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Lenfant L, Canlorbe G, Belghiti J, Kreaden US, Hebert AE, Nikpayam M, Uzan C, Azaïs H. Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis. J Robot Surg 2023; 17:2647-2662. [PMID: 37856058 PMCID: PMC10678826 DOI: 10.1007/s11701-023-01724-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/17/2023] [Indexed: 10/20/2023]
Abstract
The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.
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Affiliation(s)
- Louis Lenfant
- Department of Urology, Academic Hospital Pitié-Salpêtrière, APHP, Sorbonne Université, 75013, Paris, France
- Department of Surgery and Oncological Gynecology, Pitié-Salpétrière University Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Geoffroy Canlorbe
- Department of Surgery and Oncological Gynecology, Pitié-Salpétrière University Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Jérémie Belghiti
- Department of Surgery and Oncological Gynecology, Pitié-Salpétrière University Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Usha Seshadri Kreaden
- Biostatistics & Global Evidence Management, Intuitive Surgical Inc, Sunnyvale, CA, USA
| | - April E Hebert
- Biostatistics & Global Evidence Management, Intuitive Surgical Inc, Sunnyvale, CA, USA
| | - Marianne Nikpayam
- Department of Surgery and Oncological Gynecology, Pitié-Salpétrière University Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Catherine Uzan
- Department of Surgery and Oncological Gynecology, Pitié-Salpétrière University Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Henri Azaïs
- Department of Surgery and Oncological Gynecology, Pitié-Salpétrière University Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France.
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP, Centre, Université de Paris Cité, Paris, France.
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Šalamun V, Riemma G, Pavec M, Laganà AS, Ban Frangež H. Risk of Reintervention or Postoperative Bleeding after Laparoscopy for Benign Gynecological Disease: A Clinical Prediction Model. Gynecol Obstet Invest 2023; 88:294-301. [PMID: 37604136 DOI: 10.1159/000533490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE The objective of the study was to develop a clinically applicable prediction tool to early seek for postoperative major complications after laparoscopic surgery for benign pathologies. DESIGN Retrospective analysis of prospectively collected data was performed. SETTING The study was conducted at Tertiary Care University Hospital. PARTICIPANTS The participants of this study were reproductive-aged women undergoing laparoscopy for benign conditions. METHODS Anamnestic, intraoperative, and postoperative characteristics from January 2019 to December 2021 were retrospectively reviewed. Patients with postoperative complications (reintervention or postoperative bleeding) were matched in a 1:2 ratio with women with same surgical indications without complications. Cases and controls were matched for preoperative hemoglobin, hematocrit, weight, height, body mass index, age, and blood volume. A prediction model was created by inserting multiple independent modifying factors through logistic regression. The receiver operating characteristic (ROC) curve was used to evaluate the predictive accuracy of the model, and the Hosmer-Lemeshow (H-L) test was carried out to evaluate the goodness-of-fit, and a calibration curve was drawn to confirm the predictive performance. A nomogram was depicted to visualize the prediction model. RESULTS Thirty-nine complicated procedures were matched with 78 uncomplicated controls. According to the multivariate logistic regression analysis findings, the prediction model was developed using C-reactive protein (CRP), intraoperative blood loss, and 24 h postoperative urinary volume, therefore a nomogram was generated. The area under the ROC curve of the prediction model was 0.879, depicting good accuracy, the sensitivity was 60.00%, while specificity reached 93.59%. The H-L test (χ2 = 4.45, p = 0.931) and the calibration curve indicated a good goodness-of-fit and prediction stability. LIMITATIONS The retrospective design, moderate sensitivity, and study population limit the generalization of the findings, requiring additional research. CONCLUSIONS This prediction model based on CRP, intraoperative blood loss, and 24 h postoperative urinary volume might be a potentially useful tool for predicting reintervention and postoperative bleeding in patients undergoing planned gynecological laparoscopy.
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Affiliation(s)
- Vesna Šalamun
- Division of Gynaecology and Obstetrics, Department of Human Reproduction, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gaetano Riemma
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy,
| | - Manca Pavec
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Helena Ban Frangež
- Division of Gynaecology and Obstetrics, Department of Human Reproduction, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Opoku AA, Onifade RA, Odukoya OA. Challenges of morbid obesity in gynecological practice. Best Pract Res Clin Obstet Gynaecol 2023; 90:102379. [PMID: 37473647 DOI: 10.1016/j.bpobgyn.2023.102379] [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: 05/26/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Abstract
Obesity is currently a global pandemic, with increasing trends worldwide. Data from the WHO, US CDC, and the UK show an increasing trend, with 50% and 25% of the US population expected to be obese and morbidly obese by 2030. Obesity affects several aspects of health, with increased risks of cardiovascular disease, diabetes, metabolic syndrome, and several malignancies. Morbid obesity significantly impacts several aspects of female life and health, from adolescence, through the reproductive years, to the postmenopausal age group. In gynecology, there is a higher prevalence of menstrual disorders and infertility and reduced success rates of assisted reproduction; increased risk of miscarriage; pelvic organ prolapse; and endometrial, ovarian, and breast cancers. Surgery in the patient with morbid obesity is associated with several logistical challenges as well as increased surgical and peri-operative risks and increased cost. In this review, we provide an overview of the current literature, with a focus on challenges of morbid obesity in gynecological practice.
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Affiliation(s)
- Albert A Opoku
- Al Wakra Hospital, Hamad Medical Corporation, P. O. Box 82228, Al Wakra, Qatar; Weill Cornell Medical College, P. O. Box 24144, Doha, Qatar.
| | - Richard Adedamola Onifade
- Al Wakra Hospital, Hamad Medical Corporation, P. O. Box 82228, Al Wakra, Qatar; Weill Cornell Medical College, P. O. Box 24144, Doha, Qatar.
| | - Olusegun A Odukoya
- Al Wakra Hospital, Hamad Medical Corporation, P. O. Box 82228, Al Wakra, Qatar.
