Katherine O'Hanlan - Academia.edu (original) (raw)
Papers by Katherine O'Hanlan
Epidemiology, 2001
A recent report from the Institute of Medicine recommends more methodologic and substantive resea... more A recent report from the Institute of Medicine recommends more methodologic and substantive research on the health of lesbians. This study addresses one methodologic topic identified in the Institute of Medicine report and by a subsequent scientific workshop on lesbian health: the definition and assessment of sexual orientation among women. Data are from the Women Physicians' Health Study, a questionnaire-based U.S. probability sample survey (N ϭ 4,501). The two items on sexual orientation (current self-identity and current sexual behavior) had a high response rate (96%), and cross-tabulation of responses indicated several combinations of identity and behavior. Three conceptually different definitions of "lesbian" are compared on the basis of (1) identity only, (2) sexual behavior only, and (3) both identity and sexual behavior. Suggestions and cautions are given to researchers who will add items on sexual orientation to new or ongoing research on women's health. (Epidemiology 2001;12:109-113
Obstetrics & Gynecology, Dec 1, 2003
This retrospective review of patients undergoing total laparoscopic hysterectomy examines whether... more This retrospective review of patients undergoing total laparoscopic hysterectomy examines whether differences in outcomes exist on the basis of body mass index (BMI). METHODS: All cases of total laparoscopic hysterectomy performed from September 1996 to July 2002 for benign diagnoses, and microinvasive cervical, early endometrial, and occult ovarian carcinoma were reviewed. There were 330 patients analyzed by BMI category (range, 18.5-54.1): ideal (n ؍ 150) less than 24.9 kg/m 2 , overweight (n ؍ 95) 25 to 29.9 kg/m 2 , and obese (n ؍ 78) 30 kg/m 2 or more. Seven patients were converted to laparotomy (four ideal BMI, two overweight, one obese) leaving 323 (98%) for analysis. Mean age (50 years), height (65 in.), and parity (1.2) were similar, with 39% nulligravidas in each group. RESULTS: Mean operating time (156 minutes), blood loss (160 mL), and length of hospital stay (1.9 days) did not vary by BMI group. Total complication rates (8.9%), and major (5.5%) and minor (3.4%) complication rates were similar in each BMI group. Urologic injury was observed in 3.1%, with two-thirds occurring in the first one-third of the patient series. CONCLUSION: Total laparoscopic hysterectomy is feasible and safe, resulting in short hospital stay, minimal blood loss, and minimal operating time for patients in all BMI groups. The laparoscopic approach may extend the benefits of minimally invasive hysterectomy to the very obese, for whom abdominal surgery poses serious risk.
Gynecologic Oncology, Dec 1, 1994
Complete hydatidiform mole has a substantial risk of developing persistent gestational trophoblas... more Complete hydatidiform mole has a substantial risk of developing persistent gestational trophoblastic disease (PTD). Whether heterozygous complete moles, arising from dispermy, have a higher risk of such progression than their homozygous counterparts is controversial. In this study, the frequency of heterozygous XY complete mole in 93 consecutive cases of histologically proven complete moles managed in Hong Kong was assessed by the technique of chromosome in situ hybridization (CISH) using DNA probes specific for the short arm of the Y chromosome. The incidence of Y-chromosome positive complete mole in the groups of patients with spontaneous remissions and the group with PTD with or without metastasis was also compared. The presence of Y chromosome was identified in 6 of the 93 cases (6.5%), and this incidence fell within the range reported in the world literature. Of these 93 patients, 5 patients defaulted follow-up, while 10 patients developed PTD, with evidence of metastasis in 2 of them. The presence of Y chromosome was also assessed in another 15 patients with documented metastatic PTD. It was found that CISH signals for Y chromosome were identified in 5.1% (4/78) of complete moles with spontaneous remission and 8% (2/25) with PTD with or without metastasis (P > 0.05). Y chromosome was detected in 5.9% (1/17) of the complete moles that developed metastasis and in 5.8% (5/86) of the complete moles that either developed spontaneous remission or developed nonmetastatic PTD (P > 0.05). There is no correlation between the presence of Y chromosome and development of persistent gestational trophoblastic disease.
