Laparoscopic hysterectomy : predictors of quality of surgery

Although hospitals increasingly opt for the laparoscopic over the conventional approach and the decline in diagnostic procedures is well compensated by an increase in numbers of all types of therapeutic procedures, the implementation of laparoscopic hysterectomy in the Netherlands seems to be hampered and scattered (chapter 2). The majority of hospitals that apply laparoscopic hysterectomy perform only a minority of the total volume of procedures, whereas the minority of hospitals performs a high annual caseload of procedures. From our studies, preference and referral tendencies seem to be suboptimal, despite knowledge indication and advantages of this minimally invasive technique (chapter 4). Gynecologists employed in a hospital that did not perform laparoscopic hysterectomies were much less likely to refer candidates for this procedure, despite basic knowledge about the indication and limitations of the approach. Furthermore, patient related factors, such as body mass index and uterus weight, might play a role in this tendency. The level of experience (expressed in number of laparoscopic hysterectomies performed) did not significantly influence the laparoscopist__s opinion on body mass index, uterus weight and previous abdominal surgery as restrictive characteristics for the laparoscopic approach. Both, performers as well as referring colleagues regarded a high body mass index, big uterus weight and previous abdominal surgery as restricting parameters for the laparoscopic approach. This is worrisome, as we know that the majority of these __challenging__ patients have an uneventful procedure (85%) and especially since there is evidence that the obese patient is better served by a laparoscopic approach than by conventional abdominal surgery. Furthermore, it was shown that with growing popularity of this procedure (half of laparoscopic hysterectomy performing gynecologists had less than five years experience), a steady state of implementation of this advanced laparoscopic surgical procedure has yet not been reached. The Laparoscopic Assisted Vaginal Hysterectomy (LAVH), a variant of laparoscopic hysterectomy, showed to be generally performed by inexperienced surgeons in low volume hospitals, while adverse events and blood loss were increased compared to Total Laparoscopic Hysterectomy (chapter 3 and chapter 5). In our prospective study in 79 surgeons (the LapTop! study), we observed that the success of surgical outcomes was significantly influenced by uterus weight, body mass index, ASA classification and previous abdominal surgeries, next to the type of laparoscopic hysterectomy (chapter 5). Surgical experience also predicted the successful outcome of laparoscopic hysterectomy with respect to blood loss and adverse events. However, also an experience independent surgical skills factor was identified, representing a crucial determinant in measuring quality of surgery. This skills factor was also present in the probability of conversion to laparotomy in the same cohort (chapter 6). The majority of conversions were performed because of strategic considerations, while uncontrollable bleeding was the main adverse event leading to a reactive conversion. A high body mass index and increased uterus weight predicted conversion probability, while experience did not.vaginal and abdominal hysterectomy (chapter 7). Therefore, minimally invasive surgery is not necessarily minimally painful. However, patients in the minimally invasive group reported a steeper decline in pain scores postoperatively. Acquiring and maintaining skills in laparoscopic hysterectomy by mentorship showed to be effective, safe and durable, as indication, operative time and adverse event rates were comparable to those of the mentor in his own hospital during and after completing the mentorship program (chapter 8). Assessment of skills in advanced laparoscopic surgery is increasingly demanded. Prediction of surgical skills based on __in vitro__ box trainers outcomes was not conclusive as surgeons with suboptimal average clinical outcomes could not be indicated by means of a box trainer task (chapter 9). However, __real time__ risk-adjusted clinical monitoring of performance by means of cumulative sum (CUSUM) analysis appeared to be a valuable tool in order to signal derailing performance in a timely fashion (chapter 10). This is paramount, as in laparoscopic hysterectomy no definitive accomplishment of the proficiency curve is foreseen and applying relevant predictors of quality of surgery should guard patient safety.J.E. Jurriaanse stichting, Bronovo Research Fund, Nederlandse Vereniging voor Endoscopische Chirurgie, Johnson & Johnson Medical BV, Covidien, BMA BV, Medical Dynamics, Olympus Nederland BV, ERBE, Skills Meducation, Roche and ChipSoft.UBL - phd migration 201

Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: an undesired side effect?

Gynecolog

Laparoscopic hysterectomy for benign indications: clinical practice guideline

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Prognosis in fertilisation rate and outcome in IVF cycles in patients with and without endometriosis: a population-based comparative cohort study with controls