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Leonardi M, Robledo KP, Gordijn SJ, Condous G. A consensus-based core feature set for surgical complexity at laparoscopic hysterectomy. Am J Obstet Gynecol 2022; 226:700.e1-700.e9. [PMID: 34785175 DOI: 10.1016/j.ajog.2021.10.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/08/2021] [Accepted: 10/23/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND There are no current standardized and accepted methods to characterize the surgical complexity of a laparoscopic hysterectomy. This leads to challenges when trying to understand the relationship between the patient and the surgical features and outcomes. The development of core feature sets for laparoscopic hysterectomy studies would enable future trials to measure the similar meaningful variables that can contribute to surgical complexity and outcomes. OBJECTIVE The purpose of this study was to develop a core feature set for the surgical complexity of a laparoscopic hysterectomy. STUDY DESIGN This was an international Delphi consensus study. A comprehensive literature review was conducted to identify the features that were reported in studies on laparoscopic hysterectomy complexity. All the features were presented for evaluation and prioritization to key experts in 3 rounds of online surveys. A priori consensus criteria were used to reach agreement on the final outcomes for inclusion in the core feature set. RESULTS Experts represented North America, South America, Europe, Africa, Asia, and Oceania. Most of them had fellowship training in minimally invasive gynecologic surgery. Sixty-four potential features were entered into round 1. Experts reached a consensus on 7 features to be included in the core feature set. These features were grouped under the following domains: 1) patient features, 2) uterine features, and 3) nonuterine pelvic features. The patient features include obesity and other nonobesity comorbidities that alter or limit the ability of a surgeon to perform the basic or routine steps in a laparoscopic hysterectomy. The uterine features include the size and presence of fibroids. The nonuterine pelvic features include endometriosis, ovarian cysts, and adhesions (bladder-to-uterus, rectouterine pouch, and other adhesions). CONCLUSION Using robust consensus science methods, an international consortium of experts has developed a core feature set that should be assessed and reported in all future studies that aim to assess the relationship between the patient features and surgical outcomes of laparoscopic hysterectomy.
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Affiliation(s)
- Mathew Leonardi
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Penrith, Australia; Sydney Medical School Nepean, The University of Sydney, Sydney, Australia; Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.
| | - Kristy P Robledo
- The National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Sanne J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - George Condous
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Penrith, Australia; Sydney Medical School Nepean, The University of Sydney, Sydney, Australia
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Delong A, Shirreff L, Murji A, Matelski JJ, Pudwell J, Bougie O. Individualized assessment of risk of complications following benign hysterectomy. J Minim Invasive Gynecol 2022; 29:976-983. [DOI: 10.1016/j.jmig.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/31/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022]
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Misal M, Girardo M, Behbehani S, Bindra V, Hoffman MR, Lim WH, Martin C, Mehta SK, Nensi A, Soares T, Taylor D, Wagner S, Wright KN, Wasson MN. Evaluating surgical complexity of endoscopic hysterectomy: an interrater and intrarater agreement study of novel scoring tool. J Minim Invasive Gynecol 2022; 29:683-690. [DOI: 10.1016/j.jmig.2022.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/08/2022] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
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Turgay B, Şükür YE, Berker B, Taşkın S, Atabekoğlu C, Özmen B, Sönmezer M. Previous Abdominal Surgery and Obesity Do Not Affect Outcomes of Total Laparoscopic Hysterectomy Adversely. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Batuhan Turgay
- Department of Obstetrics and Gynecology, School of Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey
- School of Medicine, Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Yavuz Emre Şükür
- School of Medicine, Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Bülent Berker
- School of Medicine, Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Salih Taşkın
- School of Medicine, Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Cem Atabekoğlu
- School of Medicine, Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Batuhan Özmen
- School of Medicine, Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Murat Sönmezer
- School of Medicine, Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
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Lambat Emery S, Boulvain M, Petignat P, Dubuisson J. Operative Complications and Outcomes Comparing Small and Large Uterine Weight in Case of Laparoscopic Hysterectomy for a Benign Indication. Front Surg 2021; 8:755781. [PMID: 34676242 PMCID: PMC8525797 DOI: 10.3389/fsurg.2021.755781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/06/2021] [Indexed: 11/30/2022] Open
Abstract
Study Objective: This study was performed to evaluate the association between uterine weight and operative outcomes in women undergoing laparoscopic hysterectomy for a benign indication. Methods: This is a secondary analysis of a randomized trial with data collected prospectively and retrospectively. The data of 159 women undergoing laparoscopic hysterectomy for a benign indication were analyzed. Women were divided in two groups according to the postoperative uterine weight: small uterus group (<250 grams) and large uterus group (≥250 grams). Operative complications were compared between the two groups. Operative outcomes (need for uterine morcellation, operative duration, estimated blood loss), postoperative pain, and hospital length of stay were also analyzed. Main Results: Operative complications were not significantly different between the two groups (37% in the large uterus group versus 41% in the small uterus group). Operative outcomes showed a significantly increased use of uterine morcellation in the large uterus group (61% in the large uterus group versus 10% in the small uterus group). The operative duration was 150 min in the small uterus group and 176 min in the large uterus group, which corresponds to an increase of 17% in the large uterus group. The mean pain score on the day of surgery was identical in both groups (VAS pain score 5), but significantly in favor of the large uterus group on day 1 postoperatively (VAS pain score 4 in the small uterus group and 3 in the large uterus group). There was no statistical difference between groups in the mean hospital stay (62 ± 37 hours in the small uterus group versus 54 ± 21 hours in the large uterus group). In terms of surgical indication, the small uterus group comprised more patients with endometriosis/adenomyosis (36%) and the large uterus group more patients with leiomyoma (93%). Conclusion: The results from this study show that, even if a large uterine weight is associated with increased uterine morcellation requirement and operative duration, a laparoscopic approach is safe and does not increase operative complications nor pain and/or length of hospital stay in women undergoing hysterectomy for a benign indication.
