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Kailasam A, Jatoi A, Reynolds E, Cliby W, Langstraat C. Understanding the patient experience in nonsurgical management of endometrial cancer and complex atypical hyperplasia due to obesity: A qualitative analysis. Gynecol Oncol Rep 2024; 54:101425. [PMID: 38854684 PMCID: PMC11157205 DOI: 10.1016/j.gore.2024.101425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 06/11/2024] Open
Abstract
Objectives Patients with class 3 obesity (BMI ≥ 40) and significant medical comorbidities with complex atypical hyperplasia (CAH) and early-stage endometrial cancer (EC) present challenges in standard surgical management. Progestin therapy is an alternative used for patient-centered reasons, including the desire for uterine preservation or because surgery is not a safe option. Our objective was to gain insights into the patient experience when undergoing this treatment approach. Methods We identified and recruited patients who received oral or IUD progesterone in the last 5 years for EC or CAH. We conducted semi-structured phone interviews regarding patients' experience with non-surgical management as well as decision-making factors to start progesterone and weight loss. Interviews were audio-recorded and transcriptions were analyzed for common themes. Results A total of 20 interviews were performed. We enrolled nine patients with CAH, eight with grade 1 EC, and three with grade 2 EC. The majority of patients (18/20) were managed with IUD. We identified the following 5 common themes support in diagnostic workup and long-term outcomes, autonomy in care, thoroughness in counseling, emotional impact of diagnosis, and perception of obesity as a defining identity. Conclusion The themes identified in the present study highlight the challenges and the stigma these patients face. It also demonstrates areas of opportunity in their counseling and care, which will help to build a more effective therapeutic relationship and ultimately lead to greater adherence in care.
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Affiliation(s)
- Aparna Kailasam
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - Aminah Jatoi
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - Evelyn Reynolds
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - William Cliby
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
| | - Carrie Langstraat
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
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Long L, He X, Liu Y, Lei C. Effect of two different modalities of hysterectomy on wound infection and wound dehiscence in obese patients. Int Wound J 2024; 21:e14664. [PMID: 38439170 PMCID: PMC10912368 DOI: 10.1111/iwj.14664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/29/2023] [Indexed: 03/06/2024] Open
Abstract
This research intended to investigate the influence of the operation of both kinds of hysterectomies in the risk of wound infection and the degree of wound dehiscence. Both of them were open field and laparoscope. In this research, we looked into four databases: PubMed, Web of Science, Embase and Cochrane Library. Research was conducted on various operative methods for hysterectomy in obese patients between 2000 and October 2023. Two independent investigators performed an independent review of the data, established the inclusion and exclusion criteria, and managed the results with Endnote software. It also evaluated the quality of the included literature. Finally, the data were analysed with RevMan 5.3. This study involved 874 cases, 387 cases received laparoscopy and 487 cases received open access operation. Our findings indicate that there is a significant reduction in the rate of post-operative wound infection among those who have received laparoscopy compared with who have received open surgical procedures (odds ratio [OR], 0.04; 95% confidence interval [CI], 0.01-0.15; p < 0.001); There was no statistical difference between the rate of post-operative wound dehiscence and those who received laparotomy compared with those who received open surgical procedures (OR, 0.33; 95% CI, 0.10-1.11; p = 0.07); The estimated amount of blood lost during the operation was less in the laparoscopy group compared with the open procedure (mean difference, -123.72; 95% CI, -215.16 to -32.28; p = 0.008). Generally speaking, the application of laparoscopy to overweight women who have had a hysterectomy results in a reduction in the expected amount of bleeding during surgery and a reduction in the risk of post-operative wound infections.
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Affiliation(s)
- Ling Long
- Department of Gynecological OncologyChongqing University Cancer Hospital, Chongqing Cancer Institute, Chongqing Cancer HospitalChongqingChina
| | - Xuan He
- Department of Cancer Center, Daping HospitalArmy Medical University (Third Military Medical University)ChongqingChina
| | - Yuyang Liu
- Department of Traditional Chinese Medicine, College of MedicineChangchun University of Traditional Chinese MedicineChongqingChina
| | - Cuirong Lei
- Department of Gynecological OncologyChongqing University Cancer Hospital, Chongqing Cancer Institute, Chongqing Cancer HospitalChongqingChina
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Yuan Y, Tan W, Huang Y, Huang H, Li Y, Gou Y, Zeng S, Hu Z. Association between hysterectomy and kidney stone disease: results from the National Health and Nutrition Examination Survey 2007-2018 and Mendelian randomization analysis. World J Urol 2023; 41:2133-2139. [PMID: 37314571 DOI: 10.1007/s00345-023-04465-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/29/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE Hysterectomy is one of the most common types of gynecological operations and it is associated with numerous postoperative complications. Few studies have reported a definitive association between hysterectomy and kidney stone disease (KSD). This study aimed to explore whether hysterectomy increases the risk of KSD. METHODS This is a cross-sectional study that used six continuous cycles of data obtained from the National Health and Nutrition Examination Survey from 2007 to 2018. The correlations between hysterectomy or age at hysterectomy and the prevalence of KSD were assessed using weighted multivariable-adjusted logistic regression. Further, five methods of two-sample Mendelian randomization (MR) were applied to decrease bias and infer causality in the observational study. RESULTS After adjusting for potential confounders, hysterectomy (OR: 1.37, 95% CI 1.04-1.81) was found to be positively associated with the prevalence of KSD, whereas age at hysterectomy was found to be negatively associated with the prevalence of KSD (OR: 0.96, 95% CI: 0.94-0.98). In the inverse-variance weighted method, MR analyses suggested that genetically predicted hysterectomy is causally associated with a higher risk of KSD (OR: 11.961, 95% CI 1.12-1.28E2). CONCLUSIONS Hysterectomy could increase the risk of KSD. Younger age at hysterectomy is associated with a higher risk of KSD. Further prospective cohort studies with larger sample sizes and longer follow-up times are needed.
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Affiliation(s)
- Ye Yuan
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Wei Tan
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yinchao Huang
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Hao Huang
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yadong Li
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yuanqing Gou
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Shengjie Zeng
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Zili Hu
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Kim EK, Applebaum JC, Kravitz ES, Hinkle SN, Koelper NC, Andy UU, Harvie HS. "Every minute counts": association between operative time and post-operative complications for patients undergoing minimally invasive sacrocolpopexy. Int Urogynecol J 2023; 34:263-270. [PMID: 36418567 DOI: 10.1007/s00192-022-05412-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Our aim was to assess whether operative time is independently associated with post-operative complications for minimally invasive sacrocolpopexy (MISCP). METHODS Using the National Surgical Quality Improvement Program (NSQIP) database, patients undergoing MISCP from 2015 to 2020 were identified by CPT code. The following data were extracted: demographics, concomitant procedures (hysterectomies, midurethral sling, and anterior or posterior repair), and post-operative complications. Complications were categorized into minor, major, and composite, modeled after the Clavien-Dindo classification. For analysis, covariates associated with operative time and composite complications were identified using a general linear model and Chi-squared or Fisher's exact test as appropriate. Then, adjusted spline regression was performed as a test of nonlinearity between operative time and composite complications. Adjusted relative risks of complications by 60-min increments were estimated using Poisson regression with robust error variance. RESULTS A total of 13,239 patients who underwent MISCP were analyzed. Overall, mean operative time (SD) was 189.5 (78.3) min. Post-operative complication rates were 2.6% for minor, 4.7% for major, and 7.3% for composite complications. Age, smoking, and sling were the only covariates associated with both operative time and post-operative complications. Adjusted spline regression demonstrated linearity (p<0.0001). With each 60-min increase in operative time, adjusted relative risks (95% CI) were 1.14 for composite (1.09, 1.19), 1.16 for minor (1.10, 1.21), and 1.11 (1.03, 1.20) for major complications. CONCLUSIONS Operative time is independently and linearly associated with post-operative complications for patients undergoing MISCP, even when adjusted for demographic variables and concomitant procedures.
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Affiliation(s)
- Edward K Kim
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Jeremy C Applebaum
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth S Kravitz
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stefanie N Hinkle
- Department of Biostatics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nathanael C Koelper
- Center for Research on Reproductive and Women's Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Uduak U Andy
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Heidi S Harvie
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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Le Neveu M, AlAshqar A, Kohn J, Tambovtseva A, Wang K, Borahay M. Impact of Obesity on Clinical and Financial Outcomes of Minimally Invasive Hysterectomy for Benign Conditions. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:953-959. [PMID: 35598864 PMCID: PMC9481667 DOI: 10.1016/j.jogc.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the effect of obesity on clinical and financial outcomes of minimally invasive hysterectomy METHODS: This was a retrospective cohort study of 5 affiliated hospitals. We obtained demographic, operative, and financial characteristics to analyze the effects of obesity on outcomes, including operating room (OR) time, estimated blood loss (EBL), length of stay (LOS), adverse perioperative events, and hospital charges. Obesity was stratified by the following classes: no obesity (BMI <30 kg/m2), class I (BMI 30-34 kg/m2), class II (BMI 35-39 kg/m2), and class III (BMI >40 kg/m2). Descriptive statistics and multivariate logistic and linear regressions were performed. RESULTS A total of 2483 women underwent benign, minimally invasive hysterectomy. Laparoscopic was the most common approach (79.8%), followed by robotic (12.2%), and vaginal (8.0%). Mean BMI was 30.13 ± 6.99 kg/m2, and total charges were US $13 928 ± $5954. Each additional minute in the OR increased costs by US $47.89 (P < 0.001). Compared with patients without obesity, OR time and EBL were significantly higher among patients with class I or II obesity and highest among patients with class III obesity (P < 0.001). Obesity did not affect LOS or occurrence of adverse perioperative events. Although obesity appeared to be a significant predictor of hysterectomy charges, after adjusting for covariates, charges for laparoscopic and robotic hysterectomy did not differ significantly by BMI. CONCLUSION Obesity appears to have a significant effect on clinical outcomes of benign hysterectomy that is approach-dependent and most notable among patients with class III obesity. BMI was not, however, a predictor of financial outcomes.
