A prospective, randomized study of closed-suction drainage after laparoscopic-assisted vaginal hysterectomy

Residual intraperitoneal carbon dioxide gas following laparoscopy for adnexal masses: Residual gas volume assessment and postoperative outcome analysis

Free residual gas after laparoscopy may cause shoulder pain, decreasing patient satisfaction with the procedure. We analyzed the correlation between postoperative residual carbon dioxide gas and shoulder pain, explored the peri- and postoperative factors associated with residual carbon dioxide and determined the effects of the use of a drainage tube. A cohort of 326 patients who underwent laparoscopic adnexal surgery between March 2005 and June 2018 at a teaching hospital in Korea was retrospectively analyzed through a medical records review. The enrolled patients were divided into 1-, 2-, and 3-port groups. The right volume, left volume, and total volume of residual gas were calculated using a formula based on measurements obtained from chest X-rays. Continuous variables were compared using Student t tests. Categorical variables were compared with the chi-square test or Kruskal-Wallis test. The total volumes of postoperative residual carbon dioxide gas were significantly different between the 1- and 2-port groups and between the 1- and 3-port groups (157.3 ± 179.2 vs 25.1 ± 92.3 mL and 157.3 ± 179.2 vs 12.9 ± 36.4 mL, respectively). The volume of residual gas and the time to the first passage of gas were positively correlated. The total volume of residual gas was more strongly correlated with the operative wound pain score than with the shoulder pain score. Additionally, the pre- and postoperative white blood cell counts, postoperative hospitalization duration, residual carbon dioxide volume, and shoulder pain score were significantly different between patients with and without a drainage tube. Although the volume of residual gas was not correlated with the shoulder pain score, the author found that both were lower in patients with a drainage tube than in those without, indicating that a drainage tube could be safely used to decrease residual gas volume and the shoulder pain score without increasing the risk of postoperative infection.

Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

BACKGROUND

The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Armstrong Institute at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery, which integrates principles of implementation science into adoption of enhanced recovery pathways and promotes evidence-based perioperative care.

OBJECTIVE

The objective of this study is to review the enhanced recovery pathways literature in gynecologic surgery and provide the framework for an Improving Surgical Care and Recovery pathway for gynecologic surgery.

STUDY DESIGN

We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 through October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, and interventional and observational studies. Enhanced recovery pathways components relevant to gynecologic surgery were identified through review of existing pathways. A PubMed search for each component was performed in gynecologic surgery and expanded to include colorectal surgery as needed to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature.

RESULTS

Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early intravenous fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, and preoperative and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal Improving Surgical Care and Recovery pathway review were included in the final pathway.

CONCLUSION

Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.

Vaginal vault drainage after complicated single-port access laparoscopic-assisted vaginal hysterectomy

Study objective:

To evaluate the feasibility and safety of vaginal vault drainage after complicated singleport access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH).

Design:

Retrospective cohort study.

Setting:

Ulsan University Hospital (tertiary teaching hospital), South Korea.

Patients:

A total of 359 women underwent SPA-LAVH for the following conditions: benign uterine tumor, preinvasive uterine lesion, and microinvasive cervical cancer.

Interventions:

The participants included 124 women with vault drains and 235 women without drains.

Measurements:

Surgical outcomes, perioperative complications and morbidity, postoperative febrile morbidity.

Results:

There were no differences in background features between drain and no-drain groups. In surgical outcomes, mean uterine weight (364.2 ± 184.9 g vs. 263.7 ± 138.6 g; p < 0.001), operation time (87.4 ± 21.5 min vs. 73.0 ± 17.6 min; p < 0.001), blood loss (225.3 ± 122.2 mL vs. 150.4 ± 95.2 mL; p < 0.001), and hemoglobin decline (1.97 ± 0.96 g/dL vs. 1.42 ± 0.89 g/dL; p < 0.001) were significantly larger for the drain group compared with the no-drain group. However, with regard to postoperative morbidity and complications, there were no group differences in the transfusion rates (6.5% vs. 3.8%; p = 0.300), intraoperative complications (2.4% vs. 1.3%; p = 0.420), perioperative complications (2.4% vs. 0.9%; p = 0.345), and febrile morbidity ≥ 37.5°C (8.9% vs. 11.5%; p = 0.477), although the drain group was more prone to the development of pelvic fluid collection and febrile morbidity than the no-drain group.

Conclusion:

Vaginal vault drainage could be a safe alternative that allows for the management of postoperative morbidity and retains the advantages of minimally invasive surgery after complicated SPA-LAVH.

Hysterectomy for benign disease: clinical practice guidelines from the French College of Obstetrics and Gynecology

OBJECTIVE

The objective of the study was to draw up French College of Obstetrics and Gynecology (CNGOF) clinical practice guidelines based on the best available evidence concerning hysterectomy for benign disease.

