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Chen Y, jiang J, He M, Zhong K, Tang S, Deng L, Wang Y. Nomogram for predicting difficult total laparoscopic hysterectomy: a multi-institutional, retrospective model development and validation study. Int J Surg 2024; 110:3249-3257. [PMID: 38537077 PMCID: PMC11175783 DOI: 10.1097/js9.0000000000001406] [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: 09/25/2023] [Accepted: 03/12/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Total laparoscopic hysterectomy (TLH) is the most commonly performed gynaecological surgery. However, the difficulty of the operation varies depending on the patient and surgeon. Subsequently, patient's outcomes and surgical efficiency are affected. The authors aimed to develop and validate a preoperative nomogram to predict the operative difficulty in patients undergoing TLH. METHODS This retrospective study included 663 patients with TLH from Southwest Hospital and 102 patients from 958th Hospital in Chongqing, China. A multivariate logistic regression analysis was used to identify the independent predictors of operative difficulty, and a nomogram was constructed. The performance of the nomogram was validated internally and externally. RESULTS The uterine weight, history of pelvic surgery, presence of adenomyosis, surgeon's years of practice, and annual hysterectomy volume were identified as significant independent predictors of operative difficulty. The nomogram demonstrated good discrimination in the training dataset [area under the receiver operating characteristic curve (AUC), 0.827 (95% CI, 0.783-0.872], internal validation dataset [AUC, 0.793 (95% CI, 0.714-0.872)], and external validation dataset [AUC, 0.756 [95% CI, 0.658-0.854)]. The calibration curves showed good agreement between the predictions and observations for both internal and external validations. CONCLUSION The developed nomogram accurately predicted the operative difficulty of TLH, facilitated preoperative planning and patient counselling, and optimized surgical training. Further prospective multicenter clinical studies are required to optimize and validate this model.
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Affiliation(s)
- Yin Chen
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Jiahong jiang
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Min He
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Kuiyan Zhong
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Shuai Tang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Li Deng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Yanzhou Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
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Mouro S, Hamed JLC, Whiteside JL, Tumin D. Relevance of Uterine Weight for Predicting Surgical Complications in Minimally Invasive Benign Hysterectomy. J Minim Invasive Gynecol 2023; 30:976-982. [PMID: 37611741 DOI: 10.1016/j.jmig.2023.08.005] [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: 05/31/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/25/2023]
Abstract
STUDY OBJECTIVES To describe the uterine weight threshold for increasing risk of complications after a laparoscopic hysterectomy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. DESIGN Cross-sectional analysis using the American College of Surgeons NSQIP database from 2016 to 2021. SETTING American College of Surgeons NSQIP database. PATIENTS Patients undergoing minimally invasive hysterectomy for benign indications (N = 64 289). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Uterine weight was entered in grams and 30-day complications were abstracted from patient charts. In the analytic sample, median uterine weight was 135 grams (interquartile range, 90-215) and 6% of patients (n = 4085) experienced complications. Uterine weight performed very poorly in predicting complications on bivariate analysis (area under the receiver operating characteristics curve, 0.53; 95% confidence interval, 0.53-0.54). On multivariable analysis, a uterine weight cutoff of 163 grams was associated with higher odds of complications (odds ratio, 1.11; 95% confidence interval, 1.03-1.19; p = .003), but this threshold achieved only a 43% sensitivity and 62% specificity for predicting complications. CONCLUSIONS Uterine weight alone possessed negligible utility for predicting the risk of perioperative complications in minimally invasive hysterectomy.
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Affiliation(s)
- Steven Mouro
- Department of Obstetrics and Gynecology (Drs. Mouro and Whiteside), East Carolina University, Greenville, North Carolina.
| | - Jenna L Carter Hamed
- Brody School of Medicine (Ms. Carter Hamed), East Carolina University, Greenville, North Carolina
| | - James L Whiteside
- Department of Obstetrics and Gynecology (Drs. Mouro and Whiteside), East Carolina University, Greenville, North Carolina
| | - Dmitry Tumin
- Department of Pediatrics and Department of Academic Affairs (Dr. Tumin), East Carolina University, Greenville, North Carolina
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Nozaki T, Matsuda K, Kagami K, Sakamoto I. Comparison of surgical outcomes between robot-assisted and conventional laparoscopic hysterectomy for large uterus. J Robot Surg 2023; 17:2415-2419. [PMID: 37434073 DOI: 10.1007/s11701-023-01673-0] [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: 04/19/2023] [Accepted: 07/04/2023] [Indexed: 07/13/2023]
Abstract
We compared the effectiveness of conventional total laparoscopic hysterectomy (TLH) against robot-assisted total hysterectomy (RAH) in patients with a large uterus. According to the subtype of minimally invasive hysterectomy performed for benign indications, the patients (n = 843) were grouped as follows: TLH (n = 340) and RAH (n = 503). The median operative time (OT) for TLH was 98 min (47-406 min), and the estimated blood loss (EBL) was 50 mL (5-1800 mL). The median OT for RAH was 90 min (43-251 min), and the EBL was 5 mL (5-850 mL), with a significantly shorter OT and a lower EBL in RAH than in TLH. Uterine weight was categorized into four groups in increments of 250 g. The number of cases in each group was 163 (< 250 g), 116 (250-500 g), 41 (500-750 g), and 20 (≥ 750 g) for TLH, and 308 (< 250 g), 137 (250-500 g), 33 (500-750 g), and 25 (≥ 750 g) for RAH. In patients with a uterus < 250 g, there was no significant difference in OT between TLH and RAH, but in patients with a uterus ≥ 250 g, OT tended to be shorter with RAH, which was also true for a uterus ≥ 750 g. The EBL was significantly lower with RAH compared to TLH, regardless of uterine weight. In patients with a large uterus, the advantages of robotic surgery can be utilized, which may lead to a shorter OT and less EBL.
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Affiliation(s)
- Takahiro Nozaki
- Department of Gynecology, Yamanashi Central Hospital, 1-1-1 Fujimi, Yamanashi, 400-0027, Japan.
| | - Kosuke Matsuda
- Department of Gynecology, Yamanashi Central Hospital, 1-1-1 Fujimi, Yamanashi, 400-0027, Japan
| | - Keiko Kagami
- Department of Gynecology, Yamanashi Central Hospital, 1-1-1 Fujimi, Yamanashi, 400-0027, Japan
| | - Ikuko Sakamoto
- Department of Gynecology, Yamanashi Central Hospital, 1-1-1 Fujimi, Yamanashi, 400-0027, Japan
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Casarin J, Ghezzi F, Mueller M, Ceccaroni M, Papadia A, Ferreira H, Uccella S, Malzoni M, Mabrouk M, Seracchioli R, Bordi G, Gisone BE, Vaineau C, Bogani G, Roviglione G, Arena A, Ambrosoli AL, Graf C, Bruni F, Bras R, Falcone F, Raimondo D, Giovanni AD, Cromi A. Surgical Outcomes and Complications of Laparoscopic Hysterectomy for Endometriosis: a multicentric cohort study. J Minim Invasive Gynecol 2023:S1553-4650(23)00126-7. [PMID: 37004810 DOI: 10.1016/j.jmig.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/22/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023]
Abstract
STUDY OBJECTIVE To investigate the postoperative morbidity of laparoscopic hysterectomy (LH) for endometriosis/adenomyosis in terms of operative outcomes and complications. DESIGN Retrospective multicentric cohort study. SETTING Eight European minimally invasive referral centers. PATIENTS Data from 995 patients with pathologically confirmed endometriosis and/or adenomyosis who underwent LH without concomitant urological and/or gastroenterological procedures from January 2010 to December 2020. INTERVENTIONS Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS Demographic patients' characteristics, surgical outcomes, and intraoperative and postoperative complications were evaluated. We considered major postoperative surgical-related complications any grade 2 or more events (Clavien-Dindo score) that occurred within 30 days from surgery. Univariate analysis and multivariable models fit with logistic regression were used to estimate the adjusted odds ratio (OR) and corresponding 95% CI for major complications. Median age at surgery was 44 years (28-54) and about half of them (505, 50.7%) were on medical treatment (estro-progestins, progestin or GnRh-analogues) at the time of surgery. In association with LH, posterior adhesiolysis was performed in 387 (38,9%) cases and deep nodule resection in 302 (30,0%). Intraoperative complications occurred in 3% of the patients and major postoperative complications were registered in 93 (9.3%). The multivariable analysis showed an inverse correlation between the occurrence of Clavien-Dindo >2 complications and age (OR 0.94, 95%CI 0.90-0.99), while previous surgery for endometriosis (OR 1.62, 95%CI 1.01-2.60) and intraoperative complications (OR 6.49, 95%CI 2.65-16.87) were found as predictors of major events. Medical treatment at the time of surgery has emerged as a protective factor (OR 0.50, 95%CI 0.31-0.81). CONCLUSION LH for endometriosis/adenomyosis is associated with non-negligible morbidity. Knowing the factors associated with higher risks of complications might be used for risk stratification and could help clinicians during preoperative counseling. The administration of estro-progestin or progesterone preoperatively might reduce the risks of postoperative complications following surgery.