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Affiliation(s)
- Margot Le Neveu
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, 29 N. Curley Street, Baltimore, MD, 21224.
| | - Abdelrahman AlAshqar
- Department of Obstetrics and Gynecology, Kuwait University, Kuwait City, Kuwait, 1245 Chapel Street, New Haven, CT, 06511
| | - Jaden Kohn
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, 4940 Eastern Ave, Baltimore, MD 21224-2780
| | - Anastasia Tambovtseva
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, 4940 Eastern Ave, Baltimore, MD 21224-2780
| | - Karen Wang
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, 4940 Eastern Ave, Baltimore, MD 21224-2780
| | - Mostafa Borahay
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, 4940 Eastern Ave, Baltimore, MD 21224-2780
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Sehnal B, Klat J, Herboltova P, Hanacek J, Fanta M, Valha P, Hruda M, Vasicka I, Halaska MJ. Comparison of complications in very obese women undergoing hysterectomy - Abdominal vs laparoscopic approach with short- and long-term follow-up. Eur J Obstet Gynecol Reprod Biol 2022; 276:148-153. [PMID: 35908409 DOI: 10.1016/j.ejogrb.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/08/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surgical treatment of obese female patients represents a real challenge. Over the last decade, minimally invasive techniques for hysterectomy have emerged. These approaches reduce the invasiveness of standard surgical procedures while maintaining efficacy and feasibility. OBJECTIVE To evaluate the rates of perioperative, early, mid-term and late postoperative complications in very obese [body mass index (BMI) ≥ 35 and < 40 kg/m2] and severely obese (BMI ≥ 40 kg/m2) women who underwent total (non-radical) hysterectomy. DESIGN A prospective comparative multi-centre non-randomized study. METHODS In total, 328 consecutive total (non-radical) hysterectomies were performed at seven teaching gynaecological centres. Of these, 153 (46.6%) were performed using an open laparotomy (LT) approach and 175 (53.4%) were performed laparoscopically (LS). All data were collected by medical specialists at the pre-operative examination prior to surgery, during surgery and three times postoperatively (during hospital stay, at 6-week follow-up and 6 months following surgery). Another analysis considered a total of 206 women who underwent laparoscopic hysterectomy. The subjects were divided according to BMI into 120 very obese women (BMI ≥ 35 and < 40 kg/m2) and 86 severely obese women (BMI ≥ 40 kg/m2). RESULTS The total number of composite perioperative complications was significantly lower in the LS group (p = 0.006). Composite complications occurred significantly more often in patients in the LT group compared with the LS group in the early (p < 0.001) and mid-term (p < 0.001) postoperative periods. In the late postoperative period, the total number of composite postoperative complications did not differ significantly between the groups (p < 0.396). Among 206 patients who underwent laparoscopic hysterectomy, the number of complications was generally low; the rates of composite perioperative (p = 0.393), early (p = 0.642), mid-term (p = 0.738) and late (p = 1) postoperative complications were generally low; and frequency did not differ significantly with BMI. CONCLUSION The LS approach does not increase intra-operative morbidity associated with surgery, and has significantly better outcomes in terms of the postoperative complication rate.
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Affiliation(s)
- Borek Sehnal
- First Faculty of Medicine, Charles University, Department of Gynecology and Obstetrics, University Hospital Bulovka, Prague, Czech Republic
| | - Jaroslav Klat
- University Hospital and University of Ostrava, Department of Obstetrics and Gynecology, Ostrava, Czech Republic
| | | | - Jiri Hanacek
- Institute for the Care of Mother and Child, 3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Michael Fanta
- 1st Faculty of Medicine, Charles University, Department of Gynecology and Obstetrics, General Faculty Hospital, Prague, Czech Republic
| | - Petr Valha
- Hospital Ceske Budejovice, Budweis, Czech Republic
| | - Martin Hruda
- 3rd Medical Faculty, Charles University, Prague, Czech Republic; University Hospital Kralovske Vinohrady, Department of Obstetrics and Gynaecology, Prague, Czech Republic
| | - Ian Vasicka
- First Faculty of Medicine, Charles University, Department of Gynecology and Obstetrics, University Hospital Bulovka, Prague, Czech Republic
| | - Michael J Halaska
- 3rd Medical Faculty, Charles University, Prague, Czech Republic; University Hospital Kralovske Vinohrady, Department of Obstetrics and Gynaecology, Prague, Czech Republic.
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Cybulsky M, Murji A, Sunderji Z, Shapiro J, Elliott C, Shirreff L. Assessing the impact of obesity on surgical quality outcomes among patients undergoing hysterectomy for benign, non-urgent indications. Eur J Obstet Gynecol Reprod Biol 2022; 274:243-250. [PMID: 35688107 DOI: 10.1016/j.ejogrb.2022.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/07/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the impact of body mass index (BMI) on surgical quality metrics for patients undergoing benign, non-urgent hysterectomy. STUDY DESIGN A multicentre, retrospective review at 7 hospitals in Ontario, Canada (4 academic, 3 community) was conducted. Patients undergoing hysterectomy from July 2016 to June 2019 were included. Hysterectomies for premalignant, malignant and emergency indications were excluded. The primary outcome was a composite of any complication or readmission. Secondary outcomes were grade 2 or greater complication, postoperative emergency department (ED) visit, hospital readmission, operative time (ORT) and estimated blood loss (EBL). Patient characteristics (age, ASA class, preoperative diagnoses, preoperative anemia, prior surgeries), surgical factors (endometriosis, adhesions, hysterectomy route, uterine weight, concomitant procedures, ORT, EBL) and surgeon characteristics (volume, fellowship/generalist training, academic/community hospital) were recorded along with complications, hospital readmissions and ED visits. Outcomes were evaluated using logistic regression and log-regression linear analysis grouping patients by BMI category (normal, overweight, obesity class 1, 2, and 3) and by hysterectomy route (abdominal, laparoscopic, and vaginal). RESULTS 2528 hysterectomies were performed by 67 surgeons. 828 (33%) patients had a normal BMI, 889 (35%) were overweight. 500 (20%) patients had a BMI corresponding to obesity class 1, 205 (8%) class 2 and 106 (4%) class 3. Obese patients had higher ASA class (p <.001) and more prior surgeries (p <.001) compared to patients with normal BMI. Those with class 2 and 3 obesity were younger (p <.001), had greater uterine weight (p <.001) and more intra-operative adhesions (p <.001). After controlling for covariates, there were no differences in the odds of the primary or secondary outcomes, with the exception of patients with class 2 obesity who underwent vaginal hysterectomy. They had 9.1% (11 min) significantly longer ORT (0.091, 95% CI 0.002-0.18, p <.05) and patients with an overweight BMI who underwent vaginal hysterectomy had 28 ml significantly less EBL (-0.154, 95% CI -0.26 to -0.05, p <.01) compared to patients with normal BMI. CONCLUSION BMI was not independently associated with surgical quality outcomes in patients undergoing hysterectomy for benign, non-urgent indications. Abdominal, laparoscopic, and vaginal hysterectomy can be performed safely in overweight and obese patients.
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Affiliation(s)
- Marta Cybulsky
- 123 Edward Street, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario M5G 1E2, Canada
| | - Ally Murji
- 123 Edward Street, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario M5G 1E2, Canada; 600 University Avenue, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada
| | - Zahra Sunderji
- 600 University Avenue, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada
| | - Jodi Shapiro
- 123 Edward Street, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario M5G 1E2, Canada; 600 University Avenue, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada
| | - Cara Elliott
- 1 King's College Circle, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Lindsay Shirreff
- 123 Edward Street, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario M5G 1E2, Canada; 600 University Avenue, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada.
