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Nguyen KH, Joo H, Manuel S, Chen LM, Chen LL. Incorporating low haemoglobin into a risk prediction model for conversion in minimally invasive gynaecologic oncology surgeries. J OBSTET GYNAECOL 2024; 44:2349960. [PMID: 38783693 DOI: 10.1080/01443615.2024.2349960] [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: 01/24/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND A well-known complication of laparoscopic management of gynaecologic masses and cancers is the need to perform an intraoperative conversion to laparotomy. The purpose of this study was to identify novel patient risk factors for conversion from minimally invasive to open surgeries for gynaecologic oncology operations. METHODS This was a retrospective cohort study of 1356 patients ≥18 years of age who underwent surgeries for gynaecologic masses or malignancies between February 2015 and May 2020 at a single academic medical centre. Multivariable logistic regression was used to study the effects of older age, higher body mass index (BMI), higher American Society of Anaesthesiologist (ASA) physical status, and lower preoperative haemoglobin (Hb) on odds of converting from minimally invasive to open surgery. Receiver operating characteristic (ROC) curve analysis assessed the discriminatory ability of a risk prediction model for conversion. RESULTS A total of 704 planned minimally invasive surgeries were included with an overall conversion rate of 6.1% (43/704). Preoperative Hb was lowest for conversion cases, compared to minimally invasive and open cases (11.6 ± 1.9 vs 12.8 ± 1.5 vs 11.8 ± 1.9 g/dL, p<.001). Patients with preoperative Hb <10 g/dL had an adjusted odds ratio (OR) of 3.94 (CI: 1.65-9.41, p=.002) for conversion while patients with BMI ≥30 kg/m2 had an adjusted OR of 2.86 (CI: 1.50-5.46, p=.001) for conversion. ROC curve analysis using predictive variables of age >50 years, BMI ≥30 kg/m2, ASA physical status >2, and preoperative haemoglobin <10 g/dL resulted in an area under the ROC curve of 0.71. Patients with 2 or more risk factors were at highest risk of requiring an intraoperative conversion (12.0%). CONCLUSIONS Lower preoperative haemoglobin is a novel risk factor for conversion from minimally invasive to open gynaecologic oncology surgeries and stratifying patients based on conversion risk may be helpful for preoperative planning.
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Affiliation(s)
- Kevin H Nguyen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Medicine, Palo Alto, CA, USA
| | - Hyundeok Joo
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Solmaz Manuel
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Lee-May Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Lee-Lynn Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
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Mamik MM, Kim-Fine S, Yang L, Sharma V, Gala R, Aschkenazi S, Sheyn D, Howard D, Walter AJ, Kudish B, Balk EM, Antosh DD. Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review. Obstet Gynecol 2024; 144:40-52. [PMID: 38743951 DOI: 10.1097/aog.0000000000005607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/14/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. DATA SOURCES PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. METHODS OF STUDY SELECTION This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. TABULATION, INTEGRATION, AND RESULTS The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. CONCLUSION Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021233300.
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Affiliation(s)
- Mamta M Mamik
- Albert Einstein College of Medicine, Bronx, New York; University of Calgary, Calgary, Alberta, Canada; Northwestern Medicine, Chicago, Illinois; Ochsner Clinical School, Jefferson, Louisiana; Waukesha Memorial Hospital, Waukesha, Wisconsin; University Hospitals, Cleveland, Ohio; Rutgers New Jersey Medical School, Newark, New Jersey; Kaiser Permanente, Roseville, California; Florida State University, Tallahassee, Florida; Brown University School of Public Health, Providence, Rhode Island; and Houston Methodist Hospital, Houston, Texas
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Amin S, Hasanin A, Attia OA, Mostafa M, Elzayat NS, Elsherbiny M, Eissa AA. Intravenous ibuprofen versus ketorolac for perioperative pain control in open abdominal hysterectomy: a randomized controlled trial. BMC Anesthesiol 2024; 24:202. [PMID: 38849734 PMCID: PMC11157756 DOI: 10.1186/s12871-024-02571-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND We aimed to compare the analgesic effects of intravenous ibuprofen to ketorolac after open abdominal hysterectomy. METHODS This randomized double-blinded controlled trial included adult women scheduled for elective open abdominal hysterectomy. Participants were randomized to receive either 30 mg ketorolac (n = 50) or 800 mg ibuprofen (n = 50) preoperatively, then every 8 h postoperatively for 24 h. All participants received paracetamol 1 gm/6 h. Rescue analgesic was given if the visual analogue scale (VAS) for pain assessment was > 3. The primary outcome was the mean postoperative dynamic VAS during the first 24 h. Secondary outcomes were static VAS, intraoperative fentanyl consumption, postoperative morphine consumption, time to independent movement, and patient's satisfaction. RESULTS Forty-six patients in the ibuprofen group and fifty patients in the ketorolac group were analyzed. The 24-h dynamic and static VAS were similar in the two groups. The median (quartiles) dynamic VAS was 1.1 (0.9, 1.9) in the ibuprofen group versus 1.0 (0.7, 1.3) in the ketorolac group, P-value = 0.116; and the median (quartiles) static VAS was 0.9 (0.6, 1.3) in the ibuprofen group versus 0.7 (0.4, 1.1) in the ketorolac group, P-value = 0.113. The intra- and postoperative analgesic requirements were also similar in the two groups. However, patient satisfaction was slightly higher in the ketorolac group than that in the ibuprofen group (median [quartiles]: 6 [5, 7] versus 5 [4, 7], respectively), P-value: 0.009. CONCLUSION The two drugs, intravenous ibuprofen and ketorolac produced similar analgesic profile in patients undergoing open abdominal hysterectomy receiving multimodal analgesic regimen. NCT05610384, Date of registration: 09/11/2022 CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05610384. https://clinicaltrials.gov/ct2/show/NCT05610384.
