How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies

Role of laparoscopic surgery in managing hemodynamically stable abdominal trauma patients: a single level I trauma center, propensity score matching study

BACKGROUND

The role of laparoscopy in the treatment and diagnosis of penetrating thoraco-abdominal injury has been established. However, there is no clear consensus on the role of laparoscopy in blunt injury due to numerous reasons, such as concerns of missed injury and technical problems in treating various abdominal organs. This study aimed to determine the feasibility of laparoscopy and evaluate its safety in managing blunt and penetrating abdominal trauma.

METHODS

The medical records and Korean Trauma Data Base (KTDB) of patients who underwent abdominal surgery from January 2018 to December 2022 at a single level I center were collected. Patients were classified into a laparoscopy group and a laparotomy group. The laparoscopy groups were matched 1:1 with the laparotomy group by using propensity score matching (PSM). Patient demographics, injured organ and its grade, operative procedure, and postoperative outcomes were evaluated and compared between the two groups.

RESULTS

After propensity score matching, 128 patients were included. There was no significant imbalance in demographics between the two groups except sex. Injured organ and its grade showed no significant differences between the two groups except for the incidence of omentum. Small bowel and mesenteric repair were performed most often in both groups. Splenectomy, pancreatic surgery, duodenectomy, and liver resection were performed exclusively in the laparotomy group. Severe postoperative complication rate (3% vs. 20%: p = 0.004), length of stay in ICU (3.3 ± 3.2 days vs. 4.6 ± 3.7; p = 0.046), and operation time (93.9 ± 47.7 min vs. 112.8 ± 57.7; p = 0.046) were significantly lower in the laparoscopy group. The conversion rate was about 16%. There was no missed injury.

CONCLUSIONS

In hemodynamically stable abdominal trauma patients who sustained penetrating or blunt injury, laparoscopy is feasible and safe as a diagnostic and therapeutic modality in selected cohort of abdominal trauma.

Impact of surgical site infection after open and laparoscopic surgery among paediatric appendicitis patients: A meta-analysis

Operative site wound infection is one of the most frequent infections in surgery. A variety of studies have shown that the results of laparoscopy might be superior to those of an open procedure. Nevertheless, there is still a lack of clarity as to whether there is a difference between open and laparoscopy with respect to the occurrence of wound infections in different paediatric operations. In this review, we looked at randomized, controlled studies that directly measured the rate of wound infection following an appendectomy with a laparoscope. We looked up four main databases for randomized, controlled studies that compare the treatment of paediatric appendicitis with laparoscopy. The surgeries included appendectomy. Through our search, we have determined 323 related papers and selected five qualified ones to be analysed according to the eligibility criteria. Five trials were also assessed for the quality of the documents. In the 5 trials, there were no statistically significant differences in the incidence of post-operative wound infection among the paediatric appendectomy and the open-access group (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.34-1.15, p = 0.13). The four trials did not show any statistically significant difference in abdominal abscesses among the laparoscopic and open-access treatment groups (OR, 1.64; 95% CI, 0.90-3.01, p = 0.11). The four trials did not reveal any statistically significant difference in operating time (mean difference, -4.36; 95% CI, -17.31 to 8.59, p = 0.51). In light of these findings, the use of laparoscopy as compared with the open-approach approach in paediatric appendectomies is not associated with a reduction in the risk of wound infection.

Intraoperative active and passive breaks during minimally invasive surgery influence upper extremity physical strain and physical stress response-A controlled, randomized cross-over, laboratory trial

OBJECTIVE

Investigate the effect of passive, active or no intra-operative work breaks on static, median and peak muscular activity, muscular fatigue, upper body postures, heart rate, and heart rate variability.

BACKGROUND

Although laparoscopic surgery is preferred over open surgery for the benefit of the patient, it puts the surgeons at higher risk for developing musculoskeletal disorders especially due to the less dynamic and awkward working posture. The organizational intervention intraoperative work break is a workplace strategy that has previously demonstrated positive effects in small-scale intervention studies.

