STUDY OBJECTIVE:Reprocessing of single-use surgical devices (SUDs) can provide an impactful reduction in surgical waste and greenhouse gas emissions, but there is minimal data on surgeon preference and surgical performance of these reprocessed SUDs compared to new devices. This study aims to compare gynecologic surgeon assessment of the reprocessed versus new laparoscopic LigaSure bipolar vessel sealing devices. DESIGN:This was a double-blind, randomized, 2 × 2 cross-over surgical simulation study, in which participants completed a series of surgical tasks with both a new and reprocessed laparoscopic LigaSure. The primary outcome was surgeon assessment of the devices and secondary outcomes included surgeon willingness to use reprocessed SUDs in clinical practice. SETTING:The 2024 American Association of Gynecologic Laparoscopists (AAGL) Global Congress in New Orleans, LA PATIENTS: A total of 20 gynecologic surgeons from across the United States with varying levels of experience completed the study. INTERVENTIONS:Participants used a new and reprocessed laparoscopic LigaSure device in sequence, with the order randomly assigned. Participants completed a series of instructed surgical tasks using a tissue model, and subsequently assessed each device in regard to tissue handling, tissue dissection, seal completion, tissue cutting, and ergonomics using a continuous numeric scale (0-10). Participants then answered questions about overall device assessment. MEASUREMENTS AND MAIN RESULTS:Wilcoxon signed rank and Generalized Linear Mixed Models were used for statistical analysis. There was no significant difference in any aspects of the assessed performance of the new versus reprocessed device. This persisted with adjustment for surgeon sex and the type of LigaSure used in the simulation model (blunt or Maryland tip). Most participants (70%) accurately guessed which device was reprocessed, but only 30% preferred the new device to the reprocessed. A total of 90% of the participants were willing/interested in using reprocessed laparoscopic LigaSure devices in their surgical practice. CONCLUSION:The findings of this study further support the broader adoption of surgical SUD reprocessing, reinforcing ongoing efforts to mitigate healthcare's contribution to climate change.

(Abstracted from Obstet Gynecol 2021;138:557–564) Endometriosis is a highly morbid condition, globally affecting millions of women. Up to 10% of reproductive-aged women are affected.

All sequential therapies (medical followed by surgical management) for endometriosis-related dysmenorrhea were cost effective when compared with surgical management alone. OBJECTIVE: To evaluate the cost effectiveness of sequential medical and surgical therapy for the treatment of endometriosis-related dysmenorrhea. METHODS: A cost-effectiveness model was created to compare three stepwise medical and surgical treatment strategies compared with immediate surgical management for dysmenorrhea using a health care payor perspective. A theoretical study cohort was derived from the estimated number of reproductive age (18–45) women in the United States with endometriosis-related dysmenorrhea. The treatment strategies modeled were: strategy 1) nonsteroidal antiinflammatory drugs (NSAIDs) followed by surgery; strategy 2) NSAIDs, then short-acting reversible contraceptives or long-acting reversible contraceptives (LARCs) followed by surgery; strategy 3) NSAIDs, then a short-acting reversible contraceptive or LARC, then a LARC or gonadotropin-releasing hormone modulator followed by surgery; strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. Outcomes included cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Univariate, bivariate, and multivariate sensitivity analyses were performed. RESULTS: In this theoretical cohort of 4,817,894 women with endometriosis-related dysmenorrhea, all medical and surgical treatment strategies were cost effective at a standard willingness-to-pay threshold of $100,000 per QALY gained when compared with surgery alone. Strategy 2 was associated with the lowest cost per QALY gained ($1,155). Requiring a trial of a third medication before surgery would cost an additional $257 million, compared with proceeding to surgery after failing two medical treatments. The probability of improvement with surgery would need to exceed 83% for this to be the preferred first-line approach. CONCLUSION: All sequential medical and surgical management strategies for endometriosis-related dysmenorrhea were cost effective when compared with surgery alone. A trial of hormonal management after NSAIDs, before proceeding to surgery, may provide cost savings. Delaying surgical management in an individual with pain refractory to more than three medications may decrease quality of life and increase cost.

