Purpose Patients often undergo repeat surgery for endometriosis, due to recurrent or residual disease. Previous surgery is often considered a risk factor for worse surgical outcome. However, data... Show morePurpose Patients often undergo repeat surgery for endometriosis, due to recurrent or residual disease. Previous surgery is often considered a risk factor for worse surgical outcome. However, data are scarce concerning the influence of subsequent endometriosis surgery. Methods A retrospective study in a centre of expertise for endometriosis was conducted. All endometriosis subtypes and intra-operative steps were included. Detailed information regarding surgical history of patients was collected. Surgical time, intra-operative steps and major post-operative complications were obtained as outcome measures. Results 595 patients were included, of which 45.9% had previous endometriosis surgery. 7.9% had major post-operative complications and 4.4% intra-operative complications. The patient journey showed a median of 3 years between previous endometriosis surgeries. Each previous therapeutic laparotomic surgery resulted on average in 13 additional minutes (p = 0.013) of surgical time. Additionally, it resulted in more frequent performance of adhesiolysis (OR 2.96, p < 0.001) and in a higher risk for intra-operative complications (OR 1.81, p = 0.045), however no higher risk for major post-operative complications (OR 1.29, p = 0.418). Previous therapeutic laparoscopic endometriosis surgery, laparotomic and laparoscopic non-endometriosis surgery showed no association with surgical outcomes. Regardless of previous surgery, disc and segmental bowel resection showed a higher risk for major post-operative complications (OR 3.64, p = 0.017 respectively OR 3.50, p < 0.001). Conclusion Previous therapeutic laparotomic endometriosis surgery shows an association with longer surgical time, the need to perform adhesiolysis, and more intra-operative complications in the subsequent surgery for endometriosis. However, in a centre of expertise with experienced surgeons, no increased risk of major post- operative complications was observed. Show less
Background: Deep Endometriosis (DE) classification studies with Enzian never compared solitary (A, B, C, F), and combinations of anatomical locations (A&B, A&C, B&C, A&B&C), in... Show moreBackground: Deep Endometriosis (DE) classification studies with Enzian never compared solitary (A, B, C, F), and combinations of anatomical locations (A&B, A&C, B&C, A&B&C), in correlation to pain. Therefore, the results of these studies are challenging to translate to the clinical situation.Objectives: We studied pain symptoms and their correlation with the solitary and combinations of anatomical locations of deep endometriosis lesion(s) classified by the Enzian score.Materials and Methods: A prospective multi-centre study was conducted with data from university and non -university hospitals. A total of 419 surgical DE cases were collected with the web-based application called EQUSUM (www.equsum.org).Main outcome measures: Preoperative reported numeric rating scale (NRS) were collected along with the Enzian classification. Baseline characteristics, pain scores, surgical procedure and extent of the disease were also collected.Results: In general, more extensive involvement of DE does not lead to an increase in the numerical rating scale for pain measures. However, dysuria and bladder involvement do show a clear correlation AUC 0.62 (SE 0.04, CI 0.54-0.71, p< 0.01). Regarding the predictive value of dyschezia, we found a weak, but significant correlation with ureteric involvement; AUC 0.60 (SE 0.04, CI 0.53-0.67, p< 0.01).Conclusions:TPain symptoms poorly correlate with anatomical locations of deep endometriosis in almost all pain scores, with the exception of bladder involvement and dysuria which did show a correlation. Also, dyschezia seems to have predictive value for DE ureteric involvement and therefore MRI or ultrasound imaging (ureter and kidney) could be recommended in the preoperative workup of these patients.What's new? Dyschezia might have a predictive value in detecting ureteric involvement. Show less
BackgroundSurgical Process Modelling (SPM) offers the possibility to automatically gain insight in the surgical workflow, with the potential to improve OR logistics and surgical care. Most studies... Show moreBackgroundSurgical Process Modelling (SPM) offers the possibility to automatically gain insight in the surgical workflow, with the potential to improve OR logistics and surgical care. Most studies have focussed on phase recognition modelling of the laparoscopic cholecystectomy, because of its standard and frequent execution. To demonstrate the broad applicability of SPM, more diverse and complex procedures need to be studied. The aim of this study is to investigate the accuracy in which we can recognise and extract surgical phases in laparoscopic hysterectomies (LHs) with inherent variability in procedure time. To show the applicability of the approach, the model was used to automatically predict surgical end-times.MethodsA dataset of 40 video-recorded LHs was manually annotated for instrument use and divided into ten surgical phases. The use of instruments provided the feature input for building a Random Forest surgical phase recognition model that was trained to automatically recognise surgical phases. Tenfold cross-validation was performed to optimise the model for predicting the surgical end-time throughout the procedure.ResultsAverage surgery time is 12827min. Large variability within specific phases is seen. Overall, the Random Forest model reaches an accuracy of 77% recognising the current phase in the procedure. Six of the phases are predicted accurately over 80% of their duration. When predicting the surgical end-time, on average an error of 16 +/- 13min is reached throughout the procedure.Conclusionsp id=ParThis study demonstrates an intra-operative approach to recognise surgical phases in 40 laparoscopic hysterectomy cases based on instrument usage data. The model is capable of automatic detection of surgical phases for generation of a solid prediction of the surgical end-time. Show less
