Faculty Bibliography

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

BACKGROUND:This study was designed to investigate the validity of using the Fundamentals of Laparoscopic Surgery (FLS) program to assess laparoscopic competence among gynecologists. METHODS:A total of 42 gynecologists with variable surgical training and laparoscopic experience were enrolled for FLS testing which includes a computer-based cognitive examination to assess one's knowledge and a psychomotor portion for manual skills assessment. Prior to testing, participants were surveyed to document their level of surgical training and caseload for common laparoscopic procedures. Participants were required to self-evaluate their confidence in conducting laparoscopic procedures. Upon completion of the FLS test, feedback was collected regarding the use of the FLS program for training and assessing laparoscopic skills of gynecologists. RESULTS:Gynecologists with advanced levels of surgical training achieved higher scores in the FLS manual skills test than those with lower levels of training (P = 0.009). The cognitive test, however, failed to show an increased score with greater levels of surgical training (P = 0.457). Regression analyses revealed that a participant's laparoscopic expertise contributed significantly to one's FLS manual skills scores (P = 0.008) beyond surgical training level alone. In contrast, laparoscopic expertise did not reflect changes in the FLS cognitive scores significantly (P = 0.628). Self-reported confidence scores correlated well with FLS manual skills test scores (r = 0.54) but not with the cognitive scores (r = 0.16). CONCLUSION/CONCLUSIONS:The manual skills test of the FLS program appropriately measures the level of a gynecologist's psychomotor skills. The FLS cognitive test does not discriminate between advanced and novice surgeons. Modifications of questions used in the cognitive test are necessary to allow better adaptability when applying the FLS program to gynecologists.

Hysteroscopic Essure sterilizations offer women and physicians another option for contraception. Overall, the procedure is simple to perform and highly efficacious, and as a result, has gained popularity among practicing gynecologists. Unfortunately, complications occur with any type of surgery. We report 3 cases of hysteroscopic Essure sterilization complications where the Essure microinsert was noted to be misplaced or where patients had persistent postprocedure pain in the setting of appropriately placed microinserts. In all 3 cases, the microinserts were successfully removed laparoscopically.

STUDY OBJECTIVE/OBJECTIVE:The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences. DESIGN/METHODS:Observational case series (Canadian Task Force classification II-3). SETTING/METHODS:Large, urban, university teaching hospital. PATIENTS/METHODS:All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed. INTERVENTIONS/METHODS:Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate. MEASUREMENTS AND MAIN RESULTS/RESULTS:From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH. CONCLUSIONS:Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.