Mini-Laparotomy Versus Laparoscopy for Gynecologic Conditions

Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review

Uterine leiomyomas are the most common benign uterine tumors in women and are often asymptomatic, with clinical manifestation occurring in 20-25% of cases. The diagnostic pathway begins with clinical suspicion and includes an ultrasound examination, diagnostic hysteroscopy, and, when deemed necessary, magnetic resonance imaging. The decision-making process should consider the impairment of quality of life due to symptoms, reproductive desire, suspicion of malignancy, and, of course, the woman's preferences. Despite the absence of a definitive cure, the management of fibroid-related symptoms can benefit from various medical therapies, ranging from symptomatic treatments to the latest hormonal drugs aimed at reducing the clinical impact of fibroids on women's well-being. When medical therapy is not a definitive solution for a patient, it can be used as a bridge to prepare the patient for surgery. Surgical approaches continue to play a crucial role in the treatment of fibroids, as the gynecologist has the opportunity to choose from various surgical options and tailor the intervention to the patient's needs. This review aims to summarize the clinical pathway necessary for the diagnostic assessment of a patient with uterine fibromatosis, presenting all available treatment options to address the needs of different types of women.

The routes of hysterectomy: A survey of current practices amongst members of the International Society for Gynaecologic Endoscopy (ISGE)

OBJECTIVE

This study aimed to explore the current opinion on the routes of hysterectomy amongst the members of the International Society for Gynaecologic Endoscopy (ISGE), as well as the perceptions of potential barriers that inhibit gynaecologists from offering a minimally invasive hysterectomies (MIHs) to their patients.

STUDY DESIGN

An anonymous, electronic survey was designed, including the questions about the surgeon location and length of gynaecological practice, preferred approach to hysterectomy, approximate number of surgical cases performed during the year preceding the survey (2021), and potential barriers and contraindications to performing MIHs. It was validated by 12 practicing gynaecologists. Subsequently, the survey was sent to all practicing gynaecologists who are the members of the ISGE.

RESULTS

We received a response from 159 members of ISGE (29 % response rate), of which 92 % with ≥ 5 years in practice since the completion of their residency training in Gynaecology and Obstetrics. When asked about the preferred route of hysterectomy for themselves or their relatives, 59 % chose total laparoscopic hysterectomy (TLH), 19 % vaginal hysterectomy (VH), 8 % chose laparoscopically-assisted vaginal hysterectomy (LAVH) and 5 % chose total abdominal hysterectomy (TAH). However, TAH was the most performed hysterectomy procedure undertaken by the respondents in the year preceding the survey. When asked about the main obstacles to performing MIHs, more than half of the respondents highlighted insufficient training during residency and insufficient surgical experience. Only 25 % of the responders acknowledged reading the ISGE guidelines on performing vaginal hysterectomy.

CONCLUSIONS

Contrary to a full understanding of the benefits of MIHs, lack of training, as well as insufficient surgical experience and unawareness of existing evidence-based guidelines were the main reasons for the high rate of TAH among the ISGE members who participated in the study. All efforts should be directed at teaching VH and TLH techniques during residency, continuous acquisition of practical experience, and use of validated patient selection guidelines for MIH in daily clinical practice.

Incisional Outcomes of Umbilical vs Suprapubic Mini-laparotomy for Tissue Extraction: A Retrospective Cohort Study

STUDY OBJECTIVE

To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction.

DESIGN CLASSIFICATION

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Two large academic medical centers.

PATIENTS

Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016.

INTERVENTIONS

Umbilical or suprapubic minilaparotomy for tissue extraction.

MEASUREMENTS AND MAIN RESULTS

A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3 ± 0.8 cm vs 4.2 ± 0.6 cm [p < .001] and 472.6 ± 357.1 g vs 683.0 ± 475.7 g [p < .001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p = .833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia.

CONCLUSION

There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.

Laparoscopic Hysterectomy for Uterine Fibroids: Is it Safe?

As more complex cases and larger uterine specimens are able to be managed with minimally invasive surgery, the limitations of tissue retrieval with these methods are of increasing concern. Risks of morcellator-related injury, tissue dissemination, or fragmentation must be weighed against increased morbidity of abdominal approach to hysterectomy. In an effort to mitigate the risks of tissue morcellation, containment system use must be considered when fragmenting a specimen, either with power morcellation or a manual technique via the vagina or minilaparotomy.

A Safe and Simple Laparoscopic Cold Knife Section Technique for Bulky Uterus Removal

BACKGROUND

Morcellation of a bulky uterus after total laparoscopic hysterectomy (TLH) is a challenge for those dealing with advanced laparoscopic surgery. However, there are no laparoscopic standardized procedures available to date. We developed a laparoscopic cold knife technique with the aim of demonstrating a simple and reproducible method of sectioning and vaginal retrieval of the bulky uterus.

MATERIALS AND METHODS

From June 2012 to June 2014, patients who underwent TLH for benign indication, with a uterus size over 12 gestational weeks, were prospectively admitted into the clinical study. Before specimen vaginal retrieval, uterine section was achieved by Chardonnens' cold knife with the aim of obtaining two uterus halves sectioned longitudinally and held together only by the posterior cervical wall. We performed the procedure in a containment system to avoid myometrial spillage into the abdomen.

RESULTS

Twenty-nine women with a bulky uterus were treated by TLH and the cold knife section technique. The uterine size ranged from 240 to 850 g (median, 460 g), and the average morcellation operative time was 11.3 minutes. All procedures were completed successfully without complications.

CONCLUSIONS

Our data suggest that the cold knife uterine section technique after TLH is a feasible, simple, and reproducible method of bulky uterus morcellation, even if further research is advisable to fully evaluate the advantages of this procedure.

Electromechanical morcellators in minimally invasive gynecologic surgery: an update

STUDY OBJECTIVE

To assess all electromechanical morcellators used in gynecology to achieve an objective comparison between them and to make suggestions for improvements in future developments.

DESIGN

Literature review.

INTERVENTION

The PubMed, Web of Science, EMBASE, and MAUDE databases were systematically searched for all available literature using the terms "morcellator," "morcellators," "morcellate," "morcellation," and "morcellated." All articles with information on morcellation time and morcellated tissue mass or the calculated morcellation rate of electromechanical morcellators used for gynecologic laparoscopic surgery were included. For general data of an existing morcellator, the manufacturer was contacted and Google was searched. Data for morcellation rate, type of procedure, and general characteristics were compared.

MEASUREMENTS AND MAIN RESULTS

Seven articles were suitable for analysis, and 11 different morcellators were found. In the past decades the morcellation rate has increased. The described morcellation rate ranged from 6.2 to 40.4 g/min. Motor peeling is currently the fastest working principle. Comparing hysterectomy and myomectomy per device, the Morcellex and Rotocut morcellators demonstrated a higher morcellation rate for myomectomy, 25.9 vs 30 g/min and 28.4 vs 33.1 g/min, respectively, although the X-Tract morcellator showed a higher rate for hysterectomy, 14.2 vs 11.7 g/min.

CONCLUSION

Over the years, the morcellator has improved with respect to the morcellation rate. However, the morcellation process still has limitations, including tissue scattering, morcellator-related injuries, and the inevitable small blade diameter, which all come at the expense of the morcellation rate and time. Therefore, development of improved morcellators is required, with consideration of the observed limitations.