The effects of 3D/Full HD and 2D/Ultra HD imaging systems on suturing skills during total laparoscopic hysterectomy: a prospective cohort study

PURPOSE

2D/Ultra HD and 3D/Full HD imaging systems can provide surgeons with more accurate and detailed views of the surgical site. We aimed to compare the effects of 2D/Ultra HD and 3D/Full HD laparoscopy systems on laparoscopic suturing skills during total laparoscopic hysterectomy.

METHODS

In this prospective cohort study, patients were recruited from a tertiary hospital, and demographic data and surgical data were recorded. The primary outcome measures were the durations of the total operation and vaginal cuff closure. Secondary outcome measures were colpotomy duration, total number of sutures placed, duration of first, second, third and fourth sutures, mean suturing duration, total operation duration, the surgeon's perception of difficulty during the vaginal cuff suturing and complications.

RESULTS

The 3D/Full HD (n = 39) and 2D/Ultra HD (n = 42) groups were compared in terms of age, BMI, number of previous abdominal surgeries, number of previous cesarean sections, and type of delivery were examined. Both groups were considered homogeneous. The 3D/Full HD group was found to be superior in terms of colpotomy duration, duration of the first, second, and third suture, mean suturing duration, vaginal cuff closure duration, and difficulty of use compared to 2D/Ultra HD group (p < 0.05 for all).

CONCLUSION

In conclusion, the use of 3D/Full HD laparoscopy systems can lead to improved surgical outcomes in terms of colpotomy duration, duration of the first, second, and third suture, mean suturing duration, vaginal cuff closure duration, and difficulty of use compared to 2D/Ultra HD systems.

Risk factors for perioperative blood transfusion in patients undergoing total laparoscopic hysterectomy

PURPOSE

The goal is to identify risk factors associated with receiving a blood transfusion during the perioperative period in patients who undergo total laparoscopic hysterectomy (TLH) using a large-scale national database.

METHODS

In this retrospective analysis, data from the Nationwide Inpatient Sample (NIS) was utilized to review the medical records of all patients who underwent TLH from 2010 to 2019. The researchers identified patients who had received a blood transfusion during the perioperative period and compared with those who had not. The subsequent factors associated with blood transfusion were examined: hospital characteristics (type of admission and payer, patient demographics (age and race), bed size, teaching status, location, and region of hospital), length of stay (LOS), total charges during hospitalization, in-hospital mortality, comorbidities, and perioperative complications. The data was analyzed using descriptive statistics. The independent risk factors of perioperative blood transfusion after TLH was identified by performing multivariate logistic regression.

RESULTS

A total of 79,933 TLH were captured from the NIS database, among which 3433 (4.40%) patients received a perioperative blood transfusion. TLH patients affected by blood transfusion were 2 days longer hospital stays (P < 0.001), higher overall costs (P < 0.001), the patients who received a transfusion after a long-term hospitalization had a significantly higher rate of mortality (0.5% vs. 0.1%; P < 0.001). Perioperative blood transfusion after TLH was associated with chronic blood loss anemia, deficiency anemia, coagulopathy, congestive heart failure, fluid and electrolyte disorders, renal failure, metastatic cancer, sepsis, weight loss, deep vein thrombosis, gastrointestinal hemorrhage, shock, acute myocardial infarction, and pneumonia, stroke, hemorrhage, pulmonary embolism, and disease of the genitourinary system.

CONCLUSION

Studying the risk factors of perioperative blood transfusion after TLH is advantageous in order to ensure proper management and optimize outcomes.

Obvious advantage of vaginal natural orifice transluminal endoscopic surgery hysterectomy against total laparoscopic hysterectomy in small uterus patients and the future prospects at a regional core institution: A retrospective study

Objective

Owing to the combination of benefits, including permanent visual guidance and no abdominal skin incision, vaginal natural orifice transluminal endoscopic surgery hysterectomy (vNOTES-H) is currently widely used. However, the introduction of vNOTES-H has been delayed in many Japanese regional core hospitals because of its specific device and skill requirements. Therefore, the characteristics and advantages should be explained for the widespread use of this technique.

Study design

We reviewed the medical records of 17 patients with vNOTES-H and 94 patients with total laparoscopic hysterectomy (TLH) from January 1, 2015 to December 31, 2022. In this analysis, to compare the results of vNOTES-H to TLH, we excluded certain patients with a relatively heavy uterus (>255 g) and the presence of abdominal adhesions. In this report, first, the characteristics of the vNOTES-H procedures using a transvaginal access platform are explained by referring to one representative patient. Second, the patient characteristics of the vNOTES-H and TLH groups, including operation time and blood loss amount, were compared. Then, to detect the influence of vNOTES-H on the difficulty of operation among all 111 patients, we performed a multivariate logistic regression analysis to assess the influence of each of 9 factors, including "vNOTES-H", "Advanced age", "High BMI", "3 parity", "Gynaecological operation history", "Adenomyoma", "Large leiomyoma", "Heavy uterus" and "Large uterus", on the two indexes, including "Short time operation" and "Massive blood loss".

Results

In the simple comparison between the groups with vNOTES-H and TLH, the operation time in the former group was significantly shorter than in the latter group, although other factors did not show significant differences, including blood loss amount. Moreover, in the multivariate logistic regression analysis of all 111 patients, the "vNOTES-H" factor showed a significantly high possibility of "short time operation", although no factor, including "vNOTES-H", showed a significant influence on "massive blood loss".

Conclusions

vNOTES-H showed advantages in terms of operation time without increasing blood loss for patients with a relatively small uterus. However, to expand the selection for vNOTES-H, we should accumulate further patients and perform more analyses.

Pre-incisional Preventive Precise Multimodal Analgesia May Enhance the Rehabilitation Process of Acute Postoperative Pain Following Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

BACKGROUND

There has been limited research regarding the effect of preventive precise multimodal analgesia (PPMA) on the duration of acute postoperative pain after total laparoscopic hysterectomy (TLH). This randomized controlled trial aimed to evaluate how PPMA affects pain rehabilitation.

OBJECTIVES

Our primary objective was to reduce the duration of acute postoperative pain after TLH, including incisional and visceral pain.

STUDY DESIGN

A double blind randomized controlled clinical trial.

SETTING

Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China.

METHODS

Seventy patients undergoing TLH were randomized to Group PPMA or Group Control (Group C) in a 1:1 ratio. Patients in Group PPMA were given PPMA through the pre-incisional administration of parecoxib sodium 40 mg (parecoxib is not approved for use in the US) and oxycodone 0.1 mg/kg as well as local anesthetic infiltration at the incision sites. In Group C, similar doses of parecoxib sodium and oxycodone were injected during uterine removal, and a local anesthetic infiltration procedure was performed immediately before skin closure. The index of consciousness 2 was utilized to titrate the remifentanil dosage in all patients to ensure sufficient analgesia.

RESULTS

Compared with the Control, PPMA shortened the durations of incisional and visceral pain at rest (median, interquartile range [IQR]: 0, 0.0- 2.5) vs 2.0, 0.0-48.0 hours, P = 0.045; 24.0, 6.0-24.0 vs 48.0, 24.0-48.0 hours, P < 0.001; and during coughing 1.0, 0.0-3.0 vs 24.0, 0.3-48.0 hours, P = 0.001; 24.0, 24.0-48.0] vs 48.0, 48.0-72.0] hours, P < 0.001). The Visual Analog Scale (VAS) scores for incisional pain within 24 hours and visceral pain within 48 hours in Group PPMA were lower than those in Group C (P < 0.05). PPMA evidently decreased the VAS scores for incisional pain during coughing at 48 hours (P < 0.05). Pre-incisional PPMA significantly reduced postoperative opioid consumption (median, IQR: 3.0 [0.0-3.0] vs 3.0 [0.8-6.0] mg, P = 0.041) and the incidence of postoperative nausea and vomiting (25.0% vs 50.0%, P = 0.039). Postoperative recovery and hospital stay were similar between the 2 groups.

