Outcomes of robotic, laparoscopic, and open hysterectomy for benign conditions in obese patients

Comparison of surgical and oncological outcomes between different surgical approaches for overweight or obese cervical cancer patients

The purpose was to investigate the safety and advantages of different surgical approaches applied to overweight or obese cervical cancer patients by comparing their surgical and oncological outcomes. This is a retrospective cohort study. 382 patients with a body mass index of at least 24.0 kg/m2 and stage IB-IIA (The International Federation of Gynecology and Obstetrics, FIGO 2009) cervical cancer were enrolled, and then were divided into three groups: open radical hysterectomy (ORH) group, laparoscopic radical hysterectomy (LRH) group, and robot-assisted radical hysterectomy (RRH) group according to the surgical approach. IBM SPSS version 25.0 was used to analyze data. There were 51 patients in ORH group, 225 patients in LRH group and 106 patients in RRH group. In the comparison of surgical outcomes, compared to LRH and ORH, RRH had the shortest operating time, the least estimated blood loss, the shortest postoperative hospital stay, and the shortest recovery time for bowel function (P < 0.05). In the comparison of postoperative complications, ORH has the highest rate of postoperative infection and wound complication compared to LRH and RRH (P < 0.05), and RRH has the highest proportion of urinary retention. After a median follow-up time of 61 months, there was no statistically significant difference between the three groups in terms of 5-year overall survival (OS) rate and 5-year recurrence-free survival (RFS) rate, (P = 0.262, P = 0.453). In patients with overweight or obese cervical cancer, the long-term outcomes of the three surgical approaches were comparable, with RRH showing significant advantages over ORH and LRH in terms of surgical outcomes.

Effect of two different modalities of hysterectomy on wound infection and wound dehiscence in obese patients

This research intended to investigate the influence of the operation of both kinds of hysterectomies in the risk of wound infection and the degree of wound dehiscence. Both of them were open field and laparoscope. In this research, we looked into four databases: PubMed, Web of Science, Embase and Cochrane Library. Research was conducted on various operative methods for hysterectomy in obese patients between 2000 and October 2023. Two independent investigators performed an independent review of the data, established the inclusion and exclusion criteria, and managed the results with Endnote software. It also evaluated the quality of the included literature. Finally, the data were analysed with RevMan 5.3. This study involved 874 cases, 387 cases received laparoscopy and 487 cases received open access operation. Our findings indicate that there is a significant reduction in the rate of post-operative wound infection among those who have received laparoscopy compared with who have received open surgical procedures (odds ratio [OR], 0.04; 95% confidence interval [CI], 0.01-0.15; p < 0.001); There was no statistical difference between the rate of post-operative wound dehiscence and those who received laparotomy compared with those who received open surgical procedures (OR, 0.33; 95% CI, 0.10-1.11; p = 0.07); The estimated amount of blood lost during the operation was less in the laparoscopy group compared with the open procedure (mean difference, -123.72; 95% CI, -215.16 to -32.28; p = 0.008). Generally speaking, the application of laparoscopy to overweight women who have had a hysterectomy results in a reduction in the expected amount of bleeding during surgery and a reduction in the risk of post-operative wound infections.

Comparison of surgical outcomes between robot-assisted and conventional laparoscopic hysterectomy for large uterus

We compared the effectiveness of conventional total laparoscopic hysterectomy (TLH) against robot-assisted total hysterectomy (RAH) in patients with a large uterus. According to the subtype of minimally invasive hysterectomy performed for benign indications, the patients (n = 843) were grouped as follows: TLH (n = 340) and RAH (n = 503). The median operative time (OT) for TLH was 98 min (47-406 min), and the estimated blood loss (EBL) was 50 mL (5-1800 mL). The median OT for RAH was 90 min (43-251 min), and the EBL was 5 mL (5-850 mL), with a significantly shorter OT and a lower EBL in RAH than in TLH. Uterine weight was categorized into four groups in increments of 250 g. The number of cases in each group was 163 (< 250 g), 116 (250-500 g), 41 (500-750 g), and 20 (≥ 750 g) for TLH, and 308 (< 250 g), 137 (250-500 g), 33 (500-750 g), and 25 (≥ 750 g) for RAH. In patients with a uterus < 250 g, there was no significant difference in OT between TLH and RAH, but in patients with a uterus ≥ 250 g, OT tended to be shorter with RAH, which was also true for a uterus ≥ 750 g. The EBL was significantly lower with RAH compared to TLH, regardless of uterine weight. In patients with a large uterus, the advantages of robotic surgery can be utilized, which may lead to a shorter OT and less EBL.