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Chakraborty N, Rhodes S, Luchristt D, Bretschneider CE, Sheyn D. Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy? Am J Obstet Gynecol 2023; 228:205.e1-205.e12. [PMID: 36202231 DOI: 10.1016/j.ajog.2022.09.042] [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: 07/11/2022] [Revised: 09/18/2022] [Accepted: 09/28/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND It is well known that, in general, total laparoscopic hysterectomy is associated with less perioperative morbidity compared with total abdominal hysterectomy. However, total laparoscopic hysterectomy is also associated with longer operating times, which itself is an independent predictor of morbidity. Currently, it is unknown whether there is an operative time threshold beyond which total laparoscopic hysterectomy provides a diminishing return and higher risk of morbidity than a shorter abdominal hysterectomy. OBJECTIVE This study aimed to determine whether there is an operative time limit beyond which the benefits of total laparoscopic hysterectomy diminished compared with shorter total abdominal hysterectomy. STUDY DESIGN Targeted hysterectomy-specific data from the National Surgical Quality Improvement Project was used to identify patients undergoing total laparoscopic hysterectomy and total abdominal hysterectomy for benign indications between the years 2014 and 2018. The primary outcomes of interest were any major morbidity, and the length of stay after surgery was analyzed using generalized linear models. The models controlled for demographic data, comorbidities, and hysterectomy-specific information, such as uterine weight, presence of endometriosis, and pelvic inflammatory disease at the time of surgery. Missing data were addressed using multiple imputation analysis. Sensitivity analyses using propensity score matching and generalized additive models were performed to assess the effect of selection bias and nonlinear interactions between covariates and the outcomes, respectively. Common Procedural Terminology codes were used to identify women who underwent total abdominal hysterectomy (n=58,152) or total laparoscopic hysterectomy (n=58,570-58,573). Conventional laparoscopy could not be differentiated from robotic surgery as there is no mechanism for doing so within the National Surgical Quality Improvement Project. Therefore, total laparoscopic hysterectomy also includes robotic-assisted surgery. Additional exclusion criteria included any surgery lasting >360 minutes, as these represent significant outliers in the data and clinical practice; pelvic reconstructive procedure; anti-incontinence surgery; lymphadenectomy; radical hysterectomy; cytoreductive surgery; a pre- or postoperative diagnostic code for gynecologic malignancy; preoperative sepsis or renal failure; emergency surgery; or any concurrent nongynecologic surgery. Patients who underwent ureteral stenting during the procedure with no additional urologic procedures were included, as this may be performed at the time of hysterectomy or to address ureteral injury. RESULTS The mean operating time was similar for both routes, 129±60 minutes for total laparoscopic hysterectomy and 129±64 minutes for total abdominal hysterectomy (P=.45). The complication rate was higher for total abdominal hysterectomy than total laparoscopic hysterectomy (16.6% vs 7.7%; P<.001); and the median length of stay was longer for total abdominal hysterectomy (2 [interquartile range, 2-3] days vs 1 [interquartile range, 0-1] days; P<.001). After adjusting for confounders, an increase of 1 hour in operative time for hysterectomy was associated with a 45% (95% confidence interval, 41%-49%) increase in the risk of major morbidity; furthermore, total abdominal hysterectomy was associated with an additional time detriment, such that there was an additional 61% (95% confidence interval, 53%-68%) increase in the risk of a major morbidity for each additional hour of a total abdominal hysterectomy. There was no time point at which total abdominal hysterectomy was associated with less morbidity or a shorter length of stay than total laparoscopic hysterectomy, even if total laparoscopic hysterectomy was significantly longer than total abdominal hysterectomy. The same conclusions remained true with the propensity-matched analysis and generalized additive model analyses. CONCLUSION Our findings showed that there is no reasonable operative time at which total laparoscopic hysterectomy is associated with a higher rate of complications or longer length of stay than total abdominal hysterectomy.
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Affiliation(s)
- Natalie Chakraborty
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland OH; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Stephen Rhodes
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland OH
| | - Douglas Luchristt
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - C Emi Bretschneider
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland OH.
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Bruno M, Legge F, Gentile C, Carone V, Stabile G, Di Leo F, Ludovisi M, Di Florio C, Guido M. Risk Assessment Model for Complications in Minimally Invasive Hysterectomy: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010234. [PMID: 36612556 PMCID: PMC9819802 DOI: 10.3390/ijerph20010234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 06/01/2023]
Abstract
Objective: To estimate the rate of intra-operative and postoperative complications, and to define the risk of 30-day major postoperative complications (Clavien-Dindo > 2) according to the presence of one of 10 different variables of minimally invasive (MI) hysterectomy; and then to create a risk assessment model easily applicable in clinical practice. Methods: A single center single arm retrolective study. Data of consecutive patients who have undergone MI hysterectomy for gynaecologic disorders between May 2018 and April 2021 were analyzed. Perioperative surgical outcomes, occurrence of intra- and postoperative complications, and readmissions within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major postoperative complications. Results: Over the study period, 445 patients were included in the study. The majority of patients developed a minor event, while major complications (grade III) were required in 14 patients. None of the patients showed a grade IV or V complication. Univariate analysis was performed on patients who had developed intra- or postoperative complications from those who did not experience complications. Body mass index (BMI) (p-value 0.045) and surgeon’s experience (p-value 0.015) were found to be associated with a different surgery time. Regarding major postoperative complications, a statistically significant association was found for the variables: BMI (p-value 0.006), previous abdominal surgery (p-value 0.015), and surgeon’s experience (p-value 0.035) in the univariate analysis. Also in the multivariate analysis, the risk of major postoperative complications was higher in these three different variables. BMI, previous surgery, and surgeon’s experience were inserted in a reproducible risk assessment model in order to stratify the risk of major postoperative complications. Conclusions: We proposed a risk assessment model including factors not previously considered in the literature: the standardization of the surgical technique, the surgeon’s experience, the best MI approach (laparoscopy or robot-assisted), and previous abdominal surgery are crucial tools to consider. Further prospective studies with a larger population sample are needed to validate these preliminary evaluations for patients undergoing MI hysterectomy.
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Affiliation(s)
- Matteo Bruno
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Francesco Legge
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Cosimo Gentile
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Vito Carone
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Guglielmo Stabile
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Department of Obstetrics and Gynaecology, 34137 Trieste, Italy
| | - Federico Di Leo
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Manuela Ludovisi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Christian Di Florio
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Maurizio Guido
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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Tchartchian G, Bojahr B, Krentel H, De Wilde RL. Evaluation of complications, conversion rate, malignancy rate, and, surgeon's experience in laparoscopic assisted supracervical hysterectomy (LASH) of 1274 large uteri: A retrospective study. Acta Obstet Gynecol Scand 2022; 101:1450-1457. [PMID: 36203317 PMCID: PMC9812207 DOI: 10.1111/aogs.14468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Hysterectomy now belongs to standard gynecological procedures. Moreover, a shift towards laparoscopic techniques is ever more apparent as they provide many advantages such as less traumatization and shorter convalescence. Large uteri are still mentioned as contraindications for laparoscopic hysterectomy even though those patients might benefit from the lower morbidity associated with minimal invasive techniques. In this study, the largest reported so far, we analyzed intraoperative and postoperative complications as well as the surgeon's experience of laparoscopic assisted supracervical hysterectomy (LASH) in patients with a uterus weight over 500 g. MATERIAL AND METHODS The present retrospective study, between June 27, 1998 and August 31, 2019, evaluates 1274 patients with a uterus weight over 500 g who were treated with LASH for benign uterine diseases at the Clinic for Minimal Invasive Surgery (Berlin, Germany). All surgeries were performed by one of four in-house surgeons with experience in LASH: they had performed at least 500 LASH procedures before the study. Patients receiving surgical treatment for malignant tumors were not included in the study. Major and minor intraoperative and postoperative complications were recorded and evaluated. Additionally, medical files were evaluated for demographic data, American Society of Anesthesiologists score (I-IV), name of the surgeon, duration and indication for surgery, history of previous gynecological procedures and concomitant surgical interventions, weight of removed uterine tissue, duration of postoperative hospitalization in patients with complications, intraoperative conversion from laparoscopy to laparotomy, and malignancy rate. RESULTS The mean age was 47.0 ± 7.3 years and mean body mass index was 25.6 ± 7.1 kg/m2 . Average parity was 1.04 ± 1.57. Average uterus weight was 761.8 ± 317.9 g (500-4065 g). The mean duration of surgery was 96.9 ± 49.5 min; 54% of all patients were treated without concomitant intervention, conversion rate was 2.12%. The malignancy rate was 0.4% and the complication rate was 6.81% with 1.36% intraoperative complications and 5.45% postoperative complications. CONCLUSIONS The overall low complication and malignancy rates observed in this study allow us to present LASH as a safe and efficient alternative laparoscopic approach to remove uteri of any size in the hands of experienced surgeons.
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Affiliation(s)
| | - Bernd Bojahr
- Clinic for Gynecology and Breast CenterUniversitätsklinikum GreifswaldGreifswaldGermany
| | - Harald Krentel
- Clinic of Gynecology, Obstetrics, Gynecological Oncology and Senology, Academic Teaching HospitalBethesda HospitalDuisburgGermany
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Ultra-minimally invasive surgery in gynecological patients: a review of the literature. Updates Surg 2022; 74:843-855. [PMID: 35366181 PMCID: PMC9213331 DOI: 10.1007/s13304-022-01248-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/21/2022] [Indexed: 01/18/2023]
Abstract
In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m2), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.
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Haveman I, van Weelden WJ, Roovers EA, Kraayenbrink AA, Dijkhuizen FPHLJ. Robot-Assisted Total Laparoscopic Hysterectomy in Different Classes of Obesity: A Cohort Study. JSLS 2022; 26:JSLS.2021.00077. [PMID: 35281711 PMCID: PMC8896817 DOI: 10.4293/jsls.2021.00077] [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] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Robot-assisted laparoscopic hysterectomy is a safe and feasible approach in patients with higher body mass index (BMI). Slightly longer operating time in patients with high BMI did not result in higher complication or conversion rates. The purpose of this study was to evaluate whether robot-assisted total laparoscopic hysterectomy is a feasible and safe surgical approach in different classes of obesity. Methods: A single center retrospective cohort study was performed in a large secondary teaching hospital in the Netherlands. All patients who underwent robot-assisted total laparoscopic hysterectomy between January 1, 2011 and January 31, 2019 were included. Results: Data regarding patient characteristics, complication rate, conversion rate, skin-to-skin time, robot console time, and operating room time were collected. Surgery specific data were compared in patients with several classes of obesity. In total 356 cases were included. Median BMI was 29 kg/m2 (range 18 – 59). Complication rate and conversion to laparotomy did not differ significantly in different classes of obesity. Robot console time and skin-to-skin time was significantly longer in women with a BMI ≥ 40 kg/m2 (n = 34) compared to patients with normal BMI. Conclusion: Robot-assisted laparoscopic hysterectomy is a safe and feasible approach in women in different classes of obesity. The significantly prolonged operating time does not result in higher complication or conversion rates.
