Hysterectomy for benign conditions: Complications relative to surgical approach and other variables that lead to post-operative readmission within 90 days of surgery

Tools for assessing the quality of life of hysterectomized women: A systematic review

AIMS AND OBJECTIVES

Since hysterectomy surgery is a major and invasive procedure, it can affect the quality of life of women in many ways. This study aimed to review and critique the psychometric properties of tools used to measure the quality of life of hysterectomized women.

METHOD

An advanced search was conducted in international (PubMed, Web of Science, Scopus, PsycINFO, Embase) as well as national databases (SID and Magiran) to retrieve articles published from 2000 to 2024, using keywords related to hysterectomy and quality of life. Then, the psychometric properties of the tools found in these articles were evaluated by COSMIN checklist.

RESULTS

The psychometric properties of tools were analyzed using the COSMIN checklist. Among the 20 general and specific tools examined, content validity had not been evaluated in 15 tools, construct validity had not been evaluated in four tools, criterion validity had not been evaluated in eight tools, internal consistency had not been evaluated in five tools, responsiveness had not been evaluated in 16 tools, and interpretability had not been assessed in 18 tools, and measurement error had not been evaluated in any of the tools.

CONCLUSION

The results showed that none of the evaluated tools have all the criteria of Cosmin's checklist. Of course, construct validity and reliability had been assessed in most of the tools. Meanwhile, there was no tool to measure the quality of life of hysterectomized women specifically. Therefore, it seems that developing a tool with acceptable psychometric properties is necessary to measure the quality of life of hysterectomized women specifically.

Risk of Bowel Obstruction after Hysterectomy for Benign Indication According to Surgical Method in Denmark, 1984-2013

STUDY OBJECTIVE

To estimate the risk of bowel obstruction (BO) after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify risk factors for adhesive BO.

DESIGN

A national registry-based cohort.

SETTING

Danish hospitals during the period 1984-2013.

PATIENTS

Danish women who underwent hysterectomy for benign indications (N = 125 568).

INTERVENTIONS

Abdominal hysterectomies were compared with vaginal hysterectomies, laparoscopic hysterectomies, and minimally invasive (vaginal and laparoscopic) hysterectomies.

MEASUREMENTS AND MAIN RESULTS

The incidence of BO according to the surgical method was compared using Cox proportional hazard regression. The covariates included were the time period, age, concomitant operations, previous abdominal surgery or disease, and socioeconomic factors. In a subanalysis (n = 35 712 women) of the period 2004-2013, detailed information from the Danish Hysterectomy Database enabled the inclusion of patient-, surgery-, and complication-related covariates. The overall crude incidence of BO was 17.4 of 1000 hysterectomies (2196 incident cases). The 10-year cumulative incidence of BO differed among the surgical routes (abdominal, 1.7%; laparoscopic, 1.4%; and vaginal, 0.9%). In multiple-adjusted analyses, the risk of BO was higher after abdominal hysterectomy than after vaginal (hazard ratio 1.64 [95% confidence interval, 1.39-1.93]) and minimally invasive (vaginal or laparoscopic) hysterectomy (hazard ratio 1.54 [1.33-1.79]). Additional pre-existing risk factors for BO at the time of hysterectomy were increased age, low education, low income, smoking, high American Society of Anesthesiologists comorbidity score, history of infertility, abdominal infection, and previous abdominal surgery (apart from cesarean section), penetrating lesions in abdominal organs, or operative adhesiolysis. Perioperative risk factors at the time of hysterectomy included concomitant removal of the ovaries, adhesiolysis, blood transfusion, readmission, and overall presence of perioperative complications.

CONCLUSION

Abdominal hysterectomy is associated with a 54% higher risk of BO than minimally invasive (laparoscopic or vaginal) hysterectomy.

Complications of total laparoscopic hysterectomy: A retrospective study of cases performed by a single surgeon

Hysterectomy is the most common gynaecological surgery and there are different techniques of performing hysterectomy. With the advent of laparoscopic technology, laparoscopic hysterectomy (LH) is rapidly gaining its ground. However, every surgery has its complications which are specific but also depends on various factors such as surgical sk[ills and experience of surgeons, levels of operative laparoscopy and patient populations.

Aims and Objective

In this study, we evaluated the complications of total laparoscopic hysterectomy (TLH) and analysed the trend of complications, intraoperative and post-operative, over a period of time.