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Affiliation(s)
- Sarah Amin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Ola A Attia
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Nashwa S Elzayat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mona Elsherbiny
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Amany A Eissa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Zorzato PC, Ferrari FA, Garzon S, Franchi M, Cianci S, Laganà AS, Chiantera V, Casarin J, Ghezzi F, Uccella S. Advanced bipolar vessel sealing devices vs conventional bipolar energy in minimally invasive hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:1165-1174. [PMID: 37955717 PMCID: PMC10894136 DOI: 10.1007/s00404-023-07270-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH). METHODS A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs). RESULTS Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878]. CONCLUSIONS High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use.
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Affiliation(s)
- Pier Carlo Zorzato
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Filippo Alberto Ferrari
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Simone Garzon
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy.
| | - Massimo Franchi
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Stefano Cianci
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, Paolo Giaccone Hospital, Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Stefano Uccella
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
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Pecorella G, De Rosa F, Licchelli M, Panese G, Carugno JT, Morciano A, Tinelli A. Postoperative cognitive disorders and delirium in gynecologic surgery: Which surgery and anesthetic techniques to use to reduce the risk? Int J Gynaecol Obstet 2024. [PMID: 38557928 DOI: 10.1002/ijgo.15464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 04/04/2024]
Abstract
Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age-related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk-benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post-surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery.
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Affiliation(s)
- Giovanni Pecorella
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Filippo De Rosa
- Department of Anesthesia and Intensive Care, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Martina Licchelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Gaetano Panese
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Josè Tony Carugno
- Obstetrics and Gynecology Department, Minimally Invasive Gynecology Division, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Andrea Morciano
- Panico Pelvic Floor Center, Department of Gynecology and Obstetrics, Pia Fondazione "Card. G. Panico", Tricase, Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
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Carlson S, Brando A, McGregor AE, Sutaria T, Hurtado E, Padilla PF, Arnolds K. Comparison of Postoperative Complications Between Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2024; 31:43-48. [PMID: 37820828 DOI: 10.1016/j.jmig.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/24/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
STUDY OBJECTIVE To compare postoperative complications of laparoscopic myomectomy (LM) with total laparoscopic hysterectomy (TLH). A secondary outcome examined whether complications differ by age. DESIGN A retrospective cohort study. SETTING A multicenter academic healthcare system. PATIENTS Individuals > 18 years old undergoing LM from 2011 to 2021 or TLH for benign indications from 2020 to 2021. INTERVENTIONS LM or TLH. MEASUREMENTS AND MAIN RESULTS There were 1178 patients in the LM group and 1304 in the TLH group. Patients who underwent LM were younger, more often premenopausal, nonsmokers, with lower body mass index, lower preoperative hemoglobin, larger uterine size, and lower American Society of Anesthesiologists class. LM had longer operative times (154.1 ± 74.5 vs 145.9 ± 70.5 min, p <.0001), higher use of intraoperative hemostatic agents (25% vs 9.1%, p <.0001), and higher estimated blood loss (222.7 ± 313.0 vs 87.4 ± 145.9 mL, p <.0001) than TLH. Postoperatively, LM was associated with fewer surgical site infections (3.1% vs 5.8%, p <.0001), readmissions within 30 days (2.0% vs 5.6%, p <.0001), or emergency department visits within 90 days (10.9% vs 14.4%, p = .008). LM were more likely to be admitted 24 hours postoperatively (5.9% vs 3.4%, p = .0023) or receive a blood transfusion within 30 days (4.0% vs 1.0%, p <.0001). Variables associated with increased risk of postoperative complications were tobacco use, American Society of Anesthesiologists class > 3, preoperative anemia, estimated blood loss ≥ 150 mL, and specimen weight > 250 g. Logistic regression demonstrated that operative time ≥185 minutes was most strongly associated with 24-hour admission postoperatively (odds ratio [OR] = 12.95; 95% confidence interval [CI], 3.71-45.27). In individuals ≤ 37 years of age, the LM group was less likely than the TLH group to experience surgical site infection (OR, 0.30; 95% CI, 0.14-0.62) or present to the emergency department (OR, 0.40; 95% CI, 0.26-0.63). CONCLUSION In this large cohort of patients, both LM and TLH had low rates of postoperative complications, but the complications differed for each approach. In appropriate surgical candidates, either approach may be offered based upon patients' goals.
