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Pickett CM, Seeratan DD, Mol BWJ, Nieboer TE, Johnson N, Bonestroo T, Aarts JW. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2023; 8:CD003677. [PMID: 37642285 PMCID: PMC10464658 DOI: 10.1002/14651858.cd003677.pub6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH). OBJECTIVES To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies. AUTHORS' CONCLUSIONS Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.
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Affiliation(s)
- Charlotte M Pickett
- Department of Obstetrics and Gynecology, University of California San Diego, La Jolla, California, USA
| | - Dachel D Seeratan
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | | | - Neil Johnson
- Obstetrics & Gynaecology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Tijmen Bonestroo
- Department of Obstetrics and Gynecology, Rijnstate Hospital, Arnhem, Netherlands
| | - Johanna Wm Aarts
- Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Yalcin Bahat P, Gülova S, Yuksel Ozgor B, Cakmak K. Is Vaginal Hysterectomy Safe for an Enlarged Uterus? Cureus 2020; 12:e6816. [PMID: 32133272 PMCID: PMC7049894 DOI: 10.7759/cureus.6816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective The purpose of this study was to compare the surgical outcomes between two sets of women undergoing vaginal hysterectomy (VH) for benign gynecological conditions: those with moderately enlarged ( ≥12 weeks') uteruses and those with normal-sized uteruses. Materials and Methods The medical records of 84 women who underwent vaginal hysterectomies for benign gynecological conditions at Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey between 2013 and 2015 were reviewed. Age, uterine sizes, indications, duration of hospitalization, operation time, hematocrit (HCT) levels, and complications were analyzed. Results The most common indications for VH were uterine descensus. However, most women had presented with more than one indication. The mean age of the patients who underwent VH was 56.12. The maximum volume of the uterus was found to be 1244.74 ml, and the smallest volume was found to be 18.83 ml. The mean volume of the uterus was found as 122.6629 ml. The mean duration of operation was 159.70 minutes, whereas the mean duration of hospital stay was 3.79 days. The mean preoperative HCT and hemoglobin (Hgb) values were 37.098 (±3.64) gr/dl and 12.365 (±1.35) gr/dl respectively. Postoperative HCT and Hgb values were 31.363 (±3.94) gr/dl and 10.52 (±1.38) respectively. Conclusion VH is usually a simple procedure with low morbidity. It is important to choose the appropriate patient when deciding on the operation. In addition, having experienced surgeons in the field of VH increases the success of surgery.
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Affiliation(s)
- Pinar Yalcin Bahat
- Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, TUR
| | - Sibel Gülova
- Obstetrics and Gynecology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, TUR
| | - Bahar Yuksel Ozgor
- Obstetrics and Gynecology, Esenler Maternity and Children's Hospital, Istanbul, TUR
| | - Kubra Cakmak
- Obstetrics and Gynecology, Esenler Maternity and Children's Hospital, Istanbul, TUR
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La néphrectomie laparoscopique avec extraction vaginale est-elle délétère sur la sexualité des patientes ? Prog Urol 2015; 25:1153-9. [DOI: 10.1016/j.purol.2015.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/12/2015] [Accepted: 09/04/2015] [Indexed: 11/23/2022]
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Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; 2015:CD003677. [PMID: 26264829 PMCID: PMC6984437 DOI: 10.1002/14651858.cd003677.pub5] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). OBJECTIVES To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies. AUTHORS' CONCLUSIONS Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.
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Affiliation(s)
- Johanna WM Aarts
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
| | - Theodoor E Nieboer
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
| | - Neil Johnson
- University of AdelaideRobinson Research InstituteNorwich Centre Ground Floor, 55 King William RoadNorth AdelaideAdelaideSouth AustraliaAustralia5006
| | - Emma Tavender
- Monash UniversityAustralian Satellite of the Cochrane EPOC Group, Department of SurgeryLevel 6, 99 Commercial RoadMelbourneVictoriaAustraliaVIC 3004
| | - Ray Garry
- University of Teeside and South Cleveland Hospital, MiddlesbroughGynaecological Surgery94 WestgateGuisboroughYorkshireUKTS14 6AP
| | - Ben Willem J Mol
- The University of AdelaideThe Robinson Institute, School of Paediatrics and Reproductive HealthLevel 3, Medical School South BuildingFrome RoadAdelaideSouth AustraliaAustraliaSA 5005
| | - Kirsten B Kluivers
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
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Jahan S, Jahan A, Joarder M, Habib SH, Sharmin F, Nayer R. Laparoscopic hysterectomy in large uteri: Experience from a tertiary care hospital in Bangladesh. Asian J Endosc Surg 2015; 8:323-7. [PMID: 25809981 DOI: 10.1111/ases.12184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 12/15/2014] [Accepted: 02/07/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the safety and feasibility of laparoscopically assisted vaginal hysterectomy for uteri weighing more than 500 g as compared to uteri weighing less than 500 g in benign gynecological diseases. METHODS This was a retrospective study. Patients were admitted through the outpatient department. They were divided into two groups: uterine weight ≥500 g (group 1) and uterine weight >500 g (group 2). There were no exclusion criteria based on the size, number, or location of leiomyomas. The patient characteristics for the two groups were compared in terms of demographic and socioeconomic details, operating time, amount of blood loss, requirement of blood transfusion, need for analgesia, and length of hospital stay. RESULTS The characteristics age and BMI were well balanced between the two groups. Uterine weight was 267.2 ± 97.6 g in group 1 and 740.0 ± 371.4 g in group 2 (P < 0.001). Length of operation and amount of blood loss were greater in group 2 than in group 1 (operation: 89.1 ± 26.7 vs 73.3 ± 24.6 min, P < 0.01; blood loss: 570.5 ± 503.6 vs 262.5 ± 270.0 mL, P < 0.001). However, there was no significant difference in hospital stay or incidence of operative complications between the two groups. No patients were switched from laparoscopy to laparotomy during operation. The rate of blood transfusion was lower in group1 than in group 2 (4.9% vs 32.6%; P < 0.001). CONCLUSION This study demonstrated that despite the increased operating time and blood loss, laparoscopy should be considered instead of laparotomy in cases of large uteri. Laparoscopically assisted vaginal hysterectomy can be performed safely for a large uterus.
