The Effect of Perioperative Fluid Management on Intraocular Pressure during Gynecologic Laparoscopic Pelvic Surgery

Complete Vision Loss after Laparoscopic Hysterectomy

Postoperative vision loss (POVL) is a rare but devastating complication that has only recently been reported following laparoscopic surgery. We present the case of a 34-year-old gravida 6 para 4 female who experienced POVL following an uncomplicated laparoscopic hysterectomy. Operating time was 174 minutes, and EBL was 75 mL. After surgery, she complained of complete vision loss with no light perception. No cerebral hemorrhage or ischemia was detected on imaging. Funduscopic exam revealed no structural abnormalities. On postoperative day 7, she received an IV methylprednisolone taper. The following morning, she reported mild light perception. Later that night, she reported a partial return of visual acuity and was discharged home. At her 2-week postoperative visit, her vision had returned to baseline. POVL is an emergency and prompt evaluation should be initiated to optimize outcome.

Risk of Upper-body Adverse Events in Robot-assisted Total Laparoscopic Hysterectomy for Benign Gynecologic Disease

STUDY OBJECTIVE

Recent studies suggest that prolonged Trendelenburg positioning during robot-assisted total laparoscopic hysterectomy (RA-TLH) may lead to fluid shifts and pulmonary, airway, head and neck, and cranial complications in the upper body. This study examined the upper-body complications during RA-TLH for benign gynecologic disease.

DESIGN

Population-based retrospective study.

SETTING

The National Inpatient Sample.

PATIENTS

A total of 771 412 women who had total hysterectomy for benign gynecologic disease from October 2008 to September 2015, including 661 284 women who had total abdominal hysterectomy (TAH), 51 544 women who had traditional TLH, and 58 584 women who had RA-TLH.

INTERVENTIONS

A multiple-group generalized boosted model to balance the measured baseline covariates across the 3 hysterectomy groups and a generalized estimating equation model to assess the effect size of complication risk (overall and upper-body complications).

MEASUREMENTS AND MAIN RESULTS

Women in the RA-TLH group were more likely to be older, white, and have a higher comorbidity index (all, p <.001). The overall rate of upper-body complications was 4.6% across the 3 groups. RA-TLH was not associated with increased risk of upper-body complications compared with traditional TLH (odds ratio [OR] 1.06; 95% confidence interval [CI], 0.90-1.26) or TAH (OR 0.98; 95% CI, 0.87-1.11). In contrast, RA-TLH was associated with decreased risk of overall perioperative complications compared with TAH (12.0% vs 18.6%; OR 0.64; 95% CI, 0.59-0.70; p <.001). RA-TLH and traditional TLH had similar risk of overall perioperative complications (12.0% vs 13.1%; OR 0.91; 95% CI, 0.8-1.02; p = .099). Women who developed upper-body complications had a higher perioperative mortality rate (0.4% vs <0.01%; OR 79.1; 95% CI, 36.0-174). The highest rates of complications (62.5%) were observed in morbidly obese women aged 70-79 with a comorbidity index of ≥4.

CONCLUSION

In hysterectomy for benign gynecologic disease, RA-TLH was not associated with an increased risk of upper-body complications compared with TAH or traditional TLH. However, older age and higher comorbidity are key risk factors that increase the risk of upper-body complications which carry a disproportionally high mortality rate.