Analysis of Risk Factors for Intraoperative Conversion of Laparoscopic Myomectomy

Surgical Outcomes and Complications of Myomectomy: A Prospective Cohort Study

STUDY OBJECTIVE

To investigate postoperative surgical and non-surgical complications that occur within 30 days following myomectomy procedures, whether laparoscopic or via open surgery.

DESIGN

Prospective cohort study SETTING: Del Ponte Women's and Children's Hospital, Varese, Italy.

PATIENTS

Women undergoing myomectomy either with laparoscopic or open surgery from July 2020 to June 2023 INTERVENTIONS: Data of consecutive patients who underwent abdominal myomectomy procedures, either via laparoscopy or open abdominal surgery were collected. The study examined patient characteristics, size and location of fibroids, surgical data, and complications. Univariate and multivariable analyses were employed to identify factors contributing to postoperative Clavien-Dindo grade ≥ II complications.

MEASUREMENTS AND MAIN RESULTS

Overall 383 patients were included in the study. The univariate analysis showed intramural fibroid type (p = .0009), large fibroid size (p = .03), and extended operative times (p = .05) were associated with postoperative complications. Open surgical approach (p <.001) and uterine cavity opening (p = .02) also contributed to complications. Postoperative anemia emerged as the most prevalent complication. In the multivariable analysis, the open surgical approach emerged as the only independent factor associated with an increased risk of grade ≥ II complications (odds ratio 7.37; p <.0001).

CONCLUSION

In this study we found an increased likelihood of complications in case of open myomectomy. While the presence of potential selection bias may have impacted this finding, it could provide valuable insights for clinicians and surgical teams in the strategic planning of myomectomy procedures.

Predictive factors for conversion to laparotomy in women undergoing laparoscopic hysterectomy. A re-evaluation of clinicopathological factors in the era of minimally invasive gynaecology

Background

Abdominal hysterectomy has been largely replaced by minimally invasive surgery. Nevertheless, in some situations, a minimally invasive intervention must be converted to laparotomy. Factors associated with conversion to laparotomy are still a matter of debate.

Objective

The aim of this study was to evaluate the clinicopathological factors associated with the conversion of laparoscopic hysterectomy to laparotomy.

Materials and Methods

The risk factors for conversion of a preplanned laparoscopic procedure to laparotomy were retrospectively evaluated in 441 patients undergoing a hysterectomy for a benign indication between 2016 and 2020. Associations between the clinical factors were analysed using Pearson's chi-square and Fisher's exact test, and predictive values for conversion were assessed through multivariate logistic regression.

Result

Conversion occurred in 32 (7.3%) of the cases. Significant differences were detected for uterus weight (576.9gr vs 174.6gr, p<0.001), myoma size (7.0 cm vs. 1.8 cm, p<0.001), and presence of triple diagnosis consisting of leiomyoma, adenomyosis uteri, and pathological adnexal findings (p<0.013). The conversion resulted in prolonged surgery time (181.6 min vs. 119.6 min, p<0.001) and hospital stay (4.0 vs. 3.1 days, p<0.001), as well as an increased rate of wound infection (15.6% vs. 3.4%, p<0.001). A 10g increase in uterus weight raised the risk of conversion by 7.0%, and a 1cm increase in myoma diameter by 7.3%, while adnexal pathologies and extensive adhesions increased the odds of conversion to laparotomy threefold (ORs of 3.2, 1.09-9.6 and 3.6, 1.3-10.0, respectively).

Conclusion

Uterus weight, myoma size, the coexistence of pathological adnexal findings, and non-physiological adhesions are independent risk factors for conversion.

What is new?

This study provides data regarding the risk and factors increasing this risk for conversion to laparotomy during laparoscopic hysterectomy.

Surgical impact of bilateral transient occlusion of uterine and utero-ovarian arteries during laparoscopic myomectomy

The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time.

Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches

Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.

Comparison of surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.

Operative and Obstetric Outcomes after Single-port Laparoscopic Myomectomy: A Retrospective Single-center Analysis of 504 Cases

STUDY OBJECTIVE

To analyze the obstetric and operative outcomes of 504 cases of single-port laparoscopic myomectomy (SPLM).

DESIGN

Single-center retrospective study.

SETTING

A tertiary university hospital.

PATIENTS

A total of 502 patients (504 SPLM procedures) who underwent SPLM for symptom relief or growing myomas between October 2009 and April 2020.

