The timing of tracheostomy placement may be an important factor in clinical outcomes for pediatric patients with persistent dependence on mechanical ventilatory support following congenital heart surgery. A larger, multi-institution study may help further elucidate our observed clinical findings in this patient population.

Background and Objectives:To assess the feasibility and safety of minimally invasive hysterectomy for uteri >1 kg.Methods:Clinical and surgical characteristics were collected for patients in an academic tertiary care hospital. Included were patients who underwent minimally invasive hysterectomy by 1 of 3 fellowship-trained gynecologists from January 1, 2009, to July 1, 2015 and subsequently had confirmed uterine weights of 1 kg or greater on pathology report. Both robotic and conventional laparoscopic procedures were included.Results:During the study period, 95 patients underwent minimally invasive hysterectomy with confirmed uterine weight over 1 kg. Eighty-eight percent were performed with conventional laparoscopy and 12.6% with robot-assisted laparoscopy. The median weight (range) was 1326 g (range, 1000–4800). The median estimated blood loss was 200 mL (range, 50–2000), and median operating time was 191 minutes (range, 75–478). Five cases were converted to laparotomy (5.2%). Four cases were converted secondary to hemorrhage and one secondary to extensive adhesions. There were no conversions after 2011. Intraoperative transfusion was given in 6.3% of cases and postoperative transfusion in 6.3% of cases. However, after 2013, the rate of intraoperative transfusion decreased to 1.0% and postoperative transfusion to 2.1%. Of the 95 cases, there were no cases with malignancy.Conclusions:This provides the largest case series of hysterectomy over 1 kg completed by a minimally invasive approach. Our complication rate improved with experience and was comparable to other studies of minimally invasive hysterectomy for large uteri. When performed by experienced surgeons, minimally invasive hysterectomy for uteri >1 kg can be considered feasible and safe.

Operative cost and outcomes between robotic and laparoscopic hysterectomy across different uterine weights. Retrospective cohort study including patients undergoing robotic and laparoscopic hysterectomy for benign disease at an Academic university hospital. One hundred and ninety six hysterectomies were identified (101 robotic versus 95 laparoscopic). Demographic and surgical characteristics were statistically equivalent. Robotic group had a higher body mass index (±SD) (32.9 ± 6.5 versus 30.4 ± 7.1, p 0.012) and more frequent history of adnexal surgery (12.9 versus 4.2%, p 0.031). Laparoscopic group had a higher number of concurrent salpingectomy (81 versus 66.3%, p 0.02). Estimated blood loss did not differ between procedures. Compared to robotic hysterectomies, laparoscopic procedures added 47 min (CI: 31-63 min; p < 0.001) of operative time, costed $1648 more (CI: 500-2797; p = 0. 005) and had triple the odds of having an overnight admission (OR = 2.94 CI: 1.34-6.44; p = 0.007). After stratification of cases by uterine weight, the mean operative time difference between the two groups in uteri between 750 and 1000 g and in uteri >1000 g was 81.3 min (CI: 51.3-111.3, p < 0.0001) and 70 min (CI: 26-114, p < 0.005), respectively, in favor of the robotic group. Mean direct cost difference in uteri between 750 and 1000 g and uteri >1000 g was 1859$ (CI: 629-3090, p < 0.006) and 4509$ (CI: 377-8641, p < 0.004), respectively, also in favor of the robotic group. In expert hands, robotic hysterectomy for uteri weighing more than 750 g may be associated with shorter operative time and improved cost profile.

Intermediate-term patient survival of ECMO following CHS is encouraging. However, neurological impairment and unplanned cardiac reinterventions remain significant concerns. Further delineation of risk factors to improve patient outcomes is warranted.

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Purpose of reviewMinimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic disorders. To date, no formal recommendations have been made in defining a referral system for MIGS. This article reviews the evidence regarding common disorders and procedures and their outcomes, and posits a basis for MIGS referral. Recent findingsIn instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes, and therefore, benefit from the skills of MIGS subspecialists: fibroids --at least five myomas, myoma size at least 9 cm, and suspected myoma weight at least 500 g; endometriosis --presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; hysterectomy -uteri at least 250 g or 12 weeks estimated size, at least three prior laparotomies, obesity, and complex surgical history with suspected adhesive disease. SummaryA referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

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