surgery; RHML (n = 82) and OH (n = 58). Mini-laparotomy consisted of a customised incision connecting 2 left lateral port sites for specimen extraction after completing the hysterectomy robotically. Patient factors and perioperative outcomes were compared using Student's t tests and Chi-square analysis. Mean length of stay (RHML = 1.4 days; OH = 3.4 days), estimated blood loss (EBL) (RHML = 119.9 ml; OH = 547.5 ml) and operative time (RHML = 191.5 min; OH = 162.8 min) were significantly different. No significant differences were noted for patient BMI, age, comorbidities, intraoperative complications, pathology of uterus and uterus weight. Postoperative complications were significantly different between two groups (RHML = 6.0%; OH = 15.5%; p = .021). None of the patients stayed less than 24 h in OH group compared to 59.8% patients in RHML group. Type of procedure (p = .004) and EBL (p = .002) significantly predicted the length of stay. Patients undergoing RHML have significantly shorter length of stay, EBL and postoperative complications than OH. The operative time for RHML was longer than OH, but the overall decreased length of stay overcomes this disadvantage. RHML approach retains the benefits of da Vinci, while simultaneously preserving the specimen.

Vaginal vs. robotic hysterectomy for patients with endometrial cancer: A comparison of outcomes and cost of care

OBJECTIVE

To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND).

METHODS

Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores.

RESULTS

VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3h longer and median 30-day cost $3150 higher for RH compared to VH (both p<0.001). Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12min longer in the VH group for pelvic LND alone (p=0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p=0.08).

CONCLUSION

Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.

Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm

OBJECTIVE

To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy.

METHODS

A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated.

RESULTS

Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years.

CONCLUSION

When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

Non-decent Vaginal Hysterectomy in Rural Setup of MP: A Poor Acceptance

OBJECTIVE

NDVH is a minimally invasive, safe, effective, and economical surgery. Still AH is preferred for benign gynaecological indications. Our study aims to promote NDVH in all technically possible cases by adequate counselling of the patient.

METHODS

This prospective observational study enrolled 100 women seeking hysterectomy for benign gynaecological conditions (excluding prolapse) in a teaching hospital. Women were counselled on the basis of 'PREPARED' questionnaire to assess their awareness about NDVH and were offered NDVH as the proposed surgery and result is analysed.

RESULTS

We observed that there was a little awareness about NDVH and its outcome among the subjects. Ten out of 100 patients refused to perform NDVH after counselling and underwent TAH. Rest of the 90 patients opted for NDVH. Forty out of 90 patients were aware about NDVH, but they were sceptical about the outcome, and 50 were totally unaware. After applying 'PREPARED' questionnaire and counselling, we could motivate them to accept NDVH. It was successful in all cases except one where laparotomy was done for ovarian artery retraction. With no significant post-operative complications, early return to routine activity and low cost of surgery, all patients were satisfied with surgical outcome and improved quality of life.

CONCLUSION

We conclude that patients accept the surgery with open mind after proper counselling and detailing of the procedure. Most of the abdominal hysterectomy can be converted successfully to NDVH in technically feasible cases by experienced hands so adequate training to gynaecology residents is the need of the time. NDVH is economical to the patient as well as for the healthcare system.

Changes in Hysterectomy Trends After the Implementation of a Clinical Pathway

OBJECTIVE

To investigate the effect of hysterectomy pathway implementation on the proportion of total abdominal hysterectomy (TAH) procedures performed between fiscal years 2012 and 2014.

METHODS

We conducted a retrospective medical record review. All hysterectomy surgeries performed for benign indications at University of Pittsburgh Medical Center hospitals from fiscal year 2012 to fiscal year 2014 were identified through various systems including Medipac and EpicCare. We analyzed the cases by surgical approach (TAH compared with minimally invasive hysterectomy), age, and indication of surgery. Changes over time were analyzed using Cochran-Armitage test for linear trends.

RESULTS

A total number of 6,544 patients were included in this study. The mean age of the participants was 48.6 years (standard deviation 11.69). In fiscal year 2012, of 1,934 hysterectomies performed as a result of noncancerous conditions, 538 were TAH procedures (27.8%). However, this number declined in fiscal year 2013 to 22% (485 TAH procedures of 2,186 hysterectomies) and further declined in fiscal year 2014 to 17% (413 TAH surgeries of 2,424 hysterectomies). Overall, there was a significant reduction in the proportion of TAH procedures, from 27.8% in fiscal year 2012 to 17% in fiscal year 2014 (P for trend <.001). After adjusting for surgery indication, the decreasing trend of TAH procedures still persisted (P for trend <.001).