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Affiliation(s)
- Samsad Jahan
- Department of Gynecology and Obstetrics, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
| | - Akter Jahan
- Government Homeopathic College, Dhaka, Bangladesh
| | - Mahjabin Joarder
- Research Training Management International, Cox's Bazar, Bangladesh
| | | | - Farzana Sharmin
- Department of Obstetrics and Gynecology, Bangladesh Institute of Health Sciences (BIHS) & Hospital, Dhaka, Bangladesh
| | - Reefat Nayer
- Department of Gynecology and Obstetrics, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
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Balcı O. Comparison of total laparoscopic hysterectomy and abdominal hysterectomy. Turk J Obstet Gynecol 2014; 11:224-227. [PMID: 28913025 PMCID: PMC5558366 DOI: 10.4274/tjod.47108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 07/14/2014] [Indexed: 12/01/2022] Open
Abstract
Objective: The aim of this prospective study is to evaluate and compare to the outcomes of total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH) who performed in our clinic. Materials and Methods: We performed surgical procedures at Necmettin Erbakan University Faculty of Medicine, Department of Obstetrics and Gynecology between January 2013 and April 2014. Forty patients who underwent TLH (group 1) compared to 40 patients who underwent TAH (group 2). The mean age of the cases, body mass index (BMI), duration of operation, the amount of blood loss, rates of complications and post operative hospital stay were compared for two groups. Results: There were no statistically significant differences between the two groups regarding age, body mass index (BMI), specimen weight, pre-operative hemoglobin (Hb) value and rates of the complications. The mean post-operative Hb value was significantly higher in group 1 than group 2 (11.5±0.8 gr/dl vs. 10.8±1.7, p=0.02). The mean time of operation was significantly longer in group 1 than in group 2 (105.4±22.9 minutes vs. 74±18, p<0.001). The mean duration of hospital stay was statistically shorter in group 1 compared to the group 2 (2.48±0.6 days vs. 4.88±1.2, p<0.001). Conclusion: Total laparoscopic hysterectomy is safe and feasible method for gynecological diseases. TLH may offer specific benefits for properly selected patients. Its advantages are lower peri-operative morbidity, improvement of quality of life, shorter hospital stay and faster return to activity.
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Affiliation(s)
- Osman Balcı
- Necmettin Erbakan University Meram Faculty of Medicine, Department of Obstetrics and Gynecology, Konya, Turkey
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Hatta K, Terai Y, Okuda K, Nakamura Y, Yoo S, Tanaka Y, Tsunetoh S, Hayashi A, Yamashita Y, Ohmichi M. Preoperative assessment by magnetic resonance imaging is useful for planning the treatment of an enlarged uterus by total laparoscopic hysterectomy. J Obstet Gynaecol Res 2013; 39:814-9. [DOI: 10.1111/j.1447-0756.2012.02065.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 09/17/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Koji Hatta
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Yoshito Terai
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Kiyoji Okuda
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Yoshihiro Nakamura
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Saha Yoo
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Yoshimichi Tanaka
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Satoshi Tsunetoh
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Atsushi Hayashi
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Yoshiki Yamashita
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
| | - Masahide Ohmichi
- Department of Obstetrics and Gynecology; Osaka Medical College; Takatsuki; Osaka; Japan
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Wu KY, Lertvikool S, Huang KG, Su H, Yen CF, Lee CL. Laparoscopic hysterectomies for large uteri. Taiwan J Obstet Gynecol 2012; 50:411-4. [PMID: 22212310 DOI: 10.1016/j.tjog.2011.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2011] [Indexed: 10/14/2022] Open
Abstract
Laparoscopic hysterectomies increase recently due to several advantages of minimally invasive surgery. Controversy exists for laparoscopic hysterectomies for large uteri weighing >500g because some reports show increased complications and morbidities and high laparoconversion rate in the past. With familiarity of laparoscopic procedures and progress in surgical techniques, the issue should be discussed and reviewed by evidence again. Hence, we conducted a systematic review of laparoscopic hysterectomies for large uteri.
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Affiliation(s)
- Kai-Yun Wu
- Department of Obstetrics and Gynecology, Chang Gung University College of Medicine, Kwei-Shan, Tao-Yuan, Taiwan
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Sinha R, Sundaram M, Lakhotia S, Mahajan C, Manaktala G, Shah P. Total laparoscopic hysterectomy for large uterus. JOURNAL OF GYNECOLOGICAL ENDOSCOPY AND SURGERY 2012; 1:34-9. [PMID: 22442509 PMCID: PMC3304266 DOI: 10.4103/0974-1216.51908] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighing more than 500 grams. We have analyzed whether it is possible for an experienced laparoscopic surgeon to perform efficient total laparoscopic hysterectomy for large myomatous uteri regardless of the size, number and location of the myomas. DESIGN Retrospective review (Canadian Task Force Classification II-1) SETTING Dedicated high volume Gynecological laparoscopy centre. PATIENTS 173 women with symptomatic myomas who underwent total laparoscopic hysterectomy at our center. There were no exclusion criteria based on the size number or location of myomas. INTERVENTION TLH and modifications of performing the surgery by ligating the uterine arteries prior, myomectomy followed by hysterectomy, direct morcellation after uterine artery ligation. RESULTS 72% of patients had previous normal vaginal delivery and 28% had previous cesarean section. Average clinical size of the uterus was 18 weeks (10, 32). The average weight of the specimen was 700 grams (500, 2240). The average duration of surgery was 107 min (40, 300) and the average blood loss was 228 ml (10, 3200). CONCLUSION Total laparoscopic hysterectomy is a technically feasible procedure. It can be performed by experienced surgeons for large uteri regardless of the size, number or location of the myomas.