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Rajadurai VA, Nathan E, Pontré JC, Mcelhinney B, Karthigasu KA, Hart R. The effect of obesity on cost of total laparoscopic hysterectomy. Aust N Z J Obstet Gynaecol 2022; 62:566-573. [DOI: 10.1111/ajo.13520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Vinita Angeline Rajadurai
- Department of Obstetrics and Gynaecology King Edward Memorial Hospital for Women Perth Western Australia Australia
| | - Elizabeth Nathan
- Division of Obstetrics and Gynaecology University of Western Australia Perth Western Australia Australia
- Women and Infants Research Foundation King Edward Memorial Hospital Perth Western Australia Australia
| | - Jennifer Claire Pontré
- Department of Gynaecology King Edward Memorial Hospital Perth Western Australia Australia
| | - Bernadette Mcelhinney
- Department of Gynaecology King Edward Memorial Hospital Perth Western Australia Australia
| | | | - Roger Hart
- Department of Obstetrics and Gynaecology King Edward Memorial Hospital for Women Perth Western Australia Australia
- Division of Obstetrics and Gynaecology University of Western Australia Perth Western Australia Australia
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Wong JM, Whitley J, Moore KJ, Louie M. Impact of Morcellation Method and Site on Laparoscopic Hysterectomy Outcomes in Obese Patients. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2021.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jacqueline M.K. Wong
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Julia Whitley
- Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Kristin J. Moore
- Department of Family Medicine and Community Health, University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
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Bolovis D, Hitzl W, Brucker C. Robotic mesh-supported pectopexy for pelvic organ prolapse: expanding the options of pelvic floor repair. J Robot Surg 2021; 16:815-823. [PMID: 34498174 DOI: 10.1007/s11701-021-01303-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/29/2021] [Indexed: 11/30/2022]
Abstract
Pelvic organ prolapse affects 30-50% of the female population. For definitive treatment surgery is unavoidable. Sacrocolpopexy has been the gold standard for anatomical correction of pelvic organ prolapse since the 1990s. Recently, pectopexy has been introduced as a new surgical procedure to correct apical prolapse. We have translated the laparoscopic pectopexy into a robotic procedure. The charts of the first 30 consecutive patients who underwent robotic pectopexy at the department for robotic and pelvic floor surgery were reviewed. All patients were analyzed for estimated blood loss, operation time, as well as complications. Treatment success was evaluated after 3-6 months using a composite endpoint including anatomical and subjective components. Of the 30 patients analyzed, 18 underwent hysteropectopexy (n = 18), 6 patients underwent vaginopectopexy and 6 patients underwent cervicopectopexy. Additional procedures were performed in 14 patients, and this influenced operation time and intraoperative blood loss. No intraoperative complications were noted and no conversions were necessary. Treatment success according to the primary composite endpoint was achieved in 30 (100%) patients. Furthermore, neither de novo urgency nor obstructive bowel symptoms were noted in any of the patients treated with robotic pectopexy. Similar to SCP, pectopexy is designed for prolapse repair. The robotic technique for pectopexy capitalizes on the advantages of robotic surgery as compared to conventional laparoscopy since it allows for anatomical preparation and simplification of applying sutures and mesh material, reducing operating time and minimizing surgical trauma. The technique is safe, and anatomical outcomes are excellent.
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Affiliation(s)
- Dimitrios Bolovis
- Paracelsus Medical University, University Women's Hospital, Klinikum Nuernberg, Nuremberg, Germany.
| | - Wolfgang Hitzl
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria.,Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria.,Department of Research and Innovation, Paracelsus Medical University, Salzburg, Austria
| | - Cosima Brucker
- Paracelsus Medical University, University Women's Hospital, Klinikum Nuernberg, Nuremberg, Germany
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11
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O'Hanlan KA, Emeney PL, Frank MI, Milanfar LC, Sten MS, Uthman KF. Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients. JSLS 2021; 25:JSLS.2020.00087. [PMID: 34248330 PMCID: PMC8241283 DOI: 10.4293/jsls.2020.00087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients. Methods This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH. Results Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients. Conclusion TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.
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Affiliation(s)
- Katherine A O'Hanlan
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Pamela L Emeney
- University of California in San Francisco-Fresno, Fresno, CA 93701
| | - Madelyn I Frank
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Leila C Milanfar
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Margaret S Sten
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Kathryn F Uthman
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
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Khoiwal K, Kapoor N, Gaurav A, K R, Reddy KK, Chaturvedi J. The Effect of Body Mass Index on Peri-operative Parameters of Total Laparoscopic Hysterectomy: An Institutional Experience. Cureus 2021; 13:e15558. [PMID: 34277181 PMCID: PMC8270063 DOI: 10.7759/cureus.15558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/10/2022] Open
Abstract
Objectives Worldwide, there is an increase in the obese population and laparoscopic surgery is now becoming one of the preferred modes of surgery. Therefore, it is important to examine its feasibility and safety in overweight and obese women. The study was aimed to evaluate the effects of body mass index (BMI) on intraoperative and postoperative parameters in patients undergoing total laparoscopic hysterectomy (TLH). Materials and methods A retrospective data analysis was conducted over a period of two years among women who underwent TLH. Data were grouped as per their BMI into Normal, Overweight, and Obese groups. Baseline demographic and clinical characteristics, intraoperative outcomes including operative time, estimated blood loss, hemoglobin difference, the need for blood transfusion, conversion to laparotomy, uterine weight, intraoperative and postoperative complications, postoperative pain, duration of hospital stay, and readmission were noted. Results Baseline demographic characteristics were similar in all three groups. Operative time was comparable among the groups. However, a weak positive correlation was found between operative time and total BMI value, which was statistically significant (p = 0.039). For every 1 kg/m2 increase in BMI, operative time increased by 2.35 minutes. Other intraoperative parameters were comparable among all the groups except hemoglobin difference, which was significantly higher in obese women. Postoperative parameters were similar among all groups. Conclusion Total laparoscopic hysterectomy is a safe, efficient, and feasible surgical approach in higher BMI groups. This approach provides advantages over open surgery of early recovery, short hospital stay, and less postoperative pain to obese women.
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Affiliation(s)
- Kavita Khoiwal
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Nirali Kapoor
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Amrita Gaurav
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Rupendra K
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Kranti Kumar Reddy
- Preventive Medicine, All India Institute of Medical Sciences, Rishikesh, IND
| | - Jaya Chaturvedi
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, IND
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Pepin K, Cook F, Maghsoudlou P, Cohen SL. Risk-prediction Model for Patients Undergoing Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2021; 28:1751-1758.e1. [PMID: 33713836 DOI: 10.1016/j.jmig.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Develop a model for predicting adverse outcomes at the time of laparoscopic hysterectomy (LH) for benign indications. DESIGN Retrospective cohort study. SETTING Large academic center. PATIENTS All patients undergoing LH for benign indications at our institution between 2009 and 2017. INTERVENTIONS LH (including robot-assisted and laparoscopically assisted vaginal hysterectomy) was performed per standard technique. Data about the patient, surgeon, perioperative adverse outcomes (intraoperative complications, readmission, reoperation, operative time >4 hours, and postoperative medical complications or length of stay >2 days), and uterine weight were collected retrospectively. Pathologic uterine weight was used as a surrogate for predicted preoperative uterine weight. The sample was randomly split, using a random sequence generator, into 2 cohorts, one for deriving the model and the other to validate the model. MEASUREMENTS AND MAIN RESULTS A total of 3441 patients were included. The rate of composite adverse outcomes was 14.1%. The final logistic regression risk-prediction model identified 6 variables predictive of an adverse outcome at the time of LH: race, history of laparotomy, history of laparoscopy, predicted preoperative uterine weight, body mass index, and surgeon annual case volume. Specifically included were race (97% increased odds of an adverse outcome for black women [95% confidence interval (CI), 34%-110%] and 34% increased odds of an adverse outcome for women of other races [95% CI, -11% to 104%] when compared with white women), history of laparotomy (69% increased odds of an adverse outcome [95% CI, 26%-128%]), history of laparoscopy (65% increased odds of an adverse outcome [95% CI, 21%-124%]), and predicted preoperative uterine weight (2.9% increased odds of an adverse outcome for each 100-g increase in predicted weight [95% CI, 2%-4%]). Body mass index and surgeon annual case volume also had a statistically significant nonlinear relationship with the risk of an adverse outcome. The c-statistic values for the derivation and validation cohorts were 0.74 and 0.72, respectively. The model is best calibrated for patients at lower risk (<20%). CONCLUSION The LH risk-prediction model is a potentially powerful tool for predicting adverse outcomes in patients planning hysterectomy.
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Affiliation(s)
- Kristen Pepin
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou); Department of Minimally Invasive Gynecologic Surgery, Weill Cornell Medicine, New York, New York (Dr. Pepin).
| | - Francis Cook
- Department of Epidemiology, Harvard School of Public Health (Dr. Cook), Boston, Massachusetts
| | - Parmida Maghsoudlou
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou)
| | - Sarah L Cohen
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou); Department of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota (Dr. Cohen)
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The relationship between body mass index and clinical complications among patients undergoing myomectomy. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.805122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pepin KJ, Cook EF, Cohen SL. Risk of complication at the time of laparoscopic hysterectomy: a prediction model built from the National Surgical Quality Improvement Program database. Am J Obstet Gynecol 2020; 223:555.e1-555.e7. [PMID: 32247844 DOI: 10.1016/j.ajog.2020.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although laparoscopic hysterectomy is well established as a favorable mode of hysterectomy owing to decreased perioperative complications, there is still room for improvement in quality of care. Previous studies have described laparoscopic hysterectomy risk, but there is currently no tool for predicting risk of complication at the time of laparoscopic hysterectomy. OBJECTIVE This study aimed to create a prediction model for complications at the time of laparoscopic hysterectomy for benign conditions. STUDY DESIGN This is a retrospective cohort study that included patients who underwent laparoscopic hysterectomy for benign indications between 2014 and 2017 in US hospitals contributing to the American College of Surgeons - National Surgical Quality Improvement Program database. Data about patient baseline characteristics, perioperative complications (intraoperative complications, readmission, reoperation, need for transfusion, operative time greater than 4 hours, or postoperative medical complication), and uterine weight at the time of pathologic examination were collected retrospectively. Postoperative uterine weight was used as a proxy for preoperative uterine weight estimate. The sample was randomly divided into 2 patient populations, one for deriving the model and the other to validate the model. RESULTS A total of 33,123 women met the inclusion criteria. The rate of composite complication was 14.1%. Complication rates were similar in the derivation and validation cohorts (14.1% [2306 of 14,051] vs 13.9% [2289 of 14,107], P=.7207). The logistic regression risk prediction tool for hysterectomy complication identified 7 variables predictive of complication: history of laparotomy (21% increased odds of complication), age (2% increased odds of complication per year of life), body mass index (0.2% increased odds of complication per each unit increase in body mass index), parity (7% increased odds of complication per delivery), race (when compared with white women, black women had 34% increased odds and women of other races had 18% increased odds of complication), and American Society of Anesthesiologists score (when compared with American Society of Anesthesiologists 1, American Society of Anesthesiologists 2 had 31% increased odds, American Society of Anesthesiologists 3 had 62% increased odds, and American Society of Anesthesiologists 4 had 172% increased odds of complication). Predicted preoperative uterine weight also had a statistically significant nonlinear relationship with odds of complication. The c-statistics for the derivation and validation cohorts were 0.62 and 0.62, respectively. The model is well calibrated for women at all levels of risk. CONCLUSION The laparoscopic hysterectomy complication predictor model is a tool for predicting complications in patients planning to undergo hysterectomy.