LIMITATIONS

This research had some limitations, including that it was a single-center research with a limited sample size. Our study cohort did not represent the overall patient population in the People's Republic of China; therefore, the external validity of our findings remains limited. Furthermore, the prevalence of chronic pain was not tracked.

CONCLUSION

Pre-incisional PPMA may enhance the rehabilitation process of acute postoperative pain after TLH.

Effects of Erector Spinae Plane Block and Transmuscular Quadratus Lumborum Block on Postoperative Opioid Consumption in Total Laparoscopic Hysterectomy: A Randomized Controlled Clinical Trial

INTRODUCTION

Total laparoscopic hysterectomy (TLH) is a common surgical procedure that is frequently associated with substantial postoperative pain. As part of multimodal analgesia, the erector spinae plane block (ESPB) and transmuscular quadratus lumborum block (TQLB) have been demonstrated to be effective. This study aimed to evaluate whether ESPB and TQLB reduce postoperative pain and opioid consumption after TLH.

METHODS

A total of 90 female patients undergoing TLH were randomized to receive either ESPB, TQLB, or no intervention before general anesthesia. All patients received a patient-controlled sufentanil analgesia postoperatively. Postoperative pain and sufentanil consumption were evaluated. The primary outcome was cumulative sufentanil consumption at 12 h postoperatively.

RESULTS

The cumulative sufentanil consumption at 12 h postoperatively was significantly lower in Group ESPB than in Group CON after Bonferroni correction (median [interquartile range], 0 [0, 4] μg vs. 6 [0, 10] μg; median difference = - 3; 95% confidence interval, - 6-0; P = 0.010). There were no significant differences between Group TQLB and CON (0 [0, 4] μg vs. 6 [0, 10] μg; P = 0.098) or between the two block groups (P = 1.000). When compared with Group CON, ESPB and TQLB persistently reduced pain scores until 6 and 4 h after surgery, respectively (P < 0.05). However, no significant differences were found in pain scores between the two block groups.

CONCLUSIONS

ESPB and TQLB improved the quality of multimodal analgesia for TLH. ESPB may be more favorable due to the prolonged period of analgesia and decreased opioid consumption after TLH.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2100048165, Registry URL: http://www.chictr.org.cn/showproj.aspx?proj=129578 . Date of registration: July 4, 2021. The patient enrollment began on July 12, 2021.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Total laparoscopic hysterectomy when there is posterior cul-de-sac obliteration: A step-by-step nerve-sparing technique

Dense adhesions due to severe endometriosis between the posterior cervical peritoneum and the anterior sigmoid or rectum obliterate the cul-de-sac and distorts normal anatomic landmarks. Surgery for endometriosis is associated with severe complications, including ureteral and rectal injuries as well as voiding dysfunction. Surgeons should recognize the importance of not only avoiding ureteral and rectal injuries but also focusing on the preservation of the hypogastric nerves. We herein report the anatomical highlights and surgical steps of laparoscopic hysterectomy for posterior cul-de-sac obliteration with the nerve-sparing technique.

Uterine allograft removal by total laparoscopic hysterectomy after successful cesarean delivery in a living-donor uterus recipient with uterovaginal agenesis (MRKHS)

PURPOSE

To limit the burden of long-term immunosuppression (IS) after uterus transplantation (UTx), removal of the uterine allograft is indicated after maximum two pregnancies. Hitherto this has required graft hysterectomy by laparotomy. Our objective was to demonstrate, as a proof of concept, the feasibility of less traumatic transplantectomy by total laparoscopic hysterectomy (TLH).

PATIENT

A 37-year-old woman with uterovaginal agenesis due to Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who had undergone neovaginoplasty at age 19 years prior to living-donor (LD) UTx in 10/2019 at age 35 years gave birth to a healthy boy by primary cesarean section in 06/2021. During pregnancy, she developed impaired renal function, with bilateral hydronephrosis, necessitating early allograft removal in 09/2021 to prevent chronic kidney disease, particularly during a potential second pregnancy.

METHODS

Transplantectomy by TLH essentially followed standard TLH procedures. We paid meticulous attention to removing as much donor tissue as possible to prevent postoperative complications from residual donor tissue after stopping IS, as well as long-term vascular damage.

RESULTS

TLH was performed successfully without the need to convert to open surgery. Surgical time was 90 min with minimal blood loss. No major complications occurred intra- or postoperatively and during the subsequent 9-month follow-up period. Kidney function normalized.

CONCLUSIONS

To our knowledge, we report the first successful TLH-based removal of a uterine allograft in a primipara after LD UTx, thus demonstrating the feasibility of TLH in uterus recipients with MRKHS.

Preventive effect of metronidazole vaginal tablets on vaginal bacteria-related postoperative complications with total laparoscopic hysterectomy

BACKGROUND

The use of total laparoscopic hysterectomy is increasing. However, as with conventional abdominal hysterectomy, vaginal bacteria-related postoperative complications need to be managed in total laparoscopic hysterectomy. Therefore, we started to combine metronidazole vaginal tablets with intravenous administration of cephem antibiotics immediately before starting surgery to reduce complications. To evaluate the effect of this combination, and to determine the risk factors for these complications, we retrospectively collected medical records from our hospital and performed a multivariate analysis.

METHODS

We reviewed the medical records of 520 patients who underwent total laparoscopic hysterectomy from 1 January 2015 to 31 December 2021. Among these cases, we identified 16 cases as having vaginal bacteria-related postoperative complications, defined as needing more than one additional day for treatment of postoperative complications, namely postoperative infection (10 cases) and vaginal dehiscence (6 cases). First, we evaluate the effect of metronidazole vaginal tablets by dividing the patients into two groups according to whether metronidazole vaginal tablets were used, and comparing the vaginal bacteria-related postoperative complication rates and other indices. Second, we performed a multivariate logistic regression analysis to assess the influence of each of 17 representative factors, including patient characteristics and symptoms, uterus and leiomyoma sizes, concomitant procedures such as laparoscopic cystectomy and pelvic lymphadenectomy, and others.

RESULTS

In the multivariate analysis of the 520 cases, we confirmed that the use of metronidazole vaginal tablets could reduce the vaginal bacteria-related postoperative complications rate by more than half (odds ratio, 0.36). In addition to metronidazole vaginal tablets use, concomitant laparoscopic cystectomy and blood transfusion were associated with significant increases in the vaginal bacteria-related postoperative complication rate.

CONCLUSIONS

The effect of the addition of metronidazole vaginal tablets to pre- and postsurgical treatment on the reduction of vaginal bacteria-related postoperative complications was confirmed. This easy, safe, and low-cost method may improve the management of total laparoscopic hysterectomy.

Facilitating method for removal of the large uterus after laparoscopic hysterectomy: Vaginal vault vertical incision

BACKGROUND

In patients with a large uterus, an important part of the laparoscopic hysterectomy operation time is the phase of removing the uterus from the abdomen.The development of techniques that will shorten the morcellation time is the key to reducing the total operation time.