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Puntambekar S, Rayate N, Nadkarni A, Joshi S, Agrawal G, Desai R. Single-incision total laparoscopic hysterectomy with conventional laparoscopy ports. Int J Gynaecol Obstet 2012; 117:37-9. [DOI: 10.1016/j.ijgo.2011.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 11/02/2011] [Accepted: 12/22/2011] [Indexed: 10/14/2022]
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SONG T, KIM TJ, KANG H, LEE YY, CHOI CH, LEE JW, KIM BG, BAE DS. A review of the technique and complications from 2,012 cases of Laparoscopically Assisted Vaginal Hysterectomy at a single institution. Aust N Z J Obstet Gynaecol 2011; 51:239-43. [DOI: 10.1111/j.1479-828x.2011.01296.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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A prospective randomised study of total laparoscopic hysterectomy, laparoscopically assisted vaginal hysterectomy and non-descent vaginal hysterectomy for the treatment of benign diseases of the uterus. Arch Gynecol Obstet 2010; 284:907-12. [DOI: 10.1007/s00404-010-1778-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 11/11/2010] [Indexed: 10/18/2022]
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Laparoscopic-assisted vaginal hysterectomy with and without laparoscopic transsection of the uterine artery: an analysis of 1,255 cases. Arch Gynecol Obstet 2010; 284:379-84. [DOI: 10.1007/s00404-010-1662-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Accepted: 08/19/2010] [Indexed: 11/26/2022]
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Laparoscopic Hysterectomy in the Presence of Previous Caesarean Section: A Review of One Hundred Forty-One Cases in the Sydney West Advanced Pelvic Surgery Unit. J Minim Invasive Gynecol 2010; 17:186-91. [PMID: 20226406 DOI: 10.1016/j.jmig.2009.11.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 11/03/2009] [Accepted: 11/04/2009] [Indexed: 11/24/2022]
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A Modified Technique of LAVH with the Biswas Uterovaginal Elevator. J Minim Invasive Gynecol 2009; 16:755-60. [DOI: 10.1016/j.jmig.2009.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Revised: 07/24/2009] [Accepted: 07/24/2009] [Indexed: 11/22/2022]
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Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009:CD003677. [PMID: 19588344 DOI: 10.1002/14651858.cd003677.pub4] [Citation(s) in RCA: 299] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically. OBJECTIVES To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists. SELECTION CRITERIA Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included. DATA COLLECTION AND ANALYSIS Independent selection of trials and data extraction were employed following Cochrane guidelines. MAIN RESULTS There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures. AUTHORS' CONCLUSIONS Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.
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Affiliation(s)
- Theodoor E Nieboer
- Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Johan de Wittlaan, Arnhem, Netherlands, 80 6828 WJ
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Jackson S, Draycott T, Read M. Early hospital discharge following abdominal hysterectomy. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619609020726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pan HS, Ko ML, Huang LW, Chang JZ, Hwang JL, Chen SC. Total laparoscopic hysterectomy (TLH) versus coagulation of uterine arteries (CUA) at their origin plus total laparoscopic hysterectomy (TLH) for the management of myoma and adenomyosis. MINIM INVASIV THER 2009; 17:318-22. [PMID: 18850461 DOI: 10.1080/13645700802274588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We tried to evaluate the relative feasibility, surgical duration and complications of total laparoscopic hysterectomy (TLH) versus coagulation of uterine arteries at their origin (CUA) plus total laparoscopic hysterectomy for the management of myoma and adenomyosis, and to compare the estimated blood loss for both procedures. A total of 123 patients underwent TLH or CUA plus TLH for the treatment of symptomatic myoma and adenomyosis. Sixty-four women underwent TLH, whilst 68 women underwent coagulation of uterine arteries at their origin plus TLH. The mean weight and volume of the uterus as determined following TLH was 288.1+/-102.4 gm (range 182.1 approximately 396.2 gm.) and 451+/-340.6 cm(3) (range 107.4 approximately 792), respectively. The mean weight of the uterus following CUA plus TLH was 269.1+/-151.7 gm (range 215.8 approximately 430.1) whilst the mean uterine volume was 472.7+/-377.8 cm(3) (range 93.7 approximately 851.2). No significant differences with respect to surgical duration (95 vs. 96.5 minutes TLH vs. CUA + TLH; p>0.05), blood loss (177.2+/-80.1 ml for TLH and 154.9+/-30.21 ml for CUA+TLH; p>0.05) and mean+/-SD preoperative (12.05+/-1.70 gm/dl for TLH and 12.14+/-1.38 gm/dl for CUA+TLH; p>0.05) and post-operative hemoglobin level (11+/-1.03 for TLH and 11+/-1.49 for CUA + TLH; p>0.05) were observed between the two study groups. The blood loss for TLH is comparable to that for the CUA plus TLH procedure.
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Affiliation(s)
- Hun-Shan Pan
- Department of Obstetrics and Gynecology, Shin-Kong Memorial Hospital, Taipei, Taiwan
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Demir A, Bige O, Saatli B, Solak A, Saygili U, Önvural A. Prospective comparison of tissue trauma after laparoscopic hysterectomy types with retroperitoneal lateral transsection of uterine vessels using ligasure and abdominal hysterectomy. Arch Gynecol Obstet 2007; 277:325-30. [DOI: 10.1007/s00404-007-0485-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 09/27/2007] [Indexed: 11/25/2022]
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Fiaccavento A, Landi S, Barbieri F, Zaccoletti R, Tricolore C, Ceccaroni M, Pomini P, Bruni F, Soriano D, Stepniewska A, Selvaggi L, Zanolla L, Minelli L. Total laparoscopic hysterectomy in cases of very large uteri: A retrospective comparative study. J Minim Invasive Gynecol 2007; 14:559-63. [PMID: 17848315 DOI: 10.1016/j.jmig.2007.04.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 04/12/2007] [Accepted: 04/14/2007] [Indexed: 10/22/2022]
Abstract
In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighting more than 500 grams. We compared surgical outcomes and short term follow-up in 149 patients with the uterus weighing less than 350 g (group A: 40-350 g) and 100 patients with the uterus weighing more than 500 g (group B: 500-1550 g). We discovered no statistical difference between the 2 groups in terms of intraoperative complications (group A: 0%; group B: 2%) and postoperative stay (group A: 3.05 +/- 1.89 days; group B: 3.2 +/- 1.28 days). There were statistically significant differences between the 2 groups in terms of operative time (group A: 101.3 +/- 34.3 min; group B: 149.1 +/- 57.2 min.; p <.0001) and postoperative hospital stay length (group A: 2.8 +/- 0.7 days; group B: 3.5 +/- 1.7 days; p <.0001). No major complications occurred in either group. Postoperative minor complications were more frequent in group B (group A: 8.7%; group B: 18%; p = .03). Median time to well-being was comparable in both groups. In conclusion, TLH is a feasible surgical technique also in cases of very large uteri. An increase in operative time, intraoperative blood loss, hospital stay length, and postoperative minor complications can be expected as the uterine weight increases.