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Affiliation(s)
- Shahzia Lambat Emery
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Patrick Petignat
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jean Dubuisson
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Hennings LI, Sørensen JL, Hybscmann J, Strandbygaard J. Tools for measuring technical skills during gynaecologic surgery: a scoping review. BMC MEDICAL EDUCATION 2021; 21:402. [PMID: 34311735 PMCID: PMC8314568 DOI: 10.1186/s12909-021-02790-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 06/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Standardised assessment is key to structured surgical training. Currently, there is no consensus on which surgical assessment tool to use in live gynaecologic surgery. The purpose of this review is to identify assessment tools measuring technical skills in gynaecologic surgery and evaluate the measurement characteristics of each tool. METHOD We utilized the scoping review methodology and searched PubMed, Medline, Embase and Cochrane. Inclusion criteria were studies that analysed assessment tools in live gynaecologic surgery. Kane's validity argument was applied to evaluate the assessment tools in the included studies. RESULTS Eight studies out of the 544 identified fulfilled the inclusion criteria. The assessment tools were categorised as global rating scales, global and procedure rating scales combined, procedure-specific rating scales or as a non-procedure-specific error assessment tool. CONCLUSION This scoping review presents the current different tools for observational assessment of technical skills in intraoperative, gynaecologic surgery. This scoping review can serve as a guide for surgical educators who want to apply a scale or a specific tool in surgical assessment.
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Affiliation(s)
| | - Jette Led Sørensen
- Juliane Marie Centre for children, women and reproduction, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jane Hybscmann
- Juliane Marie Centre for children, women and reproduction, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Stanescu AD, Loghin MG, Ples L, Balan DG, Paunica I, Balalau OD. Therapeutic approach of uterine leiomyoma; choosing the most appropriate surgical option. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2021. [DOI: 10.25083/2559.5555/6.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The most common benign pelvic tumor in young women is uterine leiomyoma. It is often asymptomatic, but can cause symptoms such as pelvic-abdominal pain, vaginal bleeding, urinary and intestinal transit disorders. If there is a suspicion of malignancy, it is necessary to perform fractional uterine curettage to establish the histopathological diagnosis.The surgical treatment of uterine leiomyoma includes several procedures: myomectomy, subtotal or total hysterectomy. The procedure will be chosen depending on the patient's particularities: BMI, uterine size, leiomyoma location, surgical history or other associated pathologies.Laparoscopic hysterectomy has a 45-minute shorter duration of intervention than vaginal hysterectomy, and the conversion rate to the open procedure is lower.Laparoscopically treated cases have fewer postoperative complications compared to other surgical procedures and have a shorter hospitalization and recovery time.The recurrence rate of uterine leiomyoma is similar for both laparoscopic and open abdominal approach, and the frequency of long-term complications such as adhesion syndrome or pelvic pain is higher after the latter.
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Pepin K, Cook F, Maghsoudlou P, Cohen SL. Risk-prediction Model for Patients Undergoing Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2021; 28:1751-1758.e1. [PMID: 33713836 DOI: 10.1016/j.jmig.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Develop a model for predicting adverse outcomes at the time of laparoscopic hysterectomy (LH) for benign indications. DESIGN Retrospective cohort study. SETTING Large academic center. PATIENTS All patients undergoing LH for benign indications at our institution between 2009 and 2017. INTERVENTIONS LH (including robot-assisted and laparoscopically assisted vaginal hysterectomy) was performed per standard technique. Data about the patient, surgeon, perioperative adverse outcomes (intraoperative complications, readmission, reoperation, operative time >4 hours, and postoperative medical complications or length of stay >2 days), and uterine weight were collected retrospectively. Pathologic uterine weight was used as a surrogate for predicted preoperative uterine weight. The sample was randomly split, using a random sequence generator, into 2 cohorts, one for deriving the model and the other to validate the model. MEASUREMENTS AND MAIN RESULTS A total of 3441 patients were included. The rate of composite adverse outcomes was 14.1%. The final logistic regression risk-prediction model identified 6 variables predictive of an adverse outcome at the time of LH: race, history of laparotomy, history of laparoscopy, predicted preoperative uterine weight, body mass index, and surgeon annual case volume. Specifically included were race (97% increased odds of an adverse outcome for black women [95% confidence interval (CI), 34%-110%] and 34% increased odds of an adverse outcome for women of other races [95% CI, -11% to 104%] when compared with white women), history of laparotomy (69% increased odds of an adverse outcome [95% CI, 26%-128%]), history of laparoscopy (65% increased odds of an adverse outcome [95% CI, 21%-124%]), and predicted preoperative uterine weight (2.9% increased odds of an adverse outcome for each 100-g increase in predicted weight [95% CI, 2%-4%]). Body mass index and surgeon annual case volume also had a statistically significant nonlinear relationship with the risk of an adverse outcome. The c-statistic values for the derivation and validation cohorts were 0.74 and 0.72, respectively. The model is best calibrated for patients at lower risk (<20%). CONCLUSION The LH risk-prediction model is a potentially powerful tool for predicting adverse outcomes in patients planning hysterectomy.
