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Mamik MM, Kim-Fine S, Yang L, Sharma V, Gala R, Aschkenazi S, Sheyn D, Howard D, Walter AJ, Kudish B, Balk EM, Antosh DD. Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review. Obstet Gynecol 2024; 144:40-52. [PMID: 38743951 DOI: 10.1097/aog.0000000000005607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/14/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. DATA SOURCES PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. METHODS OF STUDY SELECTION This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. TABULATION, INTEGRATION, AND RESULTS The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. CONCLUSION Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021233300.
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Affiliation(s)
- Mamta M Mamik
- Albert Einstein College of Medicine, Bronx, New York; University of Calgary, Calgary, Alberta, Canada; Northwestern Medicine, Chicago, Illinois; Ochsner Clinical School, Jefferson, Louisiana; Waukesha Memorial Hospital, Waukesha, Wisconsin; University Hospitals, Cleveland, Ohio; Rutgers New Jersey Medical School, Newark, New Jersey; Kaiser Permanente, Roseville, California; Florida State University, Tallahassee, Florida; Brown University School of Public Health, Providence, Rhode Island; and Houston Methodist Hospital, Houston, Texas
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Turashvili G, Hanley K. Practical Updates and Diagnostic Challenges in Endometrial Carcinoma. Arch Pathol Lab Med 2024; 148:78-98. [PMID: 36943242 DOI: 10.5858/arpa.2022-0280-ra] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 03/23/2023]
Abstract
CONTEXT.— Clinical management of endometrial carcinoma largely depends on the morphologic parameters ascertained based on the pathologic evaluation of surgical resection specimens. However, there are numerous controversial and nonstandardized aspects of both the macroscopic and microscopic assessment of surgical specimens, including grossing, adequate sampling, diagnosis, staging, reporting, and ancillary testing. OBJECTIVE.— To provide a comprehensive practical review of standardized grossing, key morphologic findings for reporting and staging, and diagnostic and prognostic use of ancillary testing in endometrial carcinomas. DATA SOURCES.— The existing literature, recommendations of the International Society of Gynecological Pathologists, and specialty consensus guidelines. CONCLUSIONS.— This review article summarizes important aspects of the grossing and sampling of surgical resection specimens for microscopic examination, key morphologic parameters that are required for reporting and staging, and morphologic features and immunoprofiles helpful in the differential diagnosis of low-grade and high-grade endometrial carcinomas, as well as the current status of the molecular classification of endometrial carcinoma and human epidermal growth factor receptor 2 testing in serous carcinoma. The information presented herein can be helpful in overcoming diagnostic challenges and issues related to the pathology reporting of endometrial carcinoma to practicing anatomic pathologists.
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Affiliation(s)
- Gulisa Turashvili
- From the Department of Pathology, Emory University Hospital, Atlanta, Georgia
| | - Krisztina Hanley
- From the Department of Pathology, Emory University Hospital, Atlanta, Georgia
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Pham NK, Jalloul RJ, Chen HY, Hui M, Leon MG. Venous Thromboembolism After Abdominal and Minimally Invasive Large Specimen Hysterectomy. J Minim Invasive Gynecol 2023; 30:884-889. [PMID: 37422052 DOI: 10.1016/j.jmig.2023.06.017] [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: 05/02/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023]
Abstract
STUDY OBJECTIVE To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population. DESIGN Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States. SETTING National Surgical Quality Improvement Program Database. PATIENTS Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g. INTERVENTIONS Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight. MEASUREMENTS AND MAIN RESULTS A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29). CONCLUSION The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.
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Affiliation(s)
- Nguyen K Pham
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon).
| | - Randa J Jalloul
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon)
| | - Han-Yang Chen
- School of Public Health (Dr. Chen), McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Mason Hui
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon)
| | - Mateo G Leon
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon)
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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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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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6
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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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vNOTES Hysterectomy for Large Uteri: A Retrospective Cohort Study of 114 Patients. J Minim Invasive Gynecol 2020; 28:1351-1356. [PMID: 33065258 DOI: 10.1016/j.jmig.2020.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To evaluate the outcome of hysterectomy through vaginal natural orifice transluminal endoscopic surgery (vNOTES) in cases with a large uterus. DESIGN A retrospective cohort study. SETTING Belgian teaching hospital. PATIENTS Women who underwent a vNOTES hysterectomy from March 2015 to March 2020 for benign gynecologic disease with a uterine weight of 280 g or more on pathologic examination (N = 114). INTERVENTIONS All women underwent vaginally assisted NOTES hysterectomy. We performed a retrospective analysis of baseline patient characteristics and clinical outcomes. MEASUREMENTS AND MAIN RESULTS The mean age was 50 ± 3.5 years. Twenty-two (19%) patients were obese (body mass index ≥30 kg/m2), and 4 (3.5%) were morbidly obese (body mass index ≥40 kg/m2). Thirty-five (31%) patients were nulliparous, and 15 (13%) women had 1 or more cesarean sections in their medical history. Uterine weight varied from 281 g to 3361 g, with a mean weight of 559 ± 425 g. Mean surgical time was 63 ± 34 minutes. Surgical time was positively associated with uterine size. There were 4 complications: 3 bleeding complications in the first 24 hours after surgery and 1 minor late complication. Conversion to laparotomy for specimen extraction was performed in 1 case (conversion rate 0.9%). There were no conversions to laparoscopy. No ureteric, bladder, or intestinal injuries occurred in this case series, and there were neither life-threatening complications nor intensive care unit admissions. CONCLUSION The vNOTES technique can offer a safe and effective alternative to laparoscopy or laparotomy in cases with a large to very large uterus, even if the patient has a history of cesarean section, obesity, or nulliparity. In 99% of all women in this study, hysterectomy was successfully performed through vNOTES without conversion. By making use of the advantages of endoscopic surgery, vNOTES might broaden the indications of vaginal hysterectomy. Randomized controlled trials are needed to evaluate whether vaginally assisted NOTES hysterectomy is superior to laparoscopic or abdominal hysterectomy in large uteri cases.