Comparison of surgical outcomes between robot-assisted laparoscopic hysterectomy and conventional total laparoscopic hysterectomy in gynecologic benign disease: a single-center cohort study

We compared the surgical outcomes of robot-assisted laparoscopic hysterectomy (RAH) and total laparoscopic hysterectomy (TLH). This single-center cohort study compared 139 RAH cases from January, 2017 to September, 2021 and 291 TLH cases between January, 2015 and December, 2020. We retrospectively evaluated surgical outcomes, including total operative time (defined as the time from port wound incision to port wound closure), net operative time (defined as the time from the start of pneumoperitoneum to the end of pneumoperitoneum), estimated blood loss, weight of excised uterus (±adnexa), and overall complications, and the relationship between surgeon experience and operative time, net operative time, and blood loss in RAH and TLH. There was no significant difference in the total operative time between the two groups. Regardless of surgeon experience, the net operative time was significantly shorter in the RAH group than in the TLH group (p <0.001) and the estimated blood loss was significantly lower in RAH cases than in TLH cases (p = 0.01). The net operative time per uterine weight was shorter in the TLH group than that in the RAH group; however, there was no significant difference. RAH resulted in statistically better surgical outcomes in terms of net operative time and blood loss, regardless of surgeon experience. However, net operative time and blood loss also seem to be significantly affected by uterus weight. Large trials are imperative to determine the more effective surgical approach between RAH and TLH for different patient subsets.

vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE

To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30.

DESIGN

A retrospective cohort study.

SETTING

A French teaching hospital.

PATIENTS

All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma).

INTERVENTIONS

Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m²). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management.

MEASUREMENTS AND MAIN RESULTS

A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150).

CONCLUSION

The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Where are we going with sentinel nodes mapping in ovarian cancer?

Lymph node involvement is a major predictive indicator in early-stage epithelial ovarian cancer (EOC). There is presently no effective way to determine lymph node involvement other than surgical staging. As a result, traditional ovarian cancer surgery still includes pelvic and paraaortic lymphadenectomy. However, it might be linked to higher blood loss, lengthier operations, and longer hospital stays. The creation of a technique for accurately predicting nodal status without significant lymphadenectomy is thus the subject of ongoing research. Sentinel lymph nodes (SLN) mapping is a routine procedure in oncological surgery and has been proven to be effective and safe in cervical, vulvar, and uterine cancer. On the other hand, SLN mapping is not yet widely accepted and recognized in EOC. A thorough search of the literature was conducted between January 1995 to March 2022, using PubMed and Embase. This review included studies on lymphatic outflow of the ovaries and the sentinel lymph node method. A total of 13 studies involving 212 patients who underwent sentinel lymph node mapping for ovaries were included. Both open and laparoscopic approach are used. The most popular injection site is the ovarian ligaments, and a variety of agents are utilized, although the main markers were, technetium-99m radiocolloid (Tc-99m) or indocyanine green, either alone or in combination. Overall detection rate for SLN in ovaries is 84.5% (interquartile range: 27-100%). We suggest a standardized method for sentinel lymph node mapping in ovarian cancer. The detection rates, characterization and true positive rates of the approach in investigations support further study. The use of ultra-staging is essential for lower-volume metastasis and reproducibility. To ascertain the clinical utility of sentinel node in early ovarian cancer, larger collaborative prospective clinical trials are necessary.

Impact of Obesity on Clinical and Financial Outcomes of Minimally Invasive Hysterectomy for Benign Conditions

OBJECTIVE

To evaluate the effect of obesity on clinical and financial outcomes of minimally invasive hysterectomy METHODS: This was a retrospective cohort study of 5 affiliated hospitals. We obtained demographic, operative, and financial characteristics to analyze the effects of obesity on outcomes, including operating room (OR) time, estimated blood loss (EBL), length of stay (LOS), adverse perioperative events, and hospital charges. Obesity was stratified by the following classes: no obesity (BMI <30 kg/m2), class I (BMI 30-34 kg/m2), class II (BMI 35-39 kg/m2), and class III (BMI >40 kg/m2). Descriptive statistics and multivariate logistic and linear regressions were performed.