Gynecologic Oncology, Jul 1, 2013
Background: As endovascular treatment of asymptomatic infrarenal abdominal aortic aneurysm (AAA) ... more Background: As endovascular treatment of asymptomatic infrarenal abdominal aortic aneurysm (AAA) increasingly competes with surgical repair, it is necessary to optimize the surgical technique. The aim of this study was therefore to evaluate the superiority of either retroperitoneal (RP) or transperitoneal (TP) approach. Patients and methods: Intra-and peri-operative data from 80 patients with infrarenal AAA and tube graft repair were analysed retrospectively. The RP-approach was used in 37 patients and in 43 the transperitoneal. Results: There was no relevant difference in demographic data and anaesthetic regime; exceptions were differences between the two groups in terms of age (median RP 72.31 vs. TP 68.58 years, p = 0.0174), hypertension (RP 26/37 vs. TP 40/43, p = 0.0019), smoking (RP 25/37 vs. TP 38/43, p = 0.0462), pulmonary diseases (RP 15/37 vs. TP 7/43, p = 0.0232), and previous abdominal surgery (RP 3/37 vs. TP 12/43, p = 0.042). No patient died during the first 30 post-operative days. The RP-group had a longer cross-clamping time (median RP 50 vs. TP 45 min, p = 0.0115) but no difference was found in operating time. Intra-operative blood loss was higher in the RP-group (median RP 800 vs. TP 500 ml, p = 0.033) with an increased need for blood substitutes (median RP 1 vs. TP 0 packed red cells, p = 0.0068). Time spent in ICU was shorter (median RP 24 vs. TP 46 hours, p = 0.0104), but duration of hospitalisation was longer for the RP-group (median RP 13 vs. TP 10.5 days, p = 0.0156). No differences were found in the need for analgesics, the frequency of procedure related complications, and post-operative recovery. Conclusions: Surgical repair of AAA in selected patients by tube graft placement is a safe procedure independent of the approach. In particular, our findings do not support previously reported superiority of the RP-approach.
Gynecologic Oncology, Jul 1, 2013
, mean body mass index was 28.3 (range, 17.2-50). The median number of pelvic, IM, and IR nodes h... more , mean body mass index was 28.3 (range, 17.2-50). The median number of pelvic, IM, and IR nodes harvested was 24 (range, 1-32), 11 (range, 1-26), and 14 (range, 1-28), respectively. There was no difference in procedures or nodal yields between the 3 primaries, so all were considered together. Lymph node metastasis was found in 34 (21%) patients: 29/163 (18%) pelvic, 18/82 (22%) IM, and 13/71 (18%) IR. Among the 29 with positive pelvic nodes, 15 (52%) had positive aortic nodes, 13 (45%) had positive IM nodes, and 11 (38%) had positive IR nodes. Among the 134 with negative pelvic nodes, 5 (4%) had positive aortic nodes, 4 (5%) had positive IM nodes, and 2 (1.5%) had positive IR nodes. Among the 17 with positive IM nodes, 13 (76%) had positive pelvic nodes and 10 (59%) had positive IR nodes. Among the 13 with positive IR nodes, only 2 had negative IM nodes, and 2 had negative pelvic nodes. Ten of 13 with positive IR nodes had high-grade endometrial carcinoma. The rate of nodal metastasis increased significantly with the number of nodes harvested (95% CI 0.093-0.26, P b 0.0001). A total of 7/34 (21%) of stage IB cervical cancer patients, 23/95 (24%) stage I or II endometrial cancer patients, and 4/34 (12%) patients with ovarian/tubal carcinoma were upstaged from lymphadenectomy alone. Conclusions: Comprehensive laparoscopic lymphadenectomy for early pelvic carcinomas is feasible, with acceptable nodal yields. Nodal metastasis was identified up to the renal vessels in 18% of cases, most often when the pelvic and inframesenteric nodes were involved. Obtaining more nodes resulted in higher rates of upstaging and more appropriately aggressive therapy.
Journal of Minimally Invasive Gynecology, Nov 1, 2012
Pelvic congestion syndrome is characterized by chronic pelvic pain worsened with prolonged standi... more Pelvic congestion syndrome is characterized by chronic pelvic pain worsened with prolonged standing, activity and intercourse. The incidence is up to 30% when no other cause of pain can be diagnosed. The etiology appears to be due to lack of valve function in the gonadal vein leading to reflux and dilatation. Surgical ligation of the gonadal veins has been associated with 75% improvement in pain. We present a novel approach in identifying the gonadal veins by utilizing a fluorescence-capable endoscope when injected with an FDA approved dye, called Indocynine Green. The advantages of this technique are demonstrated in this video. 283 Open Communications 17dLaparoscopy (3:20 PM d 3:25 PM)
Journal of Minimally Invasive Gynecology, Nov 1, 2019
Patients or Participants: 100 patients undergoing laparoscopic hysterectomy for benign indication... more Patients or Participants: 100 patients undergoing laparoscopic hysterectomy for benign indications were recruited between January 2018 and February 2019. Interventions: Patients were randomized to receive a SHPB (n = 50) or no block (n = 50) at the start of laparoscopic hysterectomy. The block contained 10 mL of 0.25% bupivacaine injected in the presacral space. Measurements and Main Results: The proportion of patients with a mean VAS (visual analogue scale) pain score less than 4 within 2 hours postoperatively was defined a priori as the primary outcome and compared between the groups. An intention to treat analysis was performed. Patients in the SHPB group were 1.6-times more likely to have a mean VAS < 4 within 2 hours postoperatively compared to women in the no block group (52.0% of women in the block group compared to 40.0% in the no block group), however this did not reach statistical significance (OR 1.63, 95% CI 0.74 to 3.59). Patients in the SHPB group were significantly more likely to have a mean VAS < 4 within 1 hour postoperatively (OR 2.90, 95% CI 1.29 to 6.53). Total postoperative opioid use within four hours postoperatively, total recovery unit time, and hospital length of stay were no different between the two groups. Mean daily VAS pain scores were also no different for one week postoperatively. Conclusion: SHPB reduces immediate postoperative pain after laparoscopic hysterectomy however this effect does not extend to two hours postoperatively. SHPB does not impact opioid consumption, long-term pain, or recovery unit time.