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Affiliation(s)
- Sonia Carlson
- Section of Minimally Invasive Gynecologic Surgery, Department of Gynecology (Drs. Carlson, McGregor, Sutaria, Hurtado, Frazzini Padilla, and Arnolds), Cleveland Clinic Florida, Weston, FL.
| | | | - Ali E McGregor
- Section of Minimally Invasive Gynecologic Surgery, Department of Gynecology (Drs. Carlson, McGregor, Sutaria, Hurtado, Frazzini Padilla, and Arnolds), Cleveland Clinic Florida, Weston, FL
| | - Tarangi Sutaria
- Section of Minimally Invasive Gynecologic Surgery, Department of Gynecology (Drs. Carlson, McGregor, Sutaria, Hurtado, Frazzini Padilla, and Arnolds), Cleveland Clinic Florida, Weston, FL
| | - Eric Hurtado
- Section of Minimally Invasive Gynecologic Surgery, Department of Gynecology (Drs. Carlson, McGregor, Sutaria, Hurtado, Frazzini Padilla, and Arnolds), Cleveland Clinic Florida, Weston, FL
| | - Pamela Frazzini Padilla
- Section of Minimally Invasive Gynecologic Surgery, Department of Gynecology (Drs. Carlson, McGregor, Sutaria, Hurtado, Frazzini Padilla, and Arnolds), Cleveland Clinic Florida, Weston, FL
| | - Katrin Arnolds
- Section of Minimally Invasive Gynecologic Surgery, Department of Gynecology (Drs. Carlson, McGregor, Sutaria, Hurtado, Frazzini Padilla, and Arnolds), Cleveland Clinic Florida, Weston, FL
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Mouro S, Hamed JLC, Whiteside JL, Tumin D. Relevance of Uterine Weight for Predicting Surgical Complications in Minimally Invasive Benign Hysterectomy. J Minim Invasive Gynecol 2023; 30:976-982. [PMID: 37611741 DOI: 10.1016/j.jmig.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/25/2023]
Abstract
STUDY OBJECTIVES To describe the uterine weight threshold for increasing risk of complications after a laparoscopic hysterectomy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. DESIGN Cross-sectional analysis using the American College of Surgeons NSQIP database from 2016 to 2021. SETTING American College of Surgeons NSQIP database. PATIENTS Patients undergoing minimally invasive hysterectomy for benign indications (N = 64 289). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Uterine weight was entered in grams and 30-day complications were abstracted from patient charts. In the analytic sample, median uterine weight was 135 grams (interquartile range, 90-215) and 6% of patients (n = 4085) experienced complications. Uterine weight performed very poorly in predicting complications on bivariate analysis (area under the receiver operating characteristics curve, 0.53; 95% confidence interval, 0.53-0.54). On multivariable analysis, a uterine weight cutoff of 163 grams was associated with higher odds of complications (odds ratio, 1.11; 95% confidence interval, 1.03-1.19; p = .003), but this threshold achieved only a 43% sensitivity and 62% specificity for predicting complications. CONCLUSIONS Uterine weight alone possessed negligible utility for predicting the risk of perioperative complications in minimally invasive hysterectomy.
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Affiliation(s)
- Steven Mouro
- Department of Obstetrics and Gynecology (Drs. Mouro and Whiteside), East Carolina University, Greenville, North Carolina.
| | - Jenna L Carter Hamed
- Brody School of Medicine (Ms. Carter Hamed), East Carolina University, Greenville, North Carolina
| | - James L Whiteside
- Department of Obstetrics and Gynecology (Drs. Mouro and Whiteside), East Carolina University, Greenville, North Carolina
| | - Dmitry Tumin
- Department of Pediatrics and Department of Academic Affairs (Dr. Tumin), East Carolina University, Greenville, North Carolina
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Goodner C, Moran G, Williams K, Mounir D. The clinical utility of routine postoperative hemoglobin and creatinine after reconstructive surgery for apical pelvic organ prolapse. Int Urogynecol J 2023; 34:2759-2766. [PMID: 37466693 DOI: 10.1007/s00192-023-05601-6] [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: 02/21/2023] [Accepted: 06/08/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Postoperative laboratory tests are routinely ordered after apical prolapse repair on asymptomatic patients. We hypothesize that routine serum hemoglobin (Hb) and creatinine (Cr) have limited clinical utility in the postoperative period in asymptomatic patients. METHODS This is a retrospective cohort study of patients who underwent surgical repair of apical prolapse between 2017 and 2019 at our institution. Subjects were divided into two groups postoperatively: symptomatic and asymptomatic anemia. Symptomatic patients were defined as having one or more of the following: blood pressure (BP) <90/60, heart rate (HR) >100, urine output <30 cc/h, subjective dizziness, flank pain, or abdominal pain. The primary aim was to evaluate the utility of postoperative serum Hb and Cr in symptomatic and asymptomatic patients. Fisher's exact and Mann-Whitney tests analyzed categorical and continuous data respectively. A total of 325 patients were included. RESULTS Patients with symptomatic anemia had a larger decrease in Hb on postoperative day 1 (POD1) with a mean decrease of -18.11% (± 6.64) compared with asymptomatic patients, who had a mean difference of -15.49% (± 5.63; p < 0.001). The total cost of tests evaluating Hb was US$61,745. Patients with symptomatic acute kidney injury had an increase in Cr on POD1 compared with asymptomatic patients, with a mean increase of 0.23% (± 16.06) and -3.07% (± 13.10) respectively (p < 0.05). The total cost of tests including Cr was US$131,812. CONCLUSIONS Our results indicate that routine postoperative Hb and Cr testing for apical prolapse should be reserved for symptomatic patients as it has minimal clinical value in asymptomatic patients and contributes to increased overall health care cost.