The main objectives of this thesis are to obtain clinically relevant tools to evaluate quality during the introduction of new interventions in laparoscopic hysterectomy (LH) (the most frequently... Show moreThe main objectives of this thesis are to obtain clinically relevant tools to evaluate quality during the introduction of new interventions in laparoscopic hysterectomy (LH) (the most frequently performed advanced gynecological minimally invasive procedure) and to support clinicians to ensure surgical safety by means of process analysis. We performed a Delphi study to achieve consensus on a uniform and multidisciplinary applicable definition. Based on this definition, we described the relevance, evidence and controllability of conversion rate as a means of evaluation in LH. We performed a systematic review with cumulative analysis to evaluate the outcomes of abdominal, laparoscopic and vaginal hysterectomy (VH) in patients with a BMI ≥35kg/m2 and concluded that the feasibility of LH and VH should be considered prior to the abdominal approach to hysterectomy in these patients. Furthermore, we performed a prospective study using video observation, to assess the incidence and effect of equipment-/instrument-related surgical flow disturbances during LH and validated a questionnaire to detect potential safety hazards during the introduction of new interventions in an early stage. Finally, the Digital Operating Room Assistance (DORA) model was introduced which is a novel system for automated procedural progress monitoring that enables prediction of the remaining procedure duration. Show less
BACKGROUND In laparoscopic surgery, conversion to laparotomy is associated with worse clinical outcomes, especially if the conversion is due to a complication. Although apparently important, no... Show moreBACKGROUND In laparoscopic surgery, conversion to laparotomy is associated with worse clinical outcomes, especially if the conversion is due to a complication. Although apparently important, no commonly used definition of conversion exists. The aim of this study was to achieve multidisciplinary consensus on a uniform definition of conversion. METHODS On the basis of definitions currently used in the literature, a web-based Delphi consensus study was conducted among members of all four Dutch endoscopic societies. The rate of agreement (RoA) was calculated; a RoA of >70 % suggested consensus. RESULTS The survey was completed by 268 respondents in the first Delphi round (response rate, 45.6 %); 43 % were general surgeons, 49 % gynecologists, and 8 % urologists. Average ± standard deviation laparoscopic experience was 12.5 ± 7.2 years. On the basis of the results of round 1, a consensus definition was compiled. Conversion to laparotomy is an intraoperative switch from a laparoscopic to an open abdominal approach that meets the criteria of one of the two subtypes: strategic conversion, a standard laparotomy that is made directly after the assessment of the feasibility of completing the procedure laparoscopically and because of anticipated operative difficulty or logistic considerations; and reactive conversion, the need for a laparotomy because of a complication or (extension of an incision) because of (anticipated) operative difficulty after a considerable amount of dissection (i.e., >15 min in time). A laparotomy after a diagnostic laparoscopy (i.e., to assess the curability of the disease) should not be considered a conversion. In the second Delphi round, a RoA of 90 % was achieved with this definition. CONCLUSIONS After two Delphi rounds, consensus on a uniform multidisciplinary definition of conversion was achieved within a representative group of general surgeons, gynecologists, and urologists. An unambiguous interpretation will result in a more reliable clinical registration of conversion and scientific evaluation of the feasibility of a laparoscopic procedure. Show less
Background: To evaluate the implementation and maintenance of advanced laparoscopic skills after a structured mentorship program in laparoscopic hysterectomy (LH). Methods: Cohort retrospective... Show moreBackground: To evaluate the implementation and maintenance of advanced laparoscopic skills after a structured mentorship program in laparoscopic hysterectomy (LH). Methods: Cohort retrospective analysis of 104 successive LHs performed by two gynecologists during and after a mentorship program. LHs were compared for indication, patient characteristics and intraoperative characteristics. As a frame of reference, 94 LHs performed by the mentor were analyzed. Results: With regard to indication, blood loss and adverse outcomes, both trainees performed LHs during their mentorship program comparable with the LHs performed by the mentor. The difference in mean operating time between trainees and mentor was not clinically significant. Both trainees progressed along a learning curve, while operating time remained statistically constant and comparable to that of the mentor. After completing the mentorship program, both gynecologists maintained their acquired skills as blood loss, adverse outcome rates and operating time were comparable with the results during their traineeship. Conclusion: A mentorship program is an effective and durable tool for implementing a new surgical procedure in a teaching hospital with respect to patient safety aspects, as indications, operating time and adverse outcome rates are comparable to those of the mentor in his own hospital during and after completing the mentorship program. Copyright (C) 2010 S. Karger AG, Basel Show less