AIM

To evaluate the effect of vaginal cuff vertical incision in accelerating removal of the large uterus in laparoscopic hysterectomy.

METHODS

This study was performed with patients who underwent total laparoscopic hysterectomy. In the study group, a vertical incision was performed in the middle of the posterior vaginal stump before the vaginal removal of the larger uterus (weighing more than 500 g). The control group consisted of patients who underwent vaginal morcellation after conventional colpotomy. Patients in both groups were matched in terms of uterine weights +/-50 g and the same vaginal morcellation technique was applied to all patients.

RESULTS

In patients who underwent a vertical incision procedure, the time to remove the uterus from the abdomen (17.55±2.53 min vs 26.62±4.72 min, p<0.001) and the total operation time (130.81±12.83 min vs.143.29±13, 15 min, p = 0.001) was statistically significantly less than the patients without vertical incision. There was no difference between the groups in terms of intraoperative complications, drop in hemoglobin levels, time to flatus, postoperative 6th,24th hour visual analog score and length of hospital stay.

CONCLUSIONS

The vertical incision procedure reduces the time to remove the large uterus from the abdomen after laparoscopic hysterectomy and, accordingly, the total operation time. This procedure may be the preferred method before vaginal morcellation, especially in large uterus.

Comparison of laparoscopic lateral suspension and laparoscopic sacrocolpopexy with concurrent total laparoscopic hysterectomy for the treatment of pelvic organ prolapse: a randomized controlled clinical trial

INTRODUCTION AND HYPOTHESIS

We compared the outcomes of women who underwent laparoscopic lateral suspension with concurrent total laparoscopic hysterectomy (LLS-TLH) with those of women who underwent laparoscopic sacrocolpopexy with concurrent total laparoscopic hysterectomy (LSC-TLH) for apical and/or anterior vaginal wall prolapse.

METHODS

Eighty women underwent LLS-TLH or LSC-TLH operations. According to the Pelvic Organ Prolapse Quantification System (POP-Q), women with symptomatic pelvic organ prolapse of stage 2 or higher apical and/or anterior compartment prolapse were enrolled in the study. The objective cure rate according to the POP-Q system was the primary (objective) outcome. The International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and Patient Global Impression of Improvement (PGI-I) questionnaire scores were the secondary (subjective) outcomes. The primary and secondary outcomes were evaluated at 1 year after surgery.

RESULTS

The primary and secondary outcomes indicated significant improvements in both groups (p < 0.05). The objective cure rate was 92.5% for apical and 78.6% for anterior compartment prolapse in the LLS-TLH group; the respective rates were 100% and 74.1% in the LSC-TLH group. The subjective cure rate was 87.5% for the LLS-TLH group and 90% for the LSC-TLH group. No statistically significant differences between groups were found in the objective cure rate, subjective cure rate, or ICIQ-VS, ICIQ-SF, or PGI-I scores at 1 year (p > 0.05).

CONCLUSIONS

LLS-TLH can serve as a safe, effective, and feasible alternative to LSC-TLH, with low complication rates and similar short-term objective and subjective outcomes.

Effects of total laparoscopic hysterectomy on the clinical outcomes of patients with uterine fibroids

OBJECTIVE

To clarify the effects of total laparoscopic hysterectomy (TLH) on sex hormone levels, quality of life (QOL) and complications such as lower-extremity deep vein thrombosis (DVT) in patients with uterine fibroids (UFs).

METHODS

In this retrospective study, 136 patients with UFs treated in Hainan General Hospital from March 2018 to December 2020 were collected as research participants, of which 65 patients received total abdominal hysterectomy (TAH) were included in the control group and 71 patients who received TLH were assigned to the research group. The two groups were compared regarding the following items: response rate, surgical indexes, rehabilitation indicators, changes in sex hormone levels and QOL, and the occurrence of lower-extremity DVT.

RESULTS

The research group showed a significantly higher response rate, and better indicators of surgical treatment and rehabilitation than the control group (P<0.05). The sex hormones in the research group were more stable than that in the control group. The QOL was also significantly better and the incidence of total complications was statistically lower in the research group compared with the control group (both P<0.05).

CONCLUSIONS

TLH is a feasible and safe alternative than traditional TAH for UFs, as it can effectively improve patients' sex hormone levels and QOL, and reduce the incidence of complications, which is worthy of clinical promotion.

Cost effectiveness analysis of total laparoscopic hysterectomy versus total abdominal hysterectomy for uterine fibroids in Western China: a societal perspective

BACKGROUND

As a common female pelvic tumor, uterine fibroids remain the leading cause for hysterectomy in China. Hysterectomy provides a good surgical treatment of uterine fibroids, and it guarantees the removal of all uterine fibroids without lower risk of recurrence. This study compares the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) for women with uterine fibroids from a societal perspective.

METHODS

An economic analysis was conducted in 392 patients (TLH n = 75; TAH n = 317), including all relevant costs over a 12-month time horizon. Primary outcome was major surgical complications; secondary outcomes were postoperative discomfort symptoms and time of return to normal activities. Clinical, outcomes and costs data were collected from medical records, telephone survey and financial information system. Generalized linear models were used to assess costs and outcomes differences between the two groups. Incremental cost effectiveness ratio (ICER) was used to estimate the cost effectiveness.

RESULTS

Mean direct costs were $2,925.71 for TLH, $2,436.24 for TAH, respectively. Mean indirect costs were $1,133.22 for TLH, $1,394.85 for TAH, respectively. Incremental societal costs were $256.86 (95%CI: 249.03-264.69). Mean differences in outcome were: 4.53% (95%CI: 4.35-4.71) for major surgical complications; 6.75% (95%CI: 6.45-7.05) for postoperative discomfort symptoms; 1.27 (95%CI: 1.23-1.30) weeks for time to return to normal activities. ICER of TLH was $5,669.16 (95%CI: 5,384.76-5,955.56) per complication averted, $3,801.54 (95%CI: 3,634.81-3,968.28) per postoperative discomfort symptoms averted and $202.96 (95%CI: 194.97-210.95) per week saved to return to normal activities.

CONCLUSIONS

TLH is cost effective compared with TAH in preventing additional complications based on our estimated conservative threshold in China. The findings provide useful information for researchers to conduct further cost effectiveness analysis based on prospective study which can provide stronger and more evidence, in China. In addition, the data may be useful for Chinese health care policy-makers and medical insurance payers to make related health care decisions.

Strategies and Outcomes of Total Laparoscopic Hysterectomy for Large Uterine Cervical Fibroids

Background and Objectives:

To present the methods and outcomes of total laparoscopic hysterectomy with debulking surgery for large cervical fibroids.

Methods:

This is a single-center study. Twenty-one women who underwent total laparoscopic hysterectomy between October 1, 2012 and November 30, 2020 for large cervical fibroids (diameter ≥10 cm) based on a diagnosis by magnetic resonance imagining were enrolled. Conventional total laparoscopic hysterectomy for large cervical fibroids was initially attempted. If this could not be completed, debulking surgery, such as enucleation of large cervical fibroids or cervical amputation, was performed during total laparoscopic hysterectomy.

Results:

Total laparoscopic hysterectomy could be completed in all 21 patients with large cervical fibroids without blood transfusion. Conventional total laparoscopic hysterectomy was performed in four patients (19%), and 17 patients (81%) required debulking surgery at the time of total laparoscopic hysterectomy. The median diameter of the major axis of the cervical fibroid, uterine weight, intraoperative blood loss, and operative time were 12 cm, 750 g, 100 mL, and 191 min, respectively.