CONCLUSION

Implementation of a hysterectomy pathway has been associated with a decrease in the proportion of TAH hysterectomy procedures.

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic vs laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from study inception to October 9, 2014, using the intersection of the themes "robotic" and "hysterectomy." We included only randomized and quasi-randomized controlled trials of robotic vs laparoscopic hysterectomy in women for benign disease. Four trials met our inclusion criteria and were included in the analyses. We extracted data, and assessed the studies for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RRs) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 complications among 326 patients. Comparing robotic and laparoscopic hysterectomy, revealed no statistically significant differences in the rate of class 1 and 2 complications (RR, 0.66; 95% confidence interval [CI], 0.23-1.89) or in the rate of class 3 and 4 complications (RR, 0.99; 95% CI, 0.22-4.40). Analyses of secondary outcomes were limited owing to heterogeneity, but showed no significant benefit of the robotic technique over the laparoscopic technique in terms of length of hospital stay (weighted mean difference, -0.39 day; 95% CI, -0.92 to 0.14 day), total operating time (weighted mean difference, 9.0 minutes; 95% CI, -31.27 to 47.26 minutes), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were reported inconsistently and were not amenable to pooling. Current evidence demonstrates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.

Acute kidney injury in major gynaecological surgery: an observational study

OBJECTIVE

To assess the prevalence, outcomes and cost associated with acute kidney injury (AKI) defined by consensus risk, injury, failure, loss, and end-stage kidney (RIFLE) criteria after gynaecologic surgery.

DESIGN

Retrospective single-centre cohort study.

SETTING

Academic medical centre.

SAMPLE

Two thousand three hundred and forty-one adult women undergoing major inpatient gynaecologic surgery between January 2000 and November 2010.

METHODS

AKI was defined by RIFLE criteria as an increase in serum creatinine greater than or equal to 50% from the reference creatinine. We used multivariable regression analyses to determine the association between perioperative factors, AKI, mortality and cost.

MAIN OUTCOME MEASURES

AKI, combined major adverse events (hospital mortality, sepsis or mechanical ventilation), 90-day mortality and hospital cost.

RESULTS

Overall prevalence of AKI was 13%. The prevalence of AKI was associated with the primary diagnosis. Of women with benign tumour surgeries, 5% (43/801) experienced AKI compared with 18% (211/1159) of women with malignant disease (P < 0.001). Only 1.3% of the whole cohort had evidence of urologic mechanical injury. In a multivariable logistic regression analysis, AKI patients had nine times the odds of a major adverse event compared to patients without AKI (adjusted odds ratio 8.95, 95% confidence interval 5.27-15.22). We have identified several readily available perioperative factors that can be used to identify patients at high risk for AKI after in-hospital gynaecologic surgery.

CONCLUSIONS

AKI is a common complication after major inpatient gynaecologic surgery associated with an increase in resource utilisation and hospital cost, morbidity and mortality.

Cost differences among robotic, vaginal, and abdominal hysterectomy

OBJECTIVE

To compare the costs of vaginal and abdominal hysterectomy with robotically assisted hysterectomy.

METHODS

We identified all cases of robotically assisted hysterectomy, with or without bilateral salpingo-oophorectomy, treated at the Mayo Clinic (Rochester, Minnesota) from January 1, 2007, through December 31, 2009. Cases were propensity score-matched (one-to-one) to cases of vaginal and abdominal hysterectomy, selected randomly from January 1, 2004, through December 31, 2006 (before acquisition of the robotic surgical system). All billed costs were abstracted through the sixth postoperative week from the Olmsted County Healthcare Expenditure and Utilization Database and compared between cohorts with a generalized linear modeling framework. Predicted costs were estimated with the recycled predictions method. Costs of operative complications also were estimated.

RESULTS

The total number of abdominal hysterectomies collected for comparison was 234 and the total number of vaginal hysterectomies was 212. Predicted mean cost of robotically assisted hysterectomy was $2,253 more than that of vaginal hysterectomy ($13,619 compared with $11,366; P<.001), although costs of complications were not significantly different. The predicted mean costs of robotically assisted compared with abdominal hysterectomy were similar ($14,679 compared with $15,588; P=.35). The costs of complications were not significantly different.

CONCLUSIONS

Overall, vaginal hysterectomy was less costly than robotically assisted hysterectomy. Abdominal hysterectomy and robotically assisted hysterectomy had similar costs.

LEVEL OF EVIDENCE

II.