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Affiliation(s)
- Ilse Haveman
- Department of Obstetrics and Gynecology, Rijnstate hospital, Arnhem, The Netherlands
| | | | | | - Arjan A Kraayenbrink
- Department of Obstetrics and Gynecology, Rijnstate hospital, Arnhem, The Netherlands
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Buzzaccarini G, Stabile G, Török P, Petousis S, Mikuš M, Della Corte L, Barra F, Laganà AS. Surgical Approach for Enlarged Uteri: Further Tailoring of vNOTES Hysterectomy. J INVEST SURG 2021; 35:924-925. [PMID: 34433349 DOI: 10.1080/08941939.2021.1967528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | - Guglielmo Stabile
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Péter Török
- Department of Obstetrics and Gynecology, University of Debrecen Clinical Center, Debrecen, Hungary
| | - Stamatios Petousis
- 2nd Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Ippokratio General Hospital, Thessaloniki, Greece
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
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Uccella S, Garzon S, Lanzo G, Gallina D, Bosco M, Porcari I, Gueli-Alletti S, Cianci S, Franchi M, Zorzato PC. Uterine artery closure at the origin versus at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial. Acta Obstet Gynecol Scand 2021; 100:1840-1848. [PMID: 34396512 DOI: 10.1111/aogs.14238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/19/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other. MATERIAL AND METHODS We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, versus closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up. RESULTS Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] versus 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ. CONCLUSIONS Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.
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Affiliation(s)
- Stefano Uccella
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Gabriele Lanzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy
| | - Davide Gallina
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Irene Porcari
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Salvatore Gueli-Alletti
- Division of Gynecologic Oncology, Department of Women and Children's Health, A. Gemelli University Hospital and Institute for Research and Care, Rome, Italy
| | - Stefano Cianci
- Unit of Gynecology, Department of Human Pathology of Adult and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Kaya C, Yıldız Ş, Alay İ, Karakaş S, Durmuş U, Güraslan H, Ekin M. Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri. J INVEST SURG 2021; 35:918-923. [PMID: 34348579 DOI: 10.1080/08941939.2021.1958111] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM This study aimed to compare the surgical outcomes of laparoscopic hysterectomy (LH) and vaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy procedures in women with undescended-enlarged uteri. MATERIALS AND METHODS This cross-sectional study was conducted with 78 women who underwent LH (48 patients) or vNOTES hysterectomy (30 patients) for benign gynecological pathologies. The dimension of the uterus, operation time, intraoperative blood loss, the presence of peri-, postoperative complications, conversion to laparotomy, pre-, postoperative hemoglobin (Hb), and hematocrit (Hct) levels, postoperative hospital stay, total dose of postoperative analgesics, VAS scores at the postoperative 6th and 24th hours, and the final pathology reports were recorded. RESULTS There was no significant difference between LH and vNOTES hysterectomy groups regarding age (47 vs. 47.5 years, p = 0.92), parity (2 vs. 2, p = 0.74), and BMI (30.8 vs. 28.2 kg/m2, p = 0.31). The patients in the vNOTES hysterectomy group had significantly shorter durations of surgery (45 vs. 160 min) and hospitalization (48 vs. 72 h) than the LH group (p < 0.001, p < 0.001, respectively). The 24th hour VAS score was lower (VAS score 2 vs. 3, p = 0.003) in favor of the vNOTES hysterectomy group. In matched group analysis, the 24th hour VAS score (2 vs. 3, p = 0.008), operation time (45 vs. 157, p < 0.001), and hospitalization (48 vs. 72, p < 0.001) were lower in the vNOTES hysterectomy group than the LH group. CONCLUSION vNOTES hysterectomy provides favorable outcomes compared to conventional LH considering the shorter operation time, hospitalization, and lower 24th h VAS score.
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Affiliation(s)
- Cihan Kaya
- Department of Obstetrics and Gynecology, Acıbadem Mehmet Ali Aydınlar University, Acıbadem Bakirkoy Hospital, Istanbul, Turkey
| | - Şükrü Yıldız
- Department of Obstetrics and Gynecology, University of Health Sciences, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - İsmail Alay
- Department of Gynecology and Obstetrics, University of Health Sciences, Cam and Sakura City Hospital, Istanbul, Turkey
| | - Sema Karakaş
- Department of Gynecologic Oncology, University of Health Sciences, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Uğur Durmuş
- Department of Obstetrics and Gynecology, University of Health Sciences, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Hakan Güraslan
- Department of Obstetrics and Gynecology, University of Health Sciences, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Murat Ekin
- Department of Obstetrics and Gynecology, University of Health Sciences, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Casarin J, Cromi A, Bogani G, Multinu F, Uccella S, Ghezzi F. Surgical morbidity of total laparoscopic hysterectomy for benign disease: Predictors of major postoperative complications. Eur J Obstet Gynecol Reprod Biol 2021; 263:210-215. [PMID: 34229185 DOI: 10.1016/j.ejogrb.2021.06.023] [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: 04/01/2021] [Revised: 05/24/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To estimate rate of perioperative complications and to define risk factors of 30-day major (Clavien-Dindo ≥ 2) postoperative complications of total laparoscopic hysterectomy (TLH) for benign disease. STUDY DESIGN An uncontrolled single-center single-arm retrospective study. Data of consecutive patients who have undergone TLH for pathologically confirmed benign disease between January 2000 and December 2019 have been analyzed. Perioperative surgical outcomes, occurrence of postoperative complications, readmissions, and reoperations within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major (Clavien-Dindo ≥ 2) postoperative complications. RESULTS Over the study period 3090 patients were included in the study. Conversion to open surgery occurred in 54 (1.7%) cases. Mean operative time for TLH was 87.7 (±1.7) minutes while mean estimated blood loss was 119.5 (+7.4) mL. Overall, postoperative complications were registered in 430 (13.9%) patients, and major events were observed in 208 (6.7%) of the cases. Same-hospital readmissions and reoperations within 30-day from surgery occurred in 78 (2.5%) and 28 (0.9%) patients, respectively. At multivariable analysis, endometriosis (odds ratio: 3.51, 95%CI:1.54-8.30, p = 0.02), the need for conversion to open surgery (odds ratio: 1.26, 98%CI:1.03-12.64, p < 0.001), and the occurrence of any intraoperative complication (odds ratio: 3.10, 95%CI: 1.45-21.61, p < 0.001) were found as independent risk factors for major postoperative complications. CONCLUSIONS Total hysterectomy performed via laparoscopy is associated with acceptable major postoperative complications rate. A huge effort should be made to minimize the occurrence of intraoperative complications and the need for conversion to open surgery. Patients undergoing TLH for endometriosis should be counselled about the increased risk of major postoperative events.
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Affiliation(s)
- J Casarin
- Obstetrics and Gynecology Department of the University of Insubria, Varese, Italy.
| | - A Cromi
- Obstetrics and Gynecology Department of the University of Insubria, Varese, Italy
| | - G Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
| | - F Multinu
- Division of Gynecologic Surgery, IEO, European Institute of Oncology IRCSS, Milan, Italy
| | - S Uccella
- Obstetrics and Gynecology Department, University of Verona, Italy
| | - F Ghezzi
- Obstetrics and Gynecology Department of the University of Insubria, Varese, Italy
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14
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Uccella S, Kho RM, Garzon S, Casarin J, Zorzato PC, Ghezzi F. The Large Uterus Classification System: a prospective observational study. BJOG 2021; 128:1526-1533. [PMID: 33988895 PMCID: PMC8362220 DOI: 10.1111/1471-0528.16753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/22/2022]
Abstract
Objective To investigate the Large Uterus Classification System (LUCS) ability to predict surgical outcomes and complications in total laparoscopic hysterectomies (TLHs) for large uteri. Design Prospective observational study. Setting Two referral centres. Population or sample Three hundred and ninety‐two women who underwent TLH for a large uterus (uterine fundus at or over the transverse umbilical line). Methods Between 2004 and 2019, the intraoperative LUCS was estimated in all patients. The LUCS considers the uterine and adnexal vascular pedicles displacement. Type 1 is without vascular pedicles displacement. Type 2 has the cephalad displacement of adnexal vascular pedicles. The uterine vessels displacement regardless of adnexal pedicles defines Type 3. Main outcome measures Patients’ characteristics with perioperative outcomes were prospectively collected and compared between the three types of large uteri. Results Two hundred and fifty‐one (64%), 82 (20.9%) and 59 (15.1%) women had Type 1, Type 2 and Type 3 uteri, respectively. Women with Type 1 uteri had a lower uterine weight, shorter operative time, less blood loss and lower complication rates than women with Types 2 and 3. The conversion rate to laparotomy in Type 1 was similar to that in Type 2 (odds ratio [OR] 0.98; 95% CI 0.32–3.56) but lower than Type 3 (OR 0.35; 95% CI 0.14–0.97); in Type 2 it was lower than Type 3, although without the conventional statistical significance (OR 0.36; 95% CI 0.13–1.13; P = 0.07). Multivariable analysis showed that the uterine Type (1 versus 2–3) was independently associated with the total complications rate (OR 2.00; 95% CI 1.09–3.68; P = 0.02). Conclusions The LUCS appears associated with surgical outcomes and complications, potentially stratifying the surgical risk and guiding the surgical technique in TLHs for large uteri. Tweetable abstract The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri. The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.