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Agarwal M, Sinha S, Singh S, Haripriya H, Roy I. Surgical Morbidity of Laparoscopic Hysterectomy versus Abdominal Hysterectomy: A Retrospective Overview. Gynecol Minim Invasive Ther 2023; 12:161-165. [PMID: 37807994 PMCID: PMC10553594 DOI: 10.4103/gmit.gmit_30_23] [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: 04/04/2023] [Revised: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives Laparoscopic skills are not an innate behavior, nor can they be easily mimicked, and can only be acquired through hands-on training. The need for reliable training and its assessment is becoming increasingly important with the course of time. Materials and Methods A retrospective comparative study was done in a tertiary care center where all patients undergoing hysterectomy by laparoscopic and abdominal route were included in the study. Objectives Our study aims to compare the operative and postoperative complications of laparoscopic hysterectomy with abdominal hysterectomy. The study was conducted from June 2016 to October 2022. Results The mean operative time for uteri size lesser than 12 weeks was found significant in the total laparoscopic hysterectomy (TLH) group (75 ± 25 min) to total abdominal hysterectomy (TAH) (117 ± 28 min, P < 0.001). The mean blood loss in the TLH group was significant (110 ± 30 ml vs. 160 ± 116 ml, P < 0.002). The mean hospital stay was significantly shorter in TLH (4 ± 2.4 days vs. 7 ± 2.41 days, P < 0.002). The operative and postoperative complications observed were 3.1% in the TLH group and 11.7% in the TAH group. Conclusion TLH when performed efficiently has proved to be a preferable route over other conventional hysterectomies.
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Affiliation(s)
- Mukta Agarwal
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
| | - Shivangni Sinha
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
| | - Smita Singh
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
| | - H. Haripriya
- Department of Community and Family Medicine, AIIMS, Patna, Bihar, India
| | - Ishita Roy
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
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Tchartchian G, Bojahr B, Krentel H, De Wilde RL. Evaluation of complications, conversion rate, malignancy rate, and, surgeon's experience in laparoscopic assisted supracervical hysterectomy (LASH) of 1274 large uteri: A retrospective study. Acta Obstet Gynecol Scand 2022; 101:1450-1457. [PMID: 36203317 PMCID: PMC9812207 DOI: 10.1111/aogs.14468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Hysterectomy now belongs to standard gynecological procedures. Moreover, a shift towards laparoscopic techniques is ever more apparent as they provide many advantages such as less traumatization and shorter convalescence. Large uteri are still mentioned as contraindications for laparoscopic hysterectomy even though those patients might benefit from the lower morbidity associated with minimal invasive techniques. In this study, the largest reported so far, we analyzed intraoperative and postoperative complications as well as the surgeon's experience of laparoscopic assisted supracervical hysterectomy (LASH) in patients with a uterus weight over 500 g. MATERIAL AND METHODS The present retrospective study, between June 27, 1998 and August 31, 2019, evaluates 1274 patients with a uterus weight over 500 g who were treated with LASH for benign uterine diseases at the Clinic for Minimal Invasive Surgery (Berlin, Germany). All surgeries were performed by one of four in-house surgeons with experience in LASH: they had performed at least 500 LASH procedures before the study. Patients receiving surgical treatment for malignant tumors were not included in the study. Major and minor intraoperative and postoperative complications were recorded and evaluated. Additionally, medical files were evaluated for demographic data, American Society of Anesthesiologists score (I-IV), name of the surgeon, duration and indication for surgery, history of previous gynecological procedures and concomitant surgical interventions, weight of removed uterine tissue, duration of postoperative hospitalization in patients with complications, intraoperative conversion from laparoscopy to laparotomy, and malignancy rate. RESULTS The mean age was 47.0 ± 7.3 years and mean body mass index was 25.6 ± 7.1 kg/m2 . Average parity was 1.04 ± 1.57. Average uterus weight was 761.8 ± 317.9 g (500-4065 g). The mean duration of surgery was 96.9 ± 49.5 min; 54% of all patients were treated without concomitant intervention, conversion rate was 2.12%. The malignancy rate was 0.4% and the complication rate was 6.81% with 1.36% intraoperative complications and 5.45% postoperative complications. CONCLUSIONS The overall low complication and malignancy rates observed in this study allow us to present LASH as a safe and efficient alternative laparoscopic approach to remove uteri of any size in the hands of experienced surgeons.
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Affiliation(s)
| | - Bernd Bojahr
- Clinic for Gynecology and Breast CenterUniversitätsklinikum GreifswaldGreifswaldGermany
| | - Harald Krentel
- Clinic of Gynecology, Obstetrics, Gynecological Oncology and Senology, Academic Teaching HospitalBethesda HospitalDuisburgGermany
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11
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Factors associated with surgical-site infection after total laparoscopic hysterectomy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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12
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Masghati S, Parks T, James L, Howard DL. Occult Uterine Malignancy Found at Surgery for Uterine Fibroids: An Updated Systematic Review and Meta-Analysis. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0221] [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)
- Salome Masghati
- Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Tegan Parks
- Touro University of Nevada, Henderson, Nevada, USA
| | - Lucas James
- University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - David L. Howard
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Uccella S, Garzon S, Lanzo G, Gallina D, Bosco M, Porcari I, Gueli-Alletti S, Cianci S, Franchi M, Zorzato PC. Uterine artery closure at the origin versus at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial. Acta Obstet Gynecol Scand 2021; 100:1840-1848. [PMID: 34396512 DOI: 10.1111/aogs.14238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/19/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other. MATERIAL AND METHODS We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, versus closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up. RESULTS Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] versus 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ. CONCLUSIONS Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.