Methods

It was a retrospective study conducted in the private care setting. All women who underwent hysterectomy for benign conditions from a 1 January 2003 to 31 December 2017, (15 years) were included in this study. A total of 3272 patients were operated during this period. All surgeries were performed by a single surgeon.

Results

Intraoperative complications that occurred during surgery during the study period were 3 cases (0.09%) had bladder injury, 3 cases (0.09%) had bowel injury, 1 case (0.03%) had internal iliac vessel bleeding and 1 case(0.03%) needed conversion to vaginal hysterectomy due to cautery failure and post operative complications were 90 cases (2.75%) had vault bleeding, 2 cases (0.06%) had intestinal obstruction, 5 cases (0.15%) had paralytic ileus, 1 case (0.03%) had vesicovaginal fistula, 1 case(0.03%) had ureterovaginal fistula and 1 case (0.03%) had peritonitis.

Conclusions

TLH is a very effective, patient-friendly and safe technique in the hands of experienced surgeons giving good quality of life to patients postoperatively.

Surgical approach to hysterectomy for benign gynaecological disease

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.

Assessment of Adverse Events in a Matched Cohort of Women Undergoing Concurrent Midurethral Sling at the Time of Minimally Invasive Benign Gynecologic Surgery

IMPORTANCE

Procedures for stress urinary incontinence and benign gynecologic surgery are often performed concurrently, and associated complication rates have previously been unexplored.

OBJECTIVE

The aim of this study was to compare postoperative complication rates between women undergoing midurethral sling (MUS) placement at the time of benign gynecologic surgery and those undergoing MUS alone.

STUDY DESIGN

This was a retrospective matched cohort study of women undergoing MUS with or without concurrent minimally invasive benign gynecologic surgery from January 2010 through December 2020. Eligible women undergoing concurrent surgery were matched to a cohort of women undergoing MUS placement alone. The electronic medical record was queried for demographic and perioperative/postoperative data up to 12 months after surgery.

RESULTS

Thirty-eight women met inclusion criteria for the concurrent group, and 152 women were matched accordingly. The overall adverse event rate was 39.5% (95% confidence interval [CI], 0.25-0.55) for the concurrent group and 24.3% (95% CI, 0.18-0.32) for the MUS-only group ( P = 0.05). Adverse events with Clavien-Dindo grade ≤ 2 were higher in the concurrent group (Clavien-Dindo Grade 1: 5% vs 0%, P = 0.04; Clavien-Dindo Grade 2: 16% vs 6%, P = 0.04), as was composite postoperative resource utilization (76% vs 49%, P = 0.003). Mesh exposure ( P = 0.03) and sling lysis/excision rates ( P = 0.02) were higher in the concurrent group. On logistic regression, concurrent surgery cases remained significantly associated with sling mesh erosion (adjusted odds ratio, 12.6; 95% CI, 1.4-116.4).

CONCLUSIONS

Midurethral sling placement at the time of minimally invasive benign gynecologic surgery is safe but is associated with a higher incidence of postoperative hospital resource utilization and sling mesh extrusion, and a need for revision.

Trends and predictors of hysterectomy prevalence among women in the United States

BACKGROUND

Hysterectomy is the most common nonobstetrical medical procedure performed in US women. Evaluating hysterectomy prevalence trends and determinants is important for estimating gynecologic cancer rates and management of uterine conditions.

OBJECTIVE

This study aimed to assess hysterectomy prevalence trends and determinants using the Behavioral Risk Factor Surveillance System (2006-2016).

STUDY DESIGN

We estimated crude hysterectomy prevalences and multivariable-adjusted odds ratios and 95% confidence intervals for associations of race or ethnicity, age group (5-year), body mass index (categorical), smoking status, education, insurance, income, and US region with hysterectomy. Missing data were imputed. The number of women in each survey year ranged from 220,302 in 2006 to 275,631 in 2016.

RESULTS

Although overall hysterectomy prevalence changed little between 2006 and 2016 (21.4% and 21.1%, respectively), hysterectomy prevalence was lower in 2016 than in 2006 among women aged ≥40 years, particularly among non-Hispanic Black and Hispanic women. Current smoking (odds ratio, 1.38; 95% confidence interval, 1.35-1.41), increasing age (odds ratio, 1.40; 95% confidence interval, 1.39-1.40), living in the South compared with the Midwest (odds ratio, 1.36; 95% confidence interval, 1.34-1.39), higher body mass index (odds ratio, 1.26; 95% confidence interval, 1.25-1.27), Black race compared with White (odds ratio, 1.10; 95% confidence interval, 1.07-1.13), and having insurance compared with being uninsured (odds ratio, 1.26; 95% confidence interval, 1.22-1.30) were most strongly associated with increased prevalence. Hispanic ethnicity and living in the Northeast were most strongly associated with decreased prevalence (odds ratio, 0.73; 95% confidence interval, 0.70-0.76; odds ratio, 0.67; 95% confidence interval, 0.65-0.69).