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Affiliation(s)
- S Uccella
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - R M Kho
- Department Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S Garzon
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - J Casarin
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
| | - P C Zorzato
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - F Ghezzi
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
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Ishidera Y, Furugori M, Hirata G, Wakabayashi R, Shigeta H, Yoshida H. Total Laparoscopic Hysterectomy for Anterior Cervical Myoma: Possible Significance of Presurgical Assessment by Magnetic Resonance Imaging. Gynecol Minim Invasive Ther 2021; 10:61-64. [PMID: 33747778 PMCID: PMC7968599 DOI: 10.4103/gmit.gmit_104_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/04/2020] [Accepted: 03/19/2020] [Indexed: 11/15/2022] Open
Abstract
Hysterectomy for large uterine anterior cervical myoma is a challenging surgical procedure. We summarize our experience in the management of large uterine anterior cervical myoma. Three patients underwent hysterectomy for uterine anterior cervical myoma with similar sizes and different positions treated by laparoscopic surgery. Total laparoscopic hysterectomy (TLH) for cervical myoma is possible by performing ureterolysis and adopting retrograde hysterectomy. Because the position of myoma is important to determine the difficulty of TLH, we propose to measure the axis between the most caudal point of the myoma and external cervical os and pubococcygeal line as a possible useful method in objectively predicting the difficulty of TLH for large anterior cervical myoma.
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Affiliation(s)
- Yumi Ishidera
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Megumi Furugori
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Go Hirata
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Reina Wakabayashi
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Hiroyuki Shigeta
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Hiroshi Yoshida
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
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Mutter O, Ackroyd SA, Taylor GA, Diaz J. Minimally invasive hysterectomy for endometriosis: Surgical outcomes based on surgeon specialty. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/2284026521990201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: To evaluate differences in surgical outcomes of minimally invasive hysterectomy performed for endometriosis between general gynecologists and gynecologic oncologists. Methods: Utilizing the 2016–2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) hysterectomy dataset, we evaluated baseline characteristics and surgical outcomes for patients who underwent a minimally invasive hysterectomy for endometriosis between general gynecology and gynecologic oncology groups. Results: From 2016 to 2018, a total of 3751 minimally invasive hysterectomies were performed for the primary diagnosis of endometriosis. Of these cases, 3129 (83.4%) were performed by general gynecologists and 622 (16.6%) by gynecologic oncologists. There were several differences in baseline characteristics between the groups. Notably, general gynecologists performed a higher proportion of vaginal hysterectomies (7.9% vs 0.6%, p < 0.01). There were no statistically significant differences in overall 30-day complications or mortality between general gynecology and oncology groups, with the exception of a higher rate of postoperative sepsis (0.8% vs 0.2%, p = 0.01) in hysterectomies performed by oncologists. Compared to general gynecologists, oncologists had a longer operative time (134.9 ± 65.4 min vs 129 ± 60.9 min, p = 0.05). Multivariate regression of multiple tracked and composite outcomes revealed no consistent confounding variables other than race. In fact, African American race was a statistically significant predictive factor of composite complications (OR 1.80, p < 0.01), morbidity (OR 1.84, p < 0.05), and unplanned readmission (OR 2.30, p < 0.01). Surgeon specialty was not associated with composite complications, hysterectomy-specific complications, or readmission. Conclusion: There are no significant differences in surgical outcomes for minimally invasive hysterectomy for endometriosis between these two surgical subspecialties.
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Affiliation(s)
- Olga Mutter
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA, USA
| | - Sarah A Ackroyd
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA, USA
| | - George A Taylor
- Department of General Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Juan Diaz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA, USA
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Mutter O, Ackroyd S, Taylor GA, Diaz J. Surgical outcomes of hysterectomy for endometriosis: Benefits of a minimally invasive approach. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/2284026520985715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: We aimed to evaluate surgical outcomes of hysterectomy for endometriosis performed by general obstetricians and gynecologists (OB/GYNs) based on surgical approach. Methods: Using the 2016–2018 National Surgical Quality Improvement Program (NSQIP) database, we examined surgical outcomes including 30-day complication rates based on surgical approach in patients who underwent a hysterectomy for endometriosis by OB/GYNs. Results: From 2016 to 2018, 3641 hysterectomies were performed by OB/GYNs for endometriosis. 86.0% were performed via a minimally invasive (MIS) approach, with 2882 (79.2%) via a laparoscopic and 247 (6.8%) via a vaginal approach. Compared to MIS hysterectomies, those who underwent an abdominal hysterectomy included a higher proportion of African American and a lower proportion of non-Hispanic white patients, had heavier uteri, lower parity, and were more likely obese (all p < 0.05). There were no differences in age, American Society of Anesthesiologists class, comorbidities other than obesity, or a history of prior abdominal or pelvic surgery (all p > 0.05). Women undergoing hysterectomy for endometriosis experienced an overall 9.8% complication rate. Compared to abdominal approaches, MIS had a lower rate of overall complications (8.5% vs 17.8%) including wound (2.7% vs 7.2%) and major (4.4% vs 8.8%) complications (all p < 0.001). MIS had shorter operative time (129.2 ± 60.9 vs 143.8 ± 71.9), shorter length of stay (0.9 ± 1.6 vs 2.4 ± 1.8), and fewer readmissions (2.8% vs 5.5%) (all p < 0.001). Conclusion: While hysterectomy for endometriosis is a challenging procedure to perform, OB/GYNs are performing this procedure predominantly via a minimally invasive approach with fewer complications and more favorable surgical outcomes than an abdominal approach.
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Affiliation(s)
- Olga Mutter
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA, USA
| | - Sarah Ackroyd
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA, USA
| | - George A Taylor
- Department of General Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Juan Diaz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA, USA
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Uccella S, Zorzato PC, Favilli A, Bosco M, Franchi MP, Garzon S. Regarding "Trends and Risk Factors for Vaginal Cuff Dehiscence after Laparoscopic Hysterectomy". J Minim Invasive Gynecol 2021; 28:913. [PMID: 33434697 DOI: 10.1016/j.jmig.2020.12.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023]
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Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic Hysterectomy: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2021; 28:710-720. [PMID: 33348012 DOI: 10.1016/j.jmig.2020.12.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy. DATA SOURCES PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered. METHODS OF STUDY SELECTION The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence. TABULATION, INTEGRATION, AND RESULTS A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11-0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13-1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00-3.88). CONCLUSION There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.
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Feasibility and safety of total laparoscopic hysterectomy for uteri weighing from 1.5 kg to 11.000 kg. Arch Gynecol Obstet 2020; 303:169-179. [PMID: 32949285 DOI: 10.1007/s00404-020-05799-6] [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: 07/03/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess the feasibility and safety of total laparoscopic hysterectomy (TLH) for uteri ≥ 1.5 kg. METHODS We prospectively evaluated all elective TLHs (with or without adnexectomy) performed for fibromatous uteri between August 2009 and August 2019 in the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and the Department of Gynecologic Oncology, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari. Patients with large myomatous uteri (uterine weight ≥ 1.5 kg on pathology reports) were included in the analysis. We examined all procedures and collected data about intra- and post-operative short-term and long-term complications, intraoperative blood loss, operative time, hospital stay, and time to achieve well-being. RESULTS Seventy-eight patients were included. The median weight was 2,000 g (range 1,500-11,000 g), estimated blood loss was 100 mL (range 10-700 mL), operating time was 135 min (range 60-300 min), and hospital stay was 2 days (range 2-5 days). Conversion to laparotomy occurred in 4 patients (5.1%) with uterine weight ranging from 3 to 5.5 kg, due to severe adherence syndrome or inadequate visualization. As for intraoperative complications, 1 patient (who had the largest removed uterus weighing 11,000 g) experienced an intraoperative ureteral injury (grade III). No major postoperative complications occurred. CONCLUSIONS This study provides the largest case series of TLH for fibromatous uteri > 1.5 kg and includes some of the largest uteri reported to date in the literature (weighing 5,320, 5,720, and 11,000 g, respectively). The study reaffirms the feasibility and safety of a minimally invasive hysterectomy even in the case of abnormally large uteri.
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Gueli Alletti S, Perrone E, Cretì A, Cianci S, Uccella S, Fedele C, Fanfani F, Palmieri S, Fagotti A, Scambia G, Rossitto C. Feasibility and perioperative outcomes of percutaneous-assisted laparoscopic hysterectomy: A multicentric Italian experience. Eur J Obstet Gynecol Reprod Biol 2020; 245:181-185. [DOI: 10.1016/j.ejogrb.2019.12.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/16/2019] [Accepted: 12/23/2019] [Indexed: 01/25/2023]
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Uccella S, Capozzi VA, Ricco’ M, Perrone E, Zanello M, Ferrari S, Zorzato PC, Seracchioli R, Cromi A, Serati M, Ergasti R, Fanfani F, Berretta R, Malzoni M, Cianci S, Vizza E, Guido M, Legge F, Ciravolo G, Gueli Alletti S, Ghezzi F, Candiani M, Scambia G. Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire. J Minim Invasive Gynecol 2020; 27:186-194. [PMID: 30951920 DOI: 10.1016/j.jmig.2019.03.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022]
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Sezgin B, Camuzcuoğlu A, Küçük M, Camuzcuoğlu H. Bilateral uterine artery coagulation in laparoscopic hysterectomy for benign disease in uteri more than 1000 g. J Obstet Gynaecol Res 2019; 46:133-139. [PMID: 31646706 DOI: 10.1111/jog.14148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/07/2019] [Indexed: 12/17/2022]
Abstract
AIM We aimed to evaluate the efficacy of bipolar uterine artery coagulation in laparoscopic hysterectomy for uteri larger than 1000 g. METHODS Data from 674 patients who underwent laparoscopic hysterectomy were retrospectively analyzed. Among those, 75 patients with uteri weighing more than 1000 g were included. The clinical and surgical outcomes of patients with large uteri were compared according to bipolar uterine artery coagulation performance status. RESULTS The mean difference in intraoperative blood loss between the groups of patients with uterine artery occlusion and without uterine artery occlusion was statistically significant (89.26 ± 65.52 vs 227.94 ± 124.65 mL; P < 0.001). The hemoglobin decrease was also significantly lower in the patients with uterine artery occlusion (0.46 ± 0.23 vs 1.21 ± 0.79 g/dL; P < 0.001). CONCLUSION When performing laparoscopic hysterectomy of uteri weighing over 1000 g, the occlusion of the bilateral uterine arteries at the point of exit from the internal iliac arteries using bipolar coagulation at the beginning of the operation reduces intraoperative hemorrhage and hemoglobin decrease.
