Preoperative Factors That Predict the Need to Morcellate in Total Laparoscopic Hysterectomy

Nomogram for predicting difficult total laparoscopic hysterectomy: a multi-institutional, retrospective model development and validation study

BACKGROUND

Total laparoscopic hysterectomy (TLH) is the most commonly performed gynaecological surgery. However, the difficulty of the operation varies depending on the patient and surgeon. Subsequently, patient's outcomes and surgical efficiency are affected. The authors aimed to develop and validate a preoperative nomogram to predict the operative difficulty in patients undergoing TLH.

METHODS

This retrospective study included 663 patients with TLH from Southwest Hospital and 102 patients from 958th Hospital in Chongqing, China. A multivariate logistic regression analysis was used to identify the independent predictors of operative difficulty, and a nomogram was constructed. The performance of the nomogram was validated internally and externally.

RESULTS

The uterine weight, history of pelvic surgery, presence of adenomyosis, surgeon's years of practice, and annual hysterectomy volume were identified as significant independent predictors of operative difficulty. The nomogram demonstrated good discrimination in the training dataset [area under the receiver operating characteristic curve (AUC), 0.827 (95% CI, 0.783-0.872], internal validation dataset [AUC, 0.793 (95% CI, 0.714-0.872)], and external validation dataset [AUC, 0.756 [95% CI, 0.658-0.854)]. The calibration curves showed good agreement between the predictions and observations for both internal and external validations.

CONCLUSION

The developed nomogram accurately predicted the operative difficulty of TLH, facilitated preoperative planning and patient counselling, and optimized surgical training. Further prospective multicenter clinical studies are required to optimize and validate this model.

Adverse outcomes related to morcellation in Total Laparoscopic Hysterectomy

OBJECTIVE

This study aimed to comprehensively evaluate the complications associated with morcellation in Total Laparoscopic Hysterectomy (TLH) procedures, providing evidence-based insights to enhance patient safety and surgical efficacy.

DATA SOURCES

A comprehensive literature search was conducted using multiple databases, including PubMed, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. The inclusion criteria were Studies that focused on morcellation and morcellation-related complications were included. The risk of bias in the included studies was assessed using established evaluation scales.

METHODS OF STUDY SELECTION

Thirteen studies investigating complications associated with morcellation in TLH (Total Laparoscopic Hysterectomy) were included in this review.This review covers intraoperative blood loss, length of hospital stay, loss of bag integrity, mean uterine specimen and weight, morcellation time, operation time, and TLH morcellation complications.

TABULATION, INTEGRATION, AND RESULTS

The selected studies covered different approaches and aspects related to this procedure, providing valuable insights into the factors associated with complications and efficacy of the technique in various clinical settings.This review highlights the importance of evaluating and considering complications associated with morcellation in TLH.

CONCLUSION

The findings of this review provide valuable insights into complications associated with morcellation in TLH. Clinicians could use this information to make informed decisions, implement safe protocols, and improve patient care. Addressing these complications will enhance the safety and efficacy of morcellation for TLH. Ethical Compliance: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Perioperative visits in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

Perioperative visits for gynecologic surgery patients have traditionally included in-person examinations and counseling, but the advent of telemedicine has prompted clinicians to consider varying approaches to perioperative care. We aim to educate readers on the optimal setting and context of perioperative visits and provide insight from our experience to optimize care.

RECENT FINDINGS

The widespread adoption of telemedicine and a focus on equity and access has prompted gynecologic surgeons to reconsider traditional preoperative and postoperative visits.

SUMMARY

This review summarizes evidence for new approaches to perioperative care for minimally invasive gynecologic surgery, including transition to telemedicine for preoperative and postoperative care, adjuvant tools for perioperative counseling, and the value of in-person visits for preoperative planning.

Predictive factors for morcellation during total laparoscopic hysterectomy: a cohort study

OBJECTIVE

Our objective was to identify predictors of morcellation during total laparoscopic hysterectomy (TLH) DESIGN: Retrospective cohort study (Canadian Task Force classification II-2) SETTING: University Hospital Center in XXX PARTICIPANTS: Women undergoing a TLH for a benign gynecologic pathology form January 1st 2017 to January 31st 2019 INTERVENTION: All women underwent a TLH. If the uterus was to voluminous to be removed vaginally, surgeons favored in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed prior to surgery by ultrasound or MRI in order to predict morcellation.