METHODS

Twenty-one surgeons were exposed to three 90-min conditions: no breaks, 2.5-min passive (standing rest) or active (targeted stretching and mobilization exercises) breaks after 30-min work blocks. Muscular activity and fatigue of back, shoulder and forearm muscles were assessed by surface electromyography; upper body posture, i.e., spinal curvature, by inclination sensors; and heart rate and variability (HRV) by electrocardiography. Generalized estimating equations were used for statistical analyses. This study (NCT03715816) was conducted from March 2019 to October 2020.

RESULTS

The HRV-metric SDNN tended to be higher, but not statistically significantly, in the intervention conditions compared to the control condition. No statistically significant effects of both interventions were detected for muscular activity, joint angles or heart rate.

CONCLUSION

Intraoperative work breaks, whether passive or active, may counteract shoulder muscular fatigue and increase heart rate variability. This tendency may play a role in a reduced risk for developing work-related musculoskeletal disorders and acute physical stress responses.

Learning laparoscopic hysterectomy: analysis of different surgeons' individual learning curves

OBJECTIVE

The aim of this study was to examine the development of surgical skills among surgeons learning total laparoscopic hysterectomy (TLH), using differences in complication rates between surgeons with different levels of experience and analyzing the development of individual operating times.

STUDY DESIGN

This retrospective, single-center cohort study included 576 total laparoscopic hysterectomy procedures conducted between January 2015 and December 2019 at the municipal hospital in Karlsruhe, Germany. All TLHs were performed by eight surgeons, two of whom were experienced and six inexperienced. Complications were graded using the Clavien-Dindo classification.

RESULTS

No differences in complication rates were seen between experienced and inexperienced surgeons. With growing numbers of procedures, most surgeons quickly became faster, leading to reduced operating times. However, experienced surgeons who had performed more than 100 procedures also became faster, not reaching a time plateau after adjustment for weight of the uterus, presurgery score, and adnexal score.

CONCLUSIONS

Learning laparoscopic hysterectomy in routine practice is safe for patients, and surgeons rapidly become faster as growing numbers of procedures are performed. Operating times for experienced surgeons who have carried out more than 100 operations also improve, and a time plateau is not reached.

A dual-view multi-resolution laparoscope for safer and more efficient minimally invasive surgery

Minimally invasive surgery (MIS) is limited in safety and efficiency by the hand-held nature and narrow fields of view of traditional laparoscopes. A multi-resolution foveated laparoscope (MRFL) was invented to address these concerns. The MRFL is a stationary dual-view imaging device with optical panning and zooming capabilities. It is designed to simultaneously capture and display a zoomed view and supplemental wide view of the surgical field. Optical zooming and panning capabilities facilitate repositioning of the zoomed view without physically moving the system. Additional MRFL features designed to improve safety and efficiency include its snub-nosed endoscope, tool-tip auto tracking, programmable focus profiles, unique selectable display modalities, foot pedal controls, and independently controlled surgeon and assistant displays. An MRFL prototype was constructed to demonstrate and test these features. Testing of the prototype validates its design architecture and confirms the functionality of its features. The current MRFL prototype functions adequately as a proof of concept, but the system features and performance require further improvement to be practical for clinical use.

s-CAM: An Untethered Insertable Laparoscopic Surgical Camera Robot with Non-Contact Actuation