RESULTS

A total of 2483 women underwent benign, minimally invasive hysterectomy. Laparoscopic was the most common approach (79.8%), followed by robotic (12.2%), and vaginal (8.0%). Mean BMI was 30.13 ± 6.99 kg/m2, and total charges were US $13 928 ± $5954. Each additional minute in the OR increased costs by US $47.89 (P < 0.001). Compared with patients without obesity, OR time and EBL were significantly higher among patients with class I or II obesity and highest among patients with class III obesity (P < 0.001). Obesity did not affect LOS or occurrence of adverse perioperative events. Although obesity appeared to be a significant predictor of hysterectomy charges, after adjusting for covariates, charges for laparoscopic and robotic hysterectomy did not differ significantly by BMI.

CONCLUSION

Obesity appears to have a significant effect on clinical outcomes of benign hysterectomy that is approach-dependent and most notable among patients with class III obesity. BMI was not, however, a predictor of financial outcomes.

Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study

BACKGROUND

Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO₂/FiO₂ and FEV1/FVC, respectively in patients undergoing RAH.

METHODS

Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg^-1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO₂ of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH₂O. Patients in group R received recruitment maneuvers of 30 cmH₂O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored.

RESULTS

Patients who received RM had significantly higher PaO₂ (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p = 0.55).

CONCLUSION

This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Outcomes of robotic and laparoscopic surgery for benign gynaecological disease: a systematic review

Benign gynaecological diseases are usually treated with minimally invasive approaches. Robotic surgery seems an alternative to laparoscopic surgery. No definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases. In this scenario, we performed a systematic review in order to assess the advantages and disadvantages of laparoscopy versus robotic surgery and conclude whether laparoscopy should be replaced by robotic surgery for the treatment of benign gynaecological conditions, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement. We included 64 studies: no significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeons, while it is more expensive and characterised by longer operative time. In conclusion, current evidence indicates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic surgeries for benign gynaecological diseases. Impact statementWhat is already known on this subject? Benign gynaecological diseases are usually treated with minimally invasive approaches. Nevertheless, no definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases.What do the results of this study add? No significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeon, while it is more expensive and characterised by longer operative time.What are the implications of these findings for clinical practice and/or further research? Robotic surgery should not replace laparoscopy for the treatment of benign gynaecological conditions; in addition, gynaecologic surgeon should offer robotic surgery for benign diseases only after a proper counselling and a balanced decision-making process involving the patient.

Comparison of health-related quality of life of women undergoing robotic surgery, laparoscopic surgery or laparotomy for gynecologic conditions: A cross-sectional study

OBJECTIVE

To assess and compare the health-related quality of life of women undergoing robotic gynecologic surgery, laparoscopic gynecologic surgery or laparotomy for benign and cancerous conditions.

METHODS

Cross-sectional study design was used. The present study was carried out with 240 women, who underwent gynecologic surgery (robotic 48, laparoscopic 96, and laparotomy 96) in a tertiary care hospital. Instruments included a participant description questionnaire and Medical Outcomes Study Short Form-36. The data were collected 4 weeks after surgery, at the first postoperative visit of women to the clinic. Pearson χ² test, one-way analysis of variance, and regression analysis were used to assess the data.

RESULTS

Over half of the women in each group had surgery because of gynecologic cancer. All the subscale scores of Medical Outcomes Study Short Form-36 were significantly higher in the robotic group than the other surgical groups (P < 0.05). Women in the robotic group had better quality of life in terms of both the physical component and the mental component after surgery.

CONCLUSIONS

Knowledge of health-related quality of life in the recovery period after surgery is important for healthcare providers to provide adequate preventive measures, information, and follow up.

Surgical and Patient Outcomes of Robotic Versus Conventional Laparoscopic Hysterectomy: A Systematic Review

Hysterectomy is a commonly performed gynecologic surgery that can be associated with significant morbidity and mortality. However, the evolution of the surgical approach, from open to minimally invasive gynecologic surgery (MIGS), has substantially improved patient outcomes by reducing perioperative complications, pain, and length of hospitalization. The evident advantages and the approval of the da Vinci Surgical System by the Food and Drug Administration led to the exponential rise in the use of MIGS. In particular, robotic hysterectomy (RH) witnessed unparalleled popularity compared to other MIGS despite the lack of strong evidence demonstrating its superiority. Therefore, we conducted a systematic review of the literature to evaluate and compare various patient and surgical outcomes of RH with conventional laparoscopic hysterectomy (CLH), including operating time, estimated blood loss, length of hospitalization, overall complications, survival, and cost. Overall, the outcomes were comparable between RH and CLH except concerning cost. RH is significantly more expensive than CLH due to the higher costs of robotic equipment, including disposable instruments, equipment maintenance, and sterilization. Although RH demonstrated comparable outcomes and higher costs, its technical advantages such as improved ergonomics, three-dimensional view, a wider range of wristed mobility, mechanical lifting of robot's hand, and greater stability might benefit patient subsets (e.g., obesity, large uterine weights >750 g). Therefore, large and multicentered randomized control trials are imperative to determine the most effective surgical approach between RH and other MIGS for different patient subsets.