Gynecologic Oncology, Apr 1, 2015
Objectives: The purpose of this study was to determine if patients undergoing minimally invasive ... more Objectives: The purpose of this study was to determine if patients undergoing minimally invasive gynecologic surgery would benefit from preemptive analgesics. Methods: This was an institutional review board-approved, doubleblind, randomized study. The 183 subjects were randomly allocated to the following: 1) placebo local injection, treatment transversus abdominis plane block (TAP), 2) treatment local injection, placebo TAP, or 3) treatment local injection, treatment TAP. The primary outcome measurement was pain, recorded using a visual analog scale (0-10) at 1, 6, and 24 h after arriving in postoperative care unit. Secondary measurements were time until first request for pain medication and narcotic usage. Demographics, pain scores, and related measures were described using means and standard deviation for continuous variables or medians and interquartile ranges for nonnormal distributions. A Kruskal Wallis test with pairwise comparisons and Dunn adjustment was performed to compare differences in pain scores between treatment arms at each time point. Time to first request was summarized using Kaplan-Meier survival curves and differences by treatment arm was assessed using the log rank test. A mixed methods model (both fixed and random effects) was fit to account for intrasubject correlation and pain scores over time. Results: Analysis using median pain scores showed a statically significant difference at 1 h postoperatively. Specifically, pain in the treatment local, placebo TAP arm was twice that of the placebo local, treatment TAP arm (P = 0.03). There was no difference in time to first request for pain medications among the different arms based on log rank test (P = 0.60). In mixed modeling, the random intercept model for reported pain scores showed that increasing time from surgery was significantly associated with decreasing pain scores (−0.032, P b 0.001) and that increasing morphine requirements was associated with increased pain scores (0.09, P b 0.001). There was no significant difference in mean pain scores between treatment arms (P = 0.61) adjusting for age, body mass index, surgical time, or morphine usage. The addition of a random slope model did not provide better fit (P = 0.28). Conclusions: We should explore earlier time points immediately after surgery because pain scores are improved, and a more complex mixed model may demonstrate a statistical significance.
Journal of Minimally Invasive Gynecology, Nov 1, 2010
Gynecologic Oncology, Apr 1, 2015
Journal of Minimally Invasive Gynecology, Nov 1, 2011
Gynecologic Oncology, 1989
One of the few books on menopause not written by a man, here is the first book to provide all the... more One of the few books on menopause not written by a man, here is the first book to provide all the information women need to make an informed choice about Hormone Replacement Therapy (HRT). Its message is that HRT carries significant health risks and should be taken by menopausal women only as a last resort.
AORN Journal, Apr 25, 2013
The vulva and vaginal interior are considered a contaminated surgical area, and current OR guidel... more The vulva and vaginal interior are considered a contaminated surgical area, and current OR guidelines require surgeons who are gloved and gowned at the abdominal field to avoid contact with the urethral catheter, the uterine manipulator, and the introitus or to change their gloves and even regown if contact occurs. It is our belief that the perception of the vaginal field as contaminated reflects a lack of specific standards for the preoperative cleansing of the deeper vagina and a lack of preoperative prep instructions for the combined fields. We developed a comprehensive single-field prep technique designed to improve surgical efficiency and prevent contamination of the sterile field. Combining a methodical scrub, prep, and dwell, this technique allows the entire abdomino-perineovaginal field to be treated as a single sterile field for laparoscopic procedures. Our surgical site infection rate of 1.8% when using this single-field prep technique and the subsequent surgical treatment of the abdominal, vaginal, and perineal fields as a single sterile field is well within reported norms.
Gynecologic Oncology, 1989
Journal of Gynecologic Surgery, Jun 1, 2015
Background: With more laparoscopic hysterectomies being performed for increasingly large uteri, p... more Background: With more laparoscopic hysterectomies being performed for increasingly large uteri, prediction of surgical outcomes is becoming more important. There is a paucity of information regarding preoperative predictors of surgical outcomes in the large uterus that could be helpful in perioperative planning. Objective: The aim of this research was to examine the predictive value of ultrasonographically-measured uterine mass on surgical outcomes in total laparoscopic hysterectomy (TLH). Materials and Methods: This was a retrospective exploratory study analyzing surgical outcomes following TLH over a 15-year period. Subjects were recruited in four San Francisco area hospitals. For 1004 patients, data were collected regarding demographics, ultrasonographically measured uterine volumes, and surgical outcomes (operative time, estimated blood loss [EBL], length of hospital stay, and postoperative uterine mass). Uterine mass was calculated using the prolate ellipsoid formula and a volume-to-mass conversion formula. Results: The median patient age was 48 (range 15-90), the median body mass index was 26.0 (range: 16.3-70.5), and the median parity 1 (range: 0-9). As ultrasoundpredicted uterine mass increased, both median operative time (97-141 minutes; p < 0.05), and median EBL (50-150 mL; p < 0.05) increased. Incidence of blood transfusion increased by 140% (1.5%-3.6%; p < 0.05). Median length of hospital stay was 1 (range: 0-13) and similar among all groups. The Spearman correlation between ultrasonographically measured uterine volume and actual uterine mass was 0.867 (p < 0.05). Conclusions: Increasing ultrasonographically-measured uterine mass correlated with postoperative uterine mass and predicted increasing operative times and EBL for patients undergoing TLH. Length of hospital stay was unaffected. These data suggest that preoperative ultrasound measurements are beneficial for surgical planning of TLH.