Fully insertable robotic imaging devices represent a promising future of minimally invasive laparoscopic vision. Emerging research efforts in this field have resulted in several proof-of-concept prototypes. One common drawback of these designs derives from their clumsy tethering wires which not only cause operational interference but also reduce camera mobility. In this paper, a tetherless insertable surgical camera (s-CAM) robot with non-contact transabdominal actuation is presented for single-incision laparoscopic vision. Wireless video transmission and control communication using onboard power help eliminate cumbersome tethering wires. Furthermore, magnetic based camera actuation gets rid of intrinsic physical constraints of mechanical driving mechanisms, thereby improving camera mobility and reducing operational interference. In addition, a custom Bluetooth low energy (BLE) application profile and a real-time operating system (RTOS) based multitask programming framework are also proposed to facilitate embedded software design for insertable medical devices. Initial ex vivo test results of the s-CAM design have demonstrated technical feasibility of a tetherless insertable laparoscopic camera. Effective imaging is confirmed at as low as 500 lx illumination. Wireless laparoscopic vision is accessible within a distance of more than 10 m. Transabdominal BLE communication is stable at over −52 dBm and shows its potential for wireless control of insertable medical devices. RTOS based sfotware event response is bounded within 1 ms while the CPU usage is at 3∼5%. The device is able to work for 50 min with its onboard power. For the mobility, the robot can translate against the interior abdominal wall to reach full abdomen quadrants, tilt between −180∘ and +180∘, and pan in the range of 0∘∼360∘. The s-CAM has brought robotic laparoscopic imaging one step further toward less invasiveness and more dexterity.

Surgical site infection after open and laparoscopic surgery in children: a systematic review and meta-analysis

Surgical site infections (SSIs) are the most common healthcare-associated infections in patients undergoing surgery. Various randomised control trials (RCTs) indicate that laparoscopic procedures can be associated with better outcomes compared to open procedures. However, how open versus laparoscopic approaches compare across various paediatric procedures with respect to SSI rate remains poorly defined. In this review, we examined RCTs that directly compare SSI rates after open versus laparoscopic operations for appendicitis, gastro-esophageal reflux, inguinal hernia, and pyloric stenosis. MEDLINE, Embase, and Web of Science were searched for RCTs comparing four types of open versus laparoscopic operations in children. The operations included appendectomy, fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy. 364 records were identified and screened, 54 full-text articles were assessed for eligibility, and 17 RCTs were included in the analysis. SSI rate was the primary outcome. Operative time and length of stay (LOS) were the secondary outcomes. A meta-analysis was conducted using RevMan 5.4 software. Laparoscopic appendectomy had a lower SSI rate than open appendectomy (odds ratio of 2.22 [1.19, 4.15] p = 0.01). Laparoscopic fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy for pyloric stenosis were not associated with lower SSI rate compared to open surgery. Operative time was shorter in open fundoplication (- 71.22 min [- 89.79,  - 52.65] p < 0.00001) than laparoscopic fundoplication. There was no significant difference in operative time of any of the other procedures. There was no significant difference in LOS between open and laparoscopic procedures for all types of operations analysed. Based on the findings of this review, it is recommended to utilise the laparoscopic approach over the open approach to reduce SSI risk in paediatric appendectomy.

Active and passive work breaks during simulated laparoscopy among laparoscopic surgeons: study protocol for a controlled, randomised cross-over laboratory trial

INTRODUCTION

Laparoscopy has partially replaced open surgery due to the lower infection rate for the patient and hence better and shorter recovery. However, the surgeon's physical load is higher due to longer duration static and awkward body postures, increasing the risk for developing work-related musculoskeletal disorders. Interventions of an organisational nature are work breaks, being either passive or active. The primary objectives of this study are to determine whether passive and active work breaks lead to less discomfort than no work breaks and whether active work breaks lead to less discomfort than passive work breaks.

METHODS AND ANALYSIS

A controlled, randomised cross-over trial will be performed in the laboratory, of which its protocol is described here according to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statement. Recruitment of 21 laparoscopic surgeons started in April 2019 and the study is ongoing. The participating surgeons will perform three 1.5 hour experimental conditions, one without work breaks, one with 2.5 min passive work breaks including rest, and one with 2.5 min active work breaks including mobility and stretching exercises. The work breaks will be taken after 30 and 60 min of work. During the experiments, outcomes will be recorded. The primary outcome is rating of perceived discomfort measured on an 11-point numeric rating scale. The secondary outcomes are performance, muscle activity of selected muscles, upper body angles, heart rate, workload and subjective evaluation of both interventions. The collected data will be tested using a one-way or two-factorial repeated-measures analysis of variance.