INTERVENTIONS

Data on patient demographics, operative variables (estimated blood loss, hemoglobin decrease, operation time, perioperative complications, and postoperative hospital stay), and obstetric outcomes (the surgery-to-pregnancy interval and birth-related outcomes) were obtained from medical records and analyzed.

MEASUREMENTS AND MAIN RESULTS

The mean age of the patients was 40.6 ± 6.6 years. The patients had had an average of 2.3 ± 2.2 myomas removed; the largest myoma size was 6.8 ± 2.4 cm. The mean operation time, postoperative hemoglobin decrease, and postoperative hospital stay duration were 112.9 ± 45.3 minutes, 1.7 ± 1.1 g/dL, and 2.2 ± 1.4 days, respectively. The overall rate of postoperative complications was 7.7% (39/504), and the common complications were transfusions (16/504, 3.1%) or wound problems (15/504, 3.0%). Conversion to multiport or open myomectomy was required in 0.8% of the cases (4/504). A total of 376 women were of child-bearing age, and 56 attempted to become pregnant after surgery. The mean interval from surgery to pregnancy was 15.6 ± 12.2 months. The obstetric outcomes were pregnancy (42/56, 75.0%), live birth (39/56, 69.6%), and miscarriage (2/56, 3.6%). One pregnant woman was lost to follow-up. The 39 live births predominantly involved full-term delivery (36/39, 92.3%), mostly through cesarean section (36/39, 92.3%). No postpartum complications were reported. The 2 most common obstetric complications were preterm labor (7.6%) and gestational diabetes (5.1%).

CONCLUSION

SPLM seems to be an effective procedure with good operative and postoperative obstetric outcomes for women with myomas who require surgery and may wish to subsequently become pregnant.

Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

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.

Association of operative time with outcomes in minimally invasive and abdominal myomectomy

OBJECTIVE(S)

To determine the association of operative time (ORT) with perioperative morbidity and whether there is an ORT at which minimally invasive myomectomy becomes inferior to laparotomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Myomectomy cases identified by CPT code from 2005 to 2016.

INTERVENTION(S)

Cases were stratified and analyzed by surgical approach and 90-minute intervals.

MAIN OUTCOME MEASURE(S)

Thirty-day postoperative morbidity.

RESULT(S)

A total of 11,709 myomectomies were identified; 4,673 (39.9%) were minimally invasive, 6,997 (59.8%) were abdominal, and 39 (0.3%) were conversions. The incidence of complications significantly increased with ORT. After adjusting for confounders, mean ORT in minutes (95% confidence interval) was 113 (111-115) for abdominal, 156 (153-159) for minimally invasive, and 172 (148-200) for conversions. Despite shorter ORT, morbidity was greater in abdominal cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%). The minimally invasive approach in general had lower odds of complications (odds ratio, 0.23; 95% confidence interval, 0.19-0.26). However, when minimally invasive surgery ORT reached ≥ 270 minutes, the odds of a composite complication variable increased compared with abdominal cases <90 minutes (odds ratio, 2.30; 95% confidence interval, 1.69-3.13). Of minimally invasive cases, 88% were completed in <270 minutes.

CONCLUSION(S)

ORT was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach.

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications

BACKGROUND

Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes.

OBJECTIVE

The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications.

MATERIALS AND METHODS

This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO.

RESULTS

Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P <.001) and were more likely to smoke (21.0% vs 15.8%, P = .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P = .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P = .02), and cystotomy repair (1.0% vs 0.3%, P = .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65).

CONCLUSION

Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

Perioperative Outcomes of Myomectomy for Extreme Myoma Burden: Comparison of Surgical Approaches

STUDY OBJECTIVE

To describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden.

DESIGN

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

SETTING

A tertiary academic center in Boston, Massachusetts.

PATIENTS

All women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016.

INTERVENTIONS

Baseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted.

MEASUREMENTS AND MAIN RESULTS

During the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 ± 784.5 g for AM vs 586.6 ± 426.1 g for LM and 586.6 ± 426.1 g for RM; mean number: 16.8 ± 15.0 for AM vs 7.2 ± 7.0 for LM and 6.7 ± 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 ± .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17-2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001).

CONCLUSION

Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number.

Comparison of 30-day Complication Rates between Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy for the Treatment of Uterine Leiomyoma in Women Older Than Age 40

STUDY OBJECTIVE

To evaluate whether there are differences in complication rates between laparoscopic myomectomy (LM) and total laparoscopic hysterectomy (TLH) for the treatment of uterine leiomyoma in perimenopausal women.

DESIGN

A retrospective cohort study using 1:2 propensity score matching (Canadian Task Force classification II-2).