CONCLUSION

Nationwide hysterectomy prevalence decreased among women aged ≥40 years from 2006 to 2016, particularly among non-Hispanic Black and Hispanic women. Age, non-Hispanic Black race, having insurance, current smoking, and living in the South were associated with increased odds of hysterectomy, even after accounting for possible explanatory factors. Further research is needed to better understand associations of race and ethnicity and region with hysterectomy prevalence.

Effect of intravenous ascorbic acid administration on hemorrhage and wound complications in total abdominal hysterectomy: A prospective randomized clinical trial

OBJECTIVE

Previous studies mentioned the beneficial effects of vitamin C on the hemorrhage and wound healing. We evaluated the effects of vitamin C on the hemorrhage, hemoglobin concentration, and wound complications in total abdominal hysterectomy.

MATERIALS AND METHODS

In this randomized, double-blind, placebo-controlled trial, 80 patients with total abdominal hysterectomy were randomly divided into the study and control groups to receive either intravenous 2 g of vitamin C in normal saline or solely normal saline therapy. The first 1-g dose of ascorbic acid was administrated the night before surgery, and the second 1 g was administrated during surgery.

RESULTS

The mean age of the participants was 37.8 ± 4.8 years with a mean preoperative plasma vitamin C concentration of 5.07 ± 2.1 mg/dL, close to the subclinical deficiency. The basal characteristics of both groups were the same. The hemorrhage volume was slightly higher in the control group (345.2 ± 31.8 ml vs. 388.1 ± 28.3 ml, P < 0.001).

CONCLUSION

Intravenous vitamin C administration had a positive effect on reducing hemorrhage during total abdominal hysterectomy.

TRIAL REGISTRATION

Clinicaltrials.gov.identifier: NCT03965637.

Development of a Chronic Canine Ovariohysterectomy Model to Evaluate Vaginal Cuff Healing Using Two Closure Systems

Background and Purpose. This study established a suitable animal model of ovariohysterectomy; characterized the course and pattern of vaginal healing after ovariohysterectomy; and compared healing obtained after closure of the vaginal cuff with a novel cuff-closure device (Zip-stitch® clips) and VICRYL® sutures. Research Design and Study Sample. This prospective, randomized, controlled, blinded animal study was conducted in 27 mongrel hounds according to an IACUC-approved protocol. Each animal underwent ovariohysterectomy followed by vaginal cuff closure with Zip-stitch or VICRYL. At two or six weeks, animals were sacrificed for gross and histological analysis. Data Collection. The primary endpoint was the difference in the fraction of vaginal cuff healed six weeks after application of the closure device. Secondary endpoints included histopathologic cellular and tissue responses, including inflammation, necrosis, infection, and vascular and muscle changes. Results. In the test group, there were two distinct locations where fibrotic or granular tissue fusion between the anterior and posterior vaginal walls was observed: in tissue "captured" by a clip or in tissue around the clip. The fraction of the vaginal cuff healed was similar in animals treated with Zip-stitch clips and those treated with sutures at six weeks (68±10% vs 67±18%; P=.148, test for non-inferiority) after surgery. The test article performed similarly or better than the control article in terms of the intensity or extent of the secondary endpoints. Conclusions. Subject to further confirmation, this study supports Zip-stitch clips as a method to maintain immediate post-operative approximation of the vaginal cuff leading to healing but did not achieve statistical significance in its primary endpoint.

Short stay laparoscopic hysterectomy: An evaluation of feasibility and patient satisfaction

Background

Short-stay total laparoscopic hysterectomy (TLH) could lead to reduced hospital costs and decrease complications associated with hospitalisation such as hospital acquired-infection and venous thromboembolism.

Objective

To evaluate the feasibility, safety and patient satisfaction of a novel short ‘less than 23-hour’ stay TLH protocol.

Material and Methods

Prospective cohort study, at Birmingham Women’s Hospital, United Kingdom including eligible women undergoing TLH for benign indications or early stage cervical/endometrial cancer.