ETHICS AND DISSEMINATION

Ethical approval of the study protocol was received by the local medical ethical committee of the University of Tübingen in February 2019 (no 618/2018BO2). The results of this study will be presented at national and international conferences, submitted for publications in peer-reviewed journals and serve as the starting point for a feasibility study.

TRIAL REGISTRATION NUMBER

NCT03715816.

Pelvic examination may be meaningfully taught to novices and be used to predict operating times for laparoscopic excision of endometriosis in one surgical procedure

OBJECTIVE

To investigate whether pelvic examination may be meaningfully taught to novice medical students and its accuracy in predicting operating times for laparoscopic excision of endometriosis at a single surgical procedure.

METHODS

Women with suspected endometriosis scheduled for laparoscopy underwent pelvic examination to estimate operative time by medical students (novices), trainees, senior clinicians with <10 years surgical experience (experts) and ≥10 years (masters). Examination and intraoperative findings were compared and stage of disease recorded.

RESULTS

There were 138 estimations of operating time at the initial assessment and 251 estimations of operating time prior to surgery. The median surgical duration was 44 min (range 12-398) and increased progressively with revised American Society for Reproductive Medicine disease stage. Clinical predictions exceeded actual operating times by a median of 18 min (range overestimating by 180 min and underestimating by 120 min) with 80% of procedures completed in less time than predicted and none requiring a second procedure. There was no statistical difference in operative time estimations between the groups with students and trainees underestimating surgical duration by a median of two and five minutes, respectively, experts having a median time difference of zero minutes, and masters overestimating by 4.5 min.

CONCLUSION

Targeted pelvic examining may be taught to novices (medical students) and can be used to predict operating time at one surgical procedure. Less experienced examiners have a tendency to underestimate surgical duration, with masters overestimating surgical time when scheduling laparoscopies for endometriosis, and increasing disease stage is associated with a less precise estimation of surgical duration.

First experience with THE AUTOLAP™ SYSTEM: an image-based robotic camera steering device

BACKGROUND

Robotic camera holders for endoscopic surgery have been available for 20 years but market penetration is low. The current camera holders are controlled by voice, joystick, eyeball tracking, or head movements, and this type of steering has proven to be successful but excessive disturbance of surgical workflow has blocked widespread introduction. The Autolap™ system (MST, Israel) uses a radically different steering concept based on image analysis. This may improve acceptance by smooth, interactive, and fast steering. These two studies were conducted to prove safe and efficient performance of the core technology.

METHODS

A total of 66 various laparoscopic procedures were performed with the AutoLap™ by nine experienced surgeons, in two multi-center studies; 41 cholecystectomies, 13 fundoplications including hiatal hernia repair, 4 endometriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) salpingo-oophorectomies. The use of the AutoLap™ system was evaluated in terms of safety, image stability, setup and procedural time, accuracy of imaged-based movements, and user satisfaction.

RESULTS

Surgical procedures were completed with the AutoLap™ system in 64 cases (97%). The mean overall setup time of the AutoLap™ system was 4 min (04:08 ± 0.10). Procedure times were not prolonged due to the use of the system when compared to literature average. The reported user satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two studies. More than 90% of the image-based movements were accurate. No system-related adverse events were recorded while using the system.

CONCLUSION

Safe and efficient use of the core technology of the AutoLap™ system was demonstrated with high image stability and good surgeon satisfaction. The results support further clinical studies that will focus on usability, improved ergonomics and additional image-based features.

Single-port laparoscopic neosalpingostomy for hydrosalpinx

Background:

To describe the surgical technique and our initial experience of single-port laparoscopic neosalpingostomy (SP-LN) for treatment of hydrosalpinx.

Materials and methods:

This prospective observational study was carried out at University teaching hospitals. Ten women underwent SP-LN for hydrosalpinx between November 2012 and December 2015.