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Affiliation(s)
- Kristen Pepin
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou); Department of Minimally Invasive Gynecologic Surgery, Weill Cornell Medicine, New York, New York (Dr. Pepin).
| | - Francis Cook
- Department of Epidemiology, Harvard School of Public Health (Dr. Cook), Boston, Massachusetts
| | - Parmida Maghsoudlou
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou)
| | - Sarah L Cohen
- Department of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital (Drs. Pepin and Cohen, and Ms. Maghsoudlou); Department of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota (Dr. Cohen)
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Pepin KJ, Cook EF, Cohen SL. Risk of complication at the time of laparoscopic hysterectomy: a prediction model built from the National Surgical Quality Improvement Program database. Am J Obstet Gynecol 2020; 223:555.e1-555.e7. [PMID: 32247844 DOI: 10.1016/j.ajog.2020.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although laparoscopic hysterectomy is well established as a favorable mode of hysterectomy owing to decreased perioperative complications, there is still room for improvement in quality of care. Previous studies have described laparoscopic hysterectomy risk, but there is currently no tool for predicting risk of complication at the time of laparoscopic hysterectomy. OBJECTIVE This study aimed to create a prediction model for complications at the time of laparoscopic hysterectomy for benign conditions. STUDY DESIGN This is a retrospective cohort study that included patients who underwent laparoscopic hysterectomy for benign indications between 2014 and 2017 in US hospitals contributing to the American College of Surgeons - National Surgical Quality Improvement Program database. Data about patient baseline characteristics, perioperative complications (intraoperative complications, readmission, reoperation, need for transfusion, operative time greater than 4 hours, or postoperative medical complication), and uterine weight at the time of pathologic examination were collected retrospectively. Postoperative uterine weight was used as a proxy for preoperative uterine weight estimate. The sample was randomly divided into 2 patient populations, one for deriving the model and the other to validate the model. RESULTS A total of 33,123 women met the inclusion criteria. The rate of composite complication was 14.1%. Complication rates were similar in the derivation and validation cohorts (14.1% [2306 of 14,051] vs 13.9% [2289 of 14,107], P=.7207). The logistic regression risk prediction tool for hysterectomy complication identified 7 variables predictive of complication: history of laparotomy (21% increased odds of complication), age (2% increased odds of complication per year of life), body mass index (0.2% increased odds of complication per each unit increase in body mass index), parity (7% increased odds of complication per delivery), race (when compared with white women, black women had 34% increased odds and women of other races had 18% increased odds of complication), and American Society of Anesthesiologists score (when compared with American Society of Anesthesiologists 1, American Society of Anesthesiologists 2 had 31% increased odds, American Society of Anesthesiologists 3 had 62% increased odds, and American Society of Anesthesiologists 4 had 172% increased odds of complication). Predicted preoperative uterine weight also had a statistically significant nonlinear relationship with odds of complication. The c-statistics for the derivation and validation cohorts were 0.62 and 0.62, respectively. The model is well calibrated for women at all levels of risk. CONCLUSION The laparoscopic hysterectomy complication predictor model is a tool for predicting complications in patients planning to undergo hysterectomy.
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Al-Husban N, Elayyan Y, El-Qudah M, Aloran B, Batayneh R. Surgical adhesions among women undergoing laparoscopic gynecological surgery with or without adhesiolysis - prevalence, severity, and implications: retrospective cohort study at a University Hospital. Ther Adv Reprod Health 2020; 14:2633494120906010. [PMID: 32518913 PMCID: PMC7254590 DOI: 10.1177/2633494120906010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/18/2020] [Indexed: 11/30/2022] Open
Abstract
Objective: To find out the prevalence of adhesions, severity, and their relation to the current clinical scenario and to the type of previous surgery. Methods and Materials: A retrospective study of patients who already had different previous abdominopelvic surgery and subsequently underwent gynecological laparoscopic surgery for various indications. The patients’ clinical and operative notes were reviewed and analyzed. Results: There were 654 procedures performed. The most common indication for the laparoscopic surgery was secondary infertility 23.5%, followed by adnexal lesions 22.0% and primary infertility 19.6%. Intraoperative adhesions were found in 45.3%. Adhesions were deemed relevant to the clinical scenario in 21.3%. Patients who had a previous history of open (traditional) surgery were more likely to be found with adhesions in comparison with patients with history of laparoscopic surgery (odds ratio: 2.7, 95% confidence interval: 1.4–5.3, p = 0.0025). The presence of adhesions was found to be strongly associated with previous abdominopelvic surgery than non-abdominopelvic surgery (odds ratio: 4.3, p = 0.0078, 95% confidence interval: 1.5–12.5). The most common location of the adhesions was abdominal (36.1%), mixed abdominal and pelvic (35.1%), and pelvic adhesions (28.1%). Severe adhesions were found in 36.1%; 13.6% of converted laparoscopy to open surgery was due to adhesions. Cesarean sections were significantly associated with adhesions. Patients who had cesarean sections were more likely to have adhesions than those who had not (odds ratio: 5.7, 95% confidence interval: 3.8–8.6, p < 0.0001). Adhesiolysis was done without complications in 19.6% of patients with adhesions. Conclusion: Adhesions were prevalent in gynecological patients with previous abdominopelvic surgery. They were a significant contributor to the gynecological and reproductive issues. To minimize the risk of postoperative adhesions, laparoscopic approach should be encouraged instead of traditional surgery and rates of cesarean section should be reduced. Further high-quality studies are needed to establish conclusion and practical guidance toward the use of adhesion barriers.