Main outcome measures

Feasibility of discharge within 23-hours following TLH. Surgical complications and readmission rates were collected within 30-days of hysterectomy and patient’s satisfaction was assessed at 6-weeks.

Results

Of the 128 eligible women, 104/128 women (81%) were discharged within 23-hours of admission, of which 62/104 or 60% (48.4% of the whole cohort) were discharged on the same day. Adenomyosis/fibroids, and previous caesarean sections were associated with a greater likelihood of stay beyond 23-hours (P<0.05). The overall complications rate was 13/128 (10%) with two grade-3 Clavien-Dindo intraoperative complications; one serosal bowel injury oversewn and one ureteric injury requiring reimplantation. The readmissions rate was 5/128 (4%). 94% of patients were ‘happy’ or ‘very happy’ with the pathway, although satisfaction was higher in short-stay patients (RR 1.2; 95% CI 0.95–1.94).

Conclusion

Hospital discharge within 23-hours of TLH appears to be safe, feasible and acceptable to patients where a standardised, multidisciplinary care protocol is used.

What is new?

Our study is the first prospective case series in the UK reporting the safety and acceptability for performing laparoscopic hysterectomy as a 23-hour day case procedure.

Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery

INTRODUCTION

Health disparities exposed by the Covid-19 pandemic have prompted healthcare professionals to investigate disparities within their own specialty. Racial and ethnic disparities in obstetrics are well documented but inequities in gynaecology are less well known. Our aim is to review the literature on two commonly performed procedures, hysterectomy and myomectomy, and one condition, ectopic pregnancy, to evaluate the prevalence of racial, ethnic and socioeconomic disparities in benign gynaecology and minimal access surgery.

METHODS

A narrative review of 33 articles identified from a Pubmed using the following search criteria; "race"; "ethnicity"; "socioeconomic status"; "disparity"; "inequity"; and "inequality". Case reports and papers assessing gynaecological malignancy were excluded.

RESULTS

Despite minimal access surgery having fewer complications and faster recovery than open surgery, US studies have shown that black and ethnic minority women are less likely than white women to have minimally invasive hysterectomies and myomectomies. Uninsured women and patients on Medicaid are also less likely to receive minimally invasive procedures. Contributing factors include fibroid size, geographic location and access to hospitals performing minimal access surgery, and the discontinuation of power morcellation. Ethnic minority women who receive minimally invasive myomectomy have been shown to have a higher risk of complications and prolonged recovery. Black and ethnic minority women also have a higher risk of morbidity and mortality from ectopic pregnancy and are more likely to receive surgical than medical management.

CONCLUSION

Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes.

The health concerns related to hysterectomy among Taiwanese women with uterine fibroids- a mixed-methods study

This study aimed to assess health concerns after hysterectomy from different perspectives among Taiwanese women with uterine fibroids. A mixed-methods was used in this study. In a cross-sectional study, 95 patients completed a structured questionnaire (Health Concern Questionnaire-HCQ). Face-to-face interviews with 5 patients were implemented for the qualitative component from OBS-GYN outpatient departments at two hospitals in Northern Taiwan. Participants who met the following criteria, 20 years of age or older, conscious alert without mental disturbances were recruited to this study. Descriptive statistics were calculated for social demographic variables and HCQ. A content analysis was used to analyze the qualitative data. The mean age was 46.28 of 95 patients. Findings of the present study showed that the most health concerns among patients with UFs after hysterectomy are hysterectomy-related complications, follow by impacts on daily life, body image and female identity, and intimacy and sexual relations. The findings of qualitative interviews supported the above findings. In addition, the information needs of post-operative self-care were identify in this qualitative interviews. The results of this research study could help healthcare professionals to address women's health concerns and provide adequate care for Taiwanese women with uterine fibroids after hysterectomy.

Racial/Ethnic Differences in the Risk of Surgical Complications and Posthysterectomy Hospitalization among Women Undergoing Hysterectomy for Benign Conditions

STUDY OBJECTIVE

Evaluate whether 30- and 90-day surgical complication and postoperative hospitalization rates after hysterectomy for benign conditions differ by race/ethnicity and whether the differences remain after controlling for patient, hospital, and surgical characteristics.

