An evaluation of laparoscopic hysterectomy alone versus in combination with laparoscopic myomectomy for patients with uterine fibroids

Laparoscopic myomectomy to facilitate laparoscopic resection of a bleeding interstitial ectopic pregnancy

Interstitial pregnancies present a diagnostic and management challenge and are associated with significant bleeding risk. We present a case of an interstitial ectopic pregnancy where there was a diagnostic delay due to the presence of uterine fibroids and where a laparoscopic myomectomy was required in order to perform laparoscopic resection of the ruptured interstitial pregnancy.This case demonstrates the possibilities at laparoscopy for ectopic pregnancy, highlights the benefit of a structured 'buddy' system between gynaecology surgeons and brings attention to the paucity of literature on the unique management challenges of ectopic pregnancy in the presence of leiomyoma.

Strategies and Outcomes of Total Laparoscopic Hysterectomy for Large Uterine Cervical Fibroids

Background and Objectives:

To present the methods and outcomes of total laparoscopic hysterectomy with debulking surgery for large cervical fibroids.

Methods:

This is a single-center study. Twenty-one women who underwent total laparoscopic hysterectomy between October 1, 2012 and November 30, 2020 for large cervical fibroids (diameter ≥10 cm) based on a diagnosis by magnetic resonance imagining were enrolled. Conventional total laparoscopic hysterectomy for large cervical fibroids was initially attempted. If this could not be completed, debulking surgery, such as enucleation of large cervical fibroids or cervical amputation, was performed during total laparoscopic hysterectomy.

Results:

Total laparoscopic hysterectomy could be completed in all 21 patients with large cervical fibroids without blood transfusion. Conventional total laparoscopic hysterectomy was performed in four patients (19%), and 17 patients (81%) required debulking surgery at the time of total laparoscopic hysterectomy. The median diameter of the major axis of the cervical fibroid, uterine weight, intraoperative blood loss, and operative time were 12 cm, 750 g, 100 mL, and 191 min, respectively.

Conclusion:

Total laparoscopic hysterectomy for large cervical fibroids, although minimally invasive, requires a high level of laparoscopic skill. However, our data suggests that total laparoscopic hysterectomy for large cervical fibroids can be feasible, with an acceptable level of blood loss, by performing debulking surgeries such as enucleation of large cervical fibroids or cervical amputation.

Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review

OBJECTIVE

To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications.

DATA SOURCES

A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted.

METHODS OF STUDY SELECTION

One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts.

TABULATION, INTEGRATION, AND RESULTS

Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004).

CONCLUSION

The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.

A retrospective study of 323 total laparoscopic hysterectomy cases for various indications and a case report treating caesarean scar pregnancy

Background

The application of laparoscopic surgeries has been increasing, and various uterine diseases in addition to leiomyoma/adenomyoma have become indications for total laparoscopic hysterectomy (TLH). Therefore, data acquisition and analysis of TLH procedures, including TLH for rare uterine diseases, have become important for improving surgical procedures and patient selection. To determine the prevalence of and risk factors for the occurrence of intraoperative and postoperative complications of TLH, we performed a multivariate analysis of the records in our hospital.

Methods

We retrospectively reviewed the medical records of 323 patients who underwent TLH for the treatment of leiomyoma/adenomyoma (278 cases), low-grade (pre)malignant uterine tumours (40 cases) and other rare uterine diseases (5 cases) from January 1, 2015, to December 31, 2019. Of the rare uterine diseases, one case of caesarean scar pregnancy for which TLH was performed is introduced as a case report. To assess the effects of 11 representative factors, including patient characteristics, uterus and leiomyoma sizes, indications for TLH and others, we performed a multivariate logistic regression analysis.

Results

Among the 323 cases, 20 intraoperative complications and 15 postoperative complications were reported. In the multivariate analysis, “ovarian tumour” and “heavy uterus” were positively associated and “nulliparity” was negatively associated with intraoperative complications. There were no significant risk factors for postoperative complications. The only risk factor for operative complications directly related to the resected uterus was “heavy uterus”. Therefore, we could perform TLH relatively safely for patients with other indications besides leiomyoma/adenomyoma.