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Affiliation(s)
- Naser Al-Husban
- Assistant Professor, Faculty of Medicine, The University of Jordan, P.O. Box 2194, Amman 11941, Jordan
| | - Yousef Elayyan
- Department of Obstetrics and Gynecology, Jordan University Hospital, Amman, Jordan
| | - Malab El-Qudah
- Department of Obstetrics and Gynecology, Jordan University Hospital, Amman, Jordan
| | - Bayan Aloran
- Department of Obstetrics and Gynecology, Jordan University Hospital, Amman, Jordan
| | - Rima Batayneh
- Department of Obstetrics and Gynecology, Jordan University Hospital, Amman, Jordan
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Herrinton LJ, Raine-Bennett T, Liu L, Alexeeff SE, Ramos W, Suh-Burgmann B. Outcomes of Robotic Hysterectomy for Treatment of Benign Conditions: Influence of Patient Complexity. Perm J 2019; 24:19.035. [PMID: 31905335 DOI: 10.7812/tpp/19.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Robotic hysterectomy may offer advantages for complex cases over the conventional laparoscopic approach. OBJECTIVE To assess the association of surgical approach (robotic vs conventional) with blood loss, risks of readmission, reoperation, complications, and average operative time. METHODS In a retrospective cohort study, we used the electronic medical records of Kaiser Permanente Northern California, 2011 to 2015, to estimate outcomes of robotic and conventional laparoscopic hysterectomy among women with complex or noncomplex benign disease. Mixed-effects regression models accounted for patient characteristics and surgeon volume. RESULTS The study included 560 robotic and 6785 conventional laparoscopic cases. Overall, 1836 patients (25%) met criteria for being complex. The average operative time was 152 minutes for robotic hysterectomy and 157 minutes for conventional laparoscopic hysterectomy (p < 0.0001). Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. The difference in operative time for high-volume surgeons treating complex patients with robotic hysterectomy vs conventional hysterectomy was 21 minutes faster (p < 0.05). After adjustment, the risk of blood loss at least 51 mL was lower for robotic surgery than for conventional surgery for complex and noncomplex patients. Other than risk of urinary tract complications, we observed no differences in the risks of complications or risk of reoperation between robotic and conventional laparoscopy for complex and noncomplex patients. CONCLUSION For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications.
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Affiliation(s)
| | | | | | | | - Wilfredo Ramos
- Department of Obstetrics and Gynecology, Sacramento Medical Center, CA
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Orhan A, Ozerkan K, Kasapoglu I, Ocakoglu G, Cetinkaya Demir B, Gunaydin T, Uncu G. Laparoscopic hysterectomy trends in challenging cases (1995–2018). J Gynecol Obstet Hum Reprod 2019; 48:791-798. [DOI: 10.1016/j.jogoh.2019.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 12/26/2022]
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Yong PJ, Thurston J, Singh SS, Allaire C. Guideline No. 386-Gynaecologic Surgery for Patients with Obesity. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1356-1370.e7. [DOI: 10.1016/j.jogc.2018.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Yong PJ, Thurston J, Singh SS, Allaire C. Directive clinique No 386 - Chirurgie gynécologique chez les patientes obèses. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1371-1388.e7. [PMID: 31443851 DOI: 10.1016/j.jogc.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Richards L, Healey M, Cheng C, Dior U. Laparoscopic Oophorectomy to Treat Pelvic Pain FollowingOvary-Sparing Hysterectomy: Factors Associated with Surgical Complications and Pain Persistence. J Minim Invasive Gynecol 2018; 26:1044-1049. [PMID: 30308307 DOI: 10.1016/j.jmig.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/29/2018] [Accepted: 10/04/2018] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To examine the surgical management and outcomes of patients treated laparoscopically for pelvic pain following ovary-sparing hysterectomy. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING General gynecology unit at a tertiary university hospital. PATIENTS A total of 99 patients treated with laparoscopic oophorectomy for pelvic pain following ovary-sparing hysterectomy between January 2008 and December 2016. INTERVENTIONS Laparoscopic oophorectomy was performed in all patients. MEASUREMENTS AND MAIN RESULTS The patients undergoing surgery had a mean age of 48.9 years and a mean body mass index (BMI) of 28.1. They reported a mean of 3.0 previous abdominal surgeries. Sixty percent of patients reported previous abdominal hysterectomy, 21% had previous laparoscopic hysterectomy, and 19% had previous vaginal hysterectomy. At a 6-week follow-up, 59.5% of patients reported resolution of symptoms, 10.7% reported persistent symptoms, and 29.8% reported improved but not resolved symptoms. Younger patients and those reporting a previous history of gastrointestinal disease were more likely to report persistent pain at follow-up. Thirteen percent of patients had intraoperative (6%) or postoperative complications (7%), and there was a 2% rate of conversion to laparotomy. Patients at greater risk of intraoperative complications were those with a higher BMI, a greater number of previous open abdominal surgeries, or severe adhesions noted at the time of procedure. CONCLUSIONS Laparoscopic oophorectomy to treat pelvic pain following ovary-sparing hysterectomy is a feasible yet challenging procedure. Despite a significant rate of complications and a small proportion of patients reporting persistent symptoms, most experience symptom resolution or improvement after such surgery. Further studies are needed to assess long-term outcomes. Careful patient selection and counseling are critical before this procedure.
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Affiliation(s)
- Lucy Richards
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia.
| | - Martin Healey
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Claudia Cheng
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Uri Dior
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia
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Sandberg EM, Driessen SRC, Bak EAT, van Geloven N, Berger JP, Smeets MJGH, Rhemrev JPT, Jansen FW. Surgical outcomes of laparoscopic hysterectomy with concomitant endometriosis without bowel or bladder dissection: a cohort analysis to define a case-mix variable. ACTA ACUST UNITED AC 2018; 15:8. [PMID: 29576761 PMCID: PMC5856860 DOI: 10.1186/s10397-018-1039-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/07/2018] [Indexed: 11/13/2022]
Abstract
Background Pelvic endometriosis is often mentioned as one of the variables influencing surgical outcomes of laparoscopic hysterectomy (LH). However, its additional surgical risks have not been well established. The aim of this study was to analyze to what extent concomitant endometriosis influences surgical outcomes of LH and to determine if it should be considered as case-mix variable. Results A total of 2655 LH’s were analyzed, of which 397 (15.0%) with concomitant endometriosis. For blood loss and operative time, no measurable association was found for stages I (n = 106) and II (n = 103) endometriosis compared to LH without endometriosis. LH with stages III (n = 93) and IV (n = 95) endometriosis were associated with more intra-operative blood loss (p = < .001) and a prolonged operative time (p = < .001) compared to LH without endometriosis. No significant association was found between endometriosis (all stages) and complications (p = .62). Conclusions The findings of our study have provided numeric support for the influence of concomitant endometriosis on surgical outcomes of LH, without bowel or bladder dissection. Only stages III and IV were associated with a longer operative time and more blood loss and should thus be considered as case-mix variables in future quality measurement tools.