Endometriosis affects 10% of reproductive-aged women, carrying considerable morbidity [ 1 Andres MP Arcoverde FVL Souza CCC Fernandes LFC Abrão MS Kho RM Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020; 27: 373-389 Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar ]. It is defined by extrauterine growth of functional endometrial tissue, most commonly in the peritoneal cavity. However, extrapelvic implants can be encountered in the thoracic cavity with signs/symptoms of pneumothorax, hemothorax, hemoptysis, and lung nodules [ 2 Matalliotakis M Goulielmos GN Kalogiannidis I Koumantakis G Matalliotakis I Arici A Extra pelvic endometriosis: retrospective analysis on 200 cases in two different countries. Eur J Obstet Gynecol Reprod Biol. 2017; 217: 34-37 Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar , 3 Maniglio P Ricciardi E Meli F et al. Catamenial pneumothorax caused by thoracic endometriosis. Radiol Case Rep. 2018; 13: 81-85 Crossref PubMed Scopus (24) Google Scholar ].

BACKGROUND: Social media is increasingly becoming a health resource for people suffering from complex and debilitating health conditions. A comprehensive understanding of how and why social media and the Internet are used among patients with chronic gynecologic pain will allow for the intentional development and incorporation of web-based tools into patient care plans. OBJECTIVE: This study aimed to determine whether gynecologic patients with pain are more likely to use social media and the Internet to understand and manage their condition than those without pain. The survey was designed to explore how gynecologic patients with and without pain use and interact with social media and other web-based health resources and the clinical, personal, and demographic factors influencing these behaviors. STUDY DESIGN: Patients presenting with a new complaint to a gynecologist at 1 of 6 Fellowship in Minimally Invasive Gynecologic Surgeryeaffiliated hospital systems were screened, consented, and assigned to pain and no-pain groups. Participants were surveyed about social media and Internet use, symptoms, bother, physician selection, motivation, trust, and demographic information. Survey responses were compared using the Fisher exact tests, odds ratios, and risk ratios from standard tabular analysis, univariate or multivariate tests of means, and regression analyses, as appropriate. RESULTS: Of 517 participants included in the study, 475 (92%) completed the survey, 328 (69.1%) with pain and 147 (30.9%) without pain. Study participants in the pain group reported more than double the odds of using social media than those without pain (37.8% vs 19.7%; odds ratio, 2.47; 95% confidence interval, 1.54-3.96) and triple the odds of using the Internet (88.4% vs 69.4%; odds ratio, 3.37; 95% confidence, 2.04-5.56) to understand or manage their condition. Participants with pain were more likely than those without pain to engage in social media at a higher level (3.5 vs 1.7 on a scale of 0 to 10; P<.0001), be motivated by interpersonal elements of online engagement (Hotelling's T-2 = 37.3; P<.0001), prefer an interactive component to their online health resource (35.6% vs 24.3%; risk ratio, 1.46; 95% confidence interval, 1.00-2.20; P = .0433), be influenced by others in their choice of a gynecologist (0.37 vs 0.32 on a scale of 0 to 1; P = .009), use socialmedia as a coping tool (38.3% vs 17%; P = .0001), trust information found on social media (31.4% vs 16.7%; P = .0033), and trust other women with the same condition, informal health resources, and personal sources more and doctors and formal health resources less (P = .0083). Participants in both groups reported higher levels of social media engagement with higher levels of symptom bother (28% increase in engagement with every doubling of bother level (P<.0001). CONCLUSION: Patients with gynecologic pain were more likely than those without pain to use social media and the Internet to understand and manage their condition. Patients with pain engaged in and trusted social media at a higher level, with engagement rising directly with bother level.