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Affiliation(s)
- Burak Sezgin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Muğla Sıtkı Koçman University, Mugla, Turkey
| | - Aysun Camuzcuoğlu
- Department of Obstetrics and Gynecology, Private Adatıp Sakarya Hospital, Sakarya, Turkey
| | - Mert Küçük
- Department of Medical Education and Bioinformatics, Muğla Sıtkı Koçman University, Mugla, Turkey.,Department of Obstetrics and Gynecology, Mugla Sitki Kocman University, Mugla, Turkey
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Capozzi VA, Sozzi G, Gambino G, Cianciolo A, Riccò M, Monfardini L, Gaiano M, Chiantera V, Uccella S, Berretta R. Laparoscopy versus laparotomy for surgical treatment of obese women with endometrial cancer: A cost-benefit comparative analysis. Mol Clin Oncol 2019; 11:335-342. [PMID: 31475060 PMCID: PMC6713942 DOI: 10.3892/mco.2019.1901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/21/2019] [Indexed: 01/13/2023] Open
Abstract
The aim of the present study was to demonstrate the cost of obese patients affected by endometrial cancer undergoing open surgery compared with minimally invasive surgery. In the retrospective cohort study (Canadian Task Force classification II-2), the economic expenditure in pre-operative, intra-operative and post-operative phases of the selected patients was evaluated. Costs were analyzed for all blood tests, instrumental examinations, consultations, operating materials, drugs, gynecological examinations, hospital stay, intensive care hospitalization and management of operative complications. The average length of stay was longer for patients who underwent laparotomy, with an almost double median hospitalization cost in the open abdominal group compared with the laparoscopic group (€4,805.37 vs. €2,589.25; P<0.0001). Evaluation by another specialist (cardiologist, diabetologist, internist) was necessary in 30.9% of laparotomies vs. 10.4% of laparoscopies (P=0.003). A respiratory support was applied to 38 patients (28.8%), of whom 23 (41.8%) were in the open abdominal arm (P=0.011). Antibiotic and pain-relief therapies resulted in a significantly higher cost for the open abdominal than for the minimally-invasive approach (P=0.027). Considering all the pre-, intra- and post-operative course, the expenses for an obese patient operated by laparoscopy was €4,412.41 vs. €7,323.17 by open surgery, with an average saving of €2,911.03 in favor of minimally-invasive surgery. This study revealed that in obese patients with endometrial cancer, minimally invasive surgery is more advantageous both in terms of costs and post-operative complications. To conclude, laparoscopic surgery in obese patients allows an economic saving of ~60% less than open surgery.
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Affiliation(s)
- Vito Andrea Capozzi
- Department of Gynecology and Obstetrics, University of Parma, I-43125 Parma, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, University of Palermo, I-90127 Palermo, Italy
| | - Giulia Gambino
- Department of Gynecology and Obstetrics, University of Parma, I-43125 Parma, Italy
| | - Alessandra Cianciolo
- Department of Gynecology and Obstetrics, University of Parma, I-43125 Parma, Italy
| | - Matteo Riccò
- Department of Public Health, Workplace Prevention and Safety Service, AUSL1-I.R.C.C.S. di Reggio Emilia, Service for Health and Safety on The Workplaces, I-42122 Reggio, Italy
| | - Luciano Monfardini
- Department of Gynecology and Obstetrics, University of Parma, I-43125 Parma, Italy
| | - Michela Gaiano
- Department of Gynecology and Obstetrics, University of Parma, I-43125 Parma, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, University of Palermo, I-90127 Palermo, Italy
| | - Stefano Uccella
- Obstetrics and Gynecology Department, Ospedale degli Infermi, I-13875 Biella, Italy
| | - Roberto Berretta
- Department of Gynecology and Obstetrics, University of Parma, I-43125 Parma, Italy
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Cianci S, Gueli Alletti S, Rumolo V, Rosati A, Rossitto C, Cosentino F, Turco LC, Vizzielli G, Fagotti A, Gallotta V, Ciccarone F, Scambia G, Uccella S. Total laparoscopic hysterectomy for enlarged uteri: factors associated with the rate of conversion to open surgery. J OBSTET GYNAECOL 2019; 39:805-810. [DOI: 10.1080/01443615.2019.1575342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- S. Cianci
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - S. Gueli Alletti
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - V. Rumolo
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - A. Rosati
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - C. Rossitto
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - F. Cosentino
- Dipartimento di Oncologia, Fondazione di Ricerca e Cura Giovanni Paolo II, Campobasso, Italy
| | - L. C. Turco
- Dipartimento di Oncologia, Fondazione di Ricerca e Cura Giovanni Paolo II, Campobasso, Italy
| | - G. Vizzielli
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - A. Fagotti
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - V. Gallotta
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - F. Ciccarone
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - G. Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - S. Uccella
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
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Ito TE, Martin AL, Henderson EF, Gaskins JT, Vaughn VM, Biscette SM, Pasic RP. Systematic Review of Topical Hemostatic Agent Use in Minimally Invasive Gynecologic Surgery. JSLS 2019; 22:JSLS.2018.00070. [PMID: 30662251 PMCID: PMC6328362 DOI: 10.4293/jsls.2018.00070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background and Objectives: To perform a systematic review of articles evaluating hemostatic effectiveness and peri-operative outcomes when topical hemostatic agents (HA) are used in minimally invasive gynecologic surgeries (MIGS) for benign conditions. Methods: Studies published through March 31, 2017 were retrieved through PubMed, EMBASE, Cochrane, and ClinicalTrials.gov to identify all eligible studies. No studies were excluded based on publish date. All comparative studies or case series with >10 participants reporting use of at least one topical HA in MIGS for benign conditions were included as long as full-text articles were available and written in English. Studies were excluded if surgery was done for malignancy or completed via an open approach. Articles that included multiple surgical subspecialties were excluded if data related to MIGS was unable to be isolated. Evaluation for eligibility and data extraction was performed by three independent reviewers. Quality of evidence was also assessed by each reviewer. Results: From 132 articles, a total of 8 studies were included in this systematic review. We found that use of fibrin sealant decreased time to hemostasis, postoperative hemoglobin drop, and estimated blood loss (EBL) compared with bipolar energy and reduced the overall operative time in laparoscopic myomectomy. When fibrin sealant use at time of myomectomy was compared to bipolar energy there was no significant difference in the rate of postoperative complications. Furthermore, there was less of a decrease in anti-Mullerian hormone (AMH) level when a thrombin-gelatin matrix was used compared to bipolar energy on ovarian tissue. Conclusion: Application of topical HA in MIGS can reduce operative time, blood loss, and ameliorate damage to ovarian function. However, more data needs to be gathered for use of HA during different types of gynecologic procedures (adnexal surgery, myomectomy, and hysterectomy) to provide better quality evidence to guide their use.
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Affiliation(s)
- Traci E Ito
- Department of Obstetrics and Gynecology, University of Louisville Hospital, Louisville, KY, USA
| | - Alexandra L Martin
- Department of Obstetrics and Gynecology, University of Louisville Hospital, Louisville, KY, USA
| | - Edith F Henderson
- Department of Obstetrics and Gynecology, University of Louisville Hospital, Louisville, KY, USA
| | - Jeremy T Gaskins
- Department of Biostatistics, University of Louisville, Louisville, KY, USA
| | - Vida M Vaughn
- Department of Obstetrics and Gynecology, University of Louisville Hospital, Louisville, KY, USA
| | - Shan M Biscette
- Department of Obstetrics and Gynecology, University of Louisville Hospital, Louisville, KY, USA
| | - Resad P Pasic
- Department of Obstetrics and Gynecology, University of Louisville Hospital, Louisville, KY, USA
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Sinha R, Swarnasree G, Rupa B, Madhumathi S. Laparoscopic hysterectomy for large uteri: Outcomes and techniques. J Minim Access Surg 2019; 15:8-13. [PMID: 29582799 PMCID: PMC6293677 DOI: 10.4103/jmas.jmas_205_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim: The aim of this study was to analyse our data of laparoscopic hysterectomy for large uteri (>16 weeks size) regarding their perioperative outcomes and possible factors for conversions to open surgery over 5 years. It also describes our techniques for the feasibility of performing such hysterectomies by the minimally invasive way. Materials and Methods: A five-year retrospective chart review was performed at the Minimal Access and Robotic Surgery Unit of the Department of Gynecology at Apollo Hospital, Hyderabad. Demographic and pre-operative and post-operative data were recorded. Clinical assessment including bimanual examination and surgery was made by a single senior surgeon. Intra-operative conversions, complications and post-operative complications were recorded. Results: A total of 128 women were included in this study, 5 patients underwent robotic-assisted hysterectomy. The average age was 44.4, body mass index - was 27.6 and size of the uterus was 17.5 weeks. The most common diagnosis was leiomyoma. The median Operating room (OR) time was 107 min. There was a need for myomectomy in 39.8%, extensive adhesiolysis in 33.6% and dense bladder adhesion in 26.6%. The average drop in haemoglobin was 1.72 g%, and hospital stay was 2 days. The specimen was removed by vaginal morcellation (2 cases via an umbilical port). Conversion to open surgery was required in 10.9% of cases. The conversion was significantly correlated with excessive haemorrhage and bladder injury but not with difficult hysterectomy, difficult bladder dissection or adhesions. There were 3 cases of bladder injury detected and managed intraoperatively. Conclusion: Laparoscopic hysterectomy is technically feasible and safe procedure for large uteri. The learning curve is about 50 cases and can be performed by experienced surgeons regardless of the size, number or location of the myomas without much morbidity.