Gynecological Surgery, Jul 24, 2009
We report two cases of use of a single umbilical skin incision for a type 7 total laparoscopic hy... more We report two cases of use of a single umbilical skin incision for a type 7 total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy. This study is a retrospective chart review and discussion of two patients who underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy (Canadian Task Force Level III). Both patients underwent a type 7 total laparoscopic hysterectomy for benign indications in July 2007 and sustained no complications. The evidence from these two cases suggests that advanced laparoscopic procedures are possible using a single skin incision for multiple ports. Technological advances, including those in port structure, are needed to enable surgeons to employ strategies that effectively enhance instrument coordination and suturing. Benefits to the patient need to be documented prospectively before this procedure can be recommended widely.
Gynecologic Oncology, Aug 1, 1989
In the field of gynecologic oncology, surgical intervention has lege of Medicine from July 1985 t... more In the field of gynecologic oncology, surgical intervention has lege of Medicine from July 1985 to July 1987. Analysis been the traditional management of postoperative abdominal of these cases is reported in this paper. hemorrhage. Recently, arterial embolization has been reported to effectively control vaginal hemorrhage associated with gynecologic malignancy, obstetrical trauma, and hysterectomy. This study reports the use of arteriographic embolization in the management of six cases of postoperative abdominal and retroperitoneal arterial hemorrhage. Analysis of these cases provides valuable information which enhances the safety and efficacy of this procedure. Results suggest that arterial embolization, by an experienced arteriographer, should be considered early in the postoperative management of abdominal hemorrhage in gynecology and gynecologic oncology.
Journal of Minimally Invasive Gynecology, Mar 1, 2012
Type VII laparoscopic hysterectomy is classified as a ''clean-contaminated'' procedure because th... more Type VII laparoscopic hysterectomy is classified as a ''clean-contaminated'' procedure because the surgery involves contact with both the abdominal and vaginal fields. Because the vulva has traditionally been perceived as a separate but contaminated field, operating room guidelines have evolved to require that surgeons gloved and gowned at the abdominal field either avoid contact with the urethral catheter, the uterine manipulator, and the introitus or change their gloves and even re-gown after any contact with those fields. In the belief that the perception of the vaginal field as contaminated stems from inadequate preoperative preparation instructions, we have developed a rigorous abdomino-perineo-vaginal field preparation technique to improve surgical efficiency and prevent surgical site infections. This thorough scrub, preparation, and dwell technique enables the entire abdomino-perineo-vaginal field to be safely treated as a single sterile field while maintaining a low rate of surgical site infection, and should be further investigated in randomized studies. Journal of Minimally Invasive Gynecology (2012)- ,-Ó 2012 AAGL. All rights reserved.
Gynecologic Oncology, Nov 1, 2015
Compare two approaches for laparoscopic infrarenal lymphadenectomy. Retrospective chart review. S... more Compare two approaches for laparoscopic infrarenal lymphadenectomy. Retrospective chart review. Statistical analyses with SPSS. 4 stage II/III cervical carcinoma, 75 clinical stage I/II endometrial carcinoma, 36 clinically stage I/II tubal/ovarian cancer. 36 transperitoneal approaches; 79 extraperitoneal approaches. Both groups had similar age, 58years (range 29-80), BMI of 25 (range 18-41), blood loss, 150cm(3) (range 25-1500), and hospital stay, 1day (range 1-6). The extraperitoneal surgery took longer (240 v 202min; p=.001); yielded more nodes (50 v 41; p=.004). Extraperitoneal approach yielded more inframesenteric (14 v 10; p=.036), and infrarenal nodes (14 v 9; p=.001). 25% of cervical, 19% of endometrial and 14% of ovarian cancer patients had metastases in radiographically negative infrarenal nodes. 50% of cervical, 33% of endometrial and 17% of ovarian cancer patients had therapy altered by aortic lymphadenectomy. When the inframesenteric nodes were positive, 63% of endometrial and 80% of ovarian cancer patients had infrarenal metastases. More metastases were identified with increasing aortic node count. Extraperitoneal lymphadenectomy had no learning curve (p=0.320), while transperitoneal lymphadenectomy did (p=0.016). Higher BMI patients had lower aortic node yields by transperitoneal (p=.057) but not extraperitoneal approach (p=.578). Among the 14 patients whose BMI was 35-41, mean extraperitoneal total aortic nodal yield was 30; transperitoneal yield was 6. Infrarenal aortic lymphadenectomy may offer higher aortic nodal yields, even in patients with BMI&amp;amp;amp;#39;s of 45. Larger prospective studies are needed to confirm whether this dissection in high-risk patients ensures more accurate therapy, and possibly improves cure rates.