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Affiliation(s)
- Andrea Fiaccavento
- Obstetrics/Gynecology Department, Ospedale Sacro Cuore Don Calabria, Verona, Italy.
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Muzii L, Basile S, Zupi E, Marconi D, Zullo MA, Manci N, Bellati F, Angioli R, Benedetti Panici P. Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy: A prospective, randomized, multicenter study. J Minim Invasive Gynecol 2007; 14:610-5. [PMID: 17848323 DOI: 10.1016/j.jmig.2007.05.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Revised: 05/15/2007] [Accepted: 05/18/2007] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to compare operative and early postoperative outcomes of laparoscopic-assisted vaginal hysterectomy (LAVH) and minilaparotomy in a randomized clinical trial including patients undergoing total hysterectomy for benign gynecologic disease and having 1 or more of the generally considered contraindications to vaginal route. DESIGN Prospective, randomized, multicenter trial (Canadian Task Force classification I). SETTING Departments of Gynecology from 3 major university hospitals in Rome. PATIENTS Eighty-one patients who were candidates for abdominal hysterectomy. INTERVENTIONS Laparoscopic-assisted vaginal hysterectomy and minilaparotomy hysterectomy. MEASUREMENTS AND MAIN RESULTS Forty patients were randomized to LAVH and 41 to minilaparotomy. Characteristics of patients and indications for surgery in the 2 arms were comparable. In the minilaparotomy group, complications were as follows: 1 case (2.4%) of delayed laparotomy with 2 units of red blood cell transfusion, 2 cases (4.8%) of wound infection, and 3 cases (7.3%) of fever of unknown origin. No minor or major complications were observed in the LAVH group. Postoperative visual analog scale pain scores at days 1 and 2 were significantly lower in the LAVH group (p <.05). The complication rate between the 2 groups was significantly lower for LAVH (p = .026). CONCLUSION Because LAVH was associated with significantly lower early postoperative pain scores and complication rates, in general LAVH should be preferred to minilaparotomy hysterectomy when the vaginal approach cannot be used.
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Affiliation(s)
- Ludovico Muzii
- Department of Obstetrics and Gynecology, Campus Bio-Medico University, Rome, Italy.
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Leung SW, Chan CS, Lo SFL, Pang CP, Pun TC, Yuen PM. Comparison of the different types of “laparoscopic total hysterectomy”. J Minim Invasive Gynecol 2007; 14:91-6. [PMID: 17218237 DOI: 10.1016/j.jmig.2006.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2006] [Revised: 08/28/2006] [Accepted: 09/02/2006] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To review the operative outcomes among different types of laparoscopic total hysterectomy (LH) classified according to the Munro and Parker classification system. DESIGN Prospective observational cohort study (Canadian Task Force classification II). SETTING 6 major public hospitals in Hong Kong. PATIENTS 143 patients underwent LH in a 6-month period. INTERVENTIONS Type I to type IV LH according to the Munro and Parker classification system. MEASUREMENTS AND MAIN RESULTS We studied 56 type I, 49 type II, 25 type III, and 13 type IV LH. The median operative time was 105 minutes, which was significantly longer in the type IV LH group (160 minutes). The median blood loss was significantly higher in the type I LH group (300 mL). The incidence of urinary tract infection in type I LH was 8.9%, which was significantly higher than other LH groups. The overall operative complication rate was 20.3%, which was highest in the type III hysterectomy group (36%), although the difference did not reach statistical significance among the various types of hysterectomy groups. CONCLUSION There has been a change from abdominal hysterectomy to LH in the past decades, and it is time for us to explore the best type of LH. Our findings suggest that type I LH is associated with significantly more blood loss and urinary tract infection; whereas type IV LH is associated with significantly longer operating time. However, we still cannot conclude which is the best type of LH until results from a randomized controlled trial will become available.
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Affiliation(s)
- See Wai Leung
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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Vaisbuch E, Goldchmit C, Ofer D, Agmon A, Hagay Z. Laparoscopic hysterectomy versus total abdominal hysterectomy: A comparative study. Eur J Obstet Gynecol Reprod Biol 2006; 126:234-8. [PMID: 16616408 DOI: 10.1016/j.ejogrb.2005.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Revised: 05/21/2005] [Accepted: 10/12/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare the intraoperative and short-term postoperative complications of laparoscopic hysterectomy and total abdominal hysterectomy. STUDY DESIGN Retrospective study of 167 women who had laparoscopic hysterectomy and 119 women who had total abdominal hysterectomy. For assessing the learning curve, the laparoscopic hysterectomies were further subdivided to the first 30 hysterectomies and the later hysterectomies. For data analysis Student's t-test, chi2-test and Fisher's exact test were used. RESULTS There were no statistically significant differences between the two groups for age, body mass index, previous abdominal surgery, uterine weight, first postoperative day hemoglobin drop, blood transfusion and major or minor complications rate. Operation time was significantly longer for laparoscopic than abdominal hysterectomy (156+/-40 and 91.2+/-33 min, respectively; P<0.001) but the length of hospital stay was significantly shorter (3.9 and 6.55 days, respectively; P<0.001). The conversion rate of laparoscopic hysterectomy was 1.8% (three cases). CONCLUSIONS Laparoscopic hysterectomy can be safely done even during the learning curve with a low and reasonable complication rate, and a shorter hospital stay but with longer operation time. As experience is gained the operation time, complication rate and hospital stay are decreased.
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Affiliation(s)
- Edi Vaisbuch
- Department of Obstetrics and Gynecology, Kaplan Medical Center (Affiliated to the School of Medicine, Hebrew University and Hadassah), Rehovot 76100, Israel.