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Klebanoff JS, Tyan P, Nishikawa M, North A, Amdur R, Sparks A, Kazma JM, Moawad GN. Cost variance across obesity class for women undergoing laparoscopic hysterectomy by high-volume gynecologic surgeons. J Robot Surg 2020; 14:903-907. [PMID: 32253574 DOI: 10.1007/s11701-020-01074-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/28/2020] [Indexed: 01/23/2023]
Abstract
Health-care costs are affected by obesity with both the direct and indirect costs of health care increasing as body mass index (BMI) increases. However, one important aspect of obesity that lacks rigorous study is what impact BMI has on direct surgical cost. We performed a retrospective cohort study of women undergoing a laparoscopic hysterectomy at our single academic university center between January 2012 and December 2017. Women were excluded if their surgery was performed by anyone other than those surgeons with subspecialty training in minimally invasive gynecologic surgery (MIGS), if their hysterectomy was performed by a modality other than conventional laparoscopy or with robotic assistance, or if the indication for hysterectomy was related to any gynecologic malignancy. We identified 600 patients who underwent laparoscopic hysterectomy during the study period. Women who underwent robotic hysterectomy, compared to laparoscopic, had a shorter operative time, lower estimated blood loss, and shorter length of stay. Mean direct cost (± standard deviation) for the cohort was $6398.53 ± $2304.67, age was 44.5 ± 7.5 years, and BMI was 32.2 ± 7.6. Direct cost for all laparoscopic hysterectomies was evaluated across the five different BMI quintiles and no significant difference between groups was found. There was no significant difference in direct cost across procedures between obese and non-obese patients (p = 0.62) and this remained true when separated out by surgical modality. However, when evaluating morbidly obese patients, there appears to be a trend toward cost reduction with robotic hysterectomy compared to conventional laparoscopy. It does not appear that BMI has a statistically significant impact on direct cost between robotic-assisted and conventional laparoscopic hysterectomy. However, these findings may be due to surgical proficiency and warrant further investigation among surgeons with lesser volume.
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Affiliation(s)
- Jordan S Klebanoff
- Department of Obstetrics and Gynecology, The George Washington University Hospital, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA
| | - Paul Tyan
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Moena Nishikawa
- The George Washington University School of Medicine, Washington, DC, USA
| | - Alexandra North
- The University of South Carolina Medical School Greenville Campus, Greenville, SC, USA
| | - Richard Amdur
- Department of Surgery, The George Washington University Hospital, Washington, DC, USA
| | - Andrew Sparks
- Department of Surgery, The George Washington University Hospital, Washington, DC, USA
| | - Jamil M Kazma
- Department of Obstetrics and Gynecology, The George Washington University Hospital, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA
| | - Gaby N Moawad
- Department of Obstetrics and Gynecology, The George Washington University Hospital, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA.
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Differences in Postoperative Morbidity among Obese Patients Undergoing Abdominal Versus Laparoscopic Hysterectomy for Benign Indications. J Minim Invasive Gynecol 2020; 27:464-472. [DOI: 10.1016/j.jmig.2019.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/25/2019] [Accepted: 04/01/2019] [Indexed: 11/21/2022]
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18
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An analysis of 635 consequetive laparoscopic hysterectomy patients in a tertiary referral hospital. J Gynecol Obstet Hum Reprod 2020; 49:101645. [DOI: 10.1016/j.jogoh.2019.101645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 08/16/2019] [Accepted: 10/03/2019] [Indexed: 11/17/2022]
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19
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Otake A, Horai M, Tanaka E, Toda A, Miyoshi Y, Funada R, Yamamoto Y, Adachi K. Influences of Total Laparoscopic Hysterectomy According to Body Mass Index (Underweight, Normal Weight, Overweight, or Obese). Gynecol Minim Invasive Ther 2019; 8:19-24. [PMID: 30783584 PMCID: PMC6367909 DOI: 10.4103/gmit.gmit_53_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/25/2018] [Accepted: 08/20/2018] [Indexed: 12/03/2022] Open
Abstract
Study Objective: The aim of this study is to evaluate the effect of body mass index (BMI) on laparoscopic hysterectomy outcomes. Design: This was retrospective study. Setting: Minoh City Hospital, Japan. Materials and Methods: Between January 1, 2014, and June 30, 2017, 183 patients underwent total laparoscopic hysterectomy (TLH) at our institution. Intervention: Patients who underwent TLH were grouped according to BMI, as follows: underweight group (BMI <18.5 kg/m2), normal-weight group (18.5 ≤BMI <25 kg/m2), overweight group (25 ≤BMI <30 kg/m2), and obese group (BMI ≥30 kg/m2). Measurements and Main Results: Information on patients’ clinical characteristics and surgical results were collected retrospectively by medical record review. The severity of complications was graded according to the Clavien–Dindo classification. We assessed clinical characteristics, surgical results, and the perioperative complications in each BMI group. Surgical results included operation time, nonsurgical operating room time estimated blood loss, uterine weight, and postoperative hospital stay. Compared with the normal-weight group, the obese group had significantly more complications (P = 0.012) and longer operation time (P = 0.04). The underweight and overweight groups did not have significantly different surgical results than the normal-weight group. Conclusion: Underweight and overweight patients had no significant differences in surgical results, compared with patients of normal weight. Obese patients had significantly longer operation times and more perioperative complications than patients with normal weight. Laparoscopic hysterectomy has burdens and risks for obese patients. Our results suggest that appropriate weight control may decrease the risk of surgery for obese patients.
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Affiliation(s)
- Akiko Otake
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Megumi Horai
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Eriko Tanaka
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Aska Toda
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Yukari Miyoshi
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Rina Funada
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Yoshimitsu Yamamoto
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Kazusige Adachi
- Department of Obstetrics and Gynecology, Minoh City Hospital, Minoh, Osaka, Japan
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Borahay MA, Tapısız ÖL, Alanbay İ, Kılıç GS. Outcomes of robotic, laparoscopic, and open hysterectomy for benign conditions in obese patients. J Turk Ger Gynecol Assoc 2018; 19:72-77. [PMID: 29699956 PMCID: PMC5994808 DOI: 10.4274/jtgga.2018.0018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective: To compare outcomes of robotic-assisted (RAH), total laparoscopic hysterectomy (LH), and total abdominal hysterectomy (TAH) for benign conditions in obese patients. Material and Methods: Retrospective cohort (Class II-2) analysis. All obese patients who underwent RAH, LH or TAH for benign conditions by a single surgeon at the University of Texas Medical Branch between January 2009 and December 2011 were identified and their charts reviewed. The patients’ characteristics, operative data, and post-operative outcomes were collected and statistically analyzed. Results: A total of 208 patients who underwent RAH (n=51), LH (n=24) or TAH (n=133) were analyzed. There were no significant differences among the groups in demographic characteristics, indications for surgery or pathologic findings. RAH and LH were associated with lower estimated blood loss (EBL) (p<0.001) and shorter length of hospital stay (LOS) (p<0.001) compared with TAH. In addition, RAH and LH had lower intraoperative and early postoperative (≤6 weeks) complications compared with TAH (p=0.002). However, the procedure time was longer in RAH and LH (p<0.001). No significant differences were noted among the groups for late post-operative complications (after 6 weeks) or unscheduled post-operative visits. Conclusion: Minimally invasive hysterectomy appears to be safe in obese patients with the advantages of less EBL, fewer intraoperative complications, and shorter LOS.
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Affiliation(s)
- Mostafa A Borahay
- Department of Obstetrics and Gynecology, Johns Hopkins University, Maryland, USA,Department of Obstetrics and Gynecology, University of Texas Medical Branch, Texas, USA
| | - Ömer Lütfi Tapısız
- Department of Obstetrics and Gynecology, University of Health Sciences, Etlik Zübeyde Hanım Women’s Diseases Training and Research Hospital, Ankara, Turkey
| | - İbrahim Alanbay
- Department of Obstetrics and Gynecology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Gökhan Sami Kılıç
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Texas, USA
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Abstract
PURPOSE OF REVIEW The purpose is to review the key anatomical and physiological changes in obese patients and their effects on preoperative, intraoperative, and postoperative care and to highlight the best practices to safely extend minimally invasive approaches to obese patients and provide optimal surgical outcomes in this high-risk population. RECENT FINDINGS Minimally invasive surgery is safe, feasible, and cost-effective for obese patients. Obesity is associated with anatomical and physiological changes in almost all organ systems, which necessitates a multimodal approach and an experienced, multidisciplinary team. Preoperative counseling, evaluation, and optimization of medical comorbidities are critical. The optimal minimally invasive approach is primarily determined by the patient's anatomy and pathology. Specific intraoperative techniques and modifications exist to maximize surgical exposure and panniculus management. Postoperatively, comprehensive medical management can help prevent common complications in obese patients, including hypoxemia, venous thromboembolism, acute kidney injury, hyperglycemia, and prolonged hospitalization. SUMMARY Given significantly improved patient outcomes, minimally invasive approaches to gynecological surgery should be considered for all obese patients with particular attention given to specific perioperative considerations and appropriate referral to an experienced minimally invasive surgeon.