METHODS

Each recommendation for practice was allocated a grade, which depends on the level of evidence (clinical practice guidelines).

RESULTS

Hysterectomy should be performed by a high-volume surgeon (>10 hysterectomy procedures per year) (gradeC). Stimulant laxatives taken as a rectal enema are not recommended prior to hysterectomy (gradeC). It is recommended to carry out vaginal disinfection using povidone-iodine solution prior to hysterectomy (grade B). Antibiotic prophylaxis is recommended during hysterectomy, regardless of the surgical approach (grade B). The vaginal or laparoscopic approach is recommended for hysterectomy for benign disease (grade B), even if the uterus is large and/or the patient is obese (gradeC). The choice between these two surgical approaches depends on other parameters, such as the surgeon's experience, the mode of anesthesia, and organizational constraints (duration of surgery and medical economic factors). Vaginal hysterectomy is not contraindicated in nulliparous women (gradeC) or in women with previous cesarean section (gradeC). No specific hemostatic technique is recommended with a view to avoiding urinary tract injury (gradeC). In the absence of ovarian disease and a personal or family history of breast/ovarian carcinoma, the ovaries should be preserved in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended with a view to reducing the risk of peri- or postoperative complications (grade B).

CONCLUSION

The application of these recommendations should minimize risks associated with hysterectomy.

[Urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery on the Fallopian tube: Guidelines]

OBJECTIVES

To provide clinical practice guidelines from the French College of Obstetrics and Gynecology (CNGOF) based on the best evidence available, concerning the urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery including opportunistic salpingectomy and adnexectomy.

MATERIAL AND METHOD

Review of literature using following keywords: benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy.

RESULTS

Urinary catheter should be removed before 24h following uncomplicated hysterectomy (grade B). In case of urinary catheter during hysterectomy, immediate postoperative removal is possible (grade C). No hemostasis technics can be recommended to avoid urinary injury (grade C). There is not any evidence to recommend to perform a window in the broad ligament or an ureterolysis, to put ureteral stent or a uterine manipulator in order to avoid ureteral injury. An antibiotic prophylaxis by a cephalosporin is always recommended (grade B). Mechanical bowel preparation before hysterectomy is not recommended (grade B). If there is no ovarian cyst/disease and no familial or personal history of ovarian/breast cancer, ovarian conservation is recommended in premenopausal women (grade B). In postmenopausal women, informed consent and surgical approach should be taken in account to perform a salpingo-oophorectomy. Since the association salpingectomy and hysterectomy is not assessed in the prevention of ovarian cancer, systematic bilateral salpingectomy is not recommended (expert consensus).

CONCLUSIONS

Practical application of these guidelines should decrease the prevalence of visceral complications associated with benign hysterectomy.

A comparative, single-blind, randomized trial of pain associated with suction or non-suction drains after gynecologic laparoscopy

STUDY OBJECTIVE

To estimate the difference in pain associated with the wearing or removal of suction or non-suction drains after gynecologic laparoscopic surgery.

DESIGN

A randomized controlled trial from August 2006 through October 2007 (Canadian Task Force Classification I).

SETTING

Royal Hospital for Women, Department of Endo-Gynaecology and School of Women's and Children's Health University of New South Wales.

PATIENTS

A total of 168 women undergoing gynecologic laparoscopy requiring postoperative drainage.

INTERVENTIONS

Patients were randomized to receive either a suction or non-suction drain after surgery.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed before, during, and after drain removal with a 4-point verbal descriptor scale and 10-cm visual analogue scale. Visual analogue scale and verbal descriptor scale scores for suction versus non-suction groups were 3 versus 3 (p=.654) and 1 versus 1 (p=.686) before removal, 9 versus 7 (p=.016) and 3 versus 2 (p=.029) during removal, and 7 versus 5 (p=.058) and 2 versus 2 (p=.122) after removal.

CONCLUSION

There is no significant difference in patient discomfort while wearing or after removal of suction or non-suction drains. However, suction drains are more painful to have removed.

Small Intestine Injury in Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE

To review laparoscopic-assisted vaginal hysterectomy (LAVH) cases for instances of small intestine injury.

DESIGN

Retrospective review (Canadian Task Force Classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

Two thousand six hundred eighty-two women.

INTERVENTION

LAVH.

MEASUREMENTS AND MAIN RESULTS

Indications for hysterectomy were myomata uteri, adenomyosis, intractable menorrhagia, endometriosis, severe pelvic adhesions, cervical intraepithelial neoplasia, endometrial polyps, and hyperplasia. Small bowel injuries occurred in five women (1.9/1000), one (20%) of which was recognized postoperatively. Thermal injuries occurred in two patients, trocar injuries in two, and a dissection wound in one. Two-layer closure was performed for three patients, and partial resection with reanastomosis for two. All patients were discharged without sequelae.

