title: Impact of Case Order on Laparoscopic Sacrocolpopexy: Do Surgeons Need a Warm-Up?
abstract: Warm-up is defined as a preparatory activity or procedure. Using case order as a surrogate for surgeon warm-up, first cases were compared with second or later cases for intraoperative complications, operative time, and length of stay (LOS) among women undergoing laparoscopic sacrocolpopexy.
  
  
  
  This is a retrospective study of laparoscopic sacrocolpopexies performed from 2009 through 2014 at a large academic center. Any surgery preceding laparoscopic sacrocolpopexy was considered a surrogate for surgeon warm-up. Logistic and linear regression analyses were used to identify predictors of complications, operative time, and LOS.
  
  
  
  Of 480 procedures, 192 (40%) were first cases and 288 (60%) were second or later. Baseline characteristics were similar between groups. Intraoperative complication rate was not different between groups (6.3% vs 3.1%, P = 0.50) even after controlling for risk factors. Operative times were comparable on initial analysis (231.2 ± 55.2 vs 225.9 ± 51.2 minutes, P = 0.28l), but a small difference was detected after adjusting for confounding factors (body mass index, menopausal status, surgeon experience, intraoperative complications, and concomitant hysterectomy or midurethral sling; adjusted β = 8.44 minutes, P = 0.037). Length of stay was longer for first case patients (1.44 ± 0.67 vs 1.24 ± 0.50 days, P < 0.001) even after adjusting for age, medical comorbidities, operative time, conversion to laparotomy, ileus/bowel obstruction, and postoperative urinary retention (adjusted β = 0.183 days, P = 0.001) as well as after accounting for delayed start time of second or later cases.
  
  
  
  Laparoscopic sacrocolpopexy performed first case of the day without preoperative surgeon warm-up conferred no significant increase in intraoperative complications. Second or later cases were associated with small decreases in operative time and in LOS.
authors.affiliation: From the *Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA; and †Division of Urogynecology, Department of Obstetrics & Gynecology, West Penn Hospital, Pittsburgh, PA.
authors.forename: Erin Seifert
authors.initials: ES
authors.lastname: Lavelle
authors.forename: Lindsay C
authors.initials: LC
authors.lastname: Turner
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Shepherd
mesh_terms: D000368:Aged; D002983:Clinical Competence; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology*; D010535:Laparoscopy; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008875:Middle Aged; D061646:Operative Time; D010043:Outcome and Process Assessment, Health Care; D056887:Pelvic Organ Prolapse / Q000601:surgery*; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D013997:Time Factors