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Affiliation(s)
- Evelien M Sandberg
- 1Department of Gynecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sara R C Driessen
- 1Department of Gynecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Evelien A T Bak
- 1Department of Gynecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Nan van Geloven
- 2Department of Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Judith P Berger
- 1Department of Gynecology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Gynecology, Haaglanden Medical Centre, the Hague, the Netherlands
| | | | - Johann P T Rhemrev
- Department of Gynecology, Haaglanden Medical Centre, the Hague, the Netherlands
| | - Frank Willem Jansen
- 1Department of Gynecology, Leiden University Medical Centre, Leiden, the Netherlands.,4Department BioMechanical Engineering, Delft University of Technology, Delft, the Netherlands.,5Department of Gynecology, Minimally Invasive Surgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
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Kreuninger JA, Cohen SL, Meurs EAIM, Cox M, Vitonis A, Jansen FW, Einarsson JI. Trends in readmission rate by route of hysterectomy - a single-center experience. Acta Obstet Gynecol Scand 2017; 97:285-293. [PMID: 29192965 DOI: 10.1111/aogs.13270] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/12/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The aim of this study was to assess the 60-day readmission rates after hysterectomy according to route of surgery and analyze risk factors for postoperative readmission. MATERIAL AND METHODS This retrospective study included all women who underwent hysterectomy due to benign conditions from 2009 to 2015 at a large academic center in Boston. Readmission rates were compared among the following four types of hysterectomies: abdominal, laparoscopic, robotic and vaginal. RESULTS There were 3981 hysterectomy cases over the study period (628 abdominal hysterectomy, 2500 laparoscopic hysterectomy, 155 robotic hysterectomy and 698 vaginal hysterectomy). Intraoperative complications occurred more frequently in women undergoing abdominal hysterectomy (4.8%), followed by robotic hysterectomy (3.9%), vaginal hysterectomy (1.9%) and laparoscopic hysterectomy (1.6%) (p < 0.0001). Readmission rates were not significantly different among the groups; women receiving abdominal hysterectomy had an overall readmission rate of 3.5%, compared with 3.2% after robotic hysterectomy, 2.9% after vaginal hysterectomy and 1.9% after laparoscopic hysterectomy (p = 0.06). When stratifying for relevant variables, women who had an laparoscopic hysterectomy had a twofold reduction of readmission compared with abdominal hysterectomy (odds ratio 0.52, 95% confidence interval 0.31-0.87; p = 0.01). There was no significant difference in readmission when robotic hysterectomy or vaginal hysterectomy were compared individually with abdominal hysterectomy. Regarding risk factors related to readmission it was observed that perioperative complications were the largest driver of readmissions (odds ratio 667, 95% confidence interval 158-99; p < 0.0001). CONCLUSION The laparoscopic approach to hysterectomy was associated with fewer hospital readmissions compared with the abdominal route; vaginal, robotic and abdominal approaches had a similar risk of readmission. Perioperative complications represent the main driver of readmissions. After adjusting for perioperative factors such as surgeon type and complications, no difference in readmissions between the different routes of hysterectomy were found.
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Affiliation(s)
- Jennifer A Kreuninger
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Division of Minimally Invasive Gynecologic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Sarah L Cohen
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Elsemieke A I M Meurs
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary Cox
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Allison Vitonis
- Department of Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Frank W Jansen
- Division of Minimally Invasive Gynecologic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jon I Einarsson
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Sandberg EM, Hehenkamp WJK, Geomini PM, Janssen PF, Jansen FW, Twijnstra ARH. Laparoscopic hysterectomy for benign indications: clinical practice guideline. Arch Gynecol Obstet 2017; 296:597-606. [PMID: 28748339 PMCID: PMC5548857 DOI: 10.1007/s00404-017-4467-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/18/2017] [Indexed: 11/07/2022]
Abstract
Purpose Since the introduction of minimally invasive gynecologic surgery, the percentage of advanced laparoscopic procedures has greatly increased worldwide. It seems therefore, timely to standardize laparoscopic gynecologic care according to the principles of evidence-based medicine. With this goal in mind—the Dutch Society of Gynecological Endoscopic Surgery initiated in The Netherlands the development of a national guideline for laparoscopic hysterectomy (LH). This present article provides a summary of the main recommendations of the guideline. Methods This guideline was developed following the Dutch guideline of medical specialists and in accordance with the AGREE II tool. Clinically important issues were firstly defined and translated into research questions. A literature search per topic was then conducted to identify relevant articles. The quality of the evidence of these articles was rated following the GRADE systematic. An expert panel consisting of 18 selected gynecologists was consulted to formulate best practice recommendations for each topic. Results Ten topics were considered in this guideline, including amongst others, the different approaches for hysterectomy, advice regarding tissue extraction, pre-operative medical treatment and prevention of ureter injury. This work resulted in the development of a clinical practical guideline of LH with evidence- and expert-based recommendations. The guideline is currently being implemented in The Netherlands. Conclusion A guideline for LH was developed. It gives an overview of best clinical practice recommendations. It serves to standardize care, provides guidance for daily practice and aims to guarantee the quality of LH at an (inter)national level.