DESIGN

Retrospective cohort study using administrative data. The exposure was race/ethnicity. The outcomes included 5 different surgical complications/categories and posthysterectomy inpatient hospitalization, all identified through 30 and 90 days after hysterectomy hospital discharge, with the exception of hemorrhage/hematoma, which was only identified through 30 days. To examine the association between race/ethnicity and each outcome, we used logistic regression with clustering of procedures within hospitals, adjusting for patient and hospital characteristics and surgical approach.

SETTING

Multistate, including Florida and New York.

PATIENTS

Women aged ≥18 years who underwent hysterectomy for benign conditions using State Inpatient Databases and State Ambulatory Surgery Databases.

INTERVENTIONS

Hysterectomy for benign conditions.

MEASUREMENTS AND MAIN RESULTS

We included 183 697 women undergoing hysterectomy for benign conditions from January 2011 to September 2014. In analysis, adjusting for surgery route and other factors, black race was associated with increased risk of 30-day digestive system complications (multivariable adjusted odds ratio [aOR], 1.98; 95% confidence interval [CI], 1.78-2.21), surgical-site infection (aOR, 1.34; 95% CI, 1.18-1.53), posthysterectomy hospitalization (aOR, 1.31; 95% CI, 1.22-1.40), and urologic complications (aOR, 1.16; 95% CI, 1.01-1.34) compared with white race. Asian/Pacific Islander race was associated with increased risk of 30-day urologic complications (aOR, 1.48; 95% CI, 1.08-2.03), intraoperative injury to abdominal/pelvic organs (aOR, 1.46; 95% CI, 1.23-1.75), and hemorrhage/hematoma (aOR, 1.33; 95% CI, 1.06-1.67) compared with white race. Hispanic ethnicity was associated with increased risk of 30-day posthysterectomy hospitalization (aOR, 1.11; 95% CI, 1.02-1.20) compared with white race. All findings were similar at 90 days.

CONCLUSION

Black and Asian/Pacific Islander women had higher risk of some 30- and 90-day surgical complications after hysterectomy than white women. Black and Hispanic women had higher risk of posthysterectomy hospitalization. Intervention strategies aimed at identifying and better managing disparities in pre-existing conditions/comorbidities could reduce racial/ethnic differences in outcomes.

Experiencia de pacientes sometidas a histerectomía laparoscópica en el Hospital Universitario San José de Popayán entre 2014 y 2018

Introducción. La histerectomía es un procedimiento común en la práctica ginecológica para el manejo de condiciones benignas y malignas. En la actualidad, se ha demostrado que el abordaje mínimamente invasivo es mejor que la cirugía abierta, ya que presenta menos complicaciones intraoperatorias y posoperatorias.Objetivo. Describir la experiencia de pacientes sometidas a histerectomía laparoscópica entre 2014 y 2018 en el Hospital Universitario San José de Popayán Empresa Social del Estado.Materiales y métodos. Estudio observacional descriptivo de serie de casos que incluyó 36 pacientes intervenidas entre enero de 2014 y abril de 2018. Se evaluaron variables sociodemográficas y clínicas. Para medir el grado de satisfacción posoperatoria y la calidad de vida se realizó una encuesta telefónica.Resultados. La edad promedio de las entrevistadas fue 45 años, el tiempo quirúrgico promedio fue 124 minutos, la tasa de complicaciones intraoperatorias fue 2.78% (n=1) y la estancia hospitalaria promedio fue 1.3 días. Los principales diagnósticos preoperatorios fueron carcinoma in situ (28%) y leiomiomatosis (17%). En cuanto al grado de satisfacción, el 92% refirió mejoría en la calidad de vida y el 64% manifestó tener una recuperación posoperatoria rápida.Conclusión. Para la población estudiada, la histerectomía laparoscópica fue un procedimiento seguro con una baja tasa de complicaciones y un alto grado de satisfacción posoperatoria.

Importance of Estimated Blood Loss in Resource Utilization and Complications of Hysterectomy for Benign Indications

OBJECTIVE

To identify the variation in estimated blood loss at the time of hysterectomy for benign indications and to analyze how blood loss is associated with measures of resource utilization and complications.

METHODS

We conducted a retrospective cohort study and analyzed hysterectomy for benign indications at hospitals in the Michigan Surgical Quality Collaborative between January 1, 2013, and May 30, 2015. A sensitivity analysis was performed to identify how estimated blood loss was associated with measures of utilization (transfusion, readmission, reoperation, and length of stay) and postoperative complications. A hierarchical logistic regression model was used to identify patient level factors independently associated with estimated blood loss greater than 400 mL and to calculate a risk- and reliability-adjusted rate for each hospital.