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Affiliation(s)
- Stefano Uccella
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Gabriele Lanzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy
| | - Davide Gallina
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Irene Porcari
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Salvatore Gueli-Alletti
- Division of Gynecologic Oncology, Department of Women and Children's Health, A. Gemelli University Hospital and Institute for Research and Care, Rome, Italy
| | - Stefano Cianci
- Unit of Gynecology, Department of Human Pathology of Adult and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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14
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Viva W, Juhi D, Kristin A, Micaela M, Marcus B, Ibrahim A, Dirk B. Massive uterine fibroid: a diagnostic dilemma: a case report and review of the literature. J Med Case Rep 2021; 15:344. [PMID: 34253260 PMCID: PMC8276390 DOI: 10.1186/s13256-021-02959-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background Fibroids of the uterus are the most common benign pelvic tumors in women worldwide. Their diagnosis is usually not missed because of the widespread and well-established use of ultrasound in gynecological clinics. Hence, the development of an unusually large myoma is a rare event, particularly in first-world countries such as Germany. It is even more uncommon that a myoma is misdiagnosed as a dietary failure. Case presentation Herein, we report the case of a Caucasian woman with a giant fibroid that reached a size of over 50 cm, growing slowly over the past 15 years, and was misdiagnosed as abdominal fat due to weight gain. We aim to discuss the factors that lead to the growth of such a huge tumoral mass, including misdiagnosis and treatment, and the psychological impact. Through this case, we intend to increase the awareness among general physicians and gynecologists. Although menstrual disorders incorporate several pathologies, adequate assessment remains the primary responsibility of health care providers. A literature review revealed approximately 60 cases of giant uterine fibroids. Conclusion The use of clinical and diagnostic devices, especially ultrasound, in this case, is indispensable. In conclusion, the growth of a giant fibroid can have disastrous effects on a woman’s health, including surgical trauma and psychological issues.
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Affiliation(s)
- Wiesener Viva
- Department of Gynecology and Obstetrics, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany
| | - Dhanawat Juhi
- Department of Gynecology and Obstetrics, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany. .,Spectrum Clinic and Endoscopic Research Institute, 6A and 6B Neelamber building, Shakespeare Sarani, Kolkata, West Bengal, 700020, India.
| | - Andresen Kristin
- Department of Gynecology and Obstetrics, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany
| | - Mathiak Micaela
- Institute of Pathology, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany
| | - Both Marcus
- Department of Radiology and Neuroradiology, University Medical Center UKSH, Campus Kiel, Arnold Heller Straße 3, Haus C, 24105, Kiel, Germany
| | - Alkatout Ibrahim
- Department of Gynecology and Obstetrics, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany
| | - Bauerschlag Dirk
- Department of Gynecology and Obstetrics, University Medical Center UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105, Kiel, Germany
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15
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Uccella S, Kho RM, Garzon S, Casarin J, Zorzato PC, Ghezzi F. The Large Uterus Classification System: a prospective observational study. BJOG 2021; 128:1526-1533. [PMID: 33988895 PMCID: PMC8362220 DOI: 10.1111/1471-0528.16753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/22/2022]
Abstract
Objective To investigate the Large Uterus Classification System (LUCS) ability to predict surgical outcomes and complications in total laparoscopic hysterectomies (TLHs) for large uteri. Design Prospective observational study. Setting Two referral centres. Population or sample Three hundred and ninety‐two women who underwent TLH for a large uterus (uterine fundus at or over the transverse umbilical line). Methods Between 2004 and 2019, the intraoperative LUCS was estimated in all patients. The LUCS considers the uterine and adnexal vascular pedicles displacement. Type 1 is without vascular pedicles displacement. Type 2 has the cephalad displacement of adnexal vascular pedicles. The uterine vessels displacement regardless of adnexal pedicles defines Type 3. Main outcome measures Patients’ characteristics with perioperative outcomes were prospectively collected and compared between the three types of large uteri. Results Two hundred and fifty‐one (64%), 82 (20.9%) and 59 (15.1%) women had Type 1, Type 2 and Type 3 uteri, respectively. Women with Type 1 uteri had a lower uterine weight, shorter operative time, less blood loss and lower complication rates than women with Types 2 and 3. The conversion rate to laparotomy in Type 1 was similar to that in Type 2 (odds ratio [OR] 0.98; 95% CI 0.32–3.56) but lower than Type 3 (OR 0.35; 95% CI 0.14–0.97); in Type 2 it was lower than Type 3, although without the conventional statistical significance (OR 0.36; 95% CI 0.13–1.13; P = 0.07). Multivariable analysis showed that the uterine Type (1 versus 2–3) was independently associated with the total complications rate (OR 2.00; 95% CI 1.09–3.68; P = 0.02). Conclusions The LUCS appears associated with surgical outcomes and complications, potentially stratifying the surgical risk and guiding the surgical technique in TLHs for large uteri. Tweetable abstract The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri. The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.