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Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2006:CD003677. [PMID: 16625589 DOI: 10.1002/14651858.cd003677.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are three approaches to hysterectomy for benign disease - abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions - laparoscopic assisted vaginal hysterectomy (LAVH) where a vaginal hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation, laparoscopic hysterectomy (which we will abbreviate to LH(a)) where the laparoscopic procedures include uterine artery ligation, and total laparoscopic hysterectomy (TLH) where there is no vaginal component and the vaginal vault is sutured laparoscopically. OBJECTIVES To assess the most appropriate surgical approach to hysterectomy. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials (searched 23 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to Mar 2004), EMBASE (1985 to Mar 2004), Biological Abstracts (1968 to Mar 2004), the National Research Register and relevant citation lists. SELECTION CRITERIA Only randomised trials comparing one surgical approach to hysterectomy with another were included. DATA COLLECTION AND ANALYSIS Twenty-seven trials that included 3643 participants were included. Independent selection of trials and data extraction were employed following Cochrane guidelines. MAIN RESULTS The benefits of VH versus AH were shorter duration of hospital stay (WMD 1.0 day, 95%CI 0.7 to 1.2 days), speedier return to normal activities (WMD 9.5 days, 95%CI 6.4 to 12.6 days), fewer unspecified infections or febrile episodes (OR 0.42, 95%CI 0.21 to 0.83). The benefits of LH versus AH were lower intraoperative bloodloss (WMD 45.3 mls, 95%CI 17.9 to 72.7 mls) and a smaller drop in haemoglobin level (WMD 0.55g/L, 95%CI 0.28 to 0.82g/L), shorter duration of hospital stay (WMD 2.0 days, 95%CI 1.9 to 2.2 days), speedier return to normal activities (WMD 13.6 days, 95%CI 11.8 to 15.4 days), fewer wound or abdominal wall infections (OR 0.32, 95%CI 0.12 to 0.85), fewer unspecified infections or febrile episodes (OR 0.65, 95%CI 0.49 to 0.87), at the cost of longer operating time (WMD 10.6 minutes, 95%CI 7.4 to 13.8 minutes) and more urinary tract (bladder or ureter) injuries (OR 2.61, 95%CI 1.22 to 5.60). There was no evidence of benefits of LH versus VH and the operating time was increased (WMD 41.5 minutes, 95%CI 33.7 to 49.4 minutes). There was no evidence of benefits of LH(a) versus LAVH and the operating time was increased for LH(a) (WMD 25.3 minutes, 95%CI 10.0 to 40.6 minutes). There was statistical heterogeneity in many of the outcome measures when randomised trials were pooled for meta-analysis. No other statistically significant differences were found. However, for some important outcomes, the analyses were underpowered to detect important differences, or they were simply not reported in trials. Data were notably absent for many important long-term outcome measures. AUTHORS' CONCLUSIONS Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH, however the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically and laparoscopic approaches require greater surgical expertise. The surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards. Further research is required with full reporting of all relevant outcomes, particularly important long-term outcomes, in large RCTs, to minimise the possibility of reporting bias. Further research is also required to define the role of the newer approaches to hysterectomy such as TLH.
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Affiliation(s)
- N Johnson
- University of Auckland, Department of Obstetrics & Gynaecology, PO Box 92019, Auckland, New Zealand, 1003.
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Roumm AR, Pizzi L, Goldfarb NI, Cohn H. Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures. Surg Innov 2006; 12:261-87. [PMID: 16224649 DOI: 10.1177/155335060501200313] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.
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Affiliation(s)
- Adam R Roumm
- Department of Health Policy, Jefferson Medical College, Philadelphia, PA 19107, USA
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Agostini A, Vejux N, Bretelle F, Collette E, De Lapparent T, Cravello L, Blanc B. Value of laparoscopic assistance for vaginal hysterectomy with prophylactic bilateral oophorectomy. Am J Obstet Gynecol 2006; 194:351-4. [PMID: 16458628 DOI: 10.1016/j.ajog.2005.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2005] [Revised: 06/28/2005] [Accepted: 08/08/2005] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study was undertaken to compare morbidity for women undergoing laparoscopy-assisted vaginal hysterectomy with bilateral oophorectomy (LAVHO) and vaginal hysterectomy with bilateral oophorectomy without laparoscopic assistance (VHO). STUDY DESIGN Between April 1, 2002, and February 1, 2004, a prospective randomized study at Marseille University Hospital (La Conception) included 48 patients who underwent a hysterectomy with prophylactic bilateral oophorectomy for benign uterine conditions. These patients were allocated to 2 groups (LAVHO vs VHO). The study variables were duration of surgery and of hospitalization and surgical and postoperative complications. RESULTS There was no significant difference in the duration of surgery between the LAVHO and VHO groups (100.2 +/- 27.9 vs 83.9 +/- 34.6, P = .08). The rate of complications was significantly higher in the LAVHO group (13/24 [54.1%] vs 6/24 [25%], P = .039). CONCLUSION The overall complication rate was higher with LAVHO than VHO. It thus appears that laparoscopic assistance is not useful in performing vaginal hysterectomies with prophylactic bilateral oophorectomies in patients without other related disorders (endometriosis, adhesions, adnexal anomalies).
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Affiliation(s)
- Aubert Agostini
- Department of Obstetrics and Gynecology, La Conception University Hospital, Marseille, France
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Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005; 330:1478. [PMID: 15976422 PMCID: PMC558455 DOI: 10.1136/bmj.330.7506.1478] [Citation(s) in RCA: 290] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts. SELECTION OF STUDIES Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay). RESULTS 27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference -1.1 (-4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials. CONCLUSIONS Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.
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Affiliation(s)
- Neil Johnson
- University of Auckland, National Women's Department of Obstetrics and Gynaecology, Auckland Hospital, Auckland, New Zealand.
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Abstract
Health resources are finite, and it is increasingly necessary to practise medicine within defined budgets. Hysterectomy is recognized as one of the most frequently performed of all major surgical operations and is of great economic as well as medical and social importance. A full assessment of the value of an intervention requires consideration of both economic and clinical outcomes. New alternative therapies to uterine excision have been introduced, and new ways of performing hysterectomy have been developed. Cost-effectiveness analysis enables each of these approaches to be meaningfully compared. Using such analytic techniques, hysterectomy can be shown to be an effective and cost-effective intervention across a variety of indications. The vaginal route is the most cost-effective approach. There seems to be no obvious advantage in conserving or retaining the cervix, but there is as yet no evidence about the cost-effectiveness of concomitant oophorectomy.