Hospital costs of total vaginal hysterectomy compared with other minimally invasive hysterectomy

OBJECTIVE

The objective of the study was to determine total hospital costs and net hospital income for different types of minimally invasive hysterectomy and financial impact if a subset of patients underwent total vaginal hysterectomy (TVH) instead of their selected procedure.

STUDY DESIGN

A retrospective chart review was performed of patients who underwent hysterectomy for benign disease by TVH, laparoscopic assisted vaginal hysterectomy (LAVH), total laparoscopic hysterectomy (TLH), and robotic hysterectomy (RH) between Jan. 1, 2007, and April 30, 2010, at Thomas Jefferson University Hospital. The hospital decision support database was used to calculate net hospital income. A subset of patients with at least 1 prior vaginal delivery, no more than 1 laparotomy, and a uterine size less than 14 weeks who had undergone RH, TLH, or LAVH was identified as potential TVH candidates. The financial impact of performing TVH over the selected hysterectomy was calculated.

RESULTS

Three hundred thirty-four cases of minimally invasive hysterectomy were identified. Fifty-five percent were TVH, 33% LAVH, 3% TLH, and 9% RH. Mean total hospital costs for TVH were $7903, $10,069 for LAVH, $11,558 for TLH, and $13,429 for RH (P < .0001). Net hospital income was $1260 for TVH. The hospital incurred losses of $-1306 for LAVH, $-4049 for TLH, and $-4564 for RH (P = .03). Our criteria to determine the mode of hysterectomy increased TVH from 57% to 76% of all minimally invasive hysterectomy.

CONCLUSION

Hospital costs were greater with LAVH, TLH, and RH than for TVH. The hospital incurred financial losses with LAVH, TLH, and RH. TVH was the only minimally invasive modality of hysterectomy that generated net hospital income. Our conservative criteria to determine the route of hysterectomy would increase the number of TVHs by more than 30%.

Quality of life and costs of levonorgestrel-releasing intrauterine system or hysterectomy in the treatment of menorrhagia: a 10-year randomized controlled trial

OBJECTIVE

Menorrhagia is a common problem impairing the quality of life (QOL) of many women. Both levonorgestrel-releasing intrauterine system (LNG-IUS) and hysterectomy are effective treatment modalities but no long-term comparative studies of QOL and costs exist. The objective of this study was to compare QOL and costs of LNG-IUS or hysterectomy in the treatment of menorrhagia during 10-year follow-up.

STUDY DESIGN

A total of 236 women, aged 35-49 years, referred for menorrhagia to 5 university hospitals in Finland were randomly assigned to treatment with LNG-IUS (n = 119) or hysterectomy (n = 117) and were monitored for 10 years. The main outcome measures were health-related QOL (HRQOL), psychosocial well-being, and cost-effectiveness.

RESULTS

A total of 221 (94%) women were followed for 10 years. Although 55 (46%) women assigned to the LNG-IUS subsequently underwent hysterectomy, the overall costs in the LNG-IUS group ($3423) were substantially lower than in the hysterectomy group ($4937). Overall, levels of HRQOL and psychosocial well-being improved during first 5 years but diminished between 5 years and 10 years and the improved HRQOL returned close to the baseline level. There were no significant differences between LNG-IUS and hysterectomy groups.

CONCLUSION

Both LNG-IUS and hysterectomy improved HRQOL. The improvement was most striking during the first 5 years. Although many women eventually had hysterectomy, LNG-IUS remained cost-effective.

A comparison of abdominal and vaginal hysterectomies in Benghazi, Libya

We performed a comparative study between abdominal and vaginal hysterectomies using clinical data from Al-Jamhouria hospital (one of the largest maternity hospitals in Eastern Libya). Various parameters were taken into consideration: the rates of each type (and their subtypes); average age of patients; indications; causes; postoperative complications; and duration of stay in the hospital afterwards. Conclusions and recommendations were drawn from the results of this study. In light of the aforementioned parameters, it was found that: (1) abdominal hysterectomies were more common than vaginal hysterectomies (p < 0.001); (2) patients admitted for abdominal hysterectomies are younger than those admitted for vaginal hysterectomies (p < 0.001); (3) the most common indication for an abdominal hysterectomy was menstrual disturbances, while for vaginal hysterectomies it was vaginal prolapse; (4) the histopathological cause for abdominal and vaginal hysterectomies were observed and the most common were found to be leiomyomas and atrophic endometrium; (5) there was no significant difference between the two routes in terms of postoperative complications; (6) patients who were admitted for abdominal hysterectomies spent a longer amount of time in the hospital (p < 0.01). It was concluded that efforts should be made to further pursue vaginal and laparoscopic hysterectomies as a viable option to the more conventional abdominal route.