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Wang X, Li J, Hua K, Chen Y. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy for uterus weighing ≥1 kg. BMC Surg 2020; 20:234. [PMID: 33046022 PMCID: PMC7552525 DOI: 10.1186/s12893-020-00897-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023] Open
Abstract
Background The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) applied in gynecology has been developed recent years and been evolving. In this study, we aimed to evaluate the feasibility and effect of the vNOTES hysterectomy for uterus ≥1 kilogram (kg). Methods From January 2019 to March 2020, patients with benign indications in cases of uterus weighing ≥1 kg, underwent vNOTES hysterectomy were studied retrospectively. The patients’ demographics, indications for surgery, operation outcomes and follow-up details were recorded. Results 39 patients were performed vNOTES hysterectomy for large uterus (mean weight 1141.8 gram, range from 1000 to 1720), indications for surgery included bulky uterine myomas or adenomysosis. The mean age was 48 years (range 42–66) and mean BMI was 24 kg/m2 (range 18.4–38). Mean operating time was 123.3 min (rang 40–400) and the mean estimated blood loss was 206.7 milliliters (range 10–1300). The mean pain assessment was 2.1 (range 0–5). The mean length of stay was 2.4 nights (1–11). 1 patient experienced ureteral injury and was performed ureteral anastomosis. 3 patients were converted to vaginal-assisted trans-umbilicus single-port laparoscopy. The learning curve was analyzed to show that 20 cases were needed to achieve proficiency in vNOTES hysterectomy for large uterus ≥1 kg. Conclusion Our preliminary experience suggested that vNOTES hysterectomy for large uterus weighing ≥1 kg was feasible and safe, meanwhile this procedure had the advantages of all the minimal invasive approach such as fast recovery and aesthetic advantage.
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Affiliation(s)
- Xiaojuan Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Junwei Li
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Keqin Hua
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.
| | - Yisong Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.
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Barreras González JE, Díaz Ortega I, Castillo Sánchez Y, Pereira Fraga JG, López Milhet AB. Laparoscopic Hysterectomy for 2780 Patients: In Havana's National Center for Minimally Invasive Surgery. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Javier Ernesto Barreras González
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Israel Díaz Ortega
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Yuderkis Castillo Sánchez
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Jorge Gerardo Pereira Fraga
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Ana Bertha López Milhet
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
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Odejinmi F, Aref-Adib M, Liou N, Sideris M, Mallick R. Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision? In Vivo 2020; 33:1393-1401. [PMID: 31471384 DOI: 10.21873/invivo.11616] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/24/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.
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Affiliation(s)
| | | | - Natasha Liou
- Whipps Cross Hospital, Barts Health NHS Trust, London, U.K
| | - Michail Sideris
- Women's Health Research Unit, Queen Mary University of London, London, U.K
| | - Rebecca Mallick
- Princess Royal Hospital, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, U.K.