Conclusion:

Total laparoscopic hysterectomy for large cervical fibroids, although minimally invasive, requires a high level of laparoscopic skill. However, our data suggests that total laparoscopic hysterectomy for large cervical fibroids can be feasible, with an acceptable level of blood loss, by performing debulking surgeries such as enucleation of large cervical fibroids or cervical amputation.

Lateral closure of the uterine artery prior to laparoscopic hysterectomy: a systematic review

An alternative surgical technique with closure of the uterine artery at its origin, known as lateral approach prior to TLH, has been proposed and it may offer important benefits to both patients and surgeons. Our objectives were to review the current literature regarding surgical outcomes between lateral and conventional approach in relation to TLH. We followed the 'PRISMA' guidelines and conducted a systematic review, which involved searching PubMed and Embase databases for RCTs evaluating the topic. We identified four RCTs including 585 patients. Three of the four studies reported a significant lower bleeding during TLH with prior lateral approach. Operative time was also shorter in the lateral approach group compared to the conventional approach group in three studies.Our review provides evidence that lateral occlusion of the uterine arteries prior to total laparoscopic hysterectomy may be beneficial due to less blood loss and shorter perioperative time without compromising patient safety.

Evaluation of the Morbidity of Routine Cystoscopy Performed Intraoperatively During Total Laparoscopic Hysterectomies

Study objectives:

The primary objective is to determine the rate of morbid events (urinary tract infection, hematuria, urinary retention, false positive, incidental finding) associated with routine cystoscopies performed intraoperatively during total laparoscopic hysterectomies (TLH). The secondary objectives are 1) to determine the rate of urinary complications during TLHs in our centers and 2) to determine the detection rate of urinary complications using cystoscopy during TLHs.

Method:

Descriptive retrospective multicenter study. The study took place in Obstetrics & Gynecology departments of 2 university centers in Montreal. Patients underwent a routine cystoscopy during their TLH for a benign reason in our centers. Five hundred thirty-one charts from January 1, 2012 to January 31, 2018 were reviewed.

Results:

The morbidity rate of routine cystoscopies during TLHs is 4.19% (22/524 cases) in our centers. Our urinary complication rate is 2.45% (13/531 cases). Of these 13 complications, 4 were detected by cystoscopy.

Conclusion:

The usefulness of routine cystoscopies performed intraoperatively during TLHs is questionable due to the number of morbid events and the low rate of urinary trauma in our centers. However, it is hard to establish a direct causality link between certain morbid events and cystoscopy. More studies should be conducted on this subject.

Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients

Objective

To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients.

Methods

This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH.

Results

Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients.

Conclusion

TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.

Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports

BACKGROUND

In the presence of a large uterus, total laparoscopic hysterectomy (TLH), always requires morcellation to allow removal of the tissues from the abdominal cavity. However, uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma. Therefore, in-bag extracorporeal morcellation has been developed. However, tissue containment and extraction are extremely challenging, especially when considering the increasing uterine size to be removed through minimally invasive surgery.

CASE SUMMARY

Herein, we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH. The study enrolled patients who were planned for TLH for large uteri (weight > 500 g). TLH was performed following the procedure reported in our previous studies. The novel technique has been described step-by-step in a video, which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g, 1700 g, and 3700 g, respectively. The procedures were performed without any complications. The patients had an uneventful postoperative course, and in all cases, the pathology was benign leiomyoma.

CONCLUSION

Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies. The technique herein presented may be adopted in surgical practice, by adding it to the other available techniques of contained morcellation. It may represent a valid and feasible alternative, especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.

Incidence of and risk factors for vaginal cuff dehiscence following total laparoscopic hysterectomy: a monocentric hospital analysis

PURPOSE

Vaginal cuff dehiscence (VCD) is one of the major surgical complications following hysterectomy with data on incidence rates varying largely and studies assessing risk factors being sparse with contradictive results. The aim of this study was to assess the incidence rate of and risk factors for VCD in a homogenous cohort of women treated for benign uterine pathologies via total laparoscopic hysterectomy (TLH) with standardized follow-up.

METHODS

All patients undergoing TLH at the Department of Gynecology and Obstetrics, Saarland University Hospital between November 2010 and February 2019 were retrospectively identified from a prospectively maintained service database.

RESULTS

VCD occurred in 18 (2.9%) of 617 patients included. In univariate and multivariate analyses, a lower level of surgeon laparoscopic expertise (odds ratio 3.19, 95% confidence interval (CI) 1.0-9.38; p = 0.03) and lower weight of removed uterus (odds ratio 0.99, 95% CI 0.98-0.99; p = 0.02) were associated positively with the risk of VCD.

CONCLUSION

In this homogenous cohort undergoing TLH, laparoscopic expertise and uterine weight influenced the risk of postoperative VCD. These findings might help to further reduce the rate of this complication.

Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy.

DATA SOURCES

PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered.

METHODS OF STUDY SELECTION

The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence.

TABULATION, INTEGRATION, AND RESULTS

A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11-0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13-1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00-3.88).

CONCLUSION

There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.

A retrospective study of 323 total laparoscopic hysterectomy cases for various indications and a case report treating caesarean scar pregnancy

Background

The application of laparoscopic surgeries has been increasing, and various uterine diseases in addition to leiomyoma/adenomyoma have become indications for total laparoscopic hysterectomy (TLH). Therefore, data acquisition and analysis of TLH procedures, including TLH for rare uterine diseases, have become important for improving surgical procedures and patient selection. To determine the prevalence of and risk factors for the occurrence of intraoperative and postoperative complications of TLH, we performed a multivariate analysis of the records in our hospital.

Methods

We retrospectively reviewed the medical records of 323 patients who underwent TLH for the treatment of leiomyoma/adenomyoma (278 cases), low-grade (pre)malignant uterine tumours (40 cases) and other rare uterine diseases (5 cases) from January 1, 2015, to December 31, 2019. Of the rare uterine diseases, one case of caesarean scar pregnancy for which TLH was performed is introduced as a case report. To assess the effects of 11 representative factors, including patient characteristics, uterus and leiomyoma sizes, indications for TLH and others, we performed a multivariate logistic regression analysis.

Results

Among the 323 cases, 20 intraoperative complications and 15 postoperative complications were reported. In the multivariate analysis, “ovarian tumour” and “heavy uterus” were positively associated and “nulliparity” was negatively associated with intraoperative complications. There were no significant risk factors for postoperative complications. The only risk factor for operative complications directly related to the resected uterus was “heavy uterus”. Therefore, we could perform TLH relatively safely for patients with other indications besides leiomyoma/adenomyoma.

Conclusions

Considering the factors detected in this analysis, the indications for TLH may be expanded. Owing to the increase in TLH for indications other than leiomyoma/adenomyoma, a more accurate determination of the treatment approach can be achieved.

Single-Centre Experience of Doing Safe Total Laparoscopic Hysterectomy: Retrospective Analysis of 1200 Cases

Study Objective

Assessment of safety and feasibility of total laparoscopic hysterectomy in a high-volume tertiary care centre.

Design

Retrospective study design.

Setting

Tertiary care centre: Galaxy care Hospital, Pune, India.

