1. Impact of surgeon training and volume on myomectomy route & outcomes
Impact of surgeon volume on myomectomy route: A multicenter review from the Minimally Invasive Gynecologic Surgery Fellows’ Pelvic Research Network
Patricia J. Mattingly, MD
Stacey Scheib, MD
Kelly Wright, MD
Department of Obstetrics & Gynecology, Division of Gynecologic Specialty Surgery
Impact of surgeon training and volume on myomectomy route & outcomes

2. Disclosures
I have no disclosures.
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3. Background
Uterine leiomyomas are the most common benign tumors of the female genital tract and are clinically evident in approximately 25% of women of reproductive age.1,2
In 2010, approximately 37,134 myomectomies were performed in the United States.3
The annual number of myomectomies performed in the United States is projected to increase to 49,154 by the year
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4. Background
Compared to abdominal myomectomy, laparoscopic myomectomy less blood loss, fewer blood transfusions, less postoperative pain, decreased febrile morbidity, shorter hospital stays and a faster recovery. 4,5,6
No significant difference in risk of fibroid recurrence, major complications and pregnancy and perinatal outcomes.4,5,6
Laparoscopic myomectomy requires advanced laparoscopic skills that not all gynecologic surgeons possess. 5,7,8,9
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5. Background
Surgical outcomes have been shown to be affected by surgeon volume.10,11,12
Surgeon’s hysterectomy volume has been shown to affect surgical approach.11
Laparoscopic hysterectomy complication rates have been directly correlated with surgeon volume.10
There is limited data that examines the association between myomectomy outcomes and surgeon volume and training.
Surgical outcomes, including complication rates, operative times, blood loss, length of hospital stay and resource utilization have been shown to be affected by surgeon volume.10,11,12

6. Objectives Primary Objective
Determine if there is an association between myomectomy route and surgeon volume.
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7. Objectives Secondary Objectives:
Determine if there is an association between myomectomy route and training in a fellowship in minimally invasive gynecologic surgery.
Determine if there is an association between myomectomy perioperative outcomes and surgeon volume and training.
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8. Objectives Hypothesis
A higher proportion of myomectomies are completed laparoscopically when performed by a high-volume gynecologic surgeon or a gynecologic surgeon who has completed a fellowship in minimally invasive gynecologic surgery.
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9. Methods Design: Retrospective cohort study Inclusion:
women 18 years or older
abdominal, laparoscopic or robot-assisted laparoscopic myomectomy for benign indications
July – June
Exclusion:
emergency surgery
women younger than 18 years
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10. Methods Primary outcome:
rates of abdominal and laparoscopic myomectomy
Secondary outcomes:
operative time
route of tissue extraction
intraoperative complication
EBL, blood transfusion
conversion rate
length of hospital stay
pathology diagnosis & size (g)
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11. Methods Surgeon characteristics
major gynecologic surgeries: hysterectomy, myomectomy, endometriosis
Fellowship training
operative time, route of tissue extraction, intraoperative complication, EBL, blood transfusion, conversion rate, length of hospital stay, pathology diagnosis & size (g)
Hospital characteristics
Location, region, size, teaching status
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12. Methods Electronic medical records used to myomectomy by CPT code
Sample size:
CI 95%, 80% power
Assume the proportion of laparoscopic myomectomies by high-volume surgeons is 50% vs 25% for low-volume surgeons
the same size needed is 55
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13. Methods Statistical analysis
Demographic characteristics of the two groups will be analyzed using unpaired Student t tests for continuous variables and X2 or Fisher’s exact test for categorical variables.
Results will be expressed as unadjusted relative risks (RRs) with 95% confidence intervals (CIs).
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14. Timeline & Budget Multicenter Redcap database Recruit sites
Obtain IRB approval
Retrospective chart review
18 months
Budget: $3,000
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15. Thank you Items for Discussion Surgeon volume vs fellowship training
Define high-volume surgeon
Scope of data collection
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16. References
Borah BJ, Nicholson WK, Bradley L, et al. The impact of uterine leiomyomas: a national survey of affected women. Am J Obstet Gynecol 2013;209:319.e1-20.
Stewart EA. Uterine fibroids. Lancet. 2001;357:293–298
Wechter ME, Stewart EA, Myers ER, Kho RM, Wu JM. Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends. American Journal of Obstetrics and Gynecology. 2011;205(5). doi: /j.ajog
Bhave Chittawar P, Franik S, Pouwer AW, Farquhar C. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD
Jin C, Hu Y, Chen X-C, et al. Laparoscopic versus open myomectomy—A meta-analysis of randomized controlled trials. European Journal of Obstetrics & Gynecology and Reproductive Biology ;145(1): doi: /j.ejogrb
 Hurst B, Matthews M, Marshburn P. Laparoscopic myomectomy for symptomatic uterine myomas. Fertility and Sterility. 2005;83(1):1-23. doi: /j.fertnstert
Borah BJ, Nicholson WK, Bradley L, et al. The impact of uterine leiomyomas: a national survey of affected women. Am J Obstet Gynecol 2013;209:319.e1-20.
Stewart EA. Uterine fibroids. Lancet. 2001;357:293–298.

17. References
Mikhail E, Scott L, Miladinovic B, Imudia AN, Hart S. Association between Fellowship Training, Surgical Volume, and Laparoscopic Suturing Techniques among Members of the American Association of Gynecologic Laparoscopists. Minimally Invasive Surgery. 2016;2016:1-6. doi: /2016/
Einarsson J, Young A, Tsien L, Sangi-Haghpeykar H. Perceived Proficiency in Endoscopic Techniques Among Senior Obstetrics and Gynecology Residents. The Journal of the American Association of Gynecologic Laparoscopists. 2002;9(2): doi: /s (05)
Magrina JF. Isnt It Time to Separate the O From the G? Journal of Minimally Invasive Gynecology ;21(4): doi: /j.jmig
Wallenstein, Michelle R., et al. “Effect of Surgical Volume on Outcomes for Laparoscopic Hysterectomy for Benign Indications.” Obstetrics & Gynecology, vol. 119, no. 4, 2012, pp. 709–716., doi: /aog.0b013e318248f7a8.
Boyd LR, Novetsky AP, Curtin JP. Effect of Surgical Volume on Route of Hysterectomy and Short-Term Morbidity. Obstetrics & Gynecology. 2010;116(4): doi: /aog.0b013e3181f395d9.
Vree, Florentien E. M. The Impact of Surgeon Volume on Perioperative Outcomes in Hysterectomy.” 1 Jan. 1970, archive.org/details/pubmed-PMC