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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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12
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Torng PL, Pan SP, Hsu HC, Chen IH, Hwang JS. GnRHa Before Single-Port Laparoscopic Hysterectomy in a Large Barrel-Shaped Uterus. JSLS 2019; 23:JSLS.2019.00019. [PMID: 31341378 PMCID: PMC6634953 DOI: 10.4293/jsls.2019.00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background and Objectives: Laparoscopic hysterectomy for a large barrel-shaped uterus is difficult. We assessed the feasibility of single-port laparoscopic hysterectomy in a large barrel-shaped uterus after gonadotropin-releasing hormone agonist (GnRHa). Methods: We retrospectively reviewed 39 patients with a large barrel-shaped uterus who were treated with GnRHa (leuprolide acetate) before single-port laparoscopic hysterectomy. During the same period, 134 patients without GnRHa pretreatment were included as control subjects. Results: Patients with GnRHa treatment had an average increase in hemoglobin of 3.0 mg/dL and a decrease in uterine weight of 330.9 g (40.1%). Ancillary ports were required in 2 patients in the treatment group and none in the control group. There were no differences in uterine weights, operative time, and estimated blood loss in the 2 groups of patients. The estimated average operative time was shortened by 34 min after GnRHa treatment. However, bladder and ureter injuries were marginally higher (10.3% versus 2.2%) and days of hospital stay (3.7 versus 3.1) were significantly longer in the treatment group compared with controls. Complication rates were correlated with previous operative history, pelvic adhesion, and larger uterine weight but not with GnRHa treatment and operative sequence. Conclusions: GnRHa pretreatment in patients with a large barrel-shaped uterus during SPH is feasible with shortened operative time. However, the higher complication rates in these patients suggest that a weight-reduced barrel-shaped uterus that is achieved with GnRHa treatment could still be difficult and should be handled in cautious.
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Affiliation(s)
- Pao-Ling Torng
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Song-Po Pan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Heng-Cheng Hsu
- Department of Obstetrics and Gynecology, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - I-Hui Chen
- Department of Obstetrics and Gynecology, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
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Nagata H, Komatsu H, Nagaya Y, Tsukihara S, Sarugami M, Harada T, Kanamori Y. Comparison of Total Laparoscopic Hysterectomy with Abdominal Total Hysterectomy in Patients with Benign Disease: A Retrospective Cohort Study. Yonago Acta Med 2019; 62:273-277. [PMID: 31849566 DOI: 10.33160/yam.2019.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/19/2019] [Indexed: 11/05/2022]
Abstract
Background The present study aimed to determine whether total laparoscopic hysterectomy (TLH) is being implemented safely and appropriately compared with abdominal total hysterectomy (ATH) in our hospital. Methods We retrospectively reviewed clinical records of 102 patients who underwent total hysterectomy for benign gynecological disease at Japanese Red Cross Yamaguchi Hospital from January 2017 to August 2018. We examined periods of hospital stay, operation time, blood loss, weight of the uterus, frequency of perioperative complications, and the duration from the first visit to the date of surgery. P < 0.05 was considered to be statistically significant indicated statistical significance. Results TLH and ATH were performed in 55 (53%) and 47 (46%) cases, respectively. The TLH group had significantly longer total operation time [133 (82-205) min vs. 87 (57-155) min, P < 0.0001], lesser blood loss [5 (5-35) g vs. 100 (10-820) g, P < 0.0001], shorter hospital stay [7 (5-14) days vs. 10 (9-26) days, P < 0.0001], and lighter uterine weight [206 (27-658) g vs. 554 (79-2284) g, P < 0.0001] than the ATH group. The frequency of perioperative complications did not differ between the two groups (3.5% vs. 8.0%, P = 0.4103). Conclusion TLH had a longer operation time and a lesser excised uterine weight, but it had less intraoperative blood loss, shorter hospital stay, and no difference in perioperative complication frequency when compared with ATH.
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Affiliation(s)
- Hiroki Nagata
- Division of Reproductive-Perinatal Medicine and Gynecologic Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8503, Japan
| | - Hiroaki Komatsu
- Division of Reproductive-Perinatal Medicine and Gynecologic Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8503, Japan
| | - Yohei Nagaya
- Department of Obstetrics and Gynecology, Japanese Red Cross Yamaguchi Hospital, Yamaguchi 753-0092, Japan
| | - Satoru Tsukihara
- Department of Obstetrics and Gynecology, Japanese Red Cross Yamaguchi Hospital, Yamaguchi 753-0092, Japan
| | - Masako Sarugami
- Department of Obstetrics and Gynecology, Japanese Red Cross Yamaguchi Hospital, Yamaguchi 753-0092, Japan
| | - Tasuku Harada
- Division of Reproductive-Perinatal Medicine and Gynecologic Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8503, Japan
| | - Yasunobu Kanamori
- Department of Obstetrics and Gynecology, Japanese Red Cross Yamaguchi Hospital, Yamaguchi 753-0092, Japan
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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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Abdel Khalek Y, Bitar R, Christoforou C, Garzon S, Tropea A, Biondi A, Sleiman Z. Uterine manipulator in total laparoscopic hysterectomy: safety and usefulness. Updates Surg 2019; 72:1247-1254. [PMID: 31606857 DOI: 10.1007/s13304-019-00681-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 09/21/2019] [Indexed: 12/19/2022]
Abstract
The aim of this review is to evaluate the effectiveness and safety of uterine manipulators in facilitating total laparoscopic hysterectomy (TLH). A literature search in MEDLINE, EMBASE, Cochrane Library, UpToDate, SpringerLink, ClinicalKey and Elsevier ScienceDirect databases was performed, and articles describing TLH with or without the use of uterine manipulators were retrieved. Complications related to the use of uterine manipulators are numerous, and although uterine manipulator seems to facilitate TLH, the procedure without a uterine manipulator seems to have a comparable safety and effectiveness, although evidence based on a direct comparison of the two approaches is limited without available controlled trials. Uterine manipulator may provide support in cases of large uteri, severe endometriosis, recto vaginal adhesions and regional anesthesia, while its use may increase complications in cases of vaginal stenosis and nulliparity. Therefore, to perform TLH, the surgeon should individualize for each case if uterine manipulator is needed and which manipulator best suits the surgical procedure requirements and case characteristics. Further studies comparing the two approaches are mandatory.