Materials and Methods

This is a retrospective observational study conducted in a tertiary care resident training hospital in Pune which is a high-volume teaching hospital. 1200 total laparoscopic hysterectomy patients between July 2013 and June 2019 operated by a group of trained surgeons were analysed, and parameters, namely demography, indication of surgery, surgical time, intra-operative blood loss, post-operative complications, duration of hospital stay, discharge and follow-up, were studied.

Results

A total of 1200 women who underwent total laparoscopic hysterectomy for various indications were included in the study. TLH was successfully performed in all women. Mean age of women was 45 years. 72.00% had a BMI between 18.5 and 24.9, 16.08% had a BMI between 25 and 29.9, 3.92% had a BMI of > 29.9 while 8% had a BMI < 18.5. Indications for surgery included uterine fibroid (33.08%), adenomyosis (22.25%), endometrial hyperplasia (14.33%), endometrial polyp (7%), endometriosis (3.33%), postmenopausal bleeding (9.25%), chronic PID (5.25%), prolapse (4.25%) and risk reduction surgery in 1.25%. 2.00% had intra-operative complications while 7.58% had post-operative complications which were identified and managed successfully.

Conclusions

Advances and innovation in equipment, energy sources and surgical training have made TLH a well-tolerated and efficient surgery. Irrespective of the previous morbidity, pathology and uterine size, TLH is a duplicable and safe in a well-trained high-volume centre.

Vaginal, sexual and urinary symptoms following hysterectomy: a multi-centre randomized controlled trial

Background

Hysterectomy is the most common major gynaecological procedure. The aim of this study was to study vaginal, sexual and urinary symptoms following total abdominal hysterectomy (TAH), non-descent vaginal hysterectomy (NDVH) and total laparoscopic hysterectomy (TLH) in a low resource setting.

Methods

A multi-centre randomized controlled trial (RCT) was conducted in two public sector hospitals in Sri Lanka. Participants were patients requiring hysterectomy for non-malignant uterine causes. Exclusion criteria were uterus> 14 weeks, previous pelvic surgery, medical illnesses which contraindicated laparoscopic surgery, and those requiring incontinence surgery or pelvic floor surgery.

Vaginal, sexual function and urinary symptoms were assessed by the validated translations of ICIQ-VS and ICIQ-FLUTS questionnaires. Post-operative improvement (pre-operative – post-operative) was assessed.

Results

There was an improvement (median (IQ1-IQ3) in vaginal symptoms [TAH 6(2–8) vs 4(0–8), p < 0.001; NDVH 6(4–8.5) vs 5(0–8), p < 0.001; TLH 4(2–10.5) vs 4(0–10), p < 0.001], urinary flow symptoms [TAH 2(1–4) vs 1 (0–3), p < 0.001; NDVH 3 (2–5) vs 2 (0.5–4), p < 0.001; TLH 1(1–4) vs 1(0–3), p < 0.05], urinary voiding symptoms [TAH 0(0–0) vs 0(0–0), p = 0.20; NDVH 0(0–1) vs 0(0–0.8), p < 0.05; TLH 0(0–0) vs 0(0–0), p < 0.05] and urinary incontinence symptoms [TAH 0(0–2) vs 0(0–2), p = 0.06; NDVH 0(0–3) vs 0(0–3), p < 0.001; TLH 0(0–3) vs 0(0–2), p < 0.05] at 1-year (TAH n = 47, NDVH n = 45, TLH n = 47). There was an improvement in sexual symptoms only in the TLH group [TAH 0(0–11.5) vs 0(0–14), p = 0.08); NDVH 0(0–0) vs 0(0–0), p = 0.46; TLH 0(0–0) vs 0(0–4), p < 0.05].

There was no significant difference among the three different routes in terms of vaginal symptoms score [TAH 2 (0–2), NDVH 0 (0–2), TLH 0 (0–2), p = 0.33], sexual symptoms [TAH 0 (0–0), NDVH 0 (0–0), TLH 0 (0–0), p = 0.52], urinary flow symptoms [TAH 0 (0–1), NDVH 0 (0–1), TLH 0 (0–2), p = 0.56], urinary voiding symptoms [TAH 0 (0–0), NDVH 0 (0–0), TLH 0 (0–0), p = 0.64] and urinary incontinence symptoms [TAH 0 (0–0), NDVH 0 (0–1), TLH 0 (0–1), p = 0.35] at 1-year.

Conclusions

There was a post-operative improvement in vaginal symptoms and urinary symptoms in all three groups. There was no significant difference in pelvic organ symptoms between the three routes; TAH, NDVH and TLH.

Trial registration

Sri Lanka clinical trials registry, SLCTR/2016/020 and the International Clinical Trials Registry Platform, U1111–1194-8422, on 26 July 2016. Available from: http://slctr.lk/trials/515

Single-Incision Hysterectomy Outcomes With and Without Robotic Assistance

Objective:

To evaluate the differences in operative time and postoperative complications for total laparoscopic hysterectomy (TLH) performed using conventional laparoendoscopic single-site surgery (LESS) versus a robotic-assisted LESS approach.

Methods:

A retrospective study was conducted of all cases of conventional LESS TLH (n = 47) and robotic LESS TLH (n = 129) for benign gynecologic conditions performed from November 2014 to October 2017. Patient characteristics, operative time for hysterectomy, estimated blood loss, duration of hospitalization, and short-term postoperative complications were compared using appropriate parametric and nonparametric statistical tests.

Results:

Conventional LESS TLH cases had a 16.36-minute longer mean operative time for hysterectomy (P < .01). No difference was found in uterine weight, estimated blood loss, hospitalization, or incidence of postoperative complications when LESS TLH was performed with or without robotic assistance. When comparing uterine weight < 100 g, conventional LESS TLH cases had significantly greater operative time than the robotic LESS TLH cases (78.10 ± 23.97 minutes vs. 59.97 ± 35.17 minutes, P < .01). When comparing uterine weight > 100 g, conventional LESS TLH cases again had significantly greater operative time than the robotic LESS TLH cases (98.73 ± 50.16 minutes vs. 80.00 ± 42.97 minutes, P < .01). There was no difference in postoperative complications.

Conclusion:

Robotic single-incision laparoscopy can result in decreased operative time compared to a conventional LESS approach. Robotic-assisted and conventional LESS are similar in rate of postoperative complications, if performed by surgeons with abundant LESS experience.

The impact of chewing gum on postoperative bowel activity and postoperative pain after total laparoscopic hysterectomy

We aimed to investigate the effects of chewing gum on bowel activity and postoperative pain in patients undergoing laparoscopic hysterectomy. Patients were randomised into two groups (n = 58, study; n = 51, control). In the study group, patients started chewing sugarless gum every 2 h for 15 min, beginning at the second postoperative hour. The control group did not chew gum, and they received standard postoperative care. Both groups were compared primarily in terms of the amount of time until the first bowel movement, the time of the first passage of flatus and the time of first defaecation. The amount of time until the first bowel movement, the time of the first passage of flatus and the time of the first defaecation were found to be significantly shorter in the chewing gum group (p < .001). The amount of postoperative analgesics that were needed and VAS scores at 6-hours and 24-hours postoperatively, were found to be lower in the study group than in the control group (p < .001). Chewing gum was found to have beneficial effects on bowel motility and postoperative pain in patients undergoing laparoscopic hysterectomy. This affordable and simple method could be recommended to patients after total laparoscopic hysterectomy.Impact statementWhat is already known on this subject? Postoperative gastrointestinal dysfunction remains a source of morbidity and the major determinant of length of stay after abdominal operation. The mechanism of enhanced recovery from postoperative gastrointestinal dysfunction with the help of chewing gum is believed to be the cephalic-vagal stimulation of digestion which increases the promotability of neural and humoral factors that act on different parts of the gastrointestinal tract.What do the results of this study add? The findings of previous randomised controlled studies have been inconsistent regarding the effect of chewing gum on postoperative bowel function following abdominal gynecological surgery. In this randomised prospective study, we found that chewing gum early in the postoperative period after total laparoscopic hysterectomy hastened time to bowel motility and flatus. To our knowledge this is the first study of the impact of chewing gum on bowel motility after total laparoscopic hysterectomy.What are the implications of these findings for clinical practice and/or further research? Chewing gum early in the postoperative period following laparoscopic hysterectomy hastens time to bowel motility and flatus. The use of chewing gum is a simple and cheap strategy for promoting the recovery of gastrointestinal functions.