Background: Subfertility occurs in 30-40% of endometriosis patients. Regarding the fertilisation rate with in vitro fertilisation (IVF) and endometriosis, conflicting data has been published. This study aimed to compare endometriosis patients to non-endometriosis cycles assessing fertilisation rates in IVF.Methods: A population-based cohort study was conducted at the Leiden University Medical Center. IVF cycles of endometriosis patients and controls (unexplained infertility and tubal pathology) were analysed. The main outcome measurement was fertilisation rate.Results: 503 IVF cycles in total, 191 in the endometriosis group and 312 in the control. The mean fertilisation rate after IVF did not differ between both groups, 64.1%+/- 25.5 versus 63.9%+/- 24.8 (p=0.95) respectively, independent of age and r-ASRM classification. The median number of retrieved oocytes was lower in the endometriosis group (7.0 versus 8.0 respectively, p=0.19) and showed a significant difference when corrected for age (p=0.02). When divided into age groups, the statistical effect was only seen in the group of <= 35 years (p=0.04). In the age group <= 35, the endometriosis group also showed significantly more surgery on the internal reproductive organs compared to the control group (p<0.001). All other outcomes did not show significant differences.Conclusion: Similar fertilisation rates were found in endometriosis IVF cycles compared to controls. The oocyte retrieval was lower in the endometriosis group, however this effect was only significant in the age group <= 35 years. All other secondary outcomes did not show significant differences. In general, endometriosis patients with an IVF indication can be counselled positively regarding the chances of becoming pregnant, and do not need a different IVF approach.Gynecolog

Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy: A Systematic Review and Meta-Analysis

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Laparoscopic Hysterectomy: Eliciting Preference of Performers and Colleagues Via Conjoint Analysis

Study Objectives: To compare preferences for laparoscopic hysterectomy (LH) over abdominal hysterectomy (AH) by gynecologists who perform LH (group 1), their colleagues (group 2), and gynecologists employed by a hospital that does not provide LH (group 3), and to estimate boundary values of patient characteristics that influence preference for mode of hysterectomy. Differences in referral tendencies between groups 2 and 3 are compared. Design: Group comparison study (Canadian Task Force classification II-2). Setting: Nationwide conjoint preference study in groups 1, 2, and 3. Intervention: Web-based choice-based conjoint analysis questionnaire. Measurements and Main Results: In general, group I preferred LH significantly more often (86.3%; 95% confidence interval [Cl], 81.6-91.0) than did group 2 (70.9%; 95% CI, 63.4-78.4). Group 3 preferred LH significantly less frequently (50.3%; 95% CI, 35.7-64.9). Increases in body mass index, estimated uterus size, and number of previous abdominal surgeries caused a significant drop in shares of preferences in all groups. Conclusions: The presence of a gynecologist who performs LH positively influences the referral behavior of colleagues. The effect of an increased body mass index seems to be a restrictive parameter for choosing LH according to both referring gynecologists and those who perform LH. Level of experience does not influence preference of laparoscopists. The observed discrepancy between reported and simulated referral behavior in group 3 demonstrates that practical impediments significantly decrease referral tendencies, consequently hampering implementation of this minimally invasive approach. Journal of Minimally Invasive Gynecology (2011) 18, 582-588 (C) 2011 AAGL. All rights reserved.Medical Decision MakingAnalysis and support of clinical decision makingGynecolog

Implementation of Advanced Laparoscopic Surgery in Gynecology: National Overview of Trends

Study Objective: To estimate the implementation of laparoscopic surgery in operative gynecology. Design: Observational multicenter study (Canadian Task Force classification II-2). Setting: All hospitals in the Netherlands. Sample: Nationwide annual statistics for 2002 and 2007. Interventions: A national survey of the number of performed laparoscopic and conventional procedures was performed. Laparoscopy was categorized for complexity in level 1, 2, and 3 procedures. Outcomes were compared with results from 2002 to evaluate trends. Measurements and Main Results: In 2002, 21 414 laparoscopic and 9325 conventional procedures were performed in 74 hospitals (response rate, 74%), and in 2007, 16 863 laparoscopic and 10 973 conventional procedures were performed in 80 hospitals (response rate, 80%). Compared with 2002, in 2007, level 1 procedures were performed significantly less often and level 2 and level 3 procedures were performed significantly more often. The mean number of performed laparoscopic procedures per hospital decreased from 289 to 211 procedures. Teaching hospitals performed more than twice as many therapeutic laparoscopic procedures as nonteaching hospitals do. Cystectomy, oophorectomy, and ectopic pregnancy surgery were preferably performed using the laparoscopic approach. Laparoscopic hysterectomy was performed significantly more often, accounting for 10% of all hysterectomies. Annually, 20% of hospitals in which laparoscopic hysterectomy was implemented performed 50% of all laparoscopic hysterectomies, and 50% of the hospitals performed 20% of laparoscopic hysterectomies. Conclusion: This study describes increasing implementation of therapeutic laparoscopic gynecologic surgery. Clinics increasingly opt to perform laparoscopic surgery rather than conventional surgery. However, implementation of advanced procedures such as laparoscopic hysterectomy seems to be hampered. journal of Minimally Invasive Gynecology (2010) 17, 487-492 (c) 2010 AAGL. All rights reserved.Cervix cance

Clinical Relevance of Conversion Rate and its Evaluation in Laparoscopic Hysterectomy

Development and application of statistical models for medical scientific researc

Trends in the Implementation of Advanced Minimally Invasive Gynecologic Surgical Procedures in The Netherlands

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Hysterectomy in very obese and morbidly obese patients: a systematic review with cumulative analysis of comparative studies

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