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Affiliation(s)
- Ray Garry
- King Edward Memorial Hospital, Bagot Road, Subiaco, Perth, WA 6008, Australia.
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McKenzie CA, Grant KA. Hysterectomy-the patient's view: a survey of outcomes of hysterectomy in a district general hospital. J OBSTET GYNAECOL 2005; 20:421-5. [PMID: 15512602 DOI: 10.1080/01443610050112129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Debate continues on the preferred method of hysterectomy, usually focusing on economic implications and details such as length of inpatient stay and time to return to work. However, little published data exists on patients' level of satisfaction with hysterectomy. We performed a retrospective survey of patients' views after different methods of hysterectomy. Patients were asked about discharge timing after operation, success or failure in relieving their symptoms, the presence of any new symptoms, and overall satisfaction. Six hundred and fifty-three patients were identified. The questionnaire response rate was 82.5%. As noted by other authors there was a difference in the rate of return to normal activity, depending on the method of hysterectomy. Significantly a proportion of patients felt discharge was too early. There was no difference in overall satisfaction rates or in the incidence of new problems between methods. Overall, patients were highly satisfied with the outcome after hysterectomy with no method being superior.
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Abstract
Despite more than 1000 publications on laparoscopic hysterectomy (LH), its role remains difficult to define. LH is not there to replace vaginal hysterectomy, but may be an alternative for abdominal hysterectomy when there are (relative) contraindications for vaginal hysterectomy, including concomitant oophorectomy, previous pelvic surgery and/or risk for adhesions, the larger uterus and nulliparity, and some oncological indications. Randomized trials have demonstrated that, compared to abdominal hysterectomy, LH shortens hospital stay and induces less postoperative pain and quicker recovery at the expense of a longer operation time. LH carries a higher risk for adjacent organ injury, and may be cost-effective, despite higher direct costs, because of the shorter hospital stay and quicker recovery.
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Affiliation(s)
- Filip Claerhout
- Department Obstetrics and Gynaecology, University Hospital Leuven, UZ Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.
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32
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Affiliation(s)
- Ray Garry
- University of Western Australia, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
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Abstract
OBJECTIVE The aim of this study was to evaluate the factors considered for proficiency and to estimate the number of procedures needed to achieve competence in laparoscopic-assisted vaginal hysterectomy in a teaching hospital. METHODS The length of the learning curve, duration of surgery, change of hemoglobin (in grams per liter), conversion rate, and intra- and postoperative complications were evaluated. Cases were analyzed according to the order for the individual surgeon. RESULTS Thirty-three surgeons performed 929 laparoscopic-assisted vaginal hysterectomies during the study period. Analyzing the duration of surgery and rate of complications, we decided on a cutoff of 30 cases. Eight surgeons with more than 30 cases performed 668 laparoscopic-assisted vaginal hysterectomies. Their initial 30 cases (group A, the first 30 cases) were compared with their subsequent cases (group B, cases 31 and after). Patient age, body mass index, and uterine weight did not differ between the groups. The intraoperative complication rate dropped from 4.2% to 0.5% (P =.001), hemoglobin drop decreased from -0.8 +/- 0.9 g/L to -0.5 +/- 1.0 g/L (P =.002), and postoperative complications dropped from 12.9% to 7.0% (P =.017). The duration of surgery was also shorter (148.8 +/- 45.4 minutes versus 125.1 +/- 46.5 minutes), but this difference was taken from the results of 1 surgeon. CONCLUSION A learning experience of 30 laparoscopic-assisted vaginal hysterectomies was necessary in our institution to reach a low level of complications. Duration of the surgical procedure was not an adequate study endpoint to assess a learning effect.
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Affiliation(s)
- C Altgassen
- Department of Obstetrics and Gynecology, Campus Luebeck, University of Schleswig-Holstein, Kiel, Germany.
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Ribeiro SC, Ribeiro RM, Santos NC, Pinotti JA. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynaecol Obstet 2004; 83:37-43. [PMID: 14511870 DOI: 10.1016/s0020-7292(03)00271-6] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate operative time, blood loss and inflammatory response in patients submitted to hysterectomy. METHODS Sixty patients referred for hysterectomy were prospectively randomized to total abdominal hysterectomy (n=20), vaginal hysterectomy (n=20), or laparoscopic hysterectomy (n=20). The operative time, blood loss (variation in erythrocyte and hemoglobin) and inflammatory answer (CRP and interleukin-6 dosages) were compared by using Kruskal-Wallis, Dunn non-parametric test and variance analysis with repeated measurements. RESULTS Operative time was shorter for vaginal hysterectomy, and there was no significant difference between total abdominal hysterectomy and laparoscopic hysterectomy. Reduction in erythrocyte and hemoglobin was more noticeable after vaginal hysterectomy, followed by total abdominal hysterectomy and laparoscopic hysterectomy. CRP levels increased steadily from vaginal hysterectomy to laparoscopic hysterectomy and then to total abdominal hysterectomy. The increase in interleukin-6 was substantially higher in total abdominal hysterectomy, whereas no difference was noted between vaginal and laparoscopic hysterectomy. CONCLUSIONS Vaginal hysterectomy presents superior results in terms of operative time and inflammatory response when compared with total abdominal and laparoscopic hysterectomy and it should be the first option for hysterectomy. Laparoscopic hysterectomy should be considered when the vaginal approach is unfeasible, showing clear advantages over abdominal hysterectomy.
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Affiliation(s)
- S C Ribeiro
- Department of Obstetric and Gynecology, Clinics Hospital of São Paulo University School of Medicine (HCFMUSP), São Paulo, SP, Brazil.