Laparoscopic hysterectomy as optimal approach for 5400 grams uterus with associated polycythemia: A case report

BACKGROUND

Uterine myomas are the most common benign gynecological soft tissue tumors in women but polycythemia associated with these tumors is rare. Polycythemia is significantly associated with risk of venous thromboembolism (VTE), which is further increased in case of a large pelvic mass and obesity. Here we report the surgical challenges in the case of an obese patient with a giant fibromatous uterus and associated polycythemia.

CASE SUMMARY

A 42-year-old obese woman was referred to our department for treatment for a huge fibromatous uterus. She suffered of pelvic pressure and abdominal distension and reported severe dyspnea from several months. Laboratory analyses including hemoglobin (Hb) 19.2 g/dL and hematocrit (Hct) 59.7% were indicative of polycythemia. Arterial blood gas analysis showed arterial oxygen pressure (pO₂) of 81.5 mmHg. Abdominal computed tomography confirmed a giant fibromatous uterus measuring 28.2 cm × 17 cm × 25 cm. To reduce the thromboembolic risk, the patient underwent low molecular weight heparin, phlebotomy twice before surgery, and we opted for a laparoscopic hysterectomy. The uterus weighed 5400 g and the histology confirmed a diagnosis of leiomyoma. We did not find increased erythropoietin levels in the supernatant of the myomatous uterine tissue. There were no complications. On postoperative day 1, the Hb and the Hct levels normalized to 13.3 g/dL and 41.7%, respectively. Arterial blood gas analysis after surgery showed a pO₂ of 144.7 mmHg. These results suggested the diagnosis of myomatous erythrocytosis syndrome. The patient was discharged on the second postoperative day in very good condition with no symptoms.

CONCLUSION

We believe this is the first reported laparoscopic hysterectomy in a patient with a giant uterus, polycythemia and obesity. Multiple VTE risk factors warranted a laparoscopic approach.

Safety and feasibility of contained uterine morcellation in women undergoing laparoscopic hysterectomy

Background

Widespread concerns have been raised regarding the safety of power morcellation of uterine specimens because of the potential to disseminate occult malignancy. We sought to assess the safety and feasibility of contained manual uterine morcellation within a plastic specimen bag among women with uterine neoplasms.

Methods

A retrospective single-institution descriptive cohort study was conducted from 2003 to 2014. Patients with leiomyoma and/or uterine malignancy who underwent minimally invasive surgery with contained uterine manual morcellation were identified from surgical logs. Demographic data, pathology results, operative details and adjuvant treatments were abstracted.

Results

Eighty-eight patients were identified; 35 with leiomyoma and 53 with endometrial cancer. The mean age was 48 and 60, respectively. Uterine size/weight was greater in women with leiomyoma compared to those with cancer (15.1 weeks/448 g vs. 10.7 weeks/322 g). Mean operative time was 206 min (range 115–391) for leiomyoma cases and 238 min (range 131–399) for cancer cases. Median length of stay was 1 day (range 0–3 days). There were no cases of occult leiomyosarcoma and all specimens were successfully manually morcellated within a bag. There were no intraoperative complications. Thirty-day postoperative complications occurred in 7 patients, including one readmission for grade (G) 1 vaginal cuff separation after intercourse, G1 port-site hematoma (1), G2 port-site cellulitis (1), G2 vaginal cuff cellulitis (2), G2 bladder infection (2), G2 pulmonary edema (1), and G1 musculoskeletal injury (1).

Conclusions

Contained uterine hand morcellation is a feasible procedure with low peri-operative complication rates that allows for minimally invasive surgical procedures for women with large uterine neoplasms. Further evaluation is needed to assess survival outcomes for uterine malignancies.

Total Laparoscopic Hysterectomy for Endometriosis and an Arteriovenous Malformation

STUDY OBJECTIVE

To show laparoscopic management of an arteriovenous malformation in a patient with deep pelvic endometriosis DESIGN: A step-by-step explanation of the surgery using an instructive video.

SETTING

Hautepierre University Hospital, Strasbourg, France.

INTERVENTIONS

We describe the case of a 37-year-old patient presenting with deep pelvic endometriosis and a uterine arteriovenous malformation. Deep pelvic endometriosis was diagnosed during a tubal ligation in 2015. Laparoscopy also showed some pelvic varicosities. Hysteroscopy was performed to increase the diagnostic precision. Huge blood vessels with an arterial pulse on the anterior wall of the uterus were found. The endometriosis of the patient was very symptomatic; she suffered from dysmenorrhea, menorrhagia, intense dyspareunia, and dyschezia. Magnetic resonance imaging indicated a large arteriovenous shunt in the anterior part of the uterus and bladder endometriosis. After a pluridisciplinary medical staff meeting, we decided to begin treatment with luteinizing hormone-releasing hormone analogs. Then, she underwent embolization of the arteriovenous malformation, which produced regression of the lesions as indicated by reevaluation with magnetic resonance imaging. We decided to perform laparoscopic hysterectomy. Evaluation of the abdominal cavity showed diaphragm endometriosis, deep pelvic endometriosis, and the arteriovenous malformation. We started with left ureterolysis and opening of the rectovaginal septum. After that, we radically dissected the left side of the uterus with a left oophorectomy and then the right side, conserving the ovary. Then, we shaved the bladder for endometriosis removal. To finish, we performed a right salpingectomy with a right ovariopexy, vaginal closure, and coagulation of the diaphragm's nodules. The patient agreed to record and publish the surgery, and the local institutional review board gave its approval.

CONCLUSION

To conclude, preoperative embolization of the arteriovenous shunt improves surgery, avoiding excessive bleeding and permitting easier radical hysterectomy for deep pelvic endometriosis. Similar cases have been published [1], but to our knowledge, our video is the first regarding this subject. It appears that embolization can fail, but hysterectomy remains the gold standard treatment [2].

Thirteen Years of Experience with Opportunistic Bilateral Salpingectomy During TLH in Low-Risk Premenopausal Women

Background

Opportunistic bilateral salpingectomy (OBS), also called as prophylactic salpingectomy or risk-reducing salpingectomy is the concurrent removal of the fallopian tubes in premenopausal women. Though there are some studies comparing the intraoperative complications and effect of salpingectomy on ovarian reserve, limited data are available on long-term follow-up after OBS.

Purpose of the Study

To evaluate the surgical outcome of routine bilateral salpingectomy during total laparoscopic hysterectomy (TLH) in terms of intraoperative and postoperative complications. We also evaluated the incidence and reoperation rate for adnexal pathology after TLH.