Results:

The mean (range) age and body mass index were 29.3 (21–36) years and 22.2 (17.7–27.1) kg/m², respectively. Six women had a history of previous abdominal surgery; laparoscopic unilateral salpingectomy for tubal pregnancy in two, laparoscopic appendectomy in three, and laparotomy appendectomy in one. Six women underwent unilateral SP-LN and nine women underwent bilateral SP-LN. The mean (range) operating time, hemoglobin change, return of bowel activity, and length of hospital stay were 91.5 (70–120) minutes, 0.7 (0.1–1.6) g/dL, 19.9 (7.1–25.4) hours, and 3.7 (3–4) days, respectively. There was no conversion to multiport laparoscopy or laparotomy. There were no surgical or wound complications in any patient.

Conclusion:

SP-LN might be a feasible and safe alternative in women with hydrosalpinx. However, further study is needed to confirm this preliminary result and to explore the obstetric outcomes following SP-LN.

How Predictable Is the Operative Time of Laparoscopic Surgery for Ovarian Endometrioma?

Endometriosis is a tricky albeit common disease whose management largely relies on laparoscopy. We have studied the operative times of laparoscopic endometrioma surgery in order to assess their predictability and possible predictors. One hundred forty-eight laparoscopies were included, with a median operative time of 70 minutes (mean 75.14; 95% CI: 70.03–80.24). Half of the cases had a duration within 15–20 minutes above or below the median (IQR: 55–93.75), but the whole dataset ranged from 20 to 180 minutes, and the standard deviation was relatively large (31.4). Surgical times were significantly related to technical (number and size of the cysts) and nontechnical factors (age, parity, dysmenorrhea, and family history). At multiple logistic regression, after adjusting for number and size of the cysts, surgical times below the first quartile were associated with older age (>30 years old: aOR: 3.590; 95% CI: 1.417–9.091) and parity (≥1 delivery: aOR: 3.409; 95% CI: 1.343–8.651). Longer times, above the third quartile, were instead predicted by a familial anamnesis of endometriosis (aOR: 3.639; 95% CI: 1.246–10.627). Our findings indicate highly variable surgical times, which are predicted by unexpected nontechnical factors. This is consistent with the complexity of endometriosis and its treatment. Productivity and efficiency in endometriosis surgery should focus on the quality of healthcare outcomes rather than on the time spent in the operating theatres.

Smart tissue anastomosis robot (STAR): a vision-guided robotics system for laparoscopic suturing

This paper introduces the smart tissue anastomosis robot (STAR). Currently, the STAR is a proof-of-concept for a vision-guided robotic system featuring an actuated laparoscopic suturing tool capable of executing running sutures from image-based commands. The STAR tool is designed around a commercially available laparoscopic suturing tool that is attached to a custom-made motor stage and the STAR supervisory control architecture that enables a surgeon to select and track incisions and the placement of stitches. The STAR supervisory-control interface provides two modes: A manual mode that enables a surgeon to specify the placement of each stitch and an automatic mode that automatically computes equally-spaced stitches based on an incision contour. Our experiments on planar phantoms demonstrate that the STAR in either mode is more accurate, up to four times more consistent and five times faster than surgeons using state-of-the-art robotic surgical system, four times faster than surgeons using manual Endo360(°)®, and nine times faster than surgeons using manual laparoscopic tools.

Total laparoscopic hysterectomy: The Brisbane learning curve

BACKGROUND

Total laparoscopic hysterectomy (TLH) is becoming more commonly used for gynaecological malignancies.

AIMS

To describe our experience with TLH since its introduction to our tertiary referral centre for gynaecological cancer in 2003.

METHODS

Retrospective analysis of the first 120 consecutive cases of TLH performed at our gynaecological cancer centre. Patients were divided into the first, second and third group of 40 patients. Operating time, estimated blood loss, hospital stay, conversion to laparotomy and intra- and postoperative morbidity were evaluated.

RESULTS

The three groups were similar with regard to baseline characteristics. For the entire group the mean hospital stay was 2.4 +/- 1.4 days and eight of 120 patients (6.6%) required conversion to laparotomy. Operating time, estimated blood loss and intraoperative morbidity were similar among the three groups. Postoperative morbidity was highest (25%) in the middle one-third of the patients (P = 0.022). The percentage of pelvic lymph node dissections increased from 2.5% in the first one-third of patients to 27.5% in the final one-third of patients (P = 0.003).