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Affiliation(s)
- Yara Abdel Khalek
- Department of Obstetrics and Gynecology, Saint Joseph University, Beirut, Lebanon
| | - Roger Bitar
- Department of Obstetrics and Gynecology, Lebanese American University, Zahar Street, Beirut, Lebanon
| | | | - Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Alessandro Tropea
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT(Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), University of Pittsburgh Medical Center Italy, Palermo, Italy
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Zaki Sleiman
- Department of Obstetrics and Gynecology, Saint Joseph University, Beirut, Lebanon.
- Department of Obstetrics and Gynecology, Lebanese American University, Zahar Street, Beirut, Lebanon.
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Impact of Uterine Weight on the Surgical Outcomes of Vaginal Hysterectomy. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2018.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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17
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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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Endometrial Carcinoma, Grossing and Processing Issues: Recommendations of the International Society of Gynecologic Pathologists. Int J Gynecol Pathol 2019; 38 Suppl 1:S9-S24. [PMID: 30550481 PMCID: PMC6296844 DOI: 10.1097/pgp.0000000000000552] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endometrial cancer is the most common gynecologic neoplasm in developed countries; however, updated universal guidelines are currently not available to handle specimens obtained during the surgical treatment of patients affected by this disease. This article presents recommendations on how to gross and submit sections for microscopic examination of hysterectomy specimens and other tissues removed during the surgical management of endometrial cancer such as salpingo-oophorectomy, omentectomy, and lymph node dissection—including sentinel lymph nodes. In addition, the intraoperative assessment of some of these specimens is addressed. These recommendations are based on a review of the literature, grossing manuals from various institutions, and a collaborative effort by a subgroup of the Endometrial Cancer Task Force of the International Society of Gynecological Pathologists. The aim of these recommendations is to standardize the processing of endometrial cancer specimens which is vital for adequate pathological reporting and will ultimately improve our understanding of this disease.
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Sinha R, Bana R, Sanjay M. Comparison of Robotic and Laparoscopic Hysterectomy for the Large Uterus. JSLS 2019; 23:JSLS.2018.00068. [PMID: 30675091 PMCID: PMC6328360 DOI: 10.4293/jsls.2018.00068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background and Objectives: We compared the outcome of robotic hysterectomy (RH) with laparoscopic hysterectomy (LH) for large uteri (≥16 weeks). Methods: This was a retrospective review over 5 years of 165 women (RH, 46; LH, 119). Demographic data, conversion, hemoglobin drop, indication, operating time, postoperative stay, and intra-operative strategies (adhesiolysis, myomectomy) were recorded. Results: Mean age was 45.7 ± 6.4 years and 44.5 ± 5.4 years (no diff) and body mass index was 30.2 ± 6.3 kg/m2 and 27.8 ± 4.8 kg/m2 (P = .009) in the RH and LH groups. There was no difference in percentage of women with previous laparotomy (RH, 15.2% vs LH, 13.4%) and mean number of lower-segment caesarean section (RH, 1.0 vs LH, 0.8). Mean size of uterus was similar (RH, 20.0 weeks vs LH, 17.4 weeks). The mean number of ports was higher in the RH group (RH, 4.2 vs LH, 3.4; P < .001) as was needed for adhesiolysis (RH, 71.7% vs LH, 35.3%; P < .001). Difficult bladder dissection was more in the RH group (56.5% vs 26.1%; P < .001). Vaginal morcellation was similar in both groups (RH, 89.1%; LH, 83.2%). RH took longer operating time (131.0 vs 110.6 minutes; P = .006). RH had less drop in Hb (1.0 vs 1.8 g/dL; P < .001) and remained the same after multiple regression analysis. Postoperative stay was similar in both groups (1.4 days). Requirement of intravenous analgesia was significantly lower in the RH group (12.5 vs 30.9 hours; P < .001). Open conversion rate was 4.3% (RH) and 10.9% (LH) but not significant. Conclusion: A higher body mass index, more adhesiolysis, and difficult bladder dissection imply a more challenging nature of women who underwent RH. Despite this, RH was shown to be feasible and safe with a lower blood loss.