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Affiliation(s)
- Rooma Sinha
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - G Swarnasree
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - B Rupa
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - S Madhumathi
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
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Matsushima T, Akira S, Fukami T, Yoneyama K, Takeshita T. Efficacy of Hormonal Therapies for Decreasing Uterine Volume in Patients with Adenomyosis. Gynecol Minim Invasive Ther 2018; 7:119-123. [PMID: 30254953 PMCID: PMC6135169 DOI: 10.4103/gmit.gmit_35_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Study objective: The aim of this study is to evaluate the efficacy of hormonal therapies for inhibiting an increase in uterine volume in patients with adenomyosis. Design: This was retrospective cohort study. Setting: This study was conducted at Nippon Medical School Musashikosugi Hospital. Patients: A total of 28 women diagnosed with adenomyosis using magnetic resonance imaging. Methods: After providing informed consent, patients were treated with gonadotropin-releasing hormone agonist (GnRHa group), a low-dose estrogen and progestin combination (LEP group), or dienogest (DNG group) for ≥16 weeks. Uterine volume was assessed using the formula for an ovoid; uterine volumes before and after 16 weeks of treatment were compared. A <5% increase in uterine volume at 16 weeks was considered to reflect inhibition of uterine volume increase and efficacy of the medication. We compared the efficacy rate among the groups. Results: In the GnRHa group, a significant reduction in uterine volume was noted, from 307.4 ± 230.1 to 177.9 ± 142.1 cm3 (P < 0.001). In the LEP and the DNG groups, there was no significant change (LEP: 226.7 ± 116.6 cm3 pre-treatment and 230.5 ± 128.6 cm3 post-treatment, P = 0.85; DNG: 232.6 ± 117.8 cm3 pre-treatment and 262.1 ± 136.8 cm3 post-treatment, P = 0.37). The number of responders (efficacy rate) in the GnRHa group, LEP group, and DNG group was 25/26 (96.2%), 7/15 (46.7%), and 6/11 (54.5%), respectively. The efficacy rate of GnRHa therapy was significantly higher than that of LEP or DNG therapy (P < 0.001 and P = 0.005, respectively). Conclusion: We conclude that the efficacy of GnRHa in reducing uterine volume should be considered when prescribing hormone therapy for adenomyosis.
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Affiliation(s)
- Takashi Matsushima
- Department of Obstetrics and Gynecology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Shigeo Akira
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Takehiko Fukami
- Department of Obstetrics and Gynecology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Koichi Yoneyama
- Department of Obstetrics and Gynecology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
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29
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Uccella S, Gisone B, Serati M, Biasoli S, Marconi N, Angeretti G, Gallotta V, Cardinale S, Rausei S, Dionigi G, Scambia G, Ghezzi F. Functional outcomes of nerve-sparing laparoscopic eradication of deep infiltrating endometriosis: a prospective analysis using validated questionnaires. Arch Gynecol Obstet 2018; 298:639-647. [PMID: 30062386 DOI: 10.1007/s00404-018-4852-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/25/2018] [Indexed: 12/17/2022]
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Uccella S, Malzoni M, Cromi A, Seracchioli R, Ciravolo G, Fanfani F, Shakir F, Gueli Alletti S, Legge F, Berretta R, Corrado G, Casarella L, Donarini P, Zanello M, Perrone E, Gisone B, Vizza E, Scambia G, Ghezzi F. Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy. Am J Obstet Gynecol 2018; 218:500.e1-500.e13. [PMID: 29410107 DOI: 10.1016/j.ajog.2018.01.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/10/2018] [Accepted: 01/23/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event. OBJECTIVE The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial. STUDY DESIGN Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy. RESULTS After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence. CONCLUSION Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention.
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Affiliation(s)
- Stefano Uccella
- Department of Woman and Child Health, Fondazione "Policlinico Universitario A. Gemelli," Rome, Italy; Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy.
| | - Mario Malzoni
- Endoscopica Malzoni-Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Renato Seracchioli
- Minimally Invasive Gynecological Surgery Unit, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Giuseppe Ciravolo
- Department of Obstetrics and Gynecology, Spedali Civili di Brescia, Brescia, Italy
| | - Francesco Fanfani
- Department of Medicine and Aging Sciences, University "Gabriele d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Fevzi Shakir
- Department of Obstetrics and Gynecology, Royal Free Hospital, London, United Kingdom
| | - Salvatore Gueli Alletti
- Department of Woman and Child Health, Fondazione "Policlinico Universitario A. Gemelli," Rome, Italy
| | - Francesco Legge
- Division of Gynecology, Department of Obstetrics and Gynecology, "F. Miulli" General Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Roberto Berretta
- Department of Gynecology and Obstetrics, University of Parma, Parma, Italy
| | - Giacomo Corrado
- Department of Woman and Child Health, Fondazione "Policlinico Universitario A. Gemelli," Rome, Italy
| | - Lucia Casarella
- Endoscopica Malzoni-Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy
| | - Paolo Donarini
- Department of Obstetrics and Gynecology, Spedali Civili di Brescia, Brescia, Italy
| | - Margherita Zanello
- Minimally Invasive Gynecological Surgery Unit, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Emanuele Perrone
- Gynecologic Oncology Unit, Fondazione "Policlinico Universitario A. Gemelli," Catholic University, Rome, Italy
| | - Baldo Gisone
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Enrico Vizza
- Department of Oncological Surgery, Gynecologic Oncologic Unit, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Fondazione "Policlinico Universitario A. Gemelli," Catholic University, Rome, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
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31
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In Search for the Best Minimally Invasive Hysterectomy Approach for the Large Uterus: A Review. Clin Obstet Gynecol 2018; 60:286-295. [PMID: 28319474 DOI: 10.1097/grf.0000000000000285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Review of literature is conducted to determine the best minimally invasive hysterectomy (MIH) route for large uterus, identify preoperative considerations and describe alternative techniques to power morcellation. Studies after 2010 revealed multiple MIH approaches. Vaginal hysterectomy is preferred over laparoscopic and laparoscopic assistance with less operative time and hospital cost. In morbidly obese patients with large uteri, total laparoscopic hysterectomy is superior to vaginal hysterectomy with lesser odds of blood transfusion and lower length of hospital stay. Although MIH for the large uterus is feasible, many questions remain unanswered. Well-designed multicenter prospective trial incorporating clinical pathways to compare outcomes is needed.
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Uccella S, Morosi C, Marconi N, Arrigo A, Gisone B, Casarin J, Pinelli C, Borghi C, Ghezzi F. Laparoscopic Versus Open Hysterectomy for Benign Disease in Uteri Weighing >1 kg: A Retrospective Analysis on 258 Patients. J Minim Invasive Gynecol 2017; 25:62-69. [PMID: 28711761 DOI: 10.1016/j.jmig.2017.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/29/2017] [Accepted: 07/06/2017] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE To present a large single-center series of hysterectomies for uteri ≥1 kg and to compare the laparoscopic and open abdominal approach in terms of perioperative outcomes and complications. DESIGN A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2). SETTING An academic research center. PATIENTS Consecutive women who underwent hysterectomy for uteri ≥1 kg between January 2000 and December 2016. Patients with a preoperative diagnosis of uterine malignancy or suspected uterine malignancy were excluded. The subjects were divided according to the intended initial surgical approach (i.e., open or laparoscopic). The 2 groups were compared in terms of intraoperative data and postoperative outcomes. Multivariable analysis was performed to identify possible independent predictors of overall complications. A subanalysis including only obese women was accomplished. INTERVENTIONS Total laparoscopic versus abdominal hysterectomy (±bilateral adnexectomy). MEASUREMENTS AND MAIN RESULTS Intra- and postoperative surgical outcomes. A total of 258 patients were included; 55 (21.3%) women were initially approached by open surgery and 203 (78.7%) by laparoscopy. Nine (4.4%) conversions from laparoscopic to open surgery were registered. The median operative time was longer in the laparoscopic group (120 [range, 50-360] vs 85 [range, 35-240] minutes, p = .014). The estimated blood loss (150 [range, 0-1700] vs 200 [50-3000] mL, p = .04), postoperative hemoglobin drop, and hospital stay (1 [range, 1-8] vs 3 [range, 1-8] days, p < .001) were lower among patients operated by laparoscopy. No difference was found between groups in terms of intra- and postoperative complications. However, the overall rate of complications (10.8% vs. 27.2%, p = .015) and the incidence of significant complications (defined as intraoperative adverse events or postoperative Clavien-Dindo ≥2 events, 4.4% vs 10.9%, p = .04) were significantly higher among patients who initially received open surgery. The laparoscopic approach was found to be the only independent predictor of a lower incidence of overall complications (odds ratio = 0.42; 95% confidence interval, 0.19-0.9). The overall morbidity of minimally invasive hysterectomy was lower also in the subanalysis concerning only obese patients. CONCLUSION In experienced hands and in dedicated centers, laparoscopic hysterectomy for uteri weighing ≥1 kg is feasible and safe. Minimally invasive surgery retains its well-known advantages over open surgery even in patients with extremely enlarged uteri.
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Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy.
| | - Chiara Morosi
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Nicola Marconi
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Anna Arrigo
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Baldo Gisone
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Camilla Borghi
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
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Ito TE, Vargas MV, Moawad GN, Opoku-Anane J, Shu MKM, Marfori CQ, Robinson JK. Minimally Invasive Hysterectomy for Uteri Greater Than One Kilogram. JSLS 2017; 21:JSLS.2016.00098. [PMID: 28352147 PMCID: PMC5346020 DOI: 10.4293/jsls.2016.00098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives: To assess the feasibility and safety of minimally invasive hysterectomy for uteri >1 kg. Methods: Clinical and surgical characteristics were collected for patients in an academic tertiary care hospital. Included were patients who underwent minimally invasive hysterectomy by 1 of 3 fellowship-trained gynecologists from January 1, 2009, to July 1, 2015 and subsequently had confirmed uterine weights of 1 kg or greater on pathology report. Both robotic and conventional laparoscopic procedures were included. Results: During the study period, 95 patients underwent minimally invasive hysterectomy with confirmed uterine weight over 1 kg. Eighty-eight percent were performed with conventional laparoscopy and 12.6% with robot-assisted laparoscopy. The median weight (range) was 1326 g (range, 1000–4800). The median estimated blood loss was 200 mL (range, 50–2000), and median operating time was 191 minutes (range, 75–478). Five cases were converted to laparotomy (5.2%). Four cases were converted secondary to hemorrhage and one secondary to extensive adhesions. There were no conversions after 2011. Intraoperative transfusion was given in 6.3% of cases and postoperative transfusion in 6.3% of cases. However, after 2013, the rate of intraoperative transfusion decreased to 1.0% and postoperative transfusion to 2.1%. Of the 95 cases, there were no cases with malignancy. Conclusions: This provides the largest case series of hysterectomy over 1 kg completed by a minimally invasive approach. Our complication rate improved with experience and was comparable to other studies of minimally invasive hysterectomy for large uteri. When performed by experienced surgeons, minimally invasive hysterectomy for uteri >1 kg can be considered feasible and safe.