SETTING

American College of Surgeons National Surgical Quality Improvement Program database.

PATIENTS

Women between the ages of 40 and 60 years undergoing surgical laparoscopic surgery for uterine leiomyoma between the years 2010 and 2016.

INTERVENTIONS

Women were stratified to either LM or TLH at a ratio of 1:2 using propensity score matching. Descriptive statistics were reported as means with standard deviations. Pairwise analysis using the Student t test and chi-square test was performed where appropriate. Multivariable logistic regression was used to identify factors associated with the presence of a complication.

MEASUREMENTS AND MAIN RESULTS

After propensity score matching, there were 631 myomectomies and 1262 hysterectomies. The operating time was slightly longer for LM compared with TLH (166.8 ± 90.3 minutes vs 157.9 ± 70.9 minutes, p = .03). The overall complication rate was 6.3%. There were no differences in complications between the LM and TLH groups (5.9% vs 6.6%, p = .54). Urinary tract infections were more common in the TLH group (2.3% vs 0.6%, p = .01). There were no other differences in the rates of specific complications between the 2 groups. On logistic regression, wound class greater than 3 was most strongly associated with a risk of complications (adjusted odds ratio [aOR] = 8.89; 95% confidence interval [CI], 1.28-15.87). Other variables associated with an increased risk of complications were conversion to hysterectomy (aOR = 5.91; 95% CI, 1.7-9.63), total operating time (aOR = 1.05; 95% CI, 1.02-1.07), and length of stay over 1 day (aOR = 3.67; 95% CI, 2.31-5.8).

CONCLUSION

LM is not associated with an increased risk of complications compared with TLH in women over the age of 40 years undergoing treatment for uterine leiomyomata.

Pushing the boundaries of laparoscopic myomectomy: a comparative analysis of peri-operative outcomes in 323 women undergoing laparoscopic myomectomy in a tertiary referral centre

Background

The aim of this study was to analyse the demographic data and peri-operative outcomes of women undergoing a laparoscopic myomectomy and assess what factors, if any, precluded using the laparoscopic approach.

Methods

A single surgeon observational study of 323 patients undergoing a laparoscopic myomectomy was undertaken. Data was collected prospectively over a 12-year period and analysed using SPSS. Surgical outcomes included operating time, estimated blood loss, conversion to laparotomy, intraoperative and postoperative complications and duration of inpatient stay.

Results

A total of 323 patients underwent a laparoscopic myomectomy over the 12-year period. The majority of fibroids removed were intramural (49%) and subserosal (33%). The mean size of fibroids removed was 7.66 ± 2.83 (7.34–7.99) cm, and the mean number was 4 ± 3.62 (3.6–4.39), with the greatest being 22 removed from a single patient. Average blood loss was 279.14 ± 221.10 (254.59–303.69) ml with mean duration of surgery and inpatient stay recorded as 112.92 ± 43.21 (107.94–117.91) min and 1.88 ± 0.95 (1.77–1.99) days, respectively. No major intraoperative complications were noted, and the conversion to laparotomy rate was 0.62%. All histology following morcellation was benign. Over the 12-year period despite increasingly large and more numerous fibroids being tackled, increasing experience resulted in a simultaneous reduction in overall blood loss, operating time and duration of inpatient stay.

Conclusions

Laparoscopic myomectomy is a safe and efficacious procedure that should be considered the gold standard surgical treatment option for fibroids. With experience, the procedure can be undertaken with minimal complications, a low risk of conversion to laparotomy and early discharge from hospital, even in cases of large and multiple fibroids that historically would have required the open approach. This allows even the most complex of cases to now benefit for the advantages of the minimal access approach.

Combining situ-morcellation with continuous-fill-mattress suture in laparoscopic myomectomy: A surgical approach of choice for patients with large uterine fibroids

BACKGROUND

To investigate the efficacy and advantage of combining situ-morcellation with continuous-fill-mattress suture compared with conventional morcellation and suture in laparoscopic myomectomy.

METHODS

One hundred sixteen patients who underwent laparoscopic myomectomy from March 2014 to October 2016.

INTERVENTIONS

Patients were divided into combining situ-morcellation with continuous-fill-mattress suture group (n = 62) and conventional group (n = 54), and subsequent statistical analysis the clinical data of the 2 groups.

RESULTS

The combining situ-morcellation with continuous-fill-mattress suture group shows significantly decrease of surgery time, incision size, blood loss, postoperative drainage volume and time, postoperative vent time, hospital stay and the loss of hemoglobin value. Moreover, there is significant significance between the 2 groups in the surgery time (P = .018), the postoperative drainage volume (P = .000), and the loss of hemoglobin value (P = .000).