Bridging the urological divide

The advanced disease clinical presentations, higher morbidity and mortality rates and lack of available treatment options in prostate cancer care, attest to disparities in the delivery and outcomes of urological services in Black men of African lineage in both the Developed and Developing countries. This gap in health care and services in the global management of prostate cancer denotes the urological divide.Through the experience of a Developing country urologist with a comparative literature review, this presentation defines the determinants of the disparity through deficiencies in human, material and financial resources, as is most prevalent in Developing countries.Solutions to ending health care disparities must take into account the existing development phase of Third World countries and thus determine whether the Developed countries should export a total service delivery system or seek primarily to advance the competence and skills of the existing Developing country resources.Collaboration in prostate cancer research has the greatest promise and sustainability of bridging this urological divide and is of mutual benefit to both entities.

The cost of a hysterectomy in a UK hospital

Vaginal hysterectomy has been demonstrated to be the cheapest route to perform a hysterectomy but no detailed costing has been performed in the United Kingdom. In this study the costs incurred by a UK teaching hospital for 30 women aged between 40 and 50 years of age undergoing either abdominal (AH), laparoscopically assisted vaginal hysterectomy (LH) were compared with vaginal hysterectomy (VH). VH was significantly the cheapest procedure (993.00 Pounds, 95th Cl 883.20 Pounds to 1124.80 Pounds) and there was a tendency for LH (1148.00 Pounds, 95th Cl 1006.80 Pounds to 1289.20 Pounds) to be less expensive than AH (1340.00 Pounds, 95th CI 1080.80 Pounds to 1595.20 Pounds); this difference may be reversed if disposable laparoscopic instruments were to be used for LH. Our study agrees with data from other countries showing that VH is the cheapest type of hysterectomy. With the added benefits of shorter hospital stay, convalescence and return to work, effort should be directed towards increasing the proportion of hysterectomies performed vaginally in the UK.

A review of total laparoscopic hysterectomy using LigaSure uterine artery-sealing device: AIIMS experience

STUDY OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of total laparoscopic hysterectomy (TLH) by using the Ligasure system for the sealing of uterine arteries.

DESIGN

We conducted a retrospective review of cases who underwent TLH over 1.5 years.

SETTINGS

This study was conducted in a tertiary care hospital setting, at the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (New Delhi, India).

PATIENTS

A total of 110 patients of TLH done for uterine pathology [leiomyoma in 67 (60.9%), dysfunctional uterine bleeding in 34 (30.9%), and others in 9 (8.1%)].

INTERVENTIONS

Total laparoscopic hysterectomy, using the LigaSure system (Valleylab Inc., Boulder, CO), was done by the sealing of uterine arteries and Prashant Mangeshikar uterine manipulator for elevation of the uterus.

RESULTS

The mean age of the patients was 43.1 +/- 0.602 years and mean body mass index was 25.19 +/- 0.39 kg/m(2). The mean operating time was 116.91 +/- 3.4 minutes, mean intraoperative blood loss was 173.09 +/- 11.64 mL, and the mean weight of the removed uterus was 224.14 +/- 17.62 g. Six patients were converted from a laparoscopic to an open procedure (large myoma in 4 and dense adhesion in 2) and 1 was converted to laparoscopically assisted vaginal hysterectomy (tear in vaginal cuff). One patient (0.9%) developed lung emphysema during the intraoperative period. Postoperative complications included paralytic ileus in 3 (2.7%), retention of urine in 2 (1.8%), and febrile morbidity in 12 (10.9%) patients. There were no bladder or bowel injuries.

CONCLUSION

Laparoscopic hysterectomy by uterine artery sealing with LigaSure is a safe, efficient procedure with a low complication rate.

The effects of laparoscopic surgery and nosocomial infections on the cost of care: evidence from three common surgical procedures

OBJECTIVE

To examine the cost of care for laparoscopic versus open surgery and the added cost of nosocomial infections for three common surgical procedures: cholecystectomy, hysterectomy, and appendectomy.

METHODS

The Cardinal Health database repository was utilized to extract reimbursement data for laparoscopic and open cholecystectomy, hysterectomy, and appendectomy surgical procedures. Utilizing a 22-hospital sample and a Health Insurance Portability and Accountability Act compliant clinical data extraction technique, the Cardinal Health database repository produced a Nosocomial Infection Marker to identify and track nosocomial infection rates for these procedures. ICD-9 codes were utilized to identify 10,731 patients who had undergone these procedures between September 2004 and December 2006. Multivariable linear regression models were estimated to isolate the effects of laparoscopic versus open surgery and nosocomial infections on the cost of care.