Infectious complications of laparoscopic and robotic hysterectomy: a systematic literature review and meta-analysis

OBJECTIVE

We performed a systematic review of the literature and meta-analysis of the infectious complications of hysterectomy, comparing robotic-assisted hysterectomy to conventional laparoscopic-assisted hysterectomy.

METHODS

We searched PubMed, CINAHL, CDSR, and EMBASE through July 2018 for studies evaluating robotic-assisted hysterectomy, laparoscopic-assisted hysterectomy, and infectious complications. We employed random-effect models to obtain pooled OR estimates. Heterogeneity was evaluated with I² estimation and the Cochran Q statistic. Pooled ORs were calculated separately based on the reason for hysterectomy (eg, benign uterine diseases, endometrial cancer, and cervical cancer).

RESULTS

Fifty studies were included in the final review for the meta-analysis with 176 016 patients undergoing hysterectomy. There was no statistically significant difference in the number of infectious complication events between robotic-assisted hysterectomy and laparoscopic-assisted hysterectomy (pooled OR 0.97; 95 % CI 0.74 to 1.28). When we performed a stratified analysis, similar results were found with no statistically significant difference in infectious complications comparing robotic-assisted hysterectomy to laparoscopic-assisted hysterectomy among patients with benign uterine disease (pooled OR 1.10; 95 % CI 0.70 to 1.73), endometrial cancer (pooled OR 0.97; 95 % CI 0.55 to 1.73), or cervical cancer (pooled OR 1.09; 95 % CI 0.60 to 1.97).

CONCLUSION

In our meta-analysis the rate of infectious complications associated with robotic-assisted hysterectomy was no different than that associated with conventional laparoscopic-assisted hysterectomy.

Comparison of Robotic and Laparoscopic Hysterectomy for the Large Uterus

Background and Objectives:

We compared the outcome of robotic hysterectomy (RH) with laparoscopic hysterectomy (LH) for large uteri (≥16 weeks).

Methods:

This was a retrospective review over 5 years of 165 women (RH, 46; LH, 119). Demographic data, conversion, hemoglobin drop, indication, operating time, postoperative stay, and intra-operative strategies (adhesiolysis, myomectomy) were recorded.

Results:

Mean age was 45.7 ± 6.4 years and 44.5 ± 5.4 years (no diff) and body mass index was 30.2 ± 6.3 kg/m² and 27.8 ± 4.8 kg/m² (P = .009) in the RH and LH groups. There was no difference in percentage of women with previous laparotomy (RH, 15.2% vs LH, 13.4%) and mean number of lower-segment caesarean section (RH, 1.0 vs LH, 0.8). Mean size of uterus was similar (RH, 20.0 weeks vs LH, 17.4 weeks). The mean number of ports was higher in the RH group (RH, 4.2 vs LH, 3.4; P < .001) as was needed for adhesiolysis (RH, 71.7% vs LH, 35.3%; P < .001). Difficult bladder dissection was more in the RH group (56.5% vs 26.1%; P < .001). Vaginal morcellation was similar in both groups (RH, 89.1%; LH, 83.2%). RH took longer operating time (131.0 vs 110.6 minutes; P = .006). RH had less drop in Hb (1.0 vs 1.8 g/dL; P < .001) and remained the same after multiple regression analysis. Postoperative stay was similar in both groups (1.4 days). Requirement of intravenous analgesia was significantly lower in the RH group (12.5 vs 30.9 hours; P < .001). Open conversion rate was 4.3% (RH) and 10.9% (LH) but not significant.

Conclusion:

A higher body mass index, more adhesiolysis, and difficult bladder dissection imply a more challenging nature of women who underwent RH. Despite this, RH was shown to be feasible and safe with a lower blood loss.