Epidemiology, 2001
A recent report from the Institute of Medicine recommends more methodologic and substantive resea... more A recent report from the Institute of Medicine recommends more methodologic and substantive research on the health of lesbians. This study addresses one methodologic topic identified in the Institute of Medicine report and by a subsequent scientific workshop on lesbian health: the definition and assessment of sexual orientation among women. Data are from the Women Physicians' Health Study, a questionnaire-based U.S. probability sample survey (N ϭ 4,501). The two items on sexual orientation (current self-identity and current sexual behavior) had a high response rate (96%), and cross-tabulation of responses indicated several combinations of identity and behavior. Three conceptually different definitions of "lesbian" are compared on the basis of (1) identity only, (2) sexual behavior only, and (3) both identity and sexual behavior. Suggestions and cautions are given to researchers who will add items on sexual orientation to new or ongoing research on women's health. (Epidemiology 2001;12:109-113
Obstetrics & Gynecology, Dec 1, 2003
This retrospective review of patients undergoing total laparoscopic hysterectomy examines whether... more This retrospective review of patients undergoing total laparoscopic hysterectomy examines whether differences in outcomes exist on the basis of body mass index (BMI). METHODS: All cases of total laparoscopic hysterectomy performed from September 1996 to July 2002 for benign diagnoses, and microinvasive cervical, early endometrial, and occult ovarian carcinoma were reviewed. There were 330 patients analyzed by BMI category (range, 18.5-54.1): ideal (n ؍ 150) less than 24.9 kg/m 2 , overweight (n ؍ 95) 25 to 29.9 kg/m 2 , and obese (n ؍ 78) 30 kg/m 2 or more. Seven patients were converted to laparotomy (four ideal BMI, two overweight, one obese) leaving 323 (98%) for analysis. Mean age (50 years), height (65 in.), and parity (1.2) were similar, with 39% nulligravidas in each group. RESULTS: Mean operating time (156 minutes), blood loss (160 mL), and length of hospital stay (1.9 days) did not vary by BMI group. Total complication rates (8.9%), and major (5.5%) and minor (3.4%) complication rates were similar in each BMI group. Urologic injury was observed in 3.1%, with two-thirds occurring in the first one-third of the patient series. CONCLUSION: Total laparoscopic hysterectomy is feasible and safe, resulting in short hospital stay, minimal blood loss, and minimal operating time for patients in all BMI groups. The laparoscopic approach may extend the benefits of minimally invasive hysterectomy to the very obese, for whom abdominal surgery poses serious risk.
Gynecologic Oncology, Dec 1, 1994
Complete hydatidiform mole has a substantial risk of developing persistent gestational trophoblas... more Complete hydatidiform mole has a substantial risk of developing persistent gestational trophoblastic disease (PTD). Whether heterozygous complete moles, arising from dispermy, have a higher risk of such progression than their homozygous counterparts is controversial. In this study, the frequency of heterozygous XY complete mole in 93 consecutive cases of histologically proven complete moles managed in Hong Kong was assessed by the technique of chromosome in situ hybridization (CISH) using DNA probes specific for the short arm of the Y chromosome. The incidence of Y-chromosome positive complete mole in the groups of patients with spontaneous remissions and the group with PTD with or without metastasis was also compared. The presence of Y chromosome was identified in 6 of the 93 cases (6.5%), and this incidence fell within the range reported in the world literature. Of these 93 patients, 5 patients defaulted follow-up, while 10 patients developed PTD, with evidence of metastasis in 2 of them. The presence of Y chromosome was also assessed in another 15 patients with documented metastatic PTD. It was found that CISH signals for Y chromosome were identified in 5.1% (4/78) of complete moles with spontaneous remission and 8% (2/25) with PTD with or without metastasis (P > 0.05). Y chromosome was detected in 5.9% (1/17) of the complete moles that developed metastasis and in 5.8% (5/86) of the complete moles that either developed spontaneous remission or developed nonmetastatic PTD (P > 0.05). There is no correlation between the presence of Y chromosome and development of persistent gestational trophoblastic disease.
Gynecologic Oncology, Jul 1, 2013
Background: As endovascular treatment of asymptomatic infrarenal abdominal aortic aneurysm (AAA) ... more Background: As endovascular treatment of asymptomatic infrarenal abdominal aortic aneurysm (AAA) increasingly competes with surgical repair, it is necessary to optimize the surgical technique. The aim of this study was therefore to evaluate the superiority of either retroperitoneal (RP) or transperitoneal (TP) approach. Patients and methods: Intra-and peri-operative data from 80 patients with infrarenal AAA and tube graft repair were analysed retrospectively. The RP-approach was used in 37 patients and in 43 the transperitoneal. Results: There was no relevant difference in demographic data and anaesthetic regime; exceptions were differences between the two groups in terms of age (median RP 72.31 vs. TP 68.58 years, p = 0.0174), hypertension (RP 26/37 vs. TP 40/43, p = 0.0019), smoking (RP 25/37 vs. TP 38/43, p = 0.0462), pulmonary diseases (RP 15/37 vs. TP 7/43, p = 0.0232), and previous abdominal surgery (RP 3/37 vs. TP 12/43, p = 0.042). No patient died during the first 30 post-operative days. The RP-group had a longer cross-clamping time (median RP 50 vs. TP 45 min, p = 0.0115) but no difference was found in operating time. Intra-operative blood loss was higher in the RP-group (median RP 800 vs. TP 500 ml, p = 0.033) with an increased need for blood substitutes (median RP 1 vs. TP 0 packed red cells, p = 0.0068). Time spent in ICU was shorter (median RP 24 vs. TP 46 hours, p = 0.0104), but duration of hospitalisation was longer for the RP-group (median RP 13 vs. TP 10.5 days, p = 0.0156). No differences were found in the need for analgesics, the frequency of procedure related complications, and post-operative recovery. Conclusions: Surgical repair of AAA in selected patients by tube graft placement is a safe procedure independent of the approach. In particular, our findings do not support previously reported superiority of the RP-approach.