RESULTS

Laparoscopic surgery significantly reduces the overall cost of care for cholecystectomies, hysterectomies, and appendectomies. Controlling for the cost of nosocomial infection, incremental cost savings from laparoscopic versus open surgery for all three procedures average $1608. Cholecystectomy has the largest savings ($3299), followed by hysterectomy ($1385) and appendectomy ($1032). These cost savings in part reflect that patients undergoing laparoscopic procedures have shorter lengths of stay. In contrast, nosocomial infection increases costs substantially for each surgery type, raising costs for cholecystectomy by $4794, hysterectomy by $4528, and appendectomy by $6108.

CONCLUSION

The cost of care for laparoscopic surgery is lower than open surgery for cholecystectomy, hysterectomy, and appendectomy. This conclusion is based on actual hospital reimbursement data.

Safety and efficacy of vaginal hysterectomy in the large uterus with the LigaSure bipolar diathermy system

OBJECTIVE

This study was undertaken to assess safety and efficacy of vaginal hysterectomy in case of large uterine size (> or = 250 g) using the LigaSure bipolar diathermy (Valleylab, Boulder, CO).

STUDY DESIGN

In a retrospective study, medical records of 102 patients who underwent vaginal hysterectomy and who had uterine weight (evaluated after surgery) 250 g or greater were reviewed. All hysterectomies were performed by using the LigaSure vessel sealing system to secure vascular pedicles (uterosacral-cardinal, uterine and ovarian and round ligaments).

RESULTS

Of the 102 vaginal hysterectomies, 99 were successfully performed (97.1%; 95% confidence interval, 91.6-99.4%), whereas a conversion from the vaginal to the abdominal route was required in 3 cases. The median uterine weight was 455 g (range, 241-1913 g). The weight of the largest uterus successfully removed vaginally was 1600 g, without intraoperative and postoperative complications. The median operative time was 50 minutes (range, 25-50 minutes).

CONCLUSION

The current study confirms that very large uterine volume does not represent a real obstacle to perform vaginal hysterectomy and that results in a safe and effective technique in cases of uterine weight 250 g or greater.

Economic evaluation of uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial

PURPOSE

To investigate whether uterine artery embolization (UAE) is a cost-effective alternative to hysterectomy for patients with symptomatic uterine fibroids, the authors performed an economic evaluation alongside the multicenter randomized EMMY (EMbolization versus hysterectoMY) trial.

MATERIALS AND METHODS

Between February 2002 and February 2004, 177 patients were randomized to undergo UAE (n = 88) or hysterectomy (n = 89) and followed up until 24 months after initial treatment allocation. Conditional on the equivalence of clinical outcome, a cost minimization analysis was performed according to the intention to treat principle. Costs included health care costs inside and outside the hospital as well as costs related to absence from work (societal perspective). Cumulative standardized costs were estimated as volumes multiplied with prices. The nonparametric bootstrap method was used to quantify differences in mean (95% confidence interval [CI]) costs between the strategies.

RESULTS

In total, 81 patients underwent UAE and 75 underwent hysterectomy. In the UAE group, 19 patients (23%) underwent secondary hysterectomies. The mean total costs per patient in the UAE group were significantly lower than those in the hysterectomy group ($11,626 vs $18,563; mean difference, -$6,936 [-37%], 95% CI: -$9,548, $4,281). The direct medical in-hospital costs were significantly lower in the UAE group: $6,688 vs $8,313 (mean difference, -$1,624 [-20%], 95% CI: -$2,605, -$586). Direct medical out-of-hospital and direct nonmedical costs were low in both groups (mean cost difference, $156 in favor of hysterectomy). The costs related to absence from work differed significantly between the treatment strategies in favor of UAE (mean difference, -$5,453; 95% CI: -$7,718, -$3,107). The costs of absence from work accounted for 79% of the difference in total costs.

CONCLUSIONS

The 24-month cumulative cost of UAE is lower than that of hysterectomy. From a societal economic perspective, UAE is the superior treatment strategy in women with symptomatic uterine fibroids.

Ethics in American health 2: an ethical framework for health system reform

I argue that an ethical vision resting on explicitly articulated values and norms is critical to ensuring comprehensive health reform. Reform requires a consensus on the public good transcending self-interest and narrow agendas and underpinning collective action for universal coverage. In what I call shared health governance, individuals, providers, and institutions all have essential roles in achieving health goals and work together to create a positive environment for health. This ethical paradigm provides (1) reasoned consensus through a joint scientific and deliberative approach to judge the value of a health care intervention; (2) a method for achieving consensus that differs from aggregate tools such as a strict majority vote; (3) combined technical and ethical rationality for collective choice; (4) a joint clinical and economic approach combining efficiency with equity, but with economic solutions following and complementing clinical progress; and (5) protection for disabled individuals from discrimination.