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Affiliation(s)
- S Uccella
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - R M Kho
- Department Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S Garzon
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - J Casarin
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
| | - P C Zorzato
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - F Ghezzi
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
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Wang X, Li J, Hua K, Chen Y. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy for uterus weighing ≥1 kg. BMC Surg 2020; 20:234. [PMID: 33046022 PMCID: PMC7552525 DOI: 10.1186/s12893-020-00897-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023] Open
Abstract
Background The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) applied in gynecology has been developed recent years and been evolving. In this study, we aimed to evaluate the feasibility and effect of the vNOTES hysterectomy for uterus ≥1 kilogram (kg). Methods From January 2019 to March 2020, patients with benign indications in cases of uterus weighing ≥1 kg, underwent vNOTES hysterectomy were studied retrospectively. The patients’ demographics, indications for surgery, operation outcomes and follow-up details were recorded. Results 39 patients were performed vNOTES hysterectomy for large uterus (mean weight 1141.8 gram, range from 1000 to 1720), indications for surgery included bulky uterine myomas or adenomysosis. The mean age was 48 years (range 42–66) and mean BMI was 24 kg/m2 (range 18.4–38). Mean operating time was 123.3 min (rang 40–400) and the mean estimated blood loss was 206.7 milliliters (range 10–1300). The mean pain assessment was 2.1 (range 0–5). The mean length of stay was 2.4 nights (1–11). 1 patient experienced ureteral injury and was performed ureteral anastomosis. 3 patients were converted to vaginal-assisted trans-umbilicus single-port laparoscopy. The learning curve was analyzed to show that 20 cases were needed to achieve proficiency in vNOTES hysterectomy for large uterus ≥1 kg. Conclusion Our preliminary experience suggested that vNOTES hysterectomy for large uterus weighing ≥1 kg was feasible and safe, meanwhile this procedure had the advantages of all the minimal invasive approach such as fast recovery and aesthetic advantage.
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Affiliation(s)
- Xiaojuan Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Junwei Li
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Keqin Hua
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.
| | - Yisong Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.
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Feasibility and safety of total laparoscopic hysterectomy for uteri weighing from 1.5 kg to 11.000 kg. Arch Gynecol Obstet 2020; 303:169-179. [PMID: 32949285 DOI: 10.1007/s00404-020-05799-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess the feasibility and safety of total laparoscopic hysterectomy (TLH) for uteri ≥ 1.5 kg. METHODS We prospectively evaluated all elective TLHs (with or without adnexectomy) performed for fibromatous uteri between August 2009 and August 2019 in the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and the Department of Gynecologic Oncology, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari. Patients with large myomatous uteri (uterine weight ≥ 1.5 kg on pathology reports) were included in the analysis. We examined all procedures and collected data about intra- and post-operative short-term and long-term complications, intraoperative blood loss, operative time, hospital stay, and time to achieve well-being. RESULTS Seventy-eight patients were included. The median weight was 2,000 g (range 1,500-11,000 g), estimated blood loss was 100 mL (range 10-700 mL), operating time was 135 min (range 60-300 min), and hospital stay was 2 days (range 2-5 days). Conversion to laparotomy occurred in 4 patients (5.1%) with uterine weight ranging from 3 to 5.5 kg, due to severe adherence syndrome or inadequate visualization. As for intraoperative complications, 1 patient (who had the largest removed uterus weighing 11,000 g) experienced an intraoperative ureteral injury (grade III). No major postoperative complications occurred. CONCLUSIONS This study provides the largest case series of TLH for fibromatous uteri > 1.5 kg and includes some of the largest uteri reported to date in the literature (weighing 5,320, 5,720, and 11,000 g, respectively). The study reaffirms the feasibility and safety of a minimally invasive hysterectomy even in the case of abnormally large uteri.
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Total Laparoscopic Hysterectomy of a 7400 g Uterus. J Minim Invasive Gynecol 2020; 28:748-749. [PMID: 32610076 DOI: 10.1016/j.jmig.2020.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To demonstrate improved techniques and safety measures for total laparoscopic hysterectomy for a severely enlarged uterus. DESIGN Technical video of the surgery, which demonstrates various techniques for improved visualization, hemostasis, and manipulation for total laparoscopic hysterectomy for a 7400 g uterus. SETTING Academic tertiary care hospital, University of Louisville Hospital, Louisville, Kentucky. INTERVENTIONS A 44-year-old woman, gravida 0, presented with a severely enlarged myoma uterus, class III obesity with a body mass index of 40.4 kg/m2, and hypertension seeking minimally invasive hysterectomy. Magnetic resonance imaging demonstrated a uterus measuring 26 × 26 × 17 cm with multiple myomas. The patient was counseled in detail regarding minimally invasive surgery. She underwent total laparoscopic hysterectomy, bilateral salpingectomy, right oophorectomy, and cystoscopy. The total operative time was 4 hours 12 minutes, and the estimated blood loss was 700 mL. Pre- and postoperative hemoglobin was 13.3 g/dL and 11.3 g/dL, respectively. A 4-cm minilaparotomy incision was created as an extension of the umbilical port, and the specimen was extracted by scalpel morcellation using the extracorporeal C-incision tissue extraction technique. The patient was discharged home on postoperative day 1 and recovered without any complications. CONCLUSION There is an increasing trend in performing laparoscopic hysterectomy for large uteri, which has a lower incidence of overall complications than laparotomy [1,2]. In addition, a cost analysis has demonstrated the superiority of laparoscopic hysterectomy for myomatous uterus accounting for the rare incidence of leiomyosarcoma [3]. Our video demonstrates improved hemostasis and visualization techniques through the use of high-cephalad camera and assistant ports, generous traditional bipolar desiccation, blunt retraction with suction irrigator in the midline umbilical port, and surgical bed rotation. We also describe in detail the scalpel morcellation technique. To date, we believe this is the largest uterine size removed laparoscopically that has been reported in the literature. In the hands of an experienced surgeon and with the demonstrated techniques, a laparoscopic approach to hysterectomy of a very enlarged uterus is safe and feasible.