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Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, Clayton R, Phillips G, Whittaker M, Lilford R, Bridgman S, Brown J. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004; 328:129. [PMID: 14711749 PMCID: PMC314503 DOI: 10.1136/bmj.37984.623889.f6] [Citation(s) in RCA: 425] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the effects of laparoscopic hysterectomy and abdominal hysterectomy in the abdominal trial, and laparoscopic hysterectomy and vaginal hysterectomy in the vaginal trial. DESIGN Two parallel, multicentre, randomised trials. SETTING 28 UK centres and two South African centres. PARTICIPANTS 1380 women were recruited; 1346 had surgery; 937 were followed up at one year. Primary outcome Rate of major complications. RESULTS In the abdominal trial laparoscopic hysterectomy was associated with a higher rate of major complications than abdominal hysterectomy (11.1% v 6.2%, P = 0.02; difference 4.9%, 95% confidence interval 0.9% to 9.1%) and the number needed to treat to harm was 20. Laparoscopic hysterectomy also took longer to perform (84 minutes v 50 minutes) but was less painful (visual analogue scale 3.51 v 3.88, P = 0.01) and resulted in a shorter stay in hospital after the operation (3 days v 4 days). Six weeks after the operation, laparoscopic hysterectomy was associated with less pain and better quality of life than abdominal hysterectomy (SF-12, body image scale, and sexual activity questionnaires). In the vaginal trial we found no evidence of a difference in major complication rates between laparoscopic hysterectomy and vaginal hysterectomy (9.8% v 9.5%, P = 0.92; difference 0.3%, -5.2% to 5.8%), and the number needed to treat to harm was 333. We found no evidence of other differences between laparoscopic hysterectomy and vaginal hysterectomy except that laparoscopic hysterectomy took longer to perform (72 minutes v 39 minutes) and was associated with a higher rate of detecting unexpected pathology (16.4% v 4.8%, P = < 0.01). However, this trial was underpowered. CONCLUSIONS Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy. It also took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life. The trial comparing vaginal hysterectomy with laparoscopic hysterectomy was underpowered and is inconclusive on the rate of major complications; however, vaginal hysterectomy took less time.
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Affiliation(s)
- Ray Garry
- University of Western Australia, Department of Obstetrics and Gynaecology, King Edward Memorial Hospital, Subiaco, Perth, WA 6008, Australia.
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Shen CC, Wu MP, Lu CH, Huang EY, Chang HW, Huang FJ, Hsu TY, Chang SY. Short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy and total abdominal hysterectomy. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 2003; 10:49-54. [PMID: 12554994 DOI: 10.1016/s1074-3804(05)60234-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Chung-Chang Shen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, 4F-4, 123, Ta-Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan
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Seracchioli R, Venturoli S, Vianello F, Govoni F, Cantarelli M, Gualerzi B, Colombo FM. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 2002; 9:333-8. [PMID: 12101331 DOI: 10.1016/s1074-3804(05)60413-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To evaluate in a prospective series whether, even in presence of a large uterus, total laparoscopic hysterectomy is feasible and safe, and may be substituted for abdominal hysterectomy. DESIGN Randomized comparison (Canadian Task Force classification I). Setting. Center for Reconstructive Pelvic Endosurgery, Bologna, Italy. PATIENTS One hundred twenty-two women with large uterus (>14 wks' gestation) caused by myomas. INTERVENTION Total laparoscopic hysterectomy and total abdominal hysterectomy. MEASUREMENTS AND MAIN RESULTS Sixty women underwent laparoscopic hysterectomy (group 1) and 62 abdominal hysterectomy (group 2). Mean longitudinal diameter of the uterus, mean number and diameter of myomas, operating time, and average drop in hemoglobin were similar in the groups. One conversion to laparotomy was necessary because of a bowel injury in a patient with severe pelvic adhesions. Cystotomy occurred in one woman in group 2 and was immediately repaired. Febrile morbidity was statistically more frequent in group 2 than in group 1. Postoperative hospitalization and convalescence were statistically shorter in group 1. CONCLUSION Laparoscopic hysterectomy is safe and feasible even in the presence of large uterus, and is a valid alternative to abdominal hysterectomy when the vaginal route is contraindicated.
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Affiliation(s)
- Renato Seracchioli
- Center for Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola Hospital, University of Bologna, Massarenti 13, 40138 Bologna, Italy
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Wattiez A, Soriano D, Cohen SB, Nervo P, Canis M, Botchorishvili R, Mage G, Pouly JL, Mille P, Bruhat MA. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 2002; 9:339-45. [PMID: 12101332 DOI: 10.1016/s1074-3804(05)60414-8] [Citation(s) in RCA: 195] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
STUDY OBJECTIVE To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them. DESIGN Retrospective, comparative study (Canadian Task Force classification II-2). SETTING University tertiary referral center for endoscopic surgery. PATIENTS During 1989-1995 and 1996-1999, 695 and 952 women, respectively, with benign pathology. INTERVENTION Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS No differences in patient characteristics were found between 1989-1995 and 1996-1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22-904 g) and 292.0 g (40-980 g) and operating times 115 minutes (40-270 min) and 90 minutes (40-180 min), respectively, were recorded (p <0.005). CONCLUSION Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.
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Affiliation(s)
- A Wattiez
- Department of Obstetrics and Gynecology, Polyclinique de L'Hotel-Dieu CHU, 13 Boulevard Charles de Gaulle, Clermont-Ferrand, France
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Abstract
The place of minimal access surgery (MAS) in current gynaecological practice remains controversial. As a consequence, MAS techniques have been subject to a significant amount of prospective, evidence-based assessment. The ultimate results of these comparative trials will undoubtedly have a profound impact on the future direction of our speciality. It is timely, therefore, to review the currently available data. Evidence from 2195 patients in 23 randomised clinical trials of five different treatment modalities (ectopic, ovarian cysts, myomectomy, colposuspension and hysterectomy) clearly demonstrates that uncomplicated MAS procedures produce patient friendly benefits, at least in the short term. No matter what operation is performed, the laparoscopic approach is associated with less pain, shorter hospital stay and shorter recovery. These immediate patient-orientated benefits are a generic consequence of replacing the manoeuvres of open surgery through laparotomy incisions with minimal access. These benefits must be offset against significant disadvantages. Minimal access surgery procedures always require the use of expensive, high technology equipment and usually take longer to perform. Such procedures may be more costly than current open procedures and costs will, in part, be dependent on the amount of disposable equipment employed. Patients undergoing MAS procedures may be at risk of new and/or increased risk of traditional complications. The longer-term results of most MAS procedures have not yet been determined. These potential benefits and disadvantages of MAS require that each procedure is carefully and individually assessed. This paper seeks to review the current evidence.