Hysterectomy for benign conditions in a university hospital in Saudi Arabia

BACKGROUND AND OBJECTIVE

Hysterectomy is a common surgical procedure among women with a lifetime prevalence of 10%. The indications and complications of this procedure have not been previously reported from a teaching institution in Saudi Arabia. We examined the indications for hysterectomy and the surgical morbidity for women undergoing hysterectomy at a university hospital in Saudi Arabia.

PATIENTS AND METHODS

We reviewed the records of women who underwent hysterectomies for benign gynecological conditions between January 1990 and December 2002, at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, comparing patient characteristics, indications for hysterectomy and the rate of complications in women undergoing abdominal hysterectomy (AH) versus vaginal hysterectomy (VH).

RESULTS

Of 251 women, 199 (79%) underwent AH and 52 (21%) underwent VH. An estimated blood loss of >/=500 mL occurred in 104 patients (52.3%) in the AH group and in 20 patients (38.5%) in the VH group (difference not statistically significant). The most common indications for hysterectomy were uterine fibroids (n=107, 41.6%) and dysfunctional uterine bleeding (n=68, 27.1%). The most common indication for VH was uterine prolapse (n=45, 86.5%). The overall complication rates were 33.5%, 15.4% and 30.4% in women who underwent AH, VH and both, respectively. Intraoperative and postoperative complications occurred in 24 (9.7%) patients in the AH group and in 51 patients in the VH group (20.3%). Postoperative infection occurred in 42/199 (21.6%) in the AH group and 5/52 (9.6%) in the VH group (difference not statistically significant).

CONCLUSIONS

We describe a large series of hysterectomies, which provides information for surgeons on the expected rate of complications following hysterectomy for benign conditions. We found that the rate of complications was not significantly higher than other centers internationally.

Diagnostic laparoscopy for patients with potentially resectable pancreatic adenocarcinoma: is it cost-effective in the current era?

INTRODUCTION

For patients with potentially resectable pancreatic cancer, diagnostic laparoscopy may identify liver and peritoneal metastases that are difficult to detect with other staging modalities. The aim of this study was to utilize a population-based pancreatic cancer database to assess the cost effectiveness of preoperative laparoscopy.

MATERIAL AND METHODS

Data from a state cancer registry were linked with primary medical record data for years 1996-2003. De-identified patient records were reviewed to determine the role and findings of laparoscopic exploration. Average hospital and physician charges for laparotomy, biliary bypass, pancreaticoduodenectomy, and laparoscopy were determined by review of billing data from our institution and Medicare data for fiscal years 2005-2006. Cost-effectiveness was determined by comparing three methods of utilization of laparoscopy: (1) routine (all patients), (2) case-specific, and (3) no utilization.

RESULTS AND DISCUSSION

Of 298 potentially resectable patients, 86 underwent laparoscopy. The prevalence of unresectable disease was 14.1% diagnosed at either laparotomy or laparoscopy. The mean charge per patient for routine, case-specific, and no utilization of laparoscopy was $91,805, $90,888, and $93,134, respectively.

CONCLUSION

Cost analysis indicates that the case-specific or routine use of laparoscopy in pancreatic cancer does not add significantly to the overall expense of treatment and supports the use of laparoscopy in patients with known or suspected pancreatic adenocarcinoma.

Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy: A prospective, randomized, multicenter study

STUDY OBJECTIVE

The aim of this study was to compare operative and early postoperative outcomes of laparoscopic-assisted vaginal hysterectomy (LAVH) and minilaparotomy in a randomized clinical trial including patients undergoing total hysterectomy for benign gynecologic disease and having 1 or more of the generally considered contraindications to vaginal route.

DESIGN

Prospective, randomized, multicenter trial (Canadian Task Force classification I).

SETTING

Departments of Gynecology from 3 major university hospitals in Rome.

PATIENTS

Eighty-one patients who were candidates for abdominal hysterectomy.

INTERVENTIONS

Laparoscopic-assisted vaginal hysterectomy and minilaparotomy hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Forty patients were randomized to LAVH and 41 to minilaparotomy. Characteristics of patients and indications for surgery in the 2 arms were comparable. In the minilaparotomy group, complications were as follows: 1 case (2.4%) of delayed laparotomy with 2 units of red blood cell transfusion, 2 cases (4.8%) of wound infection, and 3 cases (7.3%) of fever of unknown origin. No minor or major complications were observed in the LAVH group. Postoperative visual analog scale pain scores at days 1 and 2 were significantly lower in the LAVH group (p <.05). The complication rate between the 2 groups was significantly lower for LAVH (p = .026).