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Differences in Postoperative Morbidity among Obese Patients Undergoing Abdominal Versus Laparoscopic Hysterectomy for Benign Indications. J Minim Invasive Gynecol 2020; 27:464-472. [DOI: 10.1016/j.jmig.2019.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/25/2019] [Accepted: 04/01/2019] [Indexed: 11/21/2022]
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Schilder J, Anderson D, Shah F, Holcomb B, Shah A, Fullarton G, Ashraf S, Fegan S, Paterson H, Schwiers ML, Singleton DW, Waggoner JR, Fryrear R, Robb BW. Hemostatic efficacy of an advanced bipolar sealer in open gynecologic, thoracic, and colectomy procedures: A prospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Serati M, Laganà AS, Casarin J, Gisone B, Cantaluppi S, Ghezzi F. Laparoscopic duplication of the uterosacral ligaments following hysterectomy for stage III–IV apical pelvic organ prolapse. Updates Surg 2019; 72:199-204. [PMID: 31691118 DOI: 10.1007/s13304-019-00690-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/27/2019] [Indexed: 12/13/2022]
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Sezgin B, Camuzcuoğlu A, Küçük M, Camuzcuoğlu H. Bilateral uterine artery coagulation in laparoscopic hysterectomy for benign disease in uteri more than 1000 g. J Obstet Gynaecol Res 2019; 46:133-139. [PMID: 31646706 DOI: 10.1111/jog.14148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/07/2019] [Indexed: 12/17/2022]
Abstract
AIM We aimed to evaluate the efficacy of bipolar uterine artery coagulation in laparoscopic hysterectomy for uteri larger than 1000 g. METHODS Data from 674 patients who underwent laparoscopic hysterectomy were retrospectively analyzed. Among those, 75 patients with uteri weighing more than 1000 g were included. The clinical and surgical outcomes of patients with large uteri were compared according to bipolar uterine artery coagulation performance status. RESULTS The mean difference in intraoperative blood loss between the groups of patients with uterine artery occlusion and without uterine artery occlusion was statistically significant (89.26 ± 65.52 vs 227.94 ± 124.65 mL; P < 0.001). The hemoglobin decrease was also significantly lower in the patients with uterine artery occlusion (0.46 ± 0.23 vs 1.21 ± 0.79 g/dL; P < 0.001). CONCLUSION When performing laparoscopic hysterectomy of uteri weighing over 1000 g, the occlusion of the bilateral uterine arteries at the point of exit from the internal iliac arteries using bipolar coagulation at the beginning of the operation reduces intraoperative hemorrhage and hemoglobin decrease.
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Affiliation(s)
- Burak Sezgin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Muğla Sıtkı Koçman University, Mugla, Turkey
| | - Aysun Camuzcuoğlu
- Department of Obstetrics and Gynecology, Private Adatıp Sakarya Hospital, Sakarya, Turkey
| | - Mert Küçük
- Department of Medical Education and Bioinformatics, Muğla Sıtkı Koçman University, Mugla, Turkey.,Department of Obstetrics and Gynecology, Mugla Sitki Kocman University, Mugla, Turkey
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Rey Valzacchi GM, Rosas P, Uzal M, Gil SJ, Viglierchio VT. Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups. J Minim Invasive Gynecol 2019; 27:926-929. [PMID: 31260748 DOI: 10.1016/j.jmig.2019.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/22/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups. DESIGN A retrospective cohort study. SETTING A tertiary referral hospital. PATIENTS All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016. INTERVENTIONS Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS A total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%). CONCLUSION The incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.
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Affiliation(s)
- Guido M Rey Valzacchi
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina.
| | - Patricio Rosas
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
| | - Mariano Uzal
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
| | - Santiago J Gil
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
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Margulies SL, Vargas MV, Denny K, Sparks AD, Marfori CQ, Moawad G, Amdur RL. Comparing benign laparoscopic and abdominal hysterectomy outcomes by time. Surg Endosc 2019; 34:758-769. [PMID: 31098703 DOI: 10.1007/s00464-019-06825-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 05/03/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND While laparoscopic hysterectomy has benefits compared to abdominal hysterectomy, the operative times are longer. Longer operative times have been associated with negative outcomes. This study's purpose was to elucidate if there is an operative time at which 30-day outcomes for laparoscopic hysterectomy become inferior to a more expeditiously completed abdominal hysterectomy. METHODS This was a retrospective cohort study (Canadian Task Force classification II-2) using the American College of Surgeons National Surgical Quality Improvement Program database to identify women undergoing hysterectomy for benign indications from 2010 to 2016 by current procedural terminology code. Hysterectomy cases were stratified by approach and 60-min intervals. 30-day post-operative outcomes were analyzed by operative time and approach. RESULTS 109,821 hysterectomies were included in our analysis, of which 66,560 (61%) were laparoscopic, and 43,261 (39%) were abdominal. In a multivariable logistic regression analysis comparing outcomes by surgical approach and operative time, there was no time combination in which patients who had a abdominal hysterectomy had significantly lower odds of the composite complications variable. This was true even in laparoscopic hysterectomies greater than 240 min compared to abdominal hysterectomies completed between 20 and 60 min. When compared to laparoscopic hysterectomies greater than 240 min, abdominal hysterectomies between 20 and 60 min had lower odds of sepsis and abdominal hysterectomies less than 180 min had lower odds of urinary tract infection. CONCLUSION Given that benefits persist even in prolonged cases, a laparoscopic approach should be offered to most patients undergoing benign hysterectomy. Surgical efficiency should be prioritized for any surgical approach.