CONCLUSIONS

TLH can be established safely in a tertiary gynaecological cancer referral centre.

Virtual reality simulation training can improve technical skills during laparoscopic salpingectomy for ectopic pregnancy

OBJECTIVES

To assess the first commercially available virtual reality (VR) simulator to incorporate procedural modules for training of inexperienced gynaecological surgeons to perform laparoscopic salpingectomy for ectopic pregnancy.

DESIGN

Prospective cohort study.

SETTING

Departments of surgery and gynaecology in central London teaching hospitals.

SAMPLE

Thirty gynaecological surgeons were recruited to the study, and were divided into novice (<10 laparoscopic procedures), intermediate (20-50) and experienced (>100) groups.

METHODS

All subjects were orientated to the VR simulator with a basic skills task, followed by performing ten repetitions of the virtual ectopic pregnancy module, in a distributed manner.

MAIN OUTCOME MEASURES

Operative performance was assessed by the time taken to perform surgery, blood loss and total instrument path length.

RESULTS

There were significant differences between the groups at the second repetition of the ectopic module for time taken (median 551.1 versus 401.2 versus 249.2 seconds, P = 0.001), total blood loss (median 304.2 versus 187.4 versus 123.3 ml, P = 0.031) and total instrument path length (median 17.8 versus 8.3 versus 6.8 m, P = 0.023). The learning curves of the experienced operators plateaued at the second session, although greater numbers of sessions were necessary for intermediate (seven) and novice (nine) surgeons to achieve similar levels of skill.

CONCLUSIONS

Gynaecological surgeons with minimal laparoscopic experience can improve their skills during short-phase training on a VR procedural module. In contrast, experienced operators showed nonsignificant improvements. Thus, VR simulation may be useful for the early part of the learning curve for surgeons who wish to learn to perform laparoscopic salpingectomy for ectopic pregnancy.

Digital recording of surgical procedures using a personal computer

OBJECTIVE

To develop a system for recording surgical procedure digitally using a personal computer with real-time compression of the video signal.

STUDY DESIGN

We built the system around a modern personal computer with a large hard disk to allow recording of over 250 h of continuous surgery. Digital capture from the camera was achieved using a standard external analogue-digital converter linked to the computer via a firewire cable. The software for capturing, compressing and editing movie files were obtained free of charge from the internet. The optimal settings for the software was determined.

RESULTS

We have successfully used this system to record over 100 major and minor hysteroscopic, laparoscopic, vaginal and open gynaecological. Despite compression, the quality of the movies was judged to be very good and still images excellent. The recordings could be integrated in to standard presentation. Still pictures could be printed to provide hard copies for patients and medical notes, and movies burnt on to CDs or DVDs.

CONCLUSIONS

A digital recording system built around a standard personal computer is relatively cheap, versatile and has a huge capacity to record surgical procedures.

Prospective Evaluation of the Learning Curve of Laparoscopic-Assisted Vaginal Hysterectomy in a University Hospital

STUDY OBJECTIVE

To prospectively analyze the learning curve of laparoscopic-assisted vaginal hysterectomy (LAVH) in a surgical team and evaluate if length of surgery can be reduced safely.

DESIGN

Prospective observational study (Canadian Task Force classification II-2).

SETTING

Department of obstetrics and gynecology in a university-affiliated hospital.

PATIENTS

One hundred and sixty consecutive women undergoing LAVH performed between January 1, 1998 and April 30, 2001.

INTERVENTION

LAVH (AAGL Classification System for Laparoscopic Hysterectomy III-B-3).