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Wattiez A, Soriano D, Fiaccavento A, Canis M, Botchorishvili R, Pouly J, Mage G, Bruhat MA. Total laparoscopic hysterectomy for very enlarged uteri. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 2002; 9:125-30. [PMID: 11960035 DOI: 10.1016/s1074-3804(05)60119-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To evaluate short-term outcome of total laparoscopic hysterectomy (TLH) performed in women with very enlarged uteri. DESIGN Case control study (Canadian Task Force classification II-2). SETTING Hospital gynecologic service. PATIENTS Thirty-four consecutive women with very enlarged uteri. INTERVENTION Total laparoscopic hysterectomy for benign pathology. MEASUREMENTS AND MAIN RESULTS Women with uterine enlargement (group 1) were compared with 68 women with uteri weighing 300 g or less (group 2) who underwent TLH during the same period. Matching was based on patient age +/- 2 years, surgeon (experienced senior, fellow), whether or not Burch operation was performed, and whether or not adnexectomy was performed. The groups were compared for complication rates, operating time, hospital stay, change in perioperative hemoglobin concentration, and vaginal and laparoscopic uterine morcellation. They did not differ statistically significantly in terms of indications for surgery, parity, postmenopausal status, and preoperative hemoglobin levels. No difference was seen in complication rates between groups. Operating time was significantly shorter (p <0.001) in women with smaller uteri than in those with very enlarged uteri, 108 +/- 35 and 156 +/- 50 minutes, respectively. The groups did not differ significantly in day 1 hemoglobin level drop, analgesia requirement (oral, intravenous opioid), time to passing gas and stool, or hospital stay. No conversion to laparotomy was required in either group. CONCLUSION A very enlarged uterus should not be considered a contraindication for TLH. However, it may be necessary to undertake certain surgical steps to ensure optimal exposure of the operative field and more effective and safer excision of the uterine vascular pedicle.
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Affiliation(s)
- A Wattiez
- Department of Obstetrics and Gynecology and Reproductive Medicine, Polyclinique de L'Hotel-Dieu CHU, 13 Boulevard Charles de Gaulle, Clermont-Ferrand, France
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Maresh MJA, Metcalfe MA, McPherson K, Overton C, Hall V, Hargreaves J, Bridgman S, Dobbins J, Casbard A. The VALUE national hysterectomy study: description of the patients and their surgery. BJOG 2002; 109:302-12. [PMID: 11950186 DOI: 10.1111/j.1471-0528.2002.01282.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe hysterectomies practised in 1994 and 1995: the patients, their surgery and short term outcomes. DESIGN One of two large cohorts, with prospective follow up, recruited to compare the outcomes of endometrial destruction with those of hysterectomy. SETTING England, Wales and Northern Ireland. POPULATION All women who had hysterectomies for non-malignant indications carried out during a 12-month period. METHODS Gynaecologists in NHS and independent hospitals were asked to report cases. Follow up data were obtained at outpatient follow up approximately six weeks post-surgery. MAIN OUTCOME MEASURES Indication for surgery, method of hysterectomy, ovarian status post-surgery, surgical complications. RESULTS 37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically-assisted hysterectomy were 67%, 30% and 3%, respectively. Forty-three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post-operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There were no operative deaths; 14 deaths were reported within the six-week post-operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95% CI 0.25-0.64). CONCLUSIONS This large study describes women who undergo hysterectomy in the UK, and presents results on early complications associated with the surgery. Operative complications occurred in one in 30 women, and post-operative complications in at least one in 10. Laparoscopic techniques tend to be associated with higher complication rates than other methods.
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Affiliation(s)
- M J A Maresh
- Royal College of Obstetricians and Gynaecologists, London, UK
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Soriano D, Goldstein A, Lecuru F, Daraï E. Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy:. Acta Obstet Gynecol Scand 2002. [DOI: 10.1034/j.1600-0412.2001.080004337.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Jugnet N, Cosson M, Wattiez A, Donnez J, Buick V, Mage G, Querleu D. Comparing vaginal and coelioscopic total or subtotal hysterectomies: prospective multicentre study including 82 patients. ACTA ACUST UNITED AC 2002. [DOI: 10.1046/j.1365-2508.2001.00472.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fahy U, Watkins K, Duffin S, Kirwan PH. Convalescence after laparoscopically assisted vaginal hysterectomy. ACTA ACUST UNITED AC 2001. [DOI: 10.1046/j.1365-2508.2000.00292.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Clayton RD, Hawe JA, Garry R. Laparoscopically assisted hysterectomy for the large uterus. ACTA ACUST UNITED AC 2001. [DOI: 10.1046/j.1365-2508.1999.00257.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cosson M, Boukerrou M, Lambaudie E, Narducci F, Crépin G. Hysterectomy for Benign Lesions: What Is Left for the Abdominal Route? J Gynecol Surg 2001. [DOI: 10.1089/104240601317207075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Møller C, Kehlet H, Friland SG, Schouenborg LO, Lund C, Ottesen B. Fast track hysterectomy. Eur J Obstet Gynecol Reprod Biol 2001; 98:18-22. [PMID: 11516794 DOI: 10.1016/s0301-2115(01)00342-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify factors limiting early discharge after laparoscopically assisted vaginal hysterectomy (LAVH) and abdominal hysterectomy, in a fast track setting with emphasis on information, treatment of pain, early mobilization, and early food intake. STUDY DESIGN A prospective, descriptive study of 32 unselected women allocated to either abdominal hysterectomy (n=16) or LAVH (n=16). The patients received the same information, care, and advice for the perioperative period except for an assumed 1-day hospital stay in the LAVH-group and 2 days in the abdominal group. RESULTS Patients were discharged median 1 day (1-3) after LAVH and 2 days (2-4) after abdominal hysterectomy. Work was resumed median 23 days after abdominal hysterectomy and 28 days after LAVH (P > 0.05). CONCLUSIONS The study questions the previously proposed advantages of shortened hospitalization and convalescence after LAVH compared with abdominal hysterectomy. Further studies with active rehabilitation are needed to demonstrate real differences between laparoscopic and open hysterectomy.
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Affiliation(s)
- C Møller
- Department of Obstetrics and Gynecology, HS-Hvidovre University Hospital, Kettegaard Alle 30, DK-2650, Hvidovre, Denmark.
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