CONCLUSION

Small bowel injury during LAVH is not common. It may have unusual characteristics and devastating consequences if not recognized and treated promptly.

Major complications associated with laparoscopic-assisted vaginal hysterectomy: ten-year experience

STUDY OBJECTIVE

To describe our experience with major complications associated with laparoscopic-assisted vaginal hysterectomy (LAVH) and compare our results with those of the American Association of Gynecologic Laparoscopists (AAGL) membership survey and another similar study.

DESIGN

Retrospective study (Canadian Task Force classification II-3).

SETTING

University-affiliated hospital.

PATIENTS

Two thousand seven hundred two women. Intervention. LAVH.

MEASUREMENTS AND MAIN RESULTS

Demographic data and medical histories (age, parity, surgical indications, pathologic findings, major complications) were analyzed. Major complications were 11 bladder injuries, 4 ureter injuries, 11 bowel injuries, 2 vascular injuries, 2 cases of massive bleeding from the vaginal cuff or colpotomy wound with associated impending shock, 2 cases of postoperative ileus, and 2 pelvic abscesses. Our overall major complication rate was 1.3% compared with 2.7% in the AAGL 1995 membership survey (p <0.001). Similar rates of febrile morbidity (2.2% and 2.0%), bleeding requiring transfusion (0.05% and 0.06%), and bowel, ureteral, or bladder injury (1.0% and 1.0%) were noted between our study and the other 1995 study (all p >0.05). Of 34 major complications in our study, 24 occurred during hysterectomy performed by inexperienced general gynecologists and 10 by an experienced endoscopist (p = 0.005).

CONCLUSION

The rate of major complications associated with LAVH can be reduced when the procedure is performed by a well-trained laparoscopic surgeon compared with a less-experienced general gynecologist.

Effects of closed suction drainage in reducing pain after laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE

To estimate whether closed suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy (LAVH) reduces the frequency and intensity of shoulder-tip, abdominal, and back pain.

DESIGN

Prospective, randomized study (Canadian Task Force classification 1).

SETTING

Teaching medical center.

PATIENTS

One hundred sixty-four women.

INTERVENTION

LAVH.

MEASUREMENTS AND MAIN RESULTS

For group 1 (80 women), closed suction (Jackson-Pratt) drains were inserted into the peritoneal cavity and cul-de-sac, whereas for group 2 (84), no drains were placed. Shoulder-tip, abdominal, and back pain were evaluated by visual analog scores (VAS) 3, 24, and 48 hours after surgery. The frequency of shoulder-tip pain was significantly lower in group 1 at 24 hours (23% vs 40%, p = 0.013) and 48 hours (9% vs 21%, p = 0.024; VAS scores at 24 hrs 2.2 +/- 1.1 vs 3.8 +/- 1.3, p = 0.010; VAS scores at 48 hours 1.5 +/- 1.0 vs 2.5 +/- 1.2, p = 0.018). At 48 hours fewer women in group 1 experienced abdominal pain (31% vs 50%, p = 0.039; VAS scores 2.0 +/- 1.1 vs 4.0 +/- 1.3, p = 0.007). No statistically significant differences in frequency and VAS scores for back pain were found at any time. The quantity of oral analgesics was greater for group 2 than for group 1 (12.4 +/- 1.6 vs 9.0 +/- 1.4, p <0.001). Economic evaluation of analgesic requirements and material costs for the two groups showed that simple analgesics were more cost-effective than closed suction drainage in the treatment of pain.

CONCLUSION

Closed suction drains may reduce the frequency and intensity of shoulder-tip and abdominal pain and postoperative analgesia requirements after LAVH, but simple oral analgesics are more cost effective.

Short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy and total abdominal hysterectomy

STUDY OBJECTIVE

To compare short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH).

DESIGN

Retrospective cohort study (Canadian Task Force classification II-1).

SETTING

University-affiliated hospital.

PATIENTS

One hundred fifty women who underwent LAVH and 146 who underwent TAH.

INTERVENTION

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Blood loss during surgery, narcotic analgesic consumption, duration of hospital stay, and convalescence time were significantly higher for women who underwent TAH than for those who underwent LAVH (p <0.05). Operating time was significantly longer for LAVH than for TAH (152.2 +/- 32.4 vs 96.5 +/- 29.6 min, p = 0.014). Eight-year follow-up showed no statistically significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital spotting, and cuff granulation between procedures (p >0.05).

CONCLUSIONS

Although short-term clinical results revealed some statistically significant differences between LAVH and TAH, long-term follow-up recorded similar frequencies of surgical sequelae.