Methods

A retrospective study of 1470 patients undergoing total laparoscopic hysterectomy (TLH) with opportunistic bilateral salpingectomy (OBS) over 13 years was carried out at Paul's Hospital.

Results

The mean age of the subjects was 43.6 ± 4.2 years, mean body mass index was 27 ± 5.4 kg/m², and median parity was 2 (range 0-7). 43% of women had at least one previous surgery. The most common indication for surgery was fibroid uterus (67%, n = 985). The total complication rate was 4.4% (n = 65). One specimen showed paratubal borderline serous malignancy. The follow-up period ranged from 6 months to 13 years during which 17 (1.1%) women had adnexal pathology, and eight women (1.1%) needed resurgery for it. No ovarian malignancies were reported on follow-up.

Conclusions

OBS is a simple and short surgical step during TLH without increasing morbidity. OBS eliminates the risk of future diseases of tubal origin, and there might be a possible reduction in incidence and reoperation rate for future ovarian pathologies.

Feasibility and safety of total laparoscopic hysterectomy for huge uteri without the use of uterine manipulator: description of emblematic cases

Background

Uterine manipulator is a very useful tool in performing total laparoscopic hysterectomy (TLH) for large uteri; however, in some cases, it cannot be used due to unfavorable anatomical conditions. The feasibility and safety of TLH for very large uteri without the use of uterine manipulator has not yet been established.

Results

We describe two emblematic cases of TLH for huge fibromatous uteri: the first one for a uterus weighing 5700 g, which is the largest uterus laparoscopically removed to date reported in literature, and the second one for a uterus of 3670 g associated with a severe lymph node neoplastic disease.

In both cases, TLH was successfully and safely performed even without the use of uterine manipulator, thus allowing a rapid recovery, especially in the second case, which was essential for a fast start of the most appropriate oncological treatment, the best quality of life and undoubtedly cosmetic advantages.

Conclusions

Although we believe in the great usefulness of the uterine manipulator in performing TLH for huge uteri, in the present paper, we demonstrate the feasibility and safety of such complex surgery also when the use of this tool is not possible due to unfavorable anatomical condition.

Complication Rate of Laparoscopic Hysterectomies in Denmark, 2011-2016

Background and Objectives

After the U. S. Food and Drug Administration's recommendation against the use of power morcellation for tissue extraction in minimally invasive hysterectomy, the number of procedures completed laparoscopically declined in favor of open surgery laparotomy. We conducted a retrospective cohort study comparing perioperative and long-term outcomes, including complications associated with laparoscopic hysterectomy before and after the FDA recommendation.

Methods

We included procedures performed in Danish government hospitals (GHs) and a hospital specializing in minimally invasive gynecological surgery (MIGS). Different types of hysterectomy over the period from January 2011 through May 2016 were examined.

Results

Hysterectomies were analyzed from GHs (n = 21,495) and from a hospital specializing in MIGS (n = 749). In the GHs, we found a decrease in open hysterectomy from 40% in 2011 to 20% in 2016. In the MIGS hospital, 4 of 749 (0.05%) open hysterectomies were performed during the 6 years; however, there was a change in operative technique. After the FDA recommendation, there was a shift from laparoscopic subtotal hysterectomy (LSH) to total laparoscopic hysterectomy (TLH) from 32% in 2011 to 82% by May 2016. Containment bags were used in LSH and large-uterus TLH after the 2014 advisory. Significantly more complications occurred in the GHs than in the MIGS hospital: 3224/21,495 (15%) vs 53/749 (7.0%), respectively.

Conclusion

The rate of minimally invasive hysterectomies continues to increase. However, after 2014, many of the morcellation techniques have been replaced by a minilaparotomy to extract the uterus at the end of surgery, compared to the use of the contained morcellation in 100% of cases in the MIGS hospital. There was a major difference in complication rates between the hospitals that is partly explainable by the challenge in training residents and the low operative volume of surgeons in GHs.

Impact of energy devices on the post-operative systemic immune response in women undergoing total laparoscopic hysterectomy for benign disease of the uterus

OBJECTIVE

Laparoscopic surgery is associated with reduced surgical stress response, lesser post- operative immune function, and consequent early recovery compared with conventional open surgery. There is a lack of evidence regarding the inflammatory stress response with the use of different energy devices. The present study was conducted to evaluate and compare the inflammatory response in total laparoscopic hysterectomy (TLH) using three different energy devices.

MATERIAL AND METHODS

A prospective randomized controlled study was conducted in 60 women with abnormal uterine bleeding undergoing TLH. They were divided into three groups based on the energy devices used, namely integrated bipolar and ultrasonic energy (Thunderbeat), ultrasonic (Harmonic) and electrothermal bipolar vessel sealing system (Ligasure). Cytokines and chemokines were measured in all three groups at different time points.

RESULTS

Serum levels of interleukin (IL)-6 and tumor necrosis factor-alpha (TNF-α) increased postsurgery in all three groups and gradually declined by 72 hours. The geometric mean serum (IL)-6 levels was highest with Ligasure at 24 hours as compared with the other groups. Levels of TNF-α, macrophage inflammatory protein (MIP-1) α, MIP-1 β were also higher at 3 hours in the Ligasure group. When the differences between the groups were measured at different time points, there was a significantly greater increase in serum IL-6 levels in the Ligasure group at 24 hours (p=0.010). No significant difference was found in the post-operative course between the groups.

CONCLUSION

A greater inflammatory response was seen after the use of Ligasure indicating greater tissue damage. However, this response was not correlated with any difference in postoperative recovery.

The use of barbed sutures for vaginal cuff closure during laparoscopic hysterectomy

PURPOSE

To compare surgical outcomes and complications of 334 women who underwent total laparoscopic hysterectomy with or without the use of barbed sutures for vaginal cuff closure.

METHODS

A retrospective study was conducted on a cohort of women who underwent total laparoscopic hysterectomy for benign gynecologic diseases at Dae-Jeon St. Mary's Hospital, between May 2009 and May 2016. Surgical outcomes and complications were compared between the two groups.

RESULTS

A total of 334 women were included: 212 cases of vaginal cuff suture performed with traditional suture material and 122 cases of vaginal cuff suture performed with the barbed suture. No difference in major complications including vaginal bleeding and vaginal cuff dehiscence was found between the two groups, with a significant reduction in operative times for the barbed suture group (P = 0.002). Underlying clinical variables including diabetes, pelvic adhesion, and obesity showed no significant differences in complication rate.

CONCLUSION

Vaginal cuff suture performed with barbed suture material is a safe and well-tolerated procedure and reduces operative times. We did not find any meaningful decrease in postoperative vaginal complications including vaginal cuff dehiscence based on the suture material.

Cost evaluation, quality of life and pelvic organ function of three approaches to hysterectomy for benign uterine conditions: study protocol for a randomized controlled trial

BACKGROUND

Hysterectomy is the commonest major gynaecological surgery. Although there are many approaches to hysterectomy, which depend on clinical criteria, certain patients may be eligible to be operated in any of the several available approaches. However, most comparative studies on hysterectomy are between two approaches. There is also a relative absence of data on long-term outcomes on quality of life and pelvic organ function. There is no single study which has considered quality of life, pelvic organ function and cost-effectiveness for the three main types of hysterectomy. Therefore, the objective of this study is to provide evidence on the optimal route of hysterectomy in terms of cost-effectiveness by way of a three-armed randomized control study between non-descent vaginal hysterectomy, total laparoscopic hysterectomy and total abdominal hysterectomy.