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Ho YL, Li CS, Liu CC, Lin CC, Hung CJ, Kao CH. Disability benefits as an incentive for hysterectomy: Uterine fibroid patients in Taiwan. Women Health 2017; 58:866-883. [PMID: 28816634 DOI: 10.1080/03630242.2017.1358793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Worker compensation insurance in Taiwan ensures that a woman under the age of 45 years who has her uterus removed can receive disability compensation benefits. The present study investigated whether such a compensation policy was related to a woman's inclination to have a hysterectomy. We extracted the records of 16,030 women diagnosed with uterine fibroids (UF) between 2000 and 2010 from the Longitudinal Taiwan Health Insurance Database. Each younger and older age group had a significantly lower hysterectomy rate compared to that of the 44-year-old age group. Moreover, significantly more patients with lower monthly wages had had hysterectomies than those with higher monthly wages. Policy makers should be aware that worker compensation regulations in Taiwan might encourage women with economic need to undergo hysterectomy surgery when approaching the age of 45 years.
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Affiliation(s)
- Ya-Lee Ho
- a Department of Business Administration and Department of Business Administration , Feng Chia University , Taichung , Taiwan
| | - Chu-Shiu Li
- b Department of Risk Management and Insurance , National Kaohsiung First University of Science and Technology, Kaohsiung, and College of Management, Asia University , Taichung , Taiwan
| | - Chwen-Chi Liu
- c Department of Risk Management and Insurance , Feng Chia University , Taichung , Taiwan
| | - Che-Chen Lin
- d Management Office for Health Data , China Medical University Hospital , Taichung , Taiwan
| | - Chih-Jen Hung
- e Department of Anesthesiology, Taichung Veterans General Hospital, and Department of Nursing , Hung Kuang University , Taichung , Taiwan
| | - Chia-Hung Kao
- f Departments of Nuclear Medicine and PET Center, China-Medical University Hospital and Graduate Institute of Clinical Medical Science, School of Medicine, College of Medicine , China-Medical University , Taichung , Taiwan
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Association Between Body Mass Index, Uterine Size, and Operative Morbidity in Women Undergoing Minimally Invasive Hysterectomy. J Minim Invasive Gynecol 2016; 23:1113-1122. [DOI: 10.1016/j.jmig.2016.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 11/20/2022]
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Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis. Obstet Gynecol 2016; 126:1161-1169. [PMID: 26551173 DOI: 10.1097/aog.0000000000001096] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To calculate the rates of urinary tract injury detected during and after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy and determine if it helps in reducing injuries detected postoperatively. DATA SOURCES We conducted a literature search for urinary tract injuries at benign gynecologic surgery in PubMed, EMBASE, ClinicalTrials.gov, and Web of Science from January 2004 to August 2014. We combined our results with a database from a previously published systematic review to include earlier studies. METHODS OF STUDY SELECTION A total of 79 studies met our inclusion criteria. Excluded were letters to the editor, studies involving only selective cystoscopy in higher risk patients, case reports, and reports that included injuries resulting from obstetric or oncologic procedures. TABULATION, INTEGRATION, AND RESULTS Data from each report were classified according to type of surgery into vaginal hysterectomy, abdominal hysterectomy, laparoscopic hysterectomy, other (nonrobotic) gynecologic and urogynecologic surgery, robotic hysterectomy, and other robotic gynecologic and urogynecologic surgery. We determined the ureteric and bladder injury rates for each surgery type from studies in which routine intraoperative cystoscopy was performed and separately from studies in which it was not performed. Intraoperatively detected rates of ureteric and bladder injury were markedly higher with routine intraoperative cystoscopy. We obtained an adjusted ureteric injury rate of 0.3% and a bladder injury rate of 0.8%. The estimated postoperative ureteric injury detection rates per 1,000 surgeries were 1.6 without routine cystoscopy and 0.7 with routine cystoscopy. Postoperative bladder injury detection rates per 1,000 surgeries were 0.8 without routine cystoscopy and 1.0 with routine cystoscopy. CONCLUSION Although routine cystoscopy clearly increases the intraoperative detection rate of urinary tract injuries, this systematic review of 79 mostly retrospective studies shows that it does not appear to have much effect on the postoperative injury detection rate.
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Driessen SRC, Sandberg EM, la Chapelle CF, Twijnstra ARH, Rhemrev JPT, Jansen FW. Case-Mix Variables and Predictors for Outcomes of Laparoscopic Hysterectomy: A Systematic Review. J Minim Invasive Gynecol 2015; 23:317-30. [PMID: 26611613 DOI: 10.1016/j.jmig.2015.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 12/14/2022]
Abstract
The assessment of surgical quality is complex, and an adequate case-mix correction is missing in currently applied quality indicators. The purpose of this study is to give an overview of all studies mentioning statistically significant associations between patient characteristics and surgical outcomes for laparoscopic hysterectomy (LH). Additionally, we identified a set of potential case-mix characteristics for LH. This systematic review was conducted according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. We searched PubMed and EMBASE from January 1, 2000 to August 1, 2015. All articles describing statistically significant associations between patient characteristics and adverse outcomes of LH for benign indications were included. Primary outcomes were blood loss, operative time, conversion, and complications. The methodologic quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. The included articles were summed per predictor and surgical outcome. Three sets of case-mix characteristics were determined, stratified by different levels of evidence. Eighty-five of 1549 identified studies were considered eligible. Uterine weight and body mass index (BMI) were the most mentioned predictors (described, respectively, 83 and 45 times) in high quality studies. For longer operative time and higher blood loss, uterine weight ≥ 250 to 300 g and ≥500 g and BMI ≥ 30 kg/m(2) dominated as predictors. Previous operations, adhesions, and higher age were also considered as predictors for longer operative time. For complications and conversions, the patient characteristics varied widely, and uterine weight, BMI, previous operations, adhesions, and age predominated. Studies of high methodologic quality indicated uterine weight and BMI as relevant case-mix characteristics for all surgical outcomes. For future development of quality indicators of LH and to compare surgical outcomes adequately, a case-mix correction is suggested for at least uterine weight and BMI. A potential case-mix correction for adhesions and previous operations can be considered. For both surgeons and patients it is valuable to be aware of potential factors predicting adverse outcomes and to anticipate this. Finally, to benchmark clinical outcomes at an international level, it is of the utmost importance to introduce uniform outcome definitions.
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Affiliation(s)
- Sara R C Driessen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Evelien M Sandberg
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Claire F la Chapelle
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andries R H Twijnstra
- Department of Obstetrics and Gynecology, Bronovo Hospital, The Hague, The Netherlands
| | - Johann P T Rhemrev
- Department of Obstetrics and Gynecology, Bronovo Hospital, The Hague, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands; Department BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands.
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Obesity Education Strategies for Cancer Prevention in Women's Health. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015; 4:249-258. [PMID: 26877893 DOI: 10.1007/s13669-015-0129-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Obesity is the cause of up to one-third of all cancers affecting women today, most notably endometrial, colon and breast cancer. Women's health providers are poised to advise women on obesity's link to cancer development, but often lack resources or training to provide appropriate counseling. Here, we review obesity's role in increasing the risk of several common reproductive system conditions faced by women, including polycystic ovarian syndrome, infertility, gynecologic surgical complications, and pregnancy complications. These events can be used as teachable moments to help frame the discussion of weight management and promote cancer prevention. We also review national guidelines and existing tangible weight-loss strategies that can be employed within the outpatient women's health setting to help women achieve weight loss goals and affect cancer prevention.
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Blikkendaal MD, Schepers EM, van Zwet EW, Twijnstra ARH, Jansen FW. Hysterectomy in very obese and morbidly obese patients: a systematic review with cumulative analysis of comparative studies. Arch Gynecol Obstet 2015; 292:723-38. [PMID: 25773357 PMCID: PMC4560773 DOI: 10.1007/s00404-015-3680-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/25/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE Some studies suggest that also regarding the patient with a body mass index (BMI) ≥35 kg/m(2) the minimally invasive approach to hysterectomy is superior. However, current practice and research on the preference of gynaecologists still show that the rate of abdominal hysterectomy (AH) increases as the BMI increases. A systematic review with cumulative analysis of comparative studies was performed to evaluate the outcomes of AH, laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) in very obese and morbidly obese patients (BMI ≥35 kg/m(2)). METHODS PubMed and EMBASE were searched for records on AH, LH and VH for benign indications or (early stage) malignancy through October 2014. Included studies were graded on level of evidence. Studies with a comparative design were pooled in a cumulative analysis. RESULTS Two randomized controlled trials, seven prospective studies and 14 retrospective studies were included (2232 patients; 1058 AHs, 959 LHs, and 215 VHs). The cumulative analysis identified that, compared to LH, AH was associated with more wound dehiscence [risk ratio (RR) 2.58, 95 % confidence interval (CI) 1.71-3.90; P = 0.000], more wound infection (RR 4.36, 95 % CI 2.79-6.80; P = 0.000), and longer hospital admission (mean difference 2.9 days, 95 % CI 1.96-3.74; P = 0.000). The pooled conversion rate was 10.6 %. Compared to AH, VH was associated with similar advantages as LH. CONCLUSIONS Compared to AH, both LH and VH are associated with fewer postoperative complications and shorter length of hospital stay. Therefore, the feasibility of LH and VH should be considered prior the abdominal approach to hysterectomy in very obese and morbidly obese patients.