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Affiliation(s)
- Traci E Ito
- Department of Obstetrics and Gynecology, The George Washington University Hospital
| | - Maria V Vargas
- Department of Obstetrics and Gynecology, The George Washington University Hospital
| | - Gaby N Moawad
- Department of Obstetrics and Gynecology, The George Washington University Hospital
| | - Jessica Opoku-Anane
- Department of Obstetrics and Gynecology, The George Washington University Hospital
| | - Michael K M Shu
- The George Washington University Hospital, and the George Washington University Medical School, Washington, DC, USA
| | - Cherie Q Marfori
- Department of Obstetrics and Gynecology, The George Washington University Hospital
| | - James K Robinson
- Department of Obstetrics and Gynecology, The George Washington University Hospital
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Sandberg EM, Twijnstra AR, Driessen SR, Jansen FW. Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2017; 24:206-217.e22. [DOI: 10.1016/j.jmig.2016.10.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/19/2016] [Accepted: 10/13/2016] [Indexed: 12/13/2022]
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Evaluation of the surgical outcome and complications of total laparoscopic hysterectomy in patients with enlarged uteruses. Int J Surg 2016; 36:90-95. [DOI: 10.1016/j.ijsu.2016.10.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022]
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Uccella S, Casarin J, Marconi N, Cromi A, Morosi C, Gisone B, Pinelli C, Ghezzi F. Laparoscopic Versus Open Hysterectomy for Benign Disease in Women with Giant Uteri (≥1500 g): Feasibility and Outcomes. J Minim Invasive Gynecol 2016; 23:922-7. [PMID: 27223048 DOI: 10.1016/j.jmig.2016.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 05/03/2016] [Accepted: 05/09/2016] [Indexed: 12/18/2022]
Abstract
UNLABELLED STUDY OBJECTIVE To evaluate perioperative outcomes and complications of laparoscopic hysterectomy (LH) in women with giant uteri (≥1.5 kg) compared with open abdominal hysterectomy (AH), which is considered the reference. DESIGN A retrospective analysis of prospectively collected data (Canadian Task Force Classification II-2). SETTING An academic research center. PATIENTS All consecutive women who underwent hysterectomy for uteri weighing ≥1500 g (total = 51) between 2000 and 2015 were analyzed. Twenty-seven (53%) patients had been scheduled for the laparoscopic approach (LH), whereas 24 (48%) had been scheduled for AH. INTERVENTIONS Hysterectomy ± mono/bilateral salpingo-oophorectomy. MAIN OUTCOME MEASURES Perioperative details, incidence, severity, and type of complications were analyzed according to surgical approach (AH vs LH). We also evaluated the trends over time in terms of perioperative outcomes. RESULTS AH was associated with a shorter operative time (97.5 vs 160 minutes, p = .004) compared with LH. Blood loss (200 vs 225 mL, p = .21) and the decrease in postoperative hemoglobin (-1.2 vs -1.1, p = .89) were similar between AH and LH. Intra- and postoperative complications were similar between the 2 groups; however, hospital stay was significantly shorter in the LH group (median = 3 days vs 1 day, p < .001). A significant trend toward a progressive increase in the use of the minimally invasive approach was registered through the years (p = .001). Parallel to this increase, we observed a significant reduction in terms of length of stay. Moreover, a decrease in the total number of complications, mainly because of a decrease in the rate of early minor events, was observed through the years. CONCLUSIONS Our experience shows that LH can be considered a feasible procedure, even in cases of uteri ≥1.5 kg, with significant advantages over open surgery in terms of postoperative hospital stay.
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Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy.
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Nicola Marconi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Chiara Morosi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Baldo Gisone
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
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Uccella S, Marconi N, Casarin J, Ceccaroni M, Boni L, Sturla D, Serati M, Carollo S, Podesta' Alluvion C, Ghezzi F. Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy. Arch Gynecol Obstet 2016; 294:771-8. [PMID: 27168180 DOI: 10.1007/s00404-016-4115-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 05/04/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Total laparoscopic hysterectomy (TLH) in the case of endometriosis may be extremely challenging. Our aim has been to analyze perioperative details and complications of TLH in women with vs. women without endometriosis. METHODS Consecutive women who underwent TLH for endometriosis (endometriosis group) were compared with consecutive patients who had TLH for other conditions (controls) in terms of perioperative outcomes. Patients in the endometriosis group were analyzed, according to the severity of the disease. RESULTS One-hundred and twelve women in the endometriosis group, 29 (25.9 %) with minimal-mild, and 83 (74.1 %) with moderate-severe stage disease (rAFS score), respectively, were compared with 572 controls. Conversion rate was 0.8 vs. 0.5 % (P = 0.51), and median operative time was 75 vs. 55 min (pxxx = x) in the endometriosis group vs. CONTROLS Intraoperative complications were similar between groups (P = 0.56). Postoperative complications occurred in 10 (12.3 %) women in the endometriosis group vs. 12 (3.3 %) among the controls (P = 0.002). The severity of complications according to Clavien-Dindo classification system was higher in the endometriosis group (Clavien-Dindo >2: 7.5 vs. 1.9 %). The risk of organ lesions, urinary lesions, postoperative complications, and severe adverse events was significantly higher in women with moderate-severe endometriosis vs. CONTROLS No differences between patients with minimal-mild endometriosis and controls were found. CONCLUSION(S) TLH in the case of endometriosis is associated with longer operative time and an almost fourfold increase in the risk and severity of complications compared with controls. In particular, the adjunctive risk of adverse events is specific for moderate/severe-stage disease but not for minimal/mild endometriosis.
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Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy.
| | - Nicola Marconi
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Luigi Boni
- Department of Surgery, Minimally Invasive Research Center, University of Insubria, Varese, Italy
| | - Davide Sturla
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy
| | - Simona Carollo
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy
| | - Carolina Podesta' Alluvion
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, F. Del Ponte Hospital, University of Insubria, Piazza Biroldi, 1, 21100, Varese, Italy
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Kehde BH, van Herendael BJ, Tas B, Jain D, Helsen K, Jochems L. Large uterus: what is the limit for a laparoscopic approach? AUTOPSY AND CASE REPORTS 2016; 6:51-6. [PMID: 27284542 PMCID: PMC4880435 DOI: 10.4322/acr.2016.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/11/2016] [Indexed: 11/26/2022] Open
Abstract
Hysterectomy is the most common surgical gynecologic procedure, which is frequently related to the treatment of leiomyoma. The laparoscopic hysterectomy is associated with a shorter hospital stay, fewer infection rates, and a faster return to daily activities. Most gynecologists do not recommend a hysterectomy via the vagina or a laparoscopic-assisted vaginal hysterectomy (LAVH) in the case of a uterus weighing more than 300 g. This case report presents the case of an LAVH undertaken in a 43-year-old patient with a uterus weighing 2,800 g. There are no definite guidelines concerning the procedure for a large uterus, and the literature is vague regarding the best surgical procedure for these cases. The size of the uterus does not seem to be an absolute contraindication for endoscopic surgery. This procedure relies entirely on the surgeon's ability.
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Affiliation(s)
- Beatriz H Kehde
- Department of Obstetrics and Gynecology - Santa Casa de Misericórdia de São Paulo, São Paulo/SP - Brazil.; Endoscopic Training Centre, Antwerp - Belgium
| | - Bruno J van Herendael
- Endoscopic Training Centre, Antwerp - Belgium.; Ziekenhuis Netwerk Antwerpen ZNA Stuivenberg - Sint Erasmus Department Gynecological Endoscopic Surgery, Antwerp - Belgium
| | - Benedictus Tas
- Ziekenhuis Netwerk Antwerpen ZNA Stuivenberg - Sint Erasmus Department Gynecological Endoscopic Surgery, Antwerp - Belgium
| | - Deepika Jain
- Endoscopic Training Centre, Antwerp - Belgium.; Department of Obstetrics and Gynecology - Anand Hospital, Beawar/Rajasthan - India
| | - Karine Helsen
- Ziekenhuis Netwerk Antwerpen ZNA Stuivenberg - Sint Erasmus Department Gynecological Endoscopic Surgery, Antwerp - Belgium
| | - Lisbeth Jochems
- Ziekenhuis Netwerk Antwerpen ZNA Stuivenberg - Sint Erasmus Department Gynecological Endoscopic Surgery, Antwerp - Belgium
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Macciò A, Chiappe G, Kotsonis P, Nieddu R, Lavra F, Serra M, Onnis P, Sollai G, Zamboni F, Madeddu C. Surgical outcome and complications of total laparoscopic hysterectomy for very large myomatous uteri in relation to uterine weight: a prospective study in a continuous series of 461 procedures. Arch Gynecol Obstet 2016; 294:525-31. [PMID: 27016346 DOI: 10.1007/s00404-016-4075-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/14/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE To analyze whether a large uterine size was associated with increased rate of intraoperative and postoperative surgical complications in patients who underwent total laparoscopic hysterectomy (TLH) for myomatous uteri. METHODS We examined prospectively data from 461 consecutive TLHs performed by a single surgeon between August 2004 and August 2014 at the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and at the Department of Gynecologic Oncology, Businco Hospital, Cagliari, Italy. Demographic and surgical data were stratified by uterine weight (range 90-5500 g) into four groups: <300 g; from 300 to 500 g; from 500 to 800 g; and >800 g. Outcomes examined included blood loss, operative time, intraoperative and postoperative complications, and duration of hospital stay. A linear regression analysis was performed to identify whether uterine weight was an independent predictor affecting these outcomes. In addition, BMI, previous surgery with adhesiolysis, and endometriosis were tested as a predictor of surgical complications and outcomes. RESULTS No significant difference was found in intraoperative and postoperative complications, as well as hospital stay, by uterine weight. Increased uterine size was significantly associated with longer operative time and increased blood loss. Beside uterine weight, prior surgery was predictive of postoperative complications. In contrast, higher BMI was not associated with increased complication rate. Independent predictors of longer operative time included previous surgery, endometriosis, and BMI. CONCLUSIONS Our results showed that in experienced hands, TLH is feasible and safe also in presence of very large uteri. TLH results in a few complications and short hospital stay regardless of uterine weight.