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Affiliation(s)
- Evelien M Sandberg
- Section Minimally Invasive Gynecologic Surgery, Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - Peggy M Geomini
- Department of Gynecology, Maxima Medical Center, Veldhoven, The Netherlands
| | - Petra F Janssen
- Department of Gynecology, Elisabeth-Twee Steden Hospital, Tilburg, The Netherlands
| | - Frank Willem Jansen
- Section Minimally Invasive Gynecologic Surgery, Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Bio Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Andries R H Twijnstra
- Section Minimally Invasive Gynecologic Surgery, Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System. Obstet Gynecol 2017; 129:996-1005. [DOI: 10.1097/aog.0000000000002034] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Macciò A, Kotsonis P, Lavra F, Chiappe G, Sanna D, Zamboni F, Madeddu C. Laparoscopic removal of a very large uterus weighting 5320 g is feasible and safe: a case report. BMC Surg 2017; 17:50. [PMID: 28472966 PMCID: PMC5418735 DOI: 10.1186/s12893-017-0248-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 04/20/2017] [Indexed: 02/07/2023] Open
Abstract
Background Total laparoscopic hysterectomy (TLH) has demonstrated to be feasible and safe in the presence of very large uteri. However, it is currently difficult to establish the upper uterine weight limit for successful performance of a laparoscopic hysterectomy. Case presentation Here we report the case of a TLH performed for a very large fibromatous uteri weighing 5320 g in a 40-year-old Caucasian woman. The surgery had no complications with an operating time of approximately 220 min. The patient was discharged from the hospital on postoperative day 3 in very good condition. To our knowledge, the present paper is the only to describe a uterus of this size removed by laparoscopic hysterectomy. Conclusions Our case demonstrates that uterine size is not a determinant for a final surgical decision to use laparoscopic hysterectomy. Therefore, if not contraindicated by the patient’s comorbidities or peculiar anatomical conditions, we believe that laparoscopic hysterectomy could be performed in the presence of large uteri without hypothetical weight limits.
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Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy.
| | - Paraskevas Kotsonis
- Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy
| | - Fabrizio Lavra
- Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy
| | - Giacomo Chiappe
- Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy
| | - Daniela Sanna
- Department of Anesthesiology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Fausto Zamboni
- Department of General Surgery, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Laparoendoscopic single-site surgery versus conventional laparoscopy for hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet 2017; 295:1089-1103. [PMID: 28357561 PMCID: PMC5388711 DOI: 10.1007/s00404-017-4323-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/06/2017] [Indexed: 02/07/2023]
Abstract
Purpose To assess the safety and effectiveness of LESS compared to conventional hysterectomy. Methods The systematic review and meta-analysis was performed according to the MOOSE guideline, and quality of evidence was assessed using GRADE. Different databases were searched up to 4th of August 2016. Randomized controlled trials and cohort studies comparing LESS to the conventional laparoscopic hysterectomy were considered for inclusion. Results Of the 668 unique articles, 23 were found relevant. We investigated safety by analyzing the complication rate and found no significant differences between both groups [OR 0.94 (0.61, 1.44), I2 = 19%]. We assessed effectiveness by analyzing conversion risk, postoperative pain, and patient satisfaction. For conversion rates to laparotomy, no differences were identified [OR 1.60 (0.40, 6.38), I2 = 45%]. In 3.5% of the cases in the LESS group, an additional port was needed during LESS. For postoperative pain scores and patient satisfaction, some of the included studies reported favorable results for LESS, but the clinical relevance was non-significant. Concerning secondary outcomes, only a difference in operative time was found in favor of the conventional group [MD 11.3 min (5.45–17.17), I2 = 89%]. The quality of evidence for our primary outcomes was low or very low due to the study designs and lack of power for the specified outcomes. Therefore, caution is urged when interpreting the results. Conclusion The single-port technique for benign hysterectomy is feasible, safe, and equally effective compared to the conventional technique. No clinically relevant advantages were identified, and as no data on cost effectiveness are available, there are currently not enough valid arguments to broadly implement LESS for hysterectomy. Electronic supplementary material The online version of this article (doi:10.1007/s00404-017-4323-y) contains supplementary material, which is available to authorized users.
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Driessen SR, Van Zwet EW, Haazebroek P, Sandberg EM, Blikkendaal MD, Twijnstra AR, Jansen FW. A dynamic quality assessment tool for laparoscopic hysterectomy to measure surgical outcomes. Am J Obstet Gynecol 2016; 215:754.e1-754.e8. [PMID: 27402052 DOI: 10.1016/j.ajog.2016.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/28/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The current health care system has an urgent need for tools to measure quality. A wide range of quality indicators have been developed in an attempt to differentiate between high-quality and low-quality health care processes. However, one of the main issues of currently used indicators is the lack of case-mix correction and improvement possibilities. Case-mix is defined as specific (patient) characteristics that are known to potentially affect (surgical) outcome. If these characteristics are not taken into consideration, comparisons of outcome among health care providers may not be valid. OBJECTIVE The objective of the study was to develop and test a quality assessment tool for laparoscopic hysterectomy, which can serve as a new outcome quality indicator. STUDY DESIGN This is a prospective, international, multicenter implementation study. A web-based application was developed with 3 main goals: (1) to measure the surgeon's performance using 3 primary outcomes (blood loss, operative time, and complications); (2) to provide immediate individual feedback using cumulative observed-minus-expected graphs; and (3) to detect consistently suboptimal performance after correcting for case-mix characteristics. All gynecologists who perform laparoscopic hysterectomies were requested to register their procedures in the application. A patient safety risk factor checklist was used by the surgeon for reflection. Thereafter a prospective implementation study was performed, and the application was tested using a survey that included the System Usability Scale. RESULTS A total of 2066 laparoscopic hysterectomies were registered by 81 gynecologists. Mean operative time was 100 ± 39 minutes, blood loss 127 ± 163 mL, and the complication rate 6.1%. The overall survey response rate was 75%, and the mean System Usability Scale was 76.5 ± 13.6, which indicates that the application was good to excellent. The majority of surgeons reported that the application made them more aware of their performance, the outcomes, and patient safety, and they noted that the application provided motivation for improving future performance. CONCLUSION We report the development and test of a real-time, dynamic, quality assessment tool for measuring individual surgical outcome for laparoscopic hysterectomy. Importantly, this tool provides opportunities for improving surgical performance. Our study provides a foundation for helping clinicians develop evidence-based quality indicators for other surgical procedures.