Gynecologic Oncology, Jul 1, 2013
, mean body mass index was 28.3 (range, 17.2-50). The median number of pelvic, IM, and IR nodes h... more , mean body mass index was 28.3 (range, 17.2-50). The median number of pelvic, IM, and IR nodes harvested was 24 (range, 1-32), 11 (range, 1-26), and 14 (range, 1-28), respectively. There was no difference in procedures or nodal yields between the 3 primaries, so all were considered together. Lymph node metastasis was found in 34 (21%) patients: 29/163 (18%) pelvic, 18/82 (22%) IM, and 13/71 (18%) IR. Among the 29 with positive pelvic nodes, 15 (52%) had positive aortic nodes, 13 (45%) had positive IM nodes, and 11 (38%) had positive IR nodes. Among the 134 with negative pelvic nodes, 5 (4%) had positive aortic nodes, 4 (5%) had positive IM nodes, and 2 (1.5%) had positive IR nodes. Among the 17 with positive IM nodes, 13 (76%) had positive pelvic nodes and 10 (59%) had positive IR nodes. Among the 13 with positive IR nodes, only 2 had negative IM nodes, and 2 had negative pelvic nodes. Ten of 13 with positive IR nodes had high-grade endometrial carcinoma. The rate of nodal metastasis increased significantly with the number of nodes harvested (95% CI 0.093-0.26, P b 0.0001). A total of 7/34 (21%) of stage IB cervical cancer patients, 23/95 (24%) stage I or II endometrial cancer patients, and 4/34 (12%) patients with ovarian/tubal carcinoma were upstaged from lymphadenectomy alone. Conclusions: Comprehensive laparoscopic lymphadenectomy for early pelvic carcinomas is feasible, with acceptable nodal yields. Nodal metastasis was identified up to the renal vessels in 18% of cases, most often when the pelvic and inframesenteric nodes were involved. Obtaining more nodes resulted in higher rates of upstaging and more appropriately aggressive therapy.
Journal of Minimally Invasive Gynecology, Nov 1, 2012
Pelvic congestion syndrome is characterized by chronic pelvic pain worsened with prolonged standi... more Pelvic congestion syndrome is characterized by chronic pelvic pain worsened with prolonged standing, activity and intercourse. The incidence is up to 30% when no other cause of pain can be diagnosed. The etiology appears to be due to lack of valve function in the gonadal vein leading to reflux and dilatation. Surgical ligation of the gonadal veins has been associated with 75% improvement in pain. We present a novel approach in identifying the gonadal veins by utilizing a fluorescence-capable endoscope when injected with an FDA approved dye, called Indocynine Green. The advantages of this technique are demonstrated in this video. 283 Open Communications 17dLaparoscopy (3:20 PM d 3:25 PM)
Journal of Minimally Invasive Gynecology, Nov 1, 2019
Patients or Participants: 100 patients undergoing laparoscopic hysterectomy for benign indication... more Patients or Participants: 100 patients undergoing laparoscopic hysterectomy for benign indications were recruited between January 2018 and February 2019. Interventions: Patients were randomized to receive a SHPB (n = 50) or no block (n = 50) at the start of laparoscopic hysterectomy. The block contained 10 mL of 0.25% bupivacaine injected in the presacral space. Measurements and Main Results: The proportion of patients with a mean VAS (visual analogue scale) pain score less than 4 within 2 hours postoperatively was defined a priori as the primary outcome and compared between the groups. An intention to treat analysis was performed. Patients in the SHPB group were 1.6-times more likely to have a mean VAS < 4 within 2 hours postoperatively compared to women in the no block group (52.0% of women in the block group compared to 40.0% in the no block group), however this did not reach statistical significance (OR 1.63, 95% CI 0.74 to 3.59). Patients in the SHPB group were significantly more likely to have a mean VAS < 4 within 1 hour postoperatively (OR 2.90, 95% CI 1.29 to 6.53). Total postoperative opioid use within four hours postoperatively, total recovery unit time, and hospital length of stay were no different between the two groups. Mean daily VAS pain scores were also no different for one week postoperatively. Conclusion: SHPB reduces immediate postoperative pain after laparoscopic hysterectomy however this effect does not extend to two hours postoperatively. SHPB does not impact opioid consumption, long-term pain, or recovery unit time.