MEASUREMENTS AND MAIN RESULTS

The primary parameter evaluated was length of surgery. Patients were grouped in cohorts of 10, in order to perform a time curve that would assist us in evaluation of the learning process. Once the plateau was reached, we evaluated the process before and after this plateau (groups 1 [learning stage] and 2 [second stage], respectively). Average length of surgery was 126 minutes (range, 60-260). Length of surgery was 138 minutes (range, 75-260) in the learning stage (first 80 cases) and 112 minutes (range, 60-225) in the second stage (p <.0001). Total rate of complications was 11.6%. There were three major complications, and they occurred before the plateau. There were 15 minor complications (9.67%), 8 during the first stage and 7 in the second stage, (p =.9; NS). A second learning curve excluding LAVH with associated surgeries was obtained. The average length of surgery for the first stage was 133 minutes (range, 75-205) and 102 minutes for the second stage (range, 60-130) (p >.0001).

CONCLUSION

Analysis of the learning curve demonstrated that the length of surgery in LAVH could be reduced without increasing the number of complications.

Laparoscopic management of tubal ectopic pregnancy in obese women

OBJECTIVE

To study the surgical morbidity associated with the laparoscopic management of tubal ectopic pregnancy in an overweight population compared with a lean population.

DESIGN

Retrospective study.

SETTING

An academic tertiary referral obstetrics and gynecology center.

PATIENT(S)

One hundred seventeen patients in two groups, lean (n = 90; body mass index <or= 30) and obese (n = 27; body mass index >30) who had pathology-confirmed tubal ectopic pregnancies that were managed laparoscopically. Each group was subdivided into a laparoscopically managed group and a group in which laparoscopy was converted to laparotomy.

INTERVENTION(S)

None. Operative time, blood loss, and complications of laparoscopic surgery as well as causes of conversion from laparoscopy to laparotomy, in obese compared with lean women, with ectopic pregnancy.

RESULT(S)

There was no significant difference in gestational age; beta-hCG level; or history of previous surgeries, ectopic pregnancy, pelvic inflammatory disease, or endometriosis or in any of the studied outcomes (conversion rate, blood loss, and operative time) between the lean and obese groups or their respective subgroups except for operative time between obese women who underwent laparotomy, which was significantly longer when compared with the case of lean women who underwent laparotomy. Intraoperative and postoperative complications were comparable between the lean and obese groups, and all complications occurred in the completed-laparoscopy group.

CONCLUSION(S)

Laparoscopic management of tubal ectopic pregnancy does not appear to significantly increase surgical morbidity in obese patients.

Anesthesia for operative endoscopy

Developments in both instruments and techniques have led to an increasing popularity of endoscopic surgery during the last two decades. Even though there are numerous advantages to using endoscopic surgery, life threatening surgical and anesthetic complications still exist. Precautions must be taken to cope with the potential complications. Anesthetic technique must provide optimal surgical conditions and lead to early recovery of the patient. Monitorization must allow safety of the patient during these potentially hazardous procedures. Both the anesthesiologist and the surgeon must be thoroughly aware of the potential complications of the procedure. This review discusses the physiological alterations occurring during operative endoscopy, the principles of anesthetic management and complications related both to surgery and to anesthesia techniques.

A case-control study to compare the variability of operating time in laparoscopic and open surgery

The purpose of this study was to compare the variability of operating times for some of the most common gynaecological procedures performed laparoscopically and by open surgery. The case notes of 60 women randomly selected from a cohort of 600 who had undergone laparoscopic surgery for ectopic pregnancy, ovarian cysts, leiomyoma and hysterectomy were reviewed. These patients were matched with an equal number of women who had been treated by open surgery for similar indications. Additional matching criteria included age (+/-2 years), size of the lesion in cases of ovarian cysts and fibroids (+/-3 cm), the period of amenorrhoea in ectopic pregnancies, and uterine size and pelvic pathology in women undergoing hysterectomy. Comparison of laparoscopy and laparotomy showed that the mean procedure times were similar for the two routes of surgery, with the exception of hysterectomy which took significantly longer if done laparoscopically. The duration of laparoscopic surgery for ectopic pregnancy, ovarian cystectomy and hysterectomy was significantly less predictable than at laparotomy. These data indicate that with the exception of hysterectomy, the average operating time for laparoscopic procedures is comparable to that for laparotomy. In contrast, the variability of duration of laparoscopic surgery tends to be much greater than with laparotomy for all procedures considered.