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Affiliation(s)
- Rooma Sinha
- Department of Gynecology, Apollo Hospitals, Jubilee Hills, Hyderabad, India
| | - Rupa Bana
- Department of Gynecology, Apollo Hospitals, Jubilee Hills, Hyderabad, India
| | - Madhumathi Sanjay
- Department of Gynecology, Apollo Hospitals, Jubilee Hills, Hyderabad, India
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20
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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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21
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Louie M, Strassle PD, Moulder JK, Dizon AM, Schiff LD, Carey ET. Uterine weight and complications after abdominal, laparoscopic, and vaginal hysterectomy. Am J Obstet Gynecol 2018; 219:480.e1-480.e8. [PMID: 29959931 DOI: 10.1016/j.ajog.2018.06.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 06/18/2018] [Accepted: 06/20/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although uterine size has been a previously cited barrier to minimally invasive hysterectomy, experienced gynecologic surgeons have been able to demonstrate that laparoscopic and vaginal hysterectomy is feasible with increasingly large uteri. By demonstrating that minimally invasive hysterectomy continues to have superior outcomes even with increased uterine weights, opportunity exists to meaningfully decrease morbidity, mortality, and cost associated with abdominal hysterectomy. OBJECTIVE We sought to determine if there is an association between uterine weight and posthysterectomy complications and if differences in that association exist across vaginal, laparoscopic, and abdominal approaches. STUDY DESIGN We conducted a cohort study of prospectively collected quality improvement data from the American College of Surgeons National Surgical Quality Improvement Program database, composed of patient information and 30-day postoperative outcomes from >500 hospitals across the United States and targeted data files, which includes additional data on procedure-specific risk factors and outcomes in >100 of those participating hospitals. We analyzed patients undergoing hysterectomy for benign conditions from 2014 through 2015, identified by Current Procedural Terminology code. We excluded patients who had cancer, surgery by a nongynecology specialty, or missing uterine weight. Patients were compared with respect to 30-day postoperative complications and uterine weight, stratified by surgical approach. Bivariable tests and multivariable logistic regression were used for analysis. RESULTS In all, 27,167 patients were analyzed. After adjusting for potential confounders, including medical and surgical variables, women with 500-g uteri were >30% more likely to have complications compared to women with uteri ≤100 g (adjusted odds ratio, 1.34; 95% confidence interval, 1.17-1.54; P < .0001), women with 750-g uteri were nearly 60% as likely (adjusted odds ratio, 1.58; 95% confidence interval, 1.37-1.82; P < .0001), and women with uteri ≥1000 g were >80% more likely (adjusted odds ratio, 1.85; 95% confidence interval, 1.55-2.21; P < .0001). The incidence of 30-day postsurgical complications was nearly double in the abdominal hysterectomy group (15%) compared to the laparoscopic group (8%). Additionally, for each stratum of uterine weight, abdominal hysterectomy had significantly higher odds of any complication compared to laparoscopic hysterectomy, even after adjusting for potential demographic, medical, and surgical confounders. For uteri <250 g, abdominal hysterectomy had twice the odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.80-2.33), and among women with uteri between 250-500 g, abdominal hysterectomy was associated with an almost 80% increase in odds of any complication (adjusted odds ratio, 1.76; 95% confidence interval, 1.41-2.19). Even among women with uteri >500 g, abdominal hysterectomy was still associated with a >30% increased odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 1.35; 95% confidence interval, 1.07-1.71). CONCLUSION We found that while uterine weight was an independent risk factor for posthysterectomy complications, abdominal hysterectomy had higher odds of any complication, compared to laparoscopic hysterectomy, even for markedly enlarged uteri. Our study suggests that uterine weight alone is not an appropriate indication for abdominal hysterectomy. We also identified that it is safe to perform larger hysterectomies laparoscopically. Patients may benefit from referral to experienced surgeons who are able to offer laparoscopic hysterectomy even for markedly enlarged uteri.