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Affiliation(s)
- Mathijs D. Blikkendaal
- Department of Gynaecology, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Evelyn M. Schepers
- Department of Gynaecology, Bronovo Hospital, PO Box 96900, 2509 JH The Hague, The Netherlands
| | - Erik W. van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Andries R. H. Twijnstra
- Department of Gynaecology, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Frank Willem Jansen
- Department of Gynaecology, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands
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Maclaran K, Agarwal N, Odejinmi F. Perioperative outcomes in laparoscopic hysterectomy: identifying surgical risk factors. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s10397-015-0914-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Ellimoottil C, Roghmann F, Blackwell R, Kadlec A, Greco K, Quek ML, Sun M, Trinh QD, Gupta G. Open Versus Robotic Radical Prostatectomy in Obese Men. Curr Urol 2015; 8:156-61. [PMID: 26889136 DOI: 10.1159/000365708] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 09/29/2014] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Robotic-assisted radical prostatectomy (RARP) has been shown to reduce blood loss, peri-operative complications and length of stay when compared to open radical prostatectomy (ORP). We sought to determine whether the reported benefits of RARP over ORP translate to obese patients. PATIENTS AND METHODS We utilized the 2009-2010 Nationwide Inpatient Sample to identify all obese men with prostate cancer who underwent ORP and RARP. Our primary outcome was the presence of a peri-operative adverse event (i.e. blood transfusion, complication, prolonged length of stay). We fit multivariable logistic regression models to examine whether RARP in obese patients was independently associated with decreased odds of all three outcomes. RESULTS We identified 9,108 obese patients who underwent radical prostatectomy. On multivariable analysis, the use of RARP in the obese population was not independently associated with decreased odds of developing a peri-operative complication (OR = 0.81, CI: 0.58-1.13, p = 0.209). RARP was, however, associated with decreased odds of blood transfusion (OR = 0.17, CI: 0.10-0.30, p < 0.001) and prolonged length of stay (OR = 0.28, CI: 0.20-0.40, p < 0.001). CONCLUSION Our findings suggest that in obese patients, the use of RARP may reduce length of stay and blood transfusions compared to ORP. Both approaches, however, are associated with similar odds of developing a complication.
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Affiliation(s)
| | - Florian Roghmann
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Department of Urology, Ruhr University Bochum, Marienhospital, Herne, Germany
| | | | - Adam Kadlec
- Loyola University Medical Center, Maywood, IL., USA
| | | | | | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
| | - Quoc-Dien Trinh
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Division of Urologic Surgery and Center for Surgery and Public Health, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA., USA
| | - Gopal Gupta
- Loyola University Medical Center, Maywood, IL., USA
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Robotic Hysterectomy for Endometrial Cancer in Obese Patients With Comorbidities: Evaluating Postoperative Complications. Int J Gynecol Cancer 2015; 25:1271-6. [DOI: 10.1097/igc.0000000000000480] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
ObjectivesThe objective of this study is to determine (1) if there is a relationship between increasing body mass index (BMI) and postoperative complications in patients undergoing robotic hysterectomy for endometrial cancer and (2) if there are additional patient characteristics, specifically preoperative comorbidities, which increase the risk of postoperative complicationMethodsA retrospective chart review was conducted on women who underwent a robotic staging surgery for endometrial cancer from 2006 to 2012. Basic demographics and preoperative and postoperative complications were extracted from the medical records. Obesity was divided into 4 categories, and complication rates were compared across these subgroups. Patients were also divided by the number of comorbidities and compared.ResultsThe cohort included 543 patients. The BMI ranged from 17.3 to 69.5 kg/m2. Three hundred eighty patients (70%) were obese (BMI >30 kg.m2). One hundred ninety patients (35%) had no comorbidities other than obesity, and 180 patients (33%) had only 1 comorbidity other than obesity (Table 1).Postoperative complications occurred in 102 (18.7%) of the patients. Severe postoperative complications, including intensive care unit admission, reintubation, reoperation, and perioperative death, occurred in 14 patients (2.6%). Of the nonobese patients, 27 (16.5%) had postoperative complications; of the obese patients, 75 (19.7%) had a complication (P = 0.38). In patients with no comorbidities, 16.3% had a complication; 18% of patients with 1 to 2 comorbidities had a complication, and 28% of patients with 3 or more comorbidities had a complication (P = 0.08).ConclusionsThe postoperative complication rate based on BMI or number of comorbidities was not statistically significant, but patients with greater number of comorbidities had an increased rate of postoperative complications. Patients with certain comorbidities, cardiac and renal specifically, had the highest rates of postoperative complications.
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Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications. J Minim Invasive Gynecol 2015; 22:1049-58. [DOI: 10.1016/j.jmig.2015.05.022] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/24/2015] [Accepted: 05/28/2015] [Indexed: 11/19/2022]
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Andryjowicz E, Wray TB, Reinaldo Ruiz V, Rudolf J, Noroozkhani S, Crowder S, Slezak JM. Safely Increase the Minimally Invasive Hysterectomy Rate: A Novel Three-Tiered Preoperative Categorization System Can Predict the Difficulty for Benign Disease. Perm J 2015. [PMID: 26222092 DOI: 10.7812/tpp/15-023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT A nonlaparotomic route is recommended for hysterectomy for benign indications. OBJECTIVE 1) Predict the difficulty of hysterectomy to treat benign disease as measured by operative time and risk of laparotomy, 2) confirm the safety and quality of increasing our minimally invasive hysterectomy (MIH) rate, and 3) determine whether the assistant's experience affected the likelihood of an MIH being performed in equally difficult hysterectomies. DESIGN All hysterectomies for benign disease performed at the Kaiser Permanente Fontana Medical Center in Fontana, CA, in 2012 were reviewed for length of surgery, length of stay, complications, and readmissions. A three-tiered category system was developed from four preoperative parameters (body mass index, number of vaginal deliveries, clinical uterine size, and history of major abdominal surgery) to anticipate length and difficulty of surgery. MAIN OUTCOME MEASURES Rates of MIH, complications, and readmissions as well as length of surgery and length of stay for similarly difficult hysterectomies. These outcomes were compared with surgeons' and assistants' experience. RESULTS Of 576 hysterectomies performed for benign disease, 89% were MIH with a 3% complication rate and 4% readmission rate. An increase in the hysterectomy category was statistically significantly associated with longer surgery times and a higher percentage of laparotomy. With the most experienced assistants, the MIH rate was 98%. CONCLUSIONS Using 4 preoperative parameters, the average operating time for hysterectomy for benign disease can be predicted. A higher hysterectomy category predicts a more difficult surgery. Our center has increased its MIH rate to 89% while maintaining safety.
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Affiliation(s)
| | - Teresa B Wray
- Former Regional Chief of Obstetrics and Gynecology for the Southern California Permanente Medical Group at the Fontana Medical Center in CA and the present Chief of Obstetrics and Gynecology at the Fontana Medical Center in CA.
| | - V Reinaldo Ruiz
- Obstetrician/Gynecologist at the Fontana Medical Center in CA.
| | - James Rudolf
- Obstetrician/Gynecologist at the Fontana Medical Center in CA.
| | | | - Sandra Crowder
- Obstetrician/Gynecologist at the Fontana Medical Center in CA.
| | - Jeff M Slezak
- Research Manager of Biostatistics for the Southern California Permanente Medical Group in Pasadena.
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Obesity and perioperative pulmonary complications in robotic gynecologic surgery. Am J Obstet Gynecol 2015; 213:33.e1-33.e7. [PMID: 25637843 DOI: 10.1016/j.ajog.2015.01.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/08/2015] [Accepted: 01/24/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Robotic gynecological surgery is feasible in obese patients, but there remain concerns about the safety of this approach because the positioning required for pelvic surgery can exacerbate obesity-related changes in respiratory physiology. The objective of our study was to evaluate pulmonary and all-cause complication rates in obese women undergoing robotic gynecological surgery and to assess variables that may be associated with complications. STUDY DESIGN A retrospective chart review was performed on obese patients (body mass index of ≥30 kg/m(2)) who underwent robotic gynecological surgery at 2 academic institutions between 2006 and 2012. The primary outcome was pulmonary complications and the secondary outcome was all-cause complications. Univariate and multivariate logistic regression analyses were used to determine the associations between patient baseline variables, operative variables, ventilator parameters, and complications. RESULTS Of 1032 patients, 146 patients (14%) had any complication, whereas only 33 patients (3%) had a pulmonary complication. Median body mass index was 37 kg/m(2). Only age was significantly associated with a higher risk of pulmonary complications (P = .01). Older age, higher estimated blood loss, and longer case length were associated with a higher rate of all-cause complications (P = .0001, P < .0001, and P = .004, respectively). No other covariates were strongly associated with complications. CONCLUSION The vast majority of obese patients can successfully tolerate robotic gynecological surgery and have overall low complications rates and even lower rates of pulmonary complications. The degree of obesity was not predictive of successful robotic surgery and subsequent complications.