Gynecologic Oncology, Apr 1, 2015
Objectives: The purpose of this study was to determine if patients undergoing minimally invasive ... more Objectives: The purpose of this study was to determine if patients undergoing minimally invasive gynecologic surgery would benefit from preemptive analgesics. Methods: This was an institutional review board-approved, doubleblind, randomized study. The 183 subjects were randomly allocated to the following: 1) placebo local injection, treatment transversus abdominis plane block (TAP), 2) treatment local injection, placebo TAP, or 3) treatment local injection, treatment TAP. The primary outcome measurement was pain, recorded using a visual analog scale (0-10) at 1, 6, and 24 h after arriving in postoperative care unit. Secondary measurements were time until first request for pain medication and narcotic usage. Demographics, pain scores, and related measures were described using means and standard deviation for continuous variables or medians and interquartile ranges for nonnormal distributions. A Kruskal Wallis test with pairwise comparisons and Dunn adjustment was performed to compare differences in pain scores between treatment arms at each time point. Time to first request was summarized using Kaplan-Meier survival curves and differences by treatment arm was assessed using the log rank test. A mixed methods model (both fixed and random effects) was fit to account for intrasubject correlation and pain scores over time. Results: Analysis using median pain scores showed a statically significant difference at 1 h postoperatively. Specifically, pain in the treatment local, placebo TAP arm was twice that of the placebo local, treatment TAP arm (P = 0.03). There was no difference in time to first request for pain medications among the different arms based on log rank test (P = 0.60). In mixed modeling, the random intercept model for reported pain scores showed that increasing time from surgery was significantly associated with decreasing pain scores (−0.032, P b 0.001) and that increasing morphine requirements was associated with increased pain scores (0.09, P b 0.001). There was no significant difference in mean pain scores between treatment arms (P = 0.61) adjusting for age, body mass index, surgical time, or morphine usage. The addition of a random slope model did not provide better fit (P = 0.28). Conclusions: We should explore earlier time points immediately after surgery because pain scores are improved, and a more complex mixed model may demonstrate a statistical significance.
Journal of Minimally Invasive Gynecology, Nov 1, 2010
Gynecologic Oncology, Apr 1, 2015
Journal of Minimally Invasive Gynecology, Nov 1, 2011
Gynecologic Oncology, 1989
One of the few books on menopause not written by a man, here is the first book to provide all the... more One of the few books on menopause not written by a man, here is the first book to provide all the information women need to make an informed choice about Hormone Replacement Therapy (HRT). Its message is that HRT carries significant health risks and should be taken by menopausal women only as a last resort.
AORN Journal, Apr 25, 2013
The vulva and vaginal interior are considered a contaminated surgical area, and current OR guidel... more The vulva and vaginal interior are considered a contaminated surgical area, and current OR guidelines require surgeons who are gloved and gowned at the abdominal field to avoid contact with the urethral catheter, the uterine manipulator, and the introitus or to change their gloves and even regown if contact occurs. It is our belief that the perception of the vaginal field as contaminated reflects a lack of specific standards for the preoperative cleansing of the deeper vagina and a lack of preoperative prep instructions for the combined fields. We developed a comprehensive single-field prep technique designed to improve surgical efficiency and prevent contamination of the sterile field. Combining a methodical scrub, prep, and dwell, this technique allows the entire abdomino-perineovaginal field to be treated as a single sterile field for laparoscopic procedures. Our surgical site infection rate of 1.8% when using this single-field prep technique and the subsequent surgical treatment of the abdominal, vaginal, and perineal fields as a single sterile field is well within reported norms.
Gynecologic Oncology, 1989
Journal of Gynecologic Surgery, Jun 1, 2015
Background: With more laparoscopic hysterectomies being performed for increasingly large uteri, p... more Background: With more laparoscopic hysterectomies being performed for increasingly large uteri, prediction of surgical outcomes is becoming more important. There is a paucity of information regarding preoperative predictors of surgical outcomes in the large uterus that could be helpful in perioperative planning. Objective: The aim of this research was to examine the predictive value of ultrasonographically-measured uterine mass on surgical outcomes in total laparoscopic hysterectomy (TLH). Materials and Methods: This was a retrospective exploratory study analyzing surgical outcomes following TLH over a 15-year period. Subjects were recruited in four San Francisco area hospitals. For 1004 patients, data were collected regarding demographics, ultrasonographically measured uterine volumes, and surgical outcomes (operative time, estimated blood loss [EBL], length of hospital stay, and postoperative uterine mass). Uterine mass was calculated using the prolate ellipsoid formula and a volume-to-mass conversion formula. Results: The median patient age was 48 (range 15-90), the median body mass index was 26.0 (range: 16.3-70.5), and the median parity 1 (range: 0-9). As ultrasoundpredicted uterine mass increased, both median operative time (97-141 minutes; p < 0.05), and median EBL (50-150 mL; p < 0.05) increased. Incidence of blood transfusion increased by 140% (1.5%-3.6%; p < 0.05). Median length of hospital stay was 1 (range: 0-13) and similar among all groups. The Spearman correlation between ultrasonographically measured uterine volume and actual uterine mass was 0.867 (p < 0.05). Conclusions: Increasing ultrasonographically-measured uterine mass correlated with postoperative uterine mass and predicted increasing operative times and EBL for patients undergoing TLH. Length of hospital stay was unaffected. These data suggest that preoperative ultrasound measurements are beneficial for surgical planning of TLH.