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Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy.
| | - Giacomo Chiappe
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Parakevas Kotsonis
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Romualdo Nieddu
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Fabrizio Lavra
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Michele Serra
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Paolo Onnis
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Azienda Ospedaliera Brotzu, Via Jenner, 09100, Cagliari, Italy
| | - Giuseppe Sollai
- Department of Oncological Surgery, A. Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Fausto Zamboni
- Department of General Surgery, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Clelia Madeddu
- Department of Medical Sciences M. Aresu, University of Cagliari, Cagliari, Italy
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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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Uccella S, Cromi A, Vigetti D, Cimetti L, Deleonibus S, Casarin J, Passi A, Riva C, Ghezzi F. Endometrial cancer cells can express fibrinogen: Immunohistochemistry and RT-PCR analysis. J OBSTET GYNAECOL 2015; 36:353-8. [DOI: 10.3109/01443615.2015.1065231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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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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Jahan S, Jahan A, Joarder M, Habib SH, Sharmin F, Nayer R. Laparoscopic hysterectomy in large uteri: Experience from a tertiary care hospital in Bangladesh. Asian J Endosc Surg 2015; 8:323-7. [PMID: 25809981 DOI: 10.1111/ases.12184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 12/15/2014] [Accepted: 02/07/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the safety and feasibility of laparoscopically assisted vaginal hysterectomy for uteri weighing more than 500 g as compared to uteri weighing less than 500 g in benign gynecological diseases. METHODS This was a retrospective study. Patients were admitted through the outpatient department. They were divided into two groups: uterine weight ≥500 g (group 1) and uterine weight >500 g (group 2). There were no exclusion criteria based on the size, number, or location of leiomyomas. The patient characteristics for the two groups were compared in terms of demographic and socioeconomic details, operating time, amount of blood loss, requirement of blood transfusion, need for analgesia, and length of hospital stay. RESULTS The characteristics age and BMI were well balanced between the two groups. Uterine weight was 267.2 ± 97.6 g in group 1 and 740.0 ± 371.4 g in group 2 (P < 0.001). Length of operation and amount of blood loss were greater in group 2 than in group 1 (operation: 89.1 ± 26.7 vs 73.3 ± 24.6 min, P < 0.01; blood loss: 570.5 ± 503.6 vs 262.5 ± 270.0 mL, P < 0.001). However, there was no significant difference in hospital stay or incidence of operative complications between the two groups. No patients were switched from laparoscopy to laparotomy during operation. The rate of blood transfusion was lower in group1 than in group 2 (4.9% vs 32.6%; P < 0.001). CONCLUSION This study demonstrated that despite the increased operating time and blood loss, laparoscopy should be considered instead of laparotomy in cases of large uteri. Laparoscopically assisted vaginal hysterectomy can be performed safely for a large uterus.
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Affiliation(s)
- Samsad Jahan
- Department of Gynecology and Obstetrics, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
| | - Akter Jahan
- Government Homeopathic College, Dhaka, Bangladesh
| | - Mahjabin Joarder
- Research Training Management International, Cox's Bazar, Bangladesh
| | | | - Farzana Sharmin
- Department of Obstetrics and Gynecology, Bangladesh Institute of Health Sciences (BIHS) & Hospital, Dhaka, Bangladesh
| | - Reefat Nayer
- Department of Gynecology and Obstetrics, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
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Uccella S, Cromi A, Casarin J, Bogani G, Serati M, Gisone B, Pinelli C, Fasola M, Ghezzi F. Minilaparoscopic Versus Standard Laparoscopic Hysterectomy for Uteri ≥16 Weeks of Gestation: Surgical Outcomes, Postoperative Quality of Life, and Cosmesis. J Laparoendosc Adv Surg Tech A 2015; 25:386-91. [PMID: 25839384 DOI: 10.1089/lap.2014.0478] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Giorgio Bogani
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Baldo Gisone
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Maddalena Fasola
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy
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Donnellan NM, Mansuria S, Aguwa N, Lum D, Meyn L, Lee T. Obesity and older age as protective factors for vaginal cuff dehiscence following total hysterectomy. GYNECOLOGICAL SURGERY 2015; 12:89-93. [PMID: 25960707 PMCID: PMC4417471 DOI: 10.1007/s10397-015-0882-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 01/19/2015] [Indexed: 01/14/2023]
Abstract
Studies have shown an increased risk of vaginal cuff dehiscence following total laparoscopic hysterectomy (TLH). Patient variables associated with dehiscence have not been well described. This study aims to identify factors associated with dehiscence following varying routes of total hysterectomy. This is a retrospective, matched, case-control study of women who underwent a total hysterectomy at a large, urban, university-based teaching hospital from January 2000 to December 2011. Women who underwent a total hysterectomy and had a dehiscence (n = 31) were matched by surgical mode to the next five total hysterectomies (n = 155). Summary statistics and conditional logistic regression were performed to compare cases to controls. Obese women (BMI ≥ 30) were 70 % less likely than normal weight women (BMI < 25) to experience a dehiscence (p = 0.02). When stratified by hysterectomy route, obese women were 86 % less likely to have a dehiscence following robotic-assisted total hysterectomy (RAH) and TLH than normal weight women (p = 0.04). Further, increasing age was protective of dehiscence in this subgroup of women (p = 0.02). Older age and obesity were associated with a decreased risk of dehiscence following RAH and TLH but not following other routes. Increased risk of dehiscence following TLH observed in previous studies may be partially due to patient characteristics.
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Affiliation(s)
- Nicole M. Donnellan
- Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital of UPMC, 300 Halket Street, Pittsburgh, PA 15213 USA
| | - Suketu Mansuria
- Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital of UPMC, 300 Halket Street, Pittsburgh, PA 15213 USA
| | - Nancy Aguwa
- School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229 USA
| | - Deirdre Lum
- Obstetrics and Gynecology, Stanford University, 900 Blake Wilbur Drive, Palo Alto, CA 94304 USA
| | - Leslie Meyn
- Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, 204 Craft Ave, Pittsburgh, PA 15213 USA
| | - Ted Lee
- Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital of UPMC, 300 Halket Street, Pittsburgh, PA 15213 USA
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46
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Treatment of vaginal cuff evisceration. Obstet Gynecol 2015; 125:230. [PMID: 25560133 DOI: 10.1097/aog.0000000000000616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stoelinga B, Huirne J, Heymans MW, Reekers JA, Ankum WM, Hehenkamp WJ. The estimated volume of the fibroid uterus: a comparison of ultrasound and bimanual examination versus volume at MRI or hysterectomy. Eur J Obstet Gynecol Reprod Biol 2015; 184:89-96. [DOI: 10.1016/j.ejogrb.2014.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 10/29/2014] [Accepted: 11/11/2014] [Indexed: 11/15/2022]
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48
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Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery for nonprolapsed uteri. Surg Endosc 2014; 29:100-7. [DOI: 10.1007/s00464-014-3639-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 05/22/2014] [Indexed: 11/25/2022]
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49
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Warda O, Ehab S, Mostafa E, Maged E, Tarek S. Optimizing vaginal hysterectomy in women with large volume non-prolapse uteri: a novel minimally-invasive "aneurysm needle clampless technique". Eur J Obstet Gynecol Reprod Biol 2014; 179:1-4. [PMID: 24965970 DOI: 10.1016/j.ejogrb.2014.04.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 04/22/2014] [Accepted: 04/29/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe and evaluate the safety and feasibility of a new clampless technique using aneurysm needle for vaginal hysterectomy compared with the standard technique as a less minimally-invasive procedure in women with benign large volume non-prolapse uteri.Study design In a pilot study, series of 46 consecutive women with benign large volume (200-500cm(3)) uterine conditions other than pelvic organ prolapse were planned for vaginal hysterectomy (VH). Patients were divided into 2 groups; group-A (21 women): for whom an (aneurysm needle clampless VH) was performed; group-B (25 women): used as a control (standard VH). Demographic characteristics and peri-operative parameters for both techniques were compared.Results Of the 46 vaginal hysterectomies, 44 were successfully performed (95.7%; 95% confidence interval, 91.6-99.4%). Two (4.3%) conversions were necessary from VH to open surgery [1 case in group A and another case in group B]. There was no statistically significant difference between both groups regarding the demographic data. Preoperative uterine volumes were comparable (232.8mL vs 226.0mL, respectively) (P>.05). The mean operative time was significantly shorter in the clampless VH group compared with the control group (70.14±7.78min vs 79.52±7.41min, respectively) (P=.007). No reported complications in our series.Conclusion Clampless VH using aneurysm needle represents a safe and less minimally-invasivepossible technique in women with benign large volume non-prolapse uteri. It takes a shorter operative.
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Affiliation(s)
- Osama Warda
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt.
| | - Sadek Ehab
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Elkhiary Mostafa
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Elshamy Maged
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Shokeir Tarek
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
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50
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Laparoscopic Hysterectomy in Case of Uteri Weighing ≥1 Kilogram: A Series of 71 Cases and Review of the Literature. J Minim Invasive Gynecol 2014; 21:460-5. [PMID: 24012921 DOI: 10.1016/j.jmig.2013.08.706] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 08/24/2013] [Accepted: 08/26/2013] [Indexed: 11/18/2022]
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