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Shah DK, Vitonis AF, Missmer SA. Association of body mass index and morbidity after abdominal, vaginal, and laparoscopic hysterectomy. Obstet Gynecol 2015; 125:589-598. [PMID: 25730220 DOI: 10.1097/aog.0000000000000698] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the association of body mass index (BMI) and operative time and perioperative morbidity after hysterectomy and determine whether the association varies among abdominal, laparoscopic, and vaginal approaches. METHODS Data abstracted from the American College of Surgeons National Safety and Quality Improvement Project registry included 55,409 women who underwent hysterectomy for benign conditions between January 2005 and December 2012. The relationships among BMI, operative time, and morbidity were examined, adjusting for age, race, ethnicity, year of surgery, smoking, diabetes, and American Society for Anesthesiologists physical classification. Adjusted means, incidence rate ratios, or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using linear, Poisson, or logistic regression, respectively. RESULTS Body mass index was positively correlated with risk of wound complications and infection in women undergoing abdominal hysterectomy. Compared with those of normal BMI, women with BMIs 40 or higher had five times the odds of wound dehiscence (2.1% compared with 0.3%, crude OR 7.35, CI 3.78-14.30; adjusted OR 5.33, CI 2.63-10.8), five times the odds of wound infection (8.9% compared with 1.4%, crude OR 6.81, CI 5.00-9.27; adjusted OR 5.34, CI 3.85-7.41), and 89% higher odds of sepsis (1.3% compared with 0.6%, crude OR 2.39, CI 1.35-4.24; adjusted OR 1.89, CI 1.01-3.52). The magnitude of the association between wound infection and BMI was smaller after vaginal hysterectomy, and no increased odds of wound complications or sepsis were noted with a laparoscopic approach despite longer operative times. Operative time increased with BMI regardless of surgical approach. No associations were noted between BMI and hospital stay or thromboembolism. CONCLUSION Obesity is associated with increased wound complications and infection in women undergoing abdominal hysterectomy and with longer operative times regardless of surgical approach. Vaginal or laparoscopic hysterectomy should be performed whenever feasible. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Divya Kelath Shah
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and the Department of Obstetrics, Gynecology, and Reproductive Biology and the Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, and the Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
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Laparoscopic and vaginal approaches to hysterectomy in the obese. Eur J Obstet Gynecol Reprod Biol 2015; 189:85-90. [PMID: 25898369 DOI: 10.1016/j.ejogrb.2015.02.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 02/14/2015] [Accepted: 02/19/2015] [Indexed: 11/17/2022]
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Association Between Obesity and the Trends of Routes of Hysterectomy Performed for Benign Indications. Obstet Gynecol 2015; 125:912-918. [DOI: 10.1097/aog.0000000000000733] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Guraslan H, Senturk MB, Dogan K, Guraslan B, Babaoglu B, Yasar L. Total laparoscopic hysterectomy in obese and morbidly obese women. Gynecol Obstet Invest 2015; 79:184-8. [PMID: 25660528 DOI: 10.1159/000367658] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/14/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The study aimed at estimating the effect of body mass index (BMI), used to classify non-obese, obese, and morbidly obese patients, on clinical outcomes in total laparoscopic hysterectomy (TLH) cases. METHODS This retrospective cohort study included 153 patients who underwent TLH for benign, premalignant, or malignant conditions between August 2010 and June 2013. Patients were divided into 3 groups according to BMI, and the following variables were analyzed: operation time, conversion rate, blood loss, total complications, and length of hospital stay. RESULTS The mean BMI was 33.5 kg/m(2) (range, 22-61). Forty-four patients were non-obese (BMI <30), 73 were obese (30≤ BMI <40), and 36 were morbidly obese (BMI ≥40). In 138 patients (90.2%), hysterectomy was performed using an endoscopic technique. The rate of conversion to laparotomy (9.8%; 95% confidence interval (CI), 5.1-14.5), blood loss (70.5 ml; range, 10-700), total complications (5.9%), and length of hospital stay (2.9 d; range, 1-8) did not vary according to BMI. Operation time was longer in obese (p = 0.003) and morbidly obese (0.002) patients than in non-obese patients. CONCLUSION TLH could be considered a safe and feasible alternative to abdominal hysterectomy in obese and morbidly obese patients.
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Affiliation(s)
- Hakan Guraslan
- Departments of Obstetrics and Gynecology, Bakirkoy Dr. Sadi Konuk Teaching and Research Hospital, İstanbul, Turkey
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Hackethal A, Brennan D, Rao A, Land R, Obermair A, Nicklin J, Garrett A, Nascimento M, Crandon A, Perrin L, Chetty N. Consideration for safe and effective gynaecological laparoscopy in the obese patient. Arch Gynecol Obstet 2014; 292:135-41. [DOI: 10.1007/s00404-014-3600-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 12/11/2014] [Indexed: 12/22/2022]
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Ho YL, Hung CJ, Lin CC, Liu CC, Li CS, Kao CH. The association between occupational characteristics and hysterectomies for treating uterine fibroids in Taiwan. Women Health 2014; 55:77-89. [PMID: 25531280 DOI: 10.1080/03630242.2014.972018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study examined the relationship between the occupational characteristics of women with uterine fibroids (UFs) and the decision to have a hysterectomy. Data from the Longitudinal Taiwan Health Insurance Database (LTHID) from 2000 to 2009 were analyzed to investigate the association between occupation and hysterectomies. Multivariable logistic regression analysis showed that, compared with white-collar UF patients, the odds ratio (OR) for hysterectomy surgery was 1.21 (95% confidence interval (CI) = 1.11-1.32) for blue-collar UF patients. Moreover, non-government employees with UFs also had significantly increased odds of having a hysterectomy compared to government employees with UFs (OR = 1.19, 95% CI = 1.04-1.36). This study provides information regarding the extent to which differences in occupation and decision-making processes might affect the marked variations in the use of hysterectomies for UFs.
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Affiliation(s)
- Ya-Lee Ho
- a Department of Business Administration , Asia University , Taichung , Taiwan
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McIlwaine K, Manwaring J, Ellett L, Cameron M, Readman E, Villegas R, Maher P. The effect of patient body mass index on surgical difficulty in gynaecological laparoscopy. Aust N Z J Obstet Gynaecol 2014; 54:564-9. [DOI: 10.1111/ajo.12258] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 08/15/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Kate McIlwaine
- Department of Endosurgery; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Janine Manwaring
- Department of Endosurgery; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Lenore Ellett
- Department of Endosurgery; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Melissa Cameron
- Department of Endosurgery; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Emma Readman
- Department of Endosurgery; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Rocio Villegas
- Department of Endosurgery; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Peter Maher
- Department of Endosurgery; Mercy Hospital for Women; Heidelberg Victoria Australia
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Odejinmi F, Maclaran K, Agarwal N. Laparoscopic treatment of uterine fibroids: a comparison of peri-operative outcomes in laparoscopic hysterectomy and myomectomy. Arch Gynecol Obstet 2014; 291:579-84. [DOI: 10.1007/s00404-014-3434-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 08/22/2014] [Indexed: 10/24/2022]
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Radosa MP, Meyberg-Solomayer G, Radosa J, Vorwergk J, Oettler K, Mothes A, Baum S, Juhasz-Boess I, Petri E, Solomayer EF, Runnebaum IB. Standardised Registration of Surgical Complications in Laparoscopic-Gynaecological Therapeutic Procedures Using the Clavien-Dindo Classification. Geburtshilfe Frauenheilkd 2014; 74:752-758. [PMID: 25221343 DOI: 10.1055/s-0034-1382925] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/18/2014] [Accepted: 06/30/2014] [Indexed: 10/24/2022] Open
Abstract
Introduction: The registration of complications represents an important component in the evaluation of surgical therapeutic procedures. The aim of the present study was to examine the frequency of occurrence as well as the severity of surgical complications after laparoscopic-gynaecological operations in a standardised manner using the Clavien-Dindo system. Material and Methods: Altogether 7438 treatment courses after laparoscopic-gynaecological interventions by 9 working groups were evaluated. Covariates recorded were the technical complexity of the operation, type of study cohort, study size, data acquisition as well as study centre. Target variables recorded were the surgical morbidity rate, subdivided into mild (Clavien-Dindo grade I-II) and severe complications (Clavien-Dindo grade III-V). In addition, a binary logistic regression analysis for the mentioned covariates and the occurrence of surgical complication was carried out. Results: 946 complications were recorded (overall complication rate: 13 %). These included 664 mild complications (8.9 %) and 305 severe complications (4.1 %). A correlation was found between the covariates technical complexity (relative risk [rR] 1.37; p < 0.01), study size (rR: 0.35; p < 0.01) and study centre (rR 0.19; p < 0.01) and the occurrence of surgical complications. Conclusion: By means of a standardised registration of complications using the Clavien-Dindo classification it appears to be possible to limit the methodologically caused underestimation of surgical morbidity in the retrospective evaluation of gynaecological-endoscopic therapeutic procedures. Factors decisively influencing the surgical morbidity of gynaecological-laparoscopic therapeutic procedures are the respective operative experience of the treating facility as well as the technical complexity of the intervention.