CONCLUSION

Because LAVH was associated with significantly lower early postoperative pain scores and complication rates, in general LAVH should be preferred to minilaparotomy hysterectomy when the vaginal approach cannot be used.

The benefits of virtual reality simulator training for laparoscopic surgery

PURPOSE OF REVIEW

Virtual reality is a computer-generated system that provides a representation of an environment. This review will analyse the literature with regard to any benefit to be derived from training with virtual reality equipment and to describe the current equipment available.

RECENT FINDINGS

Virtual reality systems are not currently realistic of the live operating environment because they lack tactile sensation, and do not represent a complete operation. The literature suggests that virtual reality training is a valuable learning tool for gynaecologists in training, particularly those in the early stages of their careers. Furthermore, it may be of benefit for the ongoing audit of surgical skills and for the early identification of a surgeon's deficiencies before operative incidents occur. It is only a matter of time before realistic virtual reality models of most complete gynaecological operations are available, with improved haptics as a result of improved computer technology.

SUMMARY

It is inevitable that in the modern climate of litigation virtual reality training will become an essential part of clinical training, as evidence for its effectiveness as a training tool exists, and in many countries training by operating on live animals is not possible.

Preoperative Uterine Artery Embolization (PUAE) Before Uterine Fibroid Myomectomy

PURPOSE

To evaluate the potential of uterine artery embolization to minimize blood loss and facilitate easier removal of fibroids during subsequent myomectomy.

METHODS

This retrospective study included 22 patients (median age 37 years), of whom at least 15 wished to preserve their fertility. They presented with at least one fibroid (mean diameter 85.6 mm) and had undergone preoperative uterine artery embolization (PUAE) with resorbable gelatin sponge.

RESULTS

No complication or technical failure of embolization was identified. Myomectomies were performed during laparoscopy (12 cases) and laparotomy (9 cases). One hysterectomy was performed. The following were noted: easier dissection of fibroids (mean 5.6 per patient, range 1-30); mean intervention time 113 min (range 25-210 min); almost bloodless surgery, with a mean peroperative blood loss of 90 ml (range 0-806 ml); mean hemoglobin pretherapeutically 12.3 g/dl (range 5.9-15.2 g/dl) and post-therapeutically 10.3 g/dl (range 5.6-13.3 g/dl), with no blood transfusion needed. Patients were discharged on day 4 on average and the mean sick leave was 1 month.

CONCLUSION

Preoperative embolization is associated with minimal intraoperative blood loss. It does not increase the complication rate or impair operative dissection, and improves the chances of performing conservative surgery.

Financial impact of hand surgery programs on academic medical centers

BACKGROUND

This study analyzes the financial performance of hand surgery in the Department of Surgery at the University of Michigan. This analysis can serve as a reference for other medical centers in the financial evaluation of a hand surgery program.

METHODS

Fiscal year 2004 billing records for all patients (n = 671) who underwent hand surgery procedures were examined. The financial data were separated into professional revenues and costs (relating to the hand surgery program in the Section of Plastic Surgery) and into facility revenues and costs (relating to the overall University of Michigan Health System). Professional net revenue was calculated by applying historical collection rates to procedural and clinic charges. Facility revenue was calculated by applying historical collection rates to the following charge categories: inpatient/operating room, clinic facility, neurology/electromyography, radiology facilities, and occupational therapy. Total professional costs were calculated by adding direct costs and allocated overhead costs. Facility costs were obtained from the hospital's cost accounting system. Professional and facility incomes were calculated by subtracting costs from revenues.

RESULTS

The net professional revenue and total costs were 1,069,836 and 1,027,421 dollars, respectively. Professional operating income was 42,415 dollars, or 3.96 percent of net professional revenue. Net facility revenue and total costs were 5,500,606 and 4,592,534 dollars, respectively. Facility operating income was 908,071 dollars, or 16.51 percent of net facility revenues.

CONCLUSIONS

While contributing to the academic mission of the institution, hand surgery is financially rewarding for the Department of Surgery. In addition, hand surgery activity contributes substantially to the financial well-being of the academic medical center.

Ten-year results of a prospective study on the prognostic role of ploidy in endometrial carcinoma

BACKGROUND

To improve the outcome of endometrial cancer patients, a more accurate prognostic assessment is mandatory. The aims of the study were to evaluate the role of flow cytometric DNA ploidy as an independent prognostic factor in patients with endometrial cancer and to verify if ploidy was able to distinguish patients with different prognosis into homogeneous subgroups for grade of differentiation and stage.