Conclusions

Considering the factors detected in this analysis, the indications for TLH may be expanded. Owing to the increase in TLH for indications other than leiomyoma/adenomyoma, a more accurate determination of the treatment approach can be achieved.

Effect of laparoscopic myomectomy on serum levels of IL-6 and TAC, and ovarian function

Effect of laparoscopic myomectomy on the serum levels of interleukin-6 (IL-6) and total antioxidant capacity (TAC), and the ovarian function of patients with uterine fibroids was studied. Ninety patients with uterine fibroids admitted to The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, from March 2013 to July 2014, were randomly divided into the experimental group (n=45) and the control group (n=45). The experimental group was treated with laparoscopic myomectomy, and the control group was treated with abdominal myomectomy. ELISA was used for detecting IL-6 and TAC content. Radioimmunoassay (RIA) was used for detecting serum ovarian function indicators, including estradiol (E₂), follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Patients in the experimental group had significantly lower intraoperative blood loss, postoperative exhaust time, number of days to recovery and return to work, number of intraoperative fibroids removed, and length of stay than those in the control group (P<0.05). TAC expression level was significantly higher in the experimental group than that in the control group, on the 1st, 3rd and 5th day after surgery (P<0.05), while IL-6 expression was significantly lower in the experimental group than that in the control group at the same time points (P<0.05). FSH and LH expression levels were significantly lower in the experimental group than those in the control group (P<0.05) at 1, 3 and 6 months after surgery, while E₂ expression level was significantly higher in the experimental group than that in the control group at the same time points (P<0.05). The incidence of postoperative complications of patients in the experimental group was significantly lower than that in the control group (P<0.05). Patients in the experimental group had significantly higher successful pregnancy rate than those in the control group (χ²=6.75, P<0.05). Reducing its effect on ovarian function, serum pain index and oxidative damage index of patients with uterine fibroid, laparoscopic myomectomy also reduces the incidence of postoperative complications and increases the pregnancy rate.

Comparison of Robotic and Laparoscopic Hysterectomy for the Large Uterus

Background and Objectives:

We compared the outcome of robotic hysterectomy (RH) with laparoscopic hysterectomy (LH) for large uteri (≥16 weeks).

Methods:

This was a retrospective review over 5 years of 165 women (RH, 46; LH, 119). Demographic data, conversion, hemoglobin drop, indication, operating time, postoperative stay, and intra-operative strategies (adhesiolysis, myomectomy) were recorded.

Results:

Mean age was 45.7 ± 6.4 years and 44.5 ± 5.4 years (no diff) and body mass index was 30.2 ± 6.3 kg/m² and 27.8 ± 4.8 kg/m² (P = .009) in the RH and LH groups. There was no difference in percentage of women with previous laparotomy (RH, 15.2% vs LH, 13.4%) and mean number of lower-segment caesarean section (RH, 1.0 vs LH, 0.8). Mean size of uterus was similar (RH, 20.0 weeks vs LH, 17.4 weeks). The mean number of ports was higher in the RH group (RH, 4.2 vs LH, 3.4; P < .001) as was needed for adhesiolysis (RH, 71.7% vs LH, 35.3%; P < .001). Difficult bladder dissection was more in the RH group (56.5% vs 26.1%; P < .001). Vaginal morcellation was similar in both groups (RH, 89.1%; LH, 83.2%). RH took longer operating time (131.0 vs 110.6 minutes; P = .006). RH had less drop in Hb (1.0 vs 1.8 g/dL; P < .001) and remained the same after multiple regression analysis. Postoperative stay was similar in both groups (1.4 days). Requirement of intravenous analgesia was significantly lower in the RH group (12.5 vs 30.9 hours; P < .001). Open conversion rate was 4.3% (RH) and 10.9% (LH) but not significant.

Conclusion:

A higher body mass index, more adhesiolysis, and difficult bladder dissection imply a more challenging nature of women who underwent RH. Despite this, RH was shown to be feasible and safe with a lower blood loss.