MAIN RESULTS

A total of 252 women underwent a TLH and the mean age was 46±7 (30-71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17-1572)±272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least one leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥250 versus <250 grams; OR 3.7 (CI 1.8-7.7, P < 0.01), having ≥ 1 leiomyoma (OR 4.1, CI 1.0-16.0, P = 0.01) and a leiomyoma of ≥5 cm (OR 8.6, CI 4.1-17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis.

CONCLUSION

Uterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.

Predictive factors of the need to morcellate in total laparoscopic hysterectomy

BACKGROUND

Specimen extraction is a major challenge in total laparoscopic hysterectomy (TLH) and tissue morcellation may be needed to extract a large uterus.

AIMS

The study aims to determine preoperative factors that could predict the need for uterine morcellation in TLH, and also find the best cut-off values of each measured parameter leading to optimum sensitivity and specificity.

MATERIALS AND METHODS

This was a cross-sectional study of women from August 2019 to May 2020 who underwent TLH, with or without salpingo-oophorectomy in our department. We performed bimanual exams preoperatively to estimate the uterine size and recorded the uterine ultrasonographic dimensions and myoma size in myomatous uteri. Receiver operating characteristic (ROC) were used to establish cut-offs that maximised the sensitivity and specificity of each factor in predicting the need for morcellation. Poisson regression was used to calculate the relative risks (RR) of each cut-off.

RESULTS

One hundred and sixty-two women were recruited in the study. ROC curves demonstrated maximum sensitivities and specificities with a cross-sectional area of 36.5 cm² , the largest leiomyoma dimension of 40 mm, uterine length of 10 cm, and bimanual uterine size of 13 weeks. Multiple modified Poisson regression revealed that the strongest predictors of morcellation were the largest leiomyoma diameter of >40 mm (RR: 3.58), the uterine cross-sectional area of >36.5 cm² (RR: 6.38), and uterine size in the bimanual exam of >13 weeks pregnancy (RR: 3.57).

CONCLUSION

The largest leiomyoma diameter, uterine cross-sectional area, and size on a bimanual exam can all be used to predict needing morcellation preoperatively in TLH.

Association of uterine dimensions and route of contained morcellation following laparoscopic hysterectomy

BACKGROUND

The aim of this study was to determine if uterine dimensions on preoperative imaging are associated with route of contained morcellation during laparoscopic hysterectomy.

METHODS

This is a prospective cohort study of patients undergoing laparoscopic hysterectomy and requiring morcellation for specimen extraction from March 2017 through August 2019. A contained extraction system was inserted and manual morcellation was performed vaginally, abdominally, or via a combination of both methods in cases of failed vaginal extraction.

RESULTS

A total of 47 patients were treated. Median age was 47 (range 38-70). Morcellation was performed vaginally for 29 patients (61.7%), abdominally for 13 patients (27.7%), and via combined approach for 5 patients (10.6%). The combined group had the highest frequency of patients who were black (vaginal: 24%, abdominal: 31%, combined: 100%; P=0.005), the longest median total operating time (vaginal: 167 minutes, abdominal: 183 minutes, combined: 268 minutes; P=0.006) and the longest median time of uterine morcellation (vaginal: 14 minutes, abdominal: 37 minutes, combined: 85 minutes; P<0.001). There was strong evidence of a positive correlation with time of uterine morcellation for both largest uterine diameter (Spearman's r: 0.62, P<0.001) and uterine volume (Spearman's r: 0.70, P<0.001). These associations remained consistent after multivariable linear regression models that were adjusted for route of morcellation, hysterectomy type, and BMI (both P<0.001).

CONCLUSIONS

Larger uterine dimensions are associated with increased total operating and morcellation times. Uterine size and volume on preoperative imaging were not associated with route of morcellation, but there was a trend towards failed vaginal extraction when uterine dimensions exceeded 16 centimeters.