Gynecological Surgery, Jul 24, 2009
We report two cases of use of a single umbilical skin incision for a type 7 total laparoscopic hy... more We report two cases of use of a single umbilical skin incision for a type 7 total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy. This study is a retrospective chart review and discussion of two patients who underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy (Canadian Task Force Level III). Both patients underwent a type 7 total laparoscopic hysterectomy for benign indications in July 2007 and sustained no complications. The evidence from these two cases suggests that advanced laparoscopic procedures are possible using a single skin incision for multiple ports. Technological advances, including those in port structure, are needed to enable surgeons to employ strategies that effectively enhance instrument coordination and suturing. Benefits to the patient need to be documented prospectively before this procedure can be recommended widely.
Gynecologic Oncology, Aug 1, 1989
In the field of gynecologic oncology, surgical intervention has lege of Medicine from July 1985 t... more In the field of gynecologic oncology, surgical intervention has lege of Medicine from July 1985 to July 1987. Analysis been the traditional management of postoperative abdominal of these cases is reported in this paper. hemorrhage. Recently, arterial embolization has been reported to effectively control vaginal hemorrhage associated with gynecologic malignancy, obstetrical trauma, and hysterectomy. This study reports the use of arteriographic embolization in the management of six cases of postoperative abdominal and retroperitoneal arterial hemorrhage. Analysis of these cases provides valuable information which enhances the safety and efficacy of this procedure. Results suggest that arterial embolization, by an experienced arteriographer, should be considered early in the postoperative management of abdominal hemorrhage in gynecology and gynecologic oncology.
Journal of Minimally Invasive Gynecology, Mar 1, 2012
Type VII laparoscopic hysterectomy is classified as a ''clean-contaminated'' procedure because th... more Type VII laparoscopic hysterectomy is classified as a ''clean-contaminated'' procedure because the surgery involves contact with both the abdominal and vaginal fields. Because the vulva has traditionally been perceived as a separate but contaminated field, operating room guidelines have evolved to require that surgeons gloved and gowned at the abdominal field either avoid contact with the urethral catheter, the uterine manipulator, and the introitus or change their gloves and even re-gown after any contact with those fields. In the belief that the perception of the vaginal field as contaminated stems from inadequate preoperative preparation instructions, we have developed a rigorous abdomino-perineo-vaginal field preparation technique to improve surgical efficiency and prevent surgical site infections. This thorough scrub, preparation, and dwell technique enables the entire abdomino-perineo-vaginal field to be safely treated as a single sterile field while maintaining a low rate of surgical site infection, and should be further investigated in randomized studies. Journal of Minimally Invasive Gynecology (2012)- ,-Ó 2012 AAGL. All rights reserved.
Gynecologic Oncology, Nov 1, 2015
Compare two approaches for laparoscopic infrarenal lymphadenectomy. Retrospective chart review. S... more Compare two approaches for laparoscopic infrarenal lymphadenectomy. Retrospective chart review. Statistical analyses with SPSS. 4 stage II/III cervical carcinoma, 75 clinical stage I/II endometrial carcinoma, 36 clinically stage I/II tubal/ovarian cancer. 36 transperitoneal approaches; 79 extraperitoneal approaches. Both groups had similar age, 58years (range 29-80), BMI of 25 (range 18-41), blood loss, 150cm(3) (range 25-1500), and hospital stay, 1day (range 1-6). The extraperitoneal surgery took longer (240 v 202min; p=.001); yielded more nodes (50 v 41; p=.004). Extraperitoneal approach yielded more inframesenteric (14 v 10; p=.036), and infrarenal nodes (14 v 9; p=.001). 25% of cervical, 19% of endometrial and 14% of ovarian cancer patients had metastases in radiographically negative infrarenal nodes. 50% of cervical, 33% of endometrial and 17% of ovarian cancer patients had therapy altered by aortic lymphadenectomy. When the inframesenteric nodes were positive, 63% of endometrial and 80% of ovarian cancer patients had infrarenal metastases. More metastases were identified with increasing aortic node count. Extraperitoneal lymphadenectomy had no learning curve (p=0.320), while transperitoneal lymphadenectomy did (p=0.016). Higher BMI patients had lower aortic node yields by transperitoneal (p=.057) but not extraperitoneal approach (p=.578). Among the 14 patients whose BMI was 35-41, mean extraperitoneal total aortic nodal yield was 30; transperitoneal yield was 6. Infrarenal aortic lymphadenectomy may offer higher aortic nodal yields, even in patients with BMI&amp;amp;amp;#39;s of 45. Larger prospective studies are needed to confirm whether this dissection in high-risk patients ensures more accurate therapy, and possibly improves cure rates.