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Affiliation(s)
- Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Paula D Strassle
- Gillings School of Global Public Health, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janelle K Moulder
- Department of Obstetrics and Gynecology, University of Tennessee Medical Center Knoxville, Knoxville, TN
| | - A Mitch Dizon
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lauren D Schiff
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Erin T Carey
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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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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Casarin J, Uccella S, Cromi A, Ghezzi F. Re: JSLS. 2017;21(1):e2016.00098. DOI: 10.4293/JSLS.2016.00098. Minimally Invasive Hysterectomy for Uteri Greater Than One Kilogram. JSLS 2017; 21:JSLS.2017.00045. [PMID: 28890651 PMCID: PMC5565640 DOI: 10.4293/jsls.2017.00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jvan Casarin
- Department of Obstetrics and Gynecology University of Insubria Varese, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology University of Insubria Varese, Italy
| | - Antonella Cromi
- 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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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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Total laparoscopic hysterectomy for large uterine cervical myoma. Mol Clin Oncol 2017; 6:655-660. [PMID: 28515917 PMCID: PMC5431257 DOI: 10.3892/mco.2017.1217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/30/2017] [Indexed: 12/17/2022] Open
Abstract
Ureterolysis is a surgical method with a high level of difficulty, which may be necessary when performing total laparoscopic hysterectomy (TLH) for large cervical myoma, despite the benign nature of this tumor. The aim of the present study was to introduce techniques that are commonly applied in malignant tumor surgery in order to safely perform TLH for large cervical myoma. Between 2014 and 2016, TLH was performed at the Shimane University Hospital (Izumo, Japan) in 153 patients with benign tumors, including 25 cases with a large uterus (uterine weight ≥500 g). The surgical methods applied in 3 of these large uterine cervical myoma cases were investigated in detail, including techniques devised by our department. TLH was performed without enucleating myomectomy in all 3 cases; however, all 3 cases required ureterolysis, transection of the anterior layer of the vesicouterine ligament and isolation of the ureter. In conclusion, although radical laparoscopic hysterectomy is commonly performed for cervical cancer at our department, techniques used for malignant tumor surgery may prove useful for benign cases with a high level of difficulty.
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Schöller D, Taran FA, Wallwiener M, Schönfisch B, Krämer B, Abele H, Neis F, Wallwiener CW, Brucker S. Laparoscopic Supracervical Hysterectomy and Laparoscopic Total Hysterectomy in Patients with Very Large Uteri: a Retrospective Single-Center Experience at a Major University Hospital. Geburtshilfe Frauenheilkd 2017; 77:251-256. [PMID: 28392578 DOI: 10.1055/s-0043-102695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Objective The main objectives of our study were to demonstrate that laparoscopic supracervical hysterectomy (LSH) or total laparoscopic hysterectomy (TLH) can be performed safely even in patients with a uterine weight ≥ 500 g, to analyze the rate of conversions to laparotomy due to uterine size and to estimate the incidence and type of intraoperative and long-term postoperative complications. Study Design Retrospective open, single-center, comparative interventional study of LSH and TLH. Results The present study comprised a total of 138 patients that underwent laparoscopic hysterectomy with a uterine weight ≥ 500 g; 109 patients (79.0 %) underwent LSH and 29 patients (21.0 %) underwent TLH. Median uterine weight across the entire cohort was 602 g, with the largest uterus weighing 1860 g. A total of 24 cases (17.4 %) among the 138 hysterectomies were converted to a laparotomy due to lack of adequate intraabdominal space and size of the uterus. Mean uterine weight of the patients in the LSH group that underwent conversion was 883 g (SD 380 g, n = 13) and 757 g (SD 371 g, n = 11) in the TLH group. The rate of conversion to laparotomy due to the uterine weight was significantly lower in the LSH group (11.9 %) compared to the TLH group (37.9 %) (p = 0.002). Intraoperative complications requiring laparotomy for other reasons but uterine size occurred in 6 patients of the study cohort (6/138; 4.3 %). Long-term postoperative complications occurred in 2 patients (2/138, 1.4 %), both patients from LSH group had to be re-operated on due to adhesions. Conclusions Our study adds further insight in the limited data set of laparoscopic hysterectomy for increased uterine weight and shows that LSH and TLH are safe and feasible even in patients with very large uteri (≥ 500 g).
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Affiliation(s)
- Dorit Schöller
- Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | | | - Markus Wallwiener
- Department of Obstetrics and Gynecology, University of Heidelberg, Heidelberg, Germany
| | | | - Bernhard Krämer
- Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Harald Abele
- Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Felix Neis
- Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | | | - Sara Brucker
- Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
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An evaluation of laparoscopic hysterectomy alone versus in combination with laparoscopic myomectomy for patients with uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2017; 210:132-138. [DOI: 10.1016/j.ejogrb.2016.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/02/2016] [Accepted: 12/04/2016] [Indexed: 12/16/2022]
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29
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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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30
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McGurk L, Oliver R, Odejinmi F. Laparoscopic supracervical hysterectomy for the larger uterus (>500 g): a case series and literature review. Arch Gynecol Obstet 2016; 295:397-405. [PMID: 27848016 DOI: 10.1007/s00404-016-4237-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 11/08/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND In clinical practice, the current trend for surgical hysterectomy for the large uterus is by laparotomy, where vaginal hysterectomy is not feasible. The benefits of a laparoscopic approach to hysterectomy are well documented, but limited literature is available on laparoscopic hysterectomy in the larger uterus. A supracervical hysterectomy should be considered for women, where there is no contraindication to a residual cervix. OBJECTIVE To compare surgical outcomes for laparoscopic supracervical hysterectomy (LSH) in the large uterus (equal or greater than 500 g) compared with normal (<500 g), results were compared to the limited literature on this topic. METHODS AND STUDY DESIGN A retrospective review was undertaken of 207 women who underwent an LSH between 2005 and 2015 at Whipps Cross University hospital. The operative outcome of patients undergoing surgery, for uteri both greater than 500 g and less than 500 g, was analysed. Data included patient demographics, intra-operative details, and complications. A literature search was performed using keywords 'laparoscopic supracervical hysterectomy' and 'laparoscopic sub-total hysterectomy' which yielded six informative articles. RESULTS In the study group of 207 patients, 67 had a large uterus (56 patients 500-1000 g, 11 patients >1000 g). The operation time and intra-operative blood loss were both greater in the larger uterus cohort (P < 0.0001 and P = 0.0021, respectively). The hospital stay and intra-operative complication rate were similar for the two study cohorts (six for the study, n = 207). Review of the literature revealed six relevant studies evaluating patients with uteri greater than 500 g. There was an agreement between all the studies that a larger uterus resulted in an increase in both intra-operative time and blood loss, but this did not translate to increase in hospital stay or intra-operative complications. CONCLUSION The use of LSH for the larger uterus is feasible and safe due to the low level of operative complications as demonstrated in our study and following a review of the literature.