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Affiliation(s)
- Samantha L Margulies
- Department of Obstetrics, Gynecology and Reproductive Health Sciences, Yale School of Medicine, 310 Cedar Street FMB 307, New Haven, CT, 06510, USA
| | - Maria V Vargas
- Department of Obstetrics and Gynecology, Minimally Invasive Gynecologic Surgery, George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC, 20037, USA.
| | - Kathryn Denny
- Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Cherie Q Marfori
- Department of Obstetrics and Gynecology, Minimally Invasive Gynecologic Surgery, George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC, 20037, USA
| | - Gaby Moawad
- Department of Obstetrics and Gynecology, Minimally Invasive Gynecologic Surgery, George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue NW, Washington, DC, 20037, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University Medical Faculty Associates, Washington, DC, USA
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Cianci S, Gueli Alletti S, Rumolo V, Rosati A, Rossitto C, Cosentino F, Turco LC, Vizzielli G, Fagotti A, Gallotta V, Ciccarone F, Scambia G, Uccella S. Total laparoscopic hysterectomy for enlarged uteri: factors associated with the rate of conversion to open surgery. J OBSTET GYNAECOL 2019; 39:805-810. [DOI: 10.1080/01443615.2019.1575342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- S. Cianci
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - S. Gueli Alletti
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - V. Rumolo
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - A. Rosati
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - C. Rossitto
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - F. Cosentino
- Dipartimento di Oncologia, Fondazione di Ricerca e Cura Giovanni Paolo II, Campobasso, Italy
| | - L. C. Turco
- Dipartimento di Oncologia, Fondazione di Ricerca e Cura Giovanni Paolo II, Campobasso, Italy
| | - G. Vizzielli
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - A. Fagotti
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - V. Gallotta
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - F. Ciccarone
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - G. Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
| | - S. Uccella
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Univeristario A. Gemelli, IRCCS, Rome, Italy
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Sinha R, Swarnasree G, Rupa B, Madhumathi S. Laparoscopic hysterectomy for large uteri: Outcomes and techniques. J Minim Access Surg 2019; 15:8-13. [PMID: 29582799 PMCID: PMC6293677 DOI: 10.4103/jmas.jmas_205_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim: The aim of this study was to analyse our data of laparoscopic hysterectomy for large uteri (>16 weeks size) regarding their perioperative outcomes and possible factors for conversions to open surgery over 5 years. It also describes our techniques for the feasibility of performing such hysterectomies by the minimally invasive way. Materials and Methods: A five-year retrospective chart review was performed at the Minimal Access and Robotic Surgery Unit of the Department of Gynecology at Apollo Hospital, Hyderabad. Demographic and pre-operative and post-operative data were recorded. Clinical assessment including bimanual examination and surgery was made by a single senior surgeon. Intra-operative conversions, complications and post-operative complications were recorded. Results: A total of 128 women were included in this study, 5 patients underwent robotic-assisted hysterectomy. The average age was 44.4, body mass index - was 27.6 and size of the uterus was 17.5 weeks. The most common diagnosis was leiomyoma. The median Operating room (OR) time was 107 min. There was a need for myomectomy in 39.8%, extensive adhesiolysis in 33.6% and dense bladder adhesion in 26.6%. The average drop in haemoglobin was 1.72 g%, and hospital stay was 2 days. The specimen was removed by vaginal morcellation (2 cases via an umbilical port). Conversion to open surgery was required in 10.9% of cases. The conversion was significantly correlated with excessive haemorrhage and bladder injury but not with difficult hysterectomy, difficult bladder dissection or adhesions. There were 3 cases of bladder injury detected and managed intraoperatively. Conclusion: Laparoscopic hysterectomy is technically feasible and safe procedure for large uteri. The learning curve is about 50 cases and can be performed by experienced surgeons regardless of the size, number or location of the myomas without much morbidity.
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Affiliation(s)
- Rooma Sinha
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - G Swarnasree
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - B Rupa
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - S Madhumathi
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
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Uccella S, Federico A, Scambia G. Reducing the Rate of Minimally Invasive Hysterectomy for Fibroids in Favor of Abdominal Surgery-There Is Always Something Evil in Good Intentions. JAMA Surg 2018; 153:1063. [PMID: 30140907 DOI: 10.1001/jamasurg.2018.2732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stefano Uccella
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, IRCCS, Rome, Italy
| | - Alex Federico
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, IRCCS, Rome, Italy
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