Definitive treatment of previable pregnancy with morbidly adherent placenta is typically gravid hysterectomy via laparotomy. We describe minimally invasive surgical techniques to these complicated cases utilizing laparoscopy. Retrospective case series from a single academic institution. After obtaining IRB approval, we searched our electronic medical record for ICD-10-CM diagnosis codes descriptive of morbidly adherent placenta in the first or second trimester (O43.211-232) from 2008 to 2020. Data was extracted and a descriptive summary reported. We identified four cases of planned laparoscopic gravid hysterectomy performed from 2017 to 2019 (see Table). All cases were within the second trimester (range 15 to 20 weeks) and the majority (n=3) had pathologic evidence of placental invasion. Median estimated blood loss was 1750mL (range 1000 to 3500mL). Median operative time was 3.3 hours. Three patients required blood transfusion. Surgical technique was consistent with a standard laparoscopic total hysterectomy with the following adjustments: pregnancy tissue was evacuated from the uterus after occlusion of the uterine blood supply to allow for vaginal extraction of the uterus. In two cases, standard dilation and evacuation technique was used prior to colpotomy through cervical dilation (n=1) or cervical transection (n=1). In two cases, pregnancy tissue was evacuated within a specimen retrieval bag after colpotomy via hysterotomy (n=1) or cervical transection (n=1).Tabled 1PregnancyPrior # of Cesarean SurgeriesSurgical TeamPathologic DiagnosisEstimated Blood Loss (mL)Operative Time (hh:mm)ComplicationsDischarged HomeCase 1IUP @ 20w5d with fetal anomalies0*Gyn-Onc, FPAccreta100003:15NonePOD#1Case 2IUP @ 20w5d with vaginal bleeding3Gyn-Onc, FP, MFMPercreta150003:22Blood transfusionPOD#2Case 3Fetal demise measuring 15w2d with fetal anomalies5MIGS, FPImplantation at cesarean scar200004:21Blood transfusionPOD#2Case 4IUP @ 19w2d with fetal anomalies1Gyn-Onc, GYN, FPIncreta350002:52Blood transfusionPOD#1* History of Asherman SyndromeIUP=Intrauterine pregnancy; w=weeks; d=days; Gyn-Onc=gynecologic oncologist; FP=family planning; MFM=maternal fetal medicine; MIGS=minimally invasive gynecologic surgeon; GYN=gynecologic surgeon; mL=milliliter; hh:mm=hours:minutes; POD=postoperative day Open table in a new tab * History of Asherman Syndrome IUP=Intrauterine pregnancy; w=weeks; d=days; Gyn-Onc=gynecologic oncologist; FP=family planning; MFM=maternal fetal medicine; MIGS=minimally invasive gynecologic surgeon; GYN=gynecologic surgeon; mL=milliliter; hh:mm=hours:minutes; POD=postoperative day Laparoscopic gravid hysterectomy is feasible in the setting of second trimester abnormal placentation. This approach appears to be safe, with the major complication in our series being need for blood transfusion. This option is recommended only with appropriate surgical expertise and careful surgical planning utilizing a multi-disciplinary team.

Endometriosis is a prevalent disease associated with significant cost; over $49 billion in medical costs is spent annually in the United States (US) alone. Limited data exist on the cost-effectiveness of various clinical regimens to guide management. We sought to determine which sequence of therapies would be most cost-effective for the treatment of endometriosis-related pain. We built a cost-effectiveness model using TreeAge Pro software to compare four distinct, stepwise strategies in the management of endometriosis-related pain (Figure 1). We compared: (Strategy 1) nonsteroidal anti-inflammatory drugs (NSAIDs) followed by surgery; (Strategy 2) NSAIDs, then short acting reversible contraceptives (SARCs) or long acting reversible contraceptives (LARCs) followed by surgery; (Strategy 3) NSAIDs, then SARCs/LARCs, then gonadotropin releasing hormone (GnRH) agonists or GnRH antagonists followed by surgery; (Strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. We adopted the societal perspective and modeled outcomes over three years. Our primary outcome was the incremental cost-effectiveness ratio (ICER). Secondary outcomes included costs and quality-adjusted-life-years (QALYs). Cohort size was based on the approximate number of women aged 18-45 with dysmenorrhea and/or cyclic pelvic pain in the US. Univariate sensitivity analysis was performed on all model inputs. A tornado diagram was made to identify which variables had the greatest influence on the model. Among a theoretical cohort of 10,018,400 women, all four strategies were cost-effective at a standard willingness to pay threshold of 100,000 per QALY gained (Table 1). Strategy 2 was associated with the lowest cost per QALY gained (ICER of $803). If all women received a trial of GnRH agonist after failing hormonal contraception (strategy 3 versus 2), the total cost would be $10 billion with a gain of 554,575 QALYs. For a routine trial of GnRH agonists to be the preferred strategy after failing hormonal contraception, rather than surgery, the cost of GnRH agonists would have to be less than 80% of their current cost. Our tornado diagram identified the probability of improvement with surgery as a key input. The probability of cure with surgery would need to exceed 82% for it to be the preferred first line treatment method. While care must be individualized, our findings suggest that stepwise treatment with more than one medical modality prior to surgery is a cost-effective approach to endometriosis management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND: Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort. OBJECTIVE: The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy. STUDY DESIGN: We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization. RESULTS: There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6 +/- 2.5 vs acetaminophen 4.4 +/- 2.5; P=.07) and up to 24 hours (placebo 3.3 +/- 2.4 vs acetaminophen 3.6 +/- 2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4 +/- 3.9 vs acetaminophen 3.3 +/- 4.0; P=.06), post anesthesia care unit (placebo 10.5 +/- 10.3 vs acetaminophen 9.7 +/- 10.3; P=.59), and up to 24 hours after surgery (placebo 1.4 +/- 2.0 vs acetaminophen 1.6 +/- 2.1; P=.61). There were no differences in demographics or surgical data between groups. CONCLUSION: There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