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Affiliation(s)
- Lauren McGurk
- Department of Obstetrics and Gynaecology, Whipps Cross University Hospital, Barts Health NHS Trust, Whipps Cross Road, Leytonstone, London, E11 1NR, England, UK.
| | - Reeba Oliver
- Department of Obstetrics and Gynaecology, Whipps Cross University Hospital, Barts Health NHS Trust, Whipps Cross Road, Leytonstone, London, E11 1NR, England, UK
| | - Funlayo Odejinmi
- Department of Obstetrics and Gynaecology, Whipps Cross University Hospital, Barts Health NHS Trust, Whipps Cross Road, Leytonstone, London, E11 1NR, England, UK
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Dixit N, Jesner O, Modarres M. Endoscopic Treatment and Power Morcellation of Uterine Fibroids. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0155-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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32
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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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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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Clark LE, Menderes G, Tower AM, Silasi DA, Azodi M. A Simple Approach to Specimen Retrieval via Posterior Colpotomy Incision. JSLS 2016; 19:JSLS.2015.00222. [PMID: 25901107 PMCID: PMC4396057 DOI: 10.4293/jsls.2014.00222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Posterior colpotomy incision for specimen retrieval is infrequently used in gynecologic laparoscopic surgery unless a concomitant hysterectomy is performed. We aim to describe a simple and unique technique for creating the colpotomy incision and to describe intraoperative and postoperative outcomes. Methods: Fifty patients underwent adnexal specimen retrieval through a posterior colpotomy incision. After devascularization and detachment of the adnexal specimen, the posterior cul-de-sac was visualized. The colpotomy incision was created by introducing a 12- or 15-mm laparoscopic trocar through the vagina into the posterior vaginal fornix under direct visualization. Specimens were placed into laparoscopic bags and removed through the vagina. The colpotomy incision was closed vaginally. Charts were reviewed for intraoperative and postoperative outcomes. Results: Twenty-nine women underwent adnexal surgery for an adnexal mass, 14 women underwent surgery for pelvic pain, and 7 women underwent adnexal surgery for primary prevention of malignancy. The specimens removed ranged in size from 2 to 16 cm (mean 5.7). The mean time patients were under anesthesia was 103 minutes (SD 57.3). There were no operative complications related to the colpotomy incision and no cases of postoperative vaginal cellulitis or pelvic infection were reported. Only 1 woman with a prior vaginal delivery reported dyspareunia postoperatively. Conclusion: This simple technique for posterior colpotomy incision can easily be added to the gynecologic surgeon's armamentarium and can be safely used for most women.
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Affiliation(s)
- Lindsay E Clark
- Department of Obstetrics and Gynecology, Bridgeport Hospital, Yale New Haven Health Systems, Bridgeport, CT
| | - Gulden Menderes
- Department of Obstetrics and Gynecology, Bridgeport Hospital, Yale New Haven Health Systems, Bridgeport, CT
| | - Amanda M Tower
- Department of Obstetrics and Gynecology, Bridgeport Hospital, Yale New Haven Health Systems, Bridgeport, CT
| | - Dan-Arin Silasi
- Department of Obstetrics and Gynecology, Bridgeport Hospital, Yale New Haven Health Systems, Bridgeport, CT
| | - Masoud Azodi
- Department of Obstetrics and Gynecology, Bridgeport Hospital, Yale New Haven Health Systems, Bridgeport, CT
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A new approach to simplify surgical colpotomy in laparoscopic hysterectomy. GYNECOLOGICAL SURGERY 2016; 13:63-69. [PMID: 26918004 PMCID: PMC4753248 DOI: 10.1007/s10397-015-0929-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 12/23/2015] [Indexed: 11/01/2022]
Abstract
New surgical techniques and technology have simplified laparoscopic hysterectomy and have enhanced the safety of this procedure. However, the surgical colpotomy step has not been addressed. This study evaluates the surgical colpotomy step in laparoscopic hysterectomy with respect to difficulty and duration. Furthermore, it proposes an alternative route that may simplify this step in laparoscopic hysterectomy. A structured interview, a prospective cohort study, and a problem analysis were performed regarding experienced difficulty and duration of surgical colpotomy in laparoscopic hysterectomy. Sixteen experts in minimally invasive gynecologic surgery from 12 hospitals participated in the structured interview using a 5-point Likert scale. The colpotomy in LH received the highest scores for complexity (2.8 ± 1.2), compared to AH and VH. Colpotomy in LH was estimated as more difficult than in AH (2.8 vs 1.4, p < .001). In the cohort study, 107 patients undergoing LH were included. Sixteen percent of the total procedure time was spent on colpotomy (SD 7.8 %). BMI was positively correlated with colpotomy time, even after correcting for longer operation time. No relation was found between colpotomy time and blood loss or uterine weight. The surgical colpotomy step in laparoscopic hysterectomy should be simplified as this study demonstrates that it is time consuming and is considered to be more difficult than in other hysterectomy procedures. A vaginal approach to the colpotomy is proposed to achieve this simplification.