CONCLUSIONS

The combining situ-morcellation with continuous-fill-mattress suture shows significant advantages in shortening surgery time and reducing blood loss compared with conventional group in laparoscopic myomectomy.

Feasibility, Safety, and Prediction of Complications for Minimally Invasive Myomectomy in Women With Large and Numerous Myomata

OBJECTIVE

To assess perioperative outcomes and identify predictors of complications for minimally invasive surgery (MIS) myomectomy in a cohort of women with large and numerous myomata.

DESIGN

Case-control study (Canadian Task Force classification II-2).

SETTING

Academic tertiary care medical center.

PATIENTS

Women undergoing MIS myomectomy performed by 3 high-volume surgeons between April 2011 and December 2014.

INTERVENTIONS

Characteristics were compared between women who experienced complications and those who did not. Factors predictive of complications were then identified.

MEASUREMENTS AND MAIN RESULTS

A total of 221 women underwent an MIS myomectomy, 47.5% via a laparoscopic approach and 52.5% via robotic surgery. The mean ± SD specimen weight was 408.1 ± 384.9 g, uterine volume was 586.1 ± 534.1 cm³, dominant myoma diameter was 9.6 ± 5.1 cm, and number of myomata removed was 4.5 ± 4.1. The most common complications were hemorrhage >1000 mL (8.6%) and blood transfusion (4.1%). The conversion rate was 1.8%. A dominant myoma diameter of ≥12 cm and a uterine volume of ≥750 cm³ increased the odds of complications (odds ratio [OR], 7.44; 95% confidence interval [CI], 2.03-31.84; p = .004 and OR, 6.15; 95% CI, 1.55-30.02; p = .014 respectively). A receiver operating characteristic curve considering dominant myoma diameter and uterine volume had an area under the curve of 0.81. A combination of dominant myoma diameter of ≥10 cm and uterine volume of 600 cm³ predicted complications with 79% sensitivity and 79% specificity.

CONCLUSION

Our cohort had large and numerous myomata with high specimen weights, but complications were comparable to those reported in previous studies of MIS myomectomy with less complex pathology. Hemorrhage and transfusion accounted for the majority of complications, and a combination of dominant myoma diameter and uterine volume was predictive of complications. Both factors can be easily defined before surgery and may be used to guide patient counseling, referrals, and implementation of preventative measures for hemorrhage and transfusion.

Efficacy and Safety of Combined Ultrasonic and Bipolar Energy Source in Laparoscopic Surgery

AIM

Energy devices represent an alternative to clips and staplers for vessel sealing. Outcome data of patients undergoing laparoscopic surgery with use of a novel combined ultrasonic and bipolar energy device (TB, Thunderbeat™) was gathered.

METHODS

Consecutive patients undergoing laparoscopic surgery using TB were prospectively included between November 2011 and January 2016. Large vessels were dissected using the energy device without additional clips or staplers. The type of procedure, operative time, length of stay, complications, blood transfusions, number and type of vessels being dissected, and need for additional clips were noted.

RESULTS

Six hundred eighty-three patients underwent 758 procedures with dissection of 1310 large vessels. No additional hemoclips or vascular staplers were used. There were 0.7 % (5/758) intraoperative and 2.6 % (20/758) postoperative bleeding complications. Eleven bleeding occurred at the stapler line of anastomosis, leaving 1.8 % (14/758) bleeding that were potentially related to inadequate hemostasis. Failure of large vessel dissection occurred in two cases (0.15 %, 2/1310) and device-related complications in 1.1 % (8/758). Two of 42 conversions (5.5 %) were bleeding-related.

CONCLUSION

TB provides a reliable and effective hemostasis. However, ligation failure may occur. As with any kind of electrosurgery, the hot tip of the instruments bears the risk of potentially fatal thermal injuries.

Complications in gynecological minimal-access oncosurgery

Complications are the limiting factors of all surgeries. More than performing the actual surgery, learning how to avoid complications before, during, and after surgery is the most important task of every surgeon. Severe complications can lead to patient death. Complications such as ureterovaginal fistulas, resulting from <2 s of inattentive preparation, can lead to years of hardship, suffering, accusation, and litigation. Excellent surgery is about performing the right surgery for the right patient without any complications. Minimally invasive surgery in complex cases is technically challenging. This article details the major causes of complications in laparoscopy for the gynecologic cancer patient and present strategies for prevention, early detection, and intra- and postoperative management.