Objective: To describe patient demographics, determine accuracy of clinical diagnosis, and evaluate reliability of laparoscopic uterine characteristics in the diagnosis of adenomyosis. Materials and Methods: Enrollment included 117 patients undergoing laparoscopic hysterectomy for benign indications. Intraoperatively, the attending surgeon predicted uterine weight; evaluated the presence of fibroids; and commented on the uterus' shape, color, and consistency while probing it with a blunt instrument. A prediction was also made about whether final pathology would reveal adenomyosis. Standardized video recordings were obtained at the start of the case. Each video was viewed retrospectively twice by three expert surgeons in a blinded fashion. Uterine characteristics were reported again with a prediction of whether or not there would be a pathologic diagnosis of adenomyosis. These data were used to calculate inter-and intrarater reliability of diagnosis. Results: Women with adenomyosis were more likely to complain of midline pain as opposed to lateral or diffuse pain (p = 0.048) with no difference in the timing of the pain (p = 0.404), compared to patients without adenomyosis. Uterine tenderness on examination was not an accurate predictor of adenomyosis (p = 0.566). Preoperative diagnosis of adenomyosis by clinicians was poor, with an accuracy rate of 51.7%. None of the intraoperative uterine characteristics were significant for predicting adenomyosis on final pathology, nor was any combination of the features (p = 0.546). Retrospective video reviews failed to reveal any uterine characteristics that generated consistent inter- or intrarater reliability (Krippendorff's α < 0.7) in making the diagnosis of adenomyosis. Conclusions: Clinical and video diagnosis of adenomyosis have low accuracy with no uterine characteristics consistently or reliably predicting adenomyosis on final pathology. (J GYNECOL SURG 34:183).

OBJECTIVE: The objective of the study was to review patient characteristics and intraoperative findings for excised cases of abdominal wall endometriosis (AWE).STUDY DESIGN: A 12 year medical record search was performed for cases of excised AWE, and the diagnosis was confirmed on pathological specimen. Descriptive data were collected and analyzed.RESULTS: Of 65 patients included, the primary clinical presentation was abdominal pain and/or a mass/lump (73.8% and 63.1%, respectively). Most patients had a history of cesarean section (81.5%) but 6 patients (9.2%) had no prior surgery. Time from the initial surgery to presentation ranged from 1 to 32 years (median, 7.0 years), and time from the most recent relevant surgery ranged from 1 to 32 years (median, 4.0 years). Five patients (7.7%) required mesh for fascial closure following the resection of the AWE. We were unable to demonstrate a correlation between the increasing numbers of open abdominal surgeries and the time to presentation or depth of involvement. Age, body mass index, and parity also were not predictive of depth of involvement. There were increased rates of umbilical lesions (75% vs 5.6%, P < .001) in nulliparous compared with multiparous women as well as in women without a history of cesarean section (66.7% vs 1.9%, P < .001).CONCLUSION: In women with a mass or pain at a prior incision, the differential diagnosis should include AWE. Although we were unable to demonstrate specific characteristics predictive for AWE, a large portion of our population had a prior cesarean section, suggesting a correlation.