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Driessen SRC, Sandberg EM, Rodrigues SP, van Zwet EW, Jansen FW. Identification of risk factors in minimally invasive surgery: a prospective multicenter study. Surg Endosc 2016; 31:2467-2473. [PMID: 27800588 PMCID: PMC5443851 DOI: 10.1007/s00464-016-5248-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 09/12/2016] [Indexed: 11/30/2022]
Abstract
Background Since the introduction of minimally invasive surgery (MIS), concerns for patient safety are more often brought to the attention. Knowledge about and awareness of patient safety risk factors are crucial in order to improve and enhance the surgical team, the environment, and finally surgical performance. The aim of this study was to identify and quantify patient safety risk factors in laparoscopic hysterectomy and to determine their influence on surgical outcomes. Methods A prospective multicenter study was conducted from April 2014 to January 2016, participating gynecologists registered their performed laparoscopic hysterectomies (LHs). If deemed necessary, gynecologists could fill out a checklist with validated patient safety risk factors. Association between procedures with and without an occurred risk factor(s) and the surgical outcomes (blood loss, operative time, and complications) were assessed, using multivariate logistic regression and generalized estimation equations. Results Eighty-five gynecologists participated in the study, registering a total of 2237 LHs. For 627(28 %) procedures, the checklist was entered (in total 920 items). The most reported risk factors were related to the surgeon (19.6 %), the surgical team (14.4 %), technology (16.6 %), and the patient (26.8 %). The procedures where a risk factor was registered had significantly less favorable outcomes, higher complication rate (10.5 vs. 4.8 % (p = 0.002), longer operative time [114 vs. 95 min (p < 0.001)], and more blood loss [110 vs. 168 mL (p = 0.047)], which was mainly due to the technological and patient-related risk factors. Conclusion Technological incidents are the most important and clinically relevant risk factors affecting surgical outcomes of LH. Future improvements of MIS need to focus on this. As awareness of safety risk factors in MIS is important, embedding of a safety risk factor checklist in registration systems will help surgeons to evaluate and improve their individual performance. This will inherently improve the surgical outcomes and thus patient safety.
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Affiliation(s)
- Sara R C Driessen
- Department of Gynaecology, Section Minimally Invasive Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Evelien M Sandberg
- Department of Gynaecology, Section Minimally Invasive Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Sharon P Rodrigues
- Department of Gynaecology, Section Minimally Invasive Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Frank Willem Jansen
- Department of Gynaecology, Section Minimally Invasive Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. .,Department BioMechanical Engineering, Delft University of Technology, PO Box 5, 2600 AA, Delft, The Netherlands.
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Driessen SRC, Wallwiener M, Taran FA, Cohen SL, Kraemer B, Wallwiener CW, van Zwet EW, Brucker SY, Jansen FW. Hospital versus individual surgeon's performance in laparoscopic hysterectomy. Arch Gynecol Obstet 2016; 295:111-117. [PMID: 27628752 PMCID: PMC5225188 DOI: 10.1007/s00404-016-4199-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/06/2016] [Indexed: 11/29/2022]
Abstract
Purpose To compare hospital versus individual surgeon’s perioperative outcomes for laparoscopic hysterectomy (LH), and to assess the relationship between surgeon experience and perioperative outcomes. Methods A retrospective analysis of all prospective collected LHs performed from 2003 to 2010 at one medical center was performed. Perioperative outcomes (operative time, blood loss, complication rate) were assessed on both a hospital level and surgeon level using Cumulative Observed minus Expected performance graphs. Results A total of 1618 LHs were performed, 16 % total laparoscopic hysterectomies and 84 % laparoscopic supracervical hysterectomies. Overall outcomes included mean (SD±) blood loss 108.9 ± 69.2 mL, mean operative time 95.4 ± 39.7 min and a complication occurred in 76 (4.7 %) of cases. Suboptimal perioperative outcomes of an individual surgeon were not always detected on a hospital level. However, collective suboptimal outcomes were faster detected on a hospital level compared to individual surgeon’s level. Evidence of a learning curve is seen; for the first 100 procedures, a decrease in operative time is observed as individual surgeon experience increases. Similarly, the risk of conversion decreases up to the first 50 procedures. Conclusion An individual outlier (i.e., surgeon with consistently suboptimal performance) will not always be detected when monitoring outcome measures only on a hospital level. However, monitoring outcome measures on a hospital level will detect suboptimal performance earlier compared to monitoring only on an individual surgeon’s level. To detect performance outliers timely, insight into an individual surgeon’s outcome and skills is recommended. Furthermore, an experienced surgeon is no guarantee for acceptable surgical outcomes.
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Affiliation(s)
- Sara R C Driessen
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Markus Wallwiener
- Department of Obstetrics and Gynecology, University of Heidelberg, INF 440, 69115, Heidelberg, Germany
| | - Florin-Andrei Taran
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Sarah L Cohen
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Bernhard Kraemer
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Christian W Wallwiener
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Sara Y Brucker
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. .,Department BioMechanical Engineering, Delft University of Technology, PO Box 5, 2600 AA, Delft, The Netherlands.
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