RESULTS

There were 18,033 hysterectomies for benign indications from 61 hospitals included for analysis. The median estimated blood loss was 100 mL, and the 90th percentile estimated blood loss was 400 mL. A sensitivity analysis demonstrated increased risks of transfusion, readmission, reoperation, length of stay, and major postoperative complications with estimated blood loss greater than 400 mL. The proportion of hysterectomies at hospitals in the collaborative with estimated blood loss greater than 400 mL ranged from 3.5% to 16.9% after risk and reliability adjustments. The risk factors with the highest adjusted odds for estimated blood loss greater than 400 mL included abdominal surgery compared with laparoscopic hysterectomy (adjusted odds ratio [aOR] 2.8, CI 2.3-3.5), surgical time longer than 3 hours (aOR 3.9, CI 3.3-4.5), and specimen weight greater than 250 g compared with less than 100 g (aOR 4.8, CI 3.9-5.8). Adhesive disease, low surgeon volume, being younger than 40 years of age, having a body mass index greater than 35, and the need for a preoperative transfusion were also statistically significantly associated with estimated blood loss greater than 400 mL.

CONCLUSION

There is fivefold variation in the hospital rate of hysterectomies with an estimated blood loss greater than 400 mL (90th percentile)-a threshold associated with significantly higher rates of health care utilization and complications. Avoidance of abdominal hysterectomy when possible may reduce intraoperative blood loss and associated sequelae.

Application of failure mode and effect analysis in total laparoscopic hysterectomy in benign conditions

BACKGROUND

Hysterectomy is the most common major gynecological operation in developed countries. The rate of intraoperative complications related to the laparoscopic approach during hysterectomy is a relevant issue. The failure mode and effect analysis (FMEA) method is a prospective approach, which tries to identify possible errors before they occur.

METHODS

In this study we applied the FMEA method to laparoscopic approach to hysterectomy in order to reduce the theorized risk of intraoperative complications. We selected a team who analyzed and deconstructed the total laparoscopic hysterectomy (TLH) process recording on the FMEA worksheet phases and activities of the entire procedure. Each activity-related failure mode and their potential effects were developed. The team also described actions to eliminate or decrease the likelihood of mistakes.

RESULTS

A numerical value reflecting the risk was assigned to each activity. Five activities were identified as high priority risk, and for each activity actions were then taken to mitigate the identified risk. After introduction of these actions, the risk scores for each activity were recalculated, and we obtained a total risk reduction of 55%.

CONCLUSIONS

It is our opinion that the systematic implementation of the FMEA model can reduce the risk of human error during laparoscopic surgery, improving patient safety.

Sodium Fluorescein for Ureteral Jet Detection: A Prospective Observational Study

Background and Objectives:

Laparoscopic hysterectomy poses the risk of lower urinary tract injury, and intraoperative recognition of urinary tract injury is often difficult. We sought to evaluate sodium fluorescein coloration of ureteral jets during cystoscopy after laparoscopic hysterectomy and to evaluate surgeons' satisfaction with this method of injury detection.

Methods:

This was an observational study, in which data were collected prospectively. A total of 30 women who underwent laparoscopic hysterectomy from August 2016 to February 2017 at the Centre Hospitalier de l'Université Laval (CHUL) de Québec. Twenty-five milligrams of 10% intravenous sodium fluorescein was administered after vaginal cuff closure. Cystoscopy was then systematically performed, and the time to visualization (time from injection to coloration of ureteral jet), the quality of coloration, and the duration of cystoscopy were recorded. Side effects were systematically recorded and rigorously analyzed.

Results:

Most frequent indications for hysterectomy were fibroids and endometriosis with uterine weight from 76 to 885 g. Ninety-three percent of patients (n = 28) had bilateral ureteral jet coloration, whereas 1 patient had no coloration bilaterally, and another patient had a complete unilateral obstruction immediately diagnosed and resolved intraoperatively after removal of the vaginal sutures. In 90% of cases (n = 27), surgeons were highly satisfied with the use of sodium fluorescein. The average time between visualization of both left and right ureteral jets was 1 minute. Side effects included hypotension (n = 3) and yellow coloration of urine (n = 15).

Conclusion:

Our study suggests that sodium fluorescein is an effective dye for documenting ureteral patency and improving visualization of ureteral jets during cystoscopy upon completion of laparoscopic hysterectomy.