METHODS

In a prospective study, DNA ploidy was evaluated from fresh tumor samples in 174 endometrial cancer patients who underwent surgery as the first treatment. Ploidy, as well as classical parameters, were analyzed in relation to the length of disease-free survival and disease-specific survival.

RESULTS

DNA aneuploidy was found in 49 patients (28.2%). Patients with DNA-aneuploid tumors had a significantly reduced disease-free interval and disease-specific survival (P < .0001). The 10-year survival probability was 53.2% for DNA-aneuploid patients and 91.0% for patients with DNA-diploid tumors. By multivariate analysis DNA-aneuploid type was the strongest independent predictor of poor outcome, followed by age and stage. Patients with DNA-aneuploid tumor had a significantly higher risk ratio for recurrence (5.03) and death due to disease (6.50) than patients with DNA-diploid tumors. Stratification by DNA-ploidy within each group by grade of differentiation allowed identification of patients with significantly different outcome. In grade 2 tumors, 10-year survival was 45.0% in aneuploid cases and 91.9% in diploid cases (P < .0001). Patients with advanced-stage (>I) diploid tumor did significantly better than patients with stage I aneuploid tumor (P = .04).

CONCLUSIONS

The presence of DNA-aneuploid type in endometrial cancer identifies high-risk cases among the patients considered 'low risk' according to stage and grade of differentiation.

Factors Associated With Increased Charges for Hysterectomy

OBJECTIVE

To evaluate factors associated with increased hospital charges for hysterectomy with specific attention to differences based on surgical approach.

METHODS

We performed a retrospective cohort study of 686 patients who underwent hysterectomy between January 1997 and September 1997 using medical chart review and hospital financial information. Demographic information, surgical approach (abdominal, vaginal, or laparoscopic), and surgical and postoperative factors were extracted from the medical record. Hospital charges were obtained from the hospital billing database. Relationships between charges and various clinical and demographic variables were examined using chi(2), Fisher exact test, t tests, or analysis of variance, where appropriate. Logistic regression was used to estimate odds ratios while controlling for important confounding variables.

RESULTS

In our logistic regression model, blood loss greater than 1,000 mL (odds ratio [OR] 11.8, 95% confidence interval [CI] 4.2-33.2) and operative time 105 minutes or more (OR 14.2, CI 5.8-34.5) were strongly associated with higher charges for hysterectomy. Other factors associated with higher charges included: postoperative fever (OR 2.2, CI 1.1-4.5), increasing length of hospitalization (OR 5.3, CI 3.7-7.7), the use of prophylactic antibiotics (OR 3.0, CI 1.3-6.6), and the laparoscopic surgical approach compared with vaginal hysterectomy (OR 2.7, CI 1.0-7.0).

CONCLUSION

Surgical factors such as operative time and blood loss were strongly associated with increased hospital charges for hysterectomy.

The value of virtual reality–simulator training in the development of laparoscopic surgical skills

OBJECTIVE

To determine the effectiveness of virtual reality (VR) training in improving the surgical skills of medical students and gynecologic trainees.

DESIGN

A prospective observational study to assess the changes observed in objectively measured surgical performance after VR training.

SETTING AND POPULATION

University teaching hospital and the laboratories of the University of Western Australia.

PARTICIPANTS

Fifteen 5th-year medical students, six junior-doctor trainees (years 1-3), and eight senior trainees (years 4-6).

INTERVENTIONS

Standard gynecologic procedures before and after VR training were undertaken on sheep. The procedures were video-recorded and edited to blind the scorer as to identity and seniority of the operator. The procedures were scored using a combination of operative time and penalties for surgical errors. The surgical scores were correlated with the VR scores.

MEASUREMENTS AND MAIN RESULTS

Operative skills were assessed using a combination score compiled from scores obtained while undertaking salpingectomy, salpingotomy, and tubal clipping. Virtual reality scores were also a combination score derived from summation of various computer-calculated measures of time and accuracy in undertaking two standardized exercises.

RESULTS

The baseline VR scores were significantly related to the overall pre-training scores (salpingectomy p = .032). A better initial VR score was also predictive of better surgical performance. The initial VR score was also predictive of improvement observed between baseline and post-training (p = .004).

CONCLUSION

Virtual reality training is of value in improving surgical skills in the clinical environment. It appears to be of most value in the earliest stages of training. These data suggest that serious consideration should be given to incorporating VR training into the training program of obstetricians and gynecologists at an early stage.

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.