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Lynam S, Young L, Morozov V, Rao G, Roque DM. Risk, risk reduction and management of occult malignancy diagnosed after uterine morcellation: a commentary. ACTA ACUST UNITED AC 2015; 11:929-44. [PMID: 26673851 DOI: 10.2217/whe.15.63] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Minimally invasive surgical techniques compared with laparotomy offer the advantages of less intraoperative blood loss, shorter hospitalization, fewer wound complications and faster return to baseline activity for both hysterectomy and myomectomy. While morcellation allows for the laparoscopic removal of large specimens, it may result in intraperitoneal dissemination of benign disease or upstaging of occult malignancy leading to compromised survival. There has been heightened scrutiny over appropriate patient selection and preoperative assessment in light of recent warnings against power morcellation issued by the US FDA. This commentary therefore summarizes the magnitude of such risks associated with uterine morcellation, current national regulatory statements and potential merits of risk-reducing approaches such as contained morcellation. The importance of patient counseling is underscored.
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Affiliation(s)
- Sarah Lynam
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Laura Young
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Vadim Morozov
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA.,Center of Excellence in Minimally Invasive Gynecology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Gautam Rao
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA.,Division of Gynecologic Oncology, Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Dana M Roque
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA.,Division of Gynecologic Oncology, Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Walsh TM, Sangi-Haghpeykar H, Ng V, Zurawin R, Guan X. Hand-Assisted Laparoscopic Hysterectomy for Large Uteri. J Minim Invasive Gynecol 2015; 22:1231-6. [DOI: 10.1016/j.jmig.2015.06.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 11/28/2022]
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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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Kho KA, Brown DN, Nezhat CH. Uterine Morcellation in Pelvic Organ Prolapse Procedures. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-015-0114-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis. ACTA ACUST UNITED AC 2015; 12:165-177. [PMID: 26283890 PMCID: PMC4532723 DOI: 10.1007/s10397-015-0894-4] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 04/22/2015] [Indexed: 12/01/2022]
Abstract
There is a concern regarding the risk of occult leiomyosarcomas found at surgery for presumed benign fibroids. We sought to produce a comprehensive review of published data addressing this issue and provide high-quality prevalence estimates for clinical practice and future research. A comprehensive literature search using the PubMed/MEDLINE database and the Cochrane Library was performed. Inclusion criteria were human studies, peer-reviewed, with original data, involving cases for surgery in which fibroid-related indications were the primary reason for surgery, and histopathology was provided. Candidate studies (4864) were found; 3844 were excluded after review of the abstract. The remaining 1020 manuscripts were reviewed in their entirety, and 133 were included in the Bayesian binomial random effect meta-analysis. The estimated rate of leiomyosarcoma was 0.51 per 1000 procedures (95 % credible interval (CrI) 0.16–0.98) or approximately 1 in 2000. Restricting the meta-analysis to the 64 prospective studies resulted in a substantially lower estimate of 0.12 leiomyosarcomas per 1000 procedures (95 % CrI <0.01–0.75) or approximately 1 leiomyosarcoma per 8300 surgeries. Results suggest that the prevalence of occult leiomyosarcomas at surgery for presumed uterine fibroids is much less frequent than previously estimated. This rate should be incorporated into both clinical practice and future research.
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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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Driessen SR, Baden NL, van Zwet EW, Twijnstra AR, Jansen FW. Trends in the Implementation of Advanced Minimally Invasive Gynecologic Surgical Procedures in The Netherlands. J Minim Invasive Gynecol 2015; 22:642-7. [DOI: 10.1016/j.jmig.2015.01.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/21/2015] [Accepted: 01/25/2015] [Indexed: 11/25/2022]
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