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Affiliation(s)
- M P Radosa
- Department of Gynecology and Obstetrics, Jena University Hospital, Jena
| | - G Meyberg-Solomayer
- Department of Obstetrics and Gynecology, University of Saarland, Homburg/Saar
| | - J Radosa
- Department of Obstetrics and Gynecology, University of Saarland, Homburg/Saar
| | - J Vorwergk
- Department of Gynecology and Obstetrics, Jena University Hospital, Jena
| | - K Oettler
- Department of Gynecology and Obstetrics, Jena University Hospital, Jena
| | - A Mothes
- Department of Gynecology and Obstetrics, Jena University Hospital, Jena
| | - S Baum
- Department of Obstetrics and Gynecology, University of Saarland, Homburg/Saar
| | - I Juhasz-Boess
- Department of Obstetrics and Gynecology, University of Saarland, Homburg/Saar
| | - E Petri
- Department of Obstetrics and Gynecology, University Greifswald, Greifswald
| | - E F Solomayer
- Department of Obstetrics and Gynecology, University of Saarland, Homburg/Saar
| | - I B Runnebaum
- Department of Gynecology and Obstetrics, Jena University Hospital, Jena
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Mynbaev OA, Eliseeva MY, Tinelli A, Malvasi A, Kosmas IP, Medvediev MV, Babenko TI, Mazitova MI, Kalzhanov ZR, Stark M. A personalized adhesion prevention strategy: E. Arslan, T. Talih, B. Oz, B. Halaclar, K. Caglayan, M. Sipahi, Comparison of lovastatin and hyaluronic acid/carboxymethyl cellulose on experimental created peritoneal adhesion model in rats, Int. J. Surg. 12 (2) (2014) 120-124. Int J Surg 2014; 12:901-5. [PMID: 25072704 DOI: 10.1016/j.ijsu.2014.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 03/02/2014] [Accepted: 03/14/2014] [Indexed: 11/26/2022]
Affiliation(s)
- O A Mynbaev
- The International Translational Medicine & Biomodeling Research Team, Department of Applied Mathematics, Moscow Institute of Physics & Technology (State University), Dolgoprudny, Moscow Region, Russia; The Department of Obstetrics, Gynecology & Reproductive Medicine, Peoples' Friendship, University of Russia, Moscow, Russia; Laboratory of Pilot Projects, Moscow State University of Medicine & Dentistry, Moscow, Russia; The New European Surgical Academy, Berlin, Germany.
| | - M Yu Eliseeva
- The Department of Obstetrics, Gynecology & Reproductive Medicine, Peoples' Friendship, University of Russia, Moscow, Russia
| | - A Tinelli
- Department of Obstetrics and Gynaecology, Division of Experimental Endoscopic Surgery, Imaging, Minimally Invasive Therapy and Technology, Vito Fazzi Hospital, Piazza Muratore, Lecce, Italy
| | - A Malvasi
- Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy
| | - I P Kosmas
- Xatzikosta General Hospital, Ioannina, Ioannina, Greece
| | - M V Medvediev
- State Establishment "Dnepropetrovsk Medical Academy of Health Ministry of Ukraine", Dnepropetrovsk, Ukraine
| | - T I Babenko
- Stavropol State Medical Academy, Stavropol, Russia
| | | | - Zh R Kalzhanov
- School of Health and Human Sciences, University of Essex, UK
| | - M Stark
- The New European Surgical Academy, Berlin, Germany
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In reply. Obstet Gynecol 2014; 123:888. [PMID: 24785626 DOI: 10.1097/aog.0000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Silasi DA, Gallo T, Silasi M, Menderes G, Azodi M. Robotic versus abdominal hysterectomy for very large uteri. JSLS 2014; 17:400-6. [PMID: 24018076 PMCID: PMC3771758 DOI: 10.4293/108680813x13693422521755] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We sought to examine the outcomes of patients with myomatous uteri weighing >1000 g who underwent hysterectomy by one of two modalities, either with a robotic system or by laparotomy. METHODS All patients who underwent robotic hysterectomy for uteri weighing >1000 g at our institution between May 2007 and January 2011 were identified, and a retrospective chart review was performed. These patients were matched to a laparotomy control group by body mass index and uterine weight, and the postoperative outcomes in both groups were analyzed and compared. RESULTS Sixty patients with uteri weighing >1000 g underwent hysterectomy, 30 with the robotic system and 30 by laparotomy. The median body mass index was 31.8 kg/m(2) (range, 18.5-56.3 kg/m(2)) and the median uterine weight was 1259 g (range, >1000 -3543 g) in the robotic group versus 30.2 kg/m(2) (range, 18 - 48 kg/m(2)) and 1509 g (range, 1000 -3570 g), respectively, in the laparotomy group (P = .31). The median operating time was 255 minutes (range, 180 -372 minutes) in the robotic group versus 150 minutes (range, 100 -285 minutes) in the laparotomy group (P < .001). There were no conversions to laparotomy. In both groups the operative time was not increased with increasing specimen weight. The median blood loss was 150 mL in the robotic group versus 425 mL in the laparotomy group. Of 30 patients in the robotic group, 23 (76.6%) were discharged from the hospital on postoperative day 1. The median hospital stay for the robotic group was 1 day, and for the laparotomy group, it was 2.5 days (P < .01). CONCLUSION Robotic surgeries for very large myomatous uteri are feasible and have minimal morbidity even in morbidly obese patients. The robotic surgery requires a longer operative time but results in a shorter hospital stay and decreased intraoperative blood loss.
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Affiliation(s)
- Dan-Arin Silasi
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Yale University School of Medicine, 333 Cedar St, FMB 328, New Haven, CT 06520, USA.
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Abstract
Strategies to improve the success of robotic hysterectomy in the morbidly obese patient are reviewed in this study. Background and Objectives: The purpose of this study was to present strategies for performing computer-enhanced telesurgery in the morbidly obese patient. Methods: This was a prospective, institutional review board-approved, descriptive feasibility study (Canadian Task Force classification II-2) conducted at a university-affiliated hospital. Twelve class III morbidly obese women with a body mass index of 40 kg/m2 or greater were selected to undergo robotic-assisted total laparoscopic hysterectomy. Robotic-assisted total laparoscopic hysterectomy, classified as type IVE, with complete detachment of the cardinal-uterosacral ligament complex, unilateral or bilateral, with entry into the vagina was performed. Results: The median estimated blood loss was 146.3 mL (range, 15–550 mL), the mean length of stay in the hospital was 25.3 hours (range, 23–48 hours), and the complication rate was 0%. The rate of conversion to laparotomy was 8%. The median surgical time was 109.6 minutes (range, 99–145 minutes). Conclusion: Robotic-assisted total laparoscopic hysterectomy can be a safe and effective method of performing hysterectomies in select morbidly obese patients, allowing them the opportunity to undergo minimally invasive surgery without increased perioperative complications.
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Affiliation(s)
- Oscar D Almeida
- Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, 176 Mobile Infirmary Blvd, Mobile, AL 36607, USA.
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Kannisto P, Harter P, Heitz F, Traut A, du Bois A, Kurzeder C. Implementation of robot-assisted gynecologic surgery for patients with low and high BMI in a German gynecological cancer center. Arch Gynecol Obstet 2014; 290:143-8. [PMID: 24532013 DOI: 10.1007/s00404-014-3169-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/24/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE To present a single center outcome from an initial series of gynecological robotic cases with a special reference to obese patients. METHODS A retrospective evaluation of 116 women, undergoing elective gynecologic robot-assisted surgery from February 2011 to December 2012. Procedures included hysterectomy (HE), radical HE, adnexectomy, myomectomy, pelvic lymphadenectomy and paraaortic lymphadenectomy, sentinel node extraction, and omentectomy. The feasibility and outcome were investigated in relation to normal and high body mass index (BMI < 30 and BMI ≥ 30). RESULTS The overall complication rate was low (15/116; 12.9 %). The number of perioperative complications was not different between the patients with normal BMI compared to those with high BMI. Five operations were converted to open surgery due to vascular injury (2), intestinal injury (2) and one insufficiently exposed paraaortic field in an endometrial cancer patient. Urinary bladder was injured once. Late complications included vaginal dehisce (2), vaginal hemorrhage (1), cuff hematoma (4), lymphocyst (1) and two urinary tract injuries. The rate of the late complications was not significantly different in the two groups of patients (p = 0.139). A significant difference in patients' positioning time was observed between normal weighted and obese patients (35 and 55 min, p < 0.001). CONCLUSION Robotic procedure was feasible and could be implemented for treating the first setting of mixed indications for gynecologic surgery. Robotic surgery may offer particular advantages in obese patients with no conversions and no wound complications.
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Affiliation(s)
- Päivi Kannisto
- Department of Obstetrics and Gynecology, University of Lund, Lund, Sweden,
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An Analysis of Methodologies That Can Be Used to Validate if a Perioperative Surgical Home Improves the Patient-centeredness, Evidence-based Practice, Quality, Safety, and Value of Patient Care. Anesthesiology 2013; 119:1261-74. [DOI: 10.1097/aln.0b013e3182a8e9e6] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Approximately 80 million inpatient and outpatient surgeries are performed annually in the United States. Widely variable and fragmented perioperative care exposes these surgical patients to lapses in expected standard of care, increases the chance for operational mistakes and accidents, results in unnecessary and potentially detrimental care, needlessly drives up costs, and adversely affects the patient healthcare experience. The American Society of Anesthesiologists and other stakeholders have proposed a more comprehensive model of perioperative care, the Perioperative Surgical Home (PSH), to improve current care of surgical patients and to meet the future demands of increased volume, quality standards, and patient-centered care. To justify implementation of this new healthcare delivery model to surgical colleagues, administrators, and patients and maintain the integrity of evidenced-based practice, the nascent PSH model must be rigorously evaluated. This special article proposes comparative effectiveness research aims or objectives and an optimal study design for the novel PSH model.
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