METHODS

A multicentre three-armed randomized control trial is being conducted at the professorial gynaecology unit of the North Colombo Teaching Hospital, Ragama, Sri Lanka and gynaecology unit of the District General Hospital, Mannar, Sri Lanka. The study population is women needing hysterectomy for non-malignant uterine causes. Patients with a uterus > 14 weeks, previous pelvic surgery, those requiring incontinence surgery or pelvic floor surgery, any medical illness which caution/contraindicate laparoscopic surgery and who cannot read and write will be excluded. The main exposure variable is non-descent vaginal hysterectomy and total laparoscopic hysterectomy. The control group will be patients undergoing total abdominal hysterectomy. The primary outcome is time to recover following surgery, which is the earliest time to resume all of the usual activities done prior to surgery. In total, 147 patients (49 per arm) are needed to have 80% power at α-0.01 considering a loss to follow-up of 20% to detect a 7-day difference between the three routes; TLH versus TAH versus NDVH. The economic evaluation will take a societal perspective and will include direct costs in relation to allocation of healthcare resources and indirect costs which are borne by the patient. A micro-costing approach will be adopted to calculate direct costs from the time of presentation to the gynaecology clinic up to 6 months after surgery. Incremental cost-effectiveness ratios (ICER) will be obtained by calculating the incremental costs divided by the incremental effects (time to recover and QALYs gained) for the intervention groups (NDVH and TLH) over the standard care (TAH) group.

DISCUSSION

The cost of the procedure, quality of life and pelvic organ function following the three main routes of hysterectomy are important to clinicians and healthcare providers, both in developed and developing countries.

TRIAL REGISTRATION

The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform ( U1111-1194-8422 ) on 26 July 2016.

Laparoscopic Versus Open Hysterectomy for Benign Disease in Uteri Weighing >1 kg: A Retrospective Analysis on 258 Patients

STUDY OBJECTIVE

To present a large single-center series of hysterectomies for uteri ≥1 kg and to compare the laparoscopic and open abdominal approach in terms of perioperative outcomes and complications.

DESIGN

A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2).

SETTING

An academic research center.

PATIENTS

Consecutive women who underwent hysterectomy for uteri ≥1 kg between January 2000 and December 2016. Patients with a preoperative diagnosis of uterine malignancy or suspected uterine malignancy were excluded. The subjects were divided according to the intended initial surgical approach (i.e., open or laparoscopic). The 2 groups were compared in terms of intraoperative data and postoperative outcomes. Multivariable analysis was performed to identify possible independent predictors of overall complications. A subanalysis including only obese women was accomplished.

INTERVENTIONS

Total laparoscopic versus abdominal hysterectomy (±bilateral adnexectomy).

MEASUREMENTS AND MAIN RESULTS

Intra- and postoperative surgical outcomes. A total of 258 patients were included; 55 (21.3%) women were initially approached by open surgery and 203 (78.7%) by laparoscopy. Nine (4.4%) conversions from laparoscopic to open surgery were registered. The median operative time was longer in the laparoscopic group (120 [range, 50-360] vs 85 [range, 35-240] minutes, p = .014). The estimated blood loss (150 [range, 0-1700] vs 200 [50-3000] mL, p = .04), postoperative hemoglobin drop, and hospital stay (1 [range, 1-8] vs 3 [range, 1-8] days, p < .001) were lower among patients operated by laparoscopy. No difference was found between groups in terms of intra- and postoperative complications. However, the overall rate of complications (10.8% vs. 27.2%, p = .015) and the incidence of significant complications (defined as intraoperative adverse events or postoperative Clavien-Dindo ≥2 events, 4.4% vs 10.9%, p = .04) were significantly higher among patients who initially received open surgery. The laparoscopic approach was found to be the only independent predictor of a lower incidence of overall complications (odds ratio = 0.42; 95% confidence interval, 0.19-0.9). The overall morbidity of minimally invasive hysterectomy was lower also in the subanalysis concerning only obese patients.

CONCLUSION

In experienced hands and in dedicated centers, laparoscopic hysterectomy for uteri weighing ≥1 kg is feasible and safe. Minimally invasive surgery retains its well-known advantages over open surgery even in patients with extremely enlarged uteri.

Transient elevations of liver enzymes and ovarian vein thrombosis arising after total laparoscopic hysterectomy

Ovarian vein thrombosis in non-pregnant patient is a rare clinical entity. Among 170 patients who underwent total laparoscopic hysterectomy (TLH) in our hospital from December 2011 to December 2015, we have one case of ovarian vein thrombosis (0.0059%). A 42-year-oId woman had a fever of 39 °C on the fourth day after TLH. A blood test revealed elevations of liver enzymes and D-dimer (AST 1157 U/L, ALT 942 U/L and D-dimer >30 μg/L). Computed tomography (CT) scan with intravenous contrast agent demonstrated right ovarian vein thrombosis which caused decline in blood flow to liver and acute liver dysfunction. Low-molecular weight heparin was initiated and liver enzymes reduced rapidly. On the seventeenth day after TLH, CT scan revealed a recanalization of the ovarian vein. We report the clinical outcomes of the case attempted with a small review of the literature.

Sterility of Selected Operative Sites During Total Laparoscopic Hysterectomy

STUDY OBJECTIVE

To describe the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy (TLH).

DESIGN

Observational study (Canadian Task Force classification III).

SETTING

Academic affiliated hospital.

PATIENTS

Thirty-one women undergoing TLH for benign indications in 2016.

INTERVENTIONS

After antibiotic prophylaxis and chlorhexidine preparation, swabs were collected from the vaginal fornices and abdomen. During subsequent TLH, additional swabs were collected from the following sites: surgeon's gloves after placement of the uterine manipulator, tips of instruments used to close the vaginal cuff, uterine fundus after extraction, and surgeon's gloves after removal of the uterus. A calibrated loop was used to inoculate each specimen onto 5% blood and chocolate agars for growth of aerobes and onto Brucella blood, phenylethyl alcohol, kanamycin vancomycin, and Bacteroides bile esculin agars for growth of anaerobes. Manual colony counts were tabulated for all positive cultures and reported in colony-forming units per milliliter (CFU/mL).

MEASUREMENTS AND MAIN RESULTS

Anaerobic growth was not seen on the instrument tips, in the vagina, or on the abdomen of any patient. Aerobic bacterial growth was not seen in the vagina of any patient. On the surgeon's gloves after uterine manipulator placement, no patients demonstrated sufficient bacterial growth to potentially cause surgical site infection (≥5000 CFU/mL). On the surgeon's gloves following uterine extraction, 1 patient demonstrated sufficient growth to potentially cause infection. None of the patients developed surgical site infections postoperatively.

CONCLUSION

Cultures from multiple operative sites yielded bacterial growth, but the bacterial concentrations did not exceed the threshold for infection in 98.9% of cultures. Given absent growth from vaginal cultures and rare growth from abdominal cultures, chlorhexidine gluconate 4% is considered an appropriate surgical preparation for use in laparoscopic hysterectomy.

Cuff Closure by Vaginal Route in TLH: Case Series and Review of Literature

Total Laparoscopic Hysterectomy (TLH) represents one of the most performed gynaecological procedures nowadays. The closure of the vaginal cuff is the most diffucult part of TLH because of the difficulty of laparoscopic suturing techniques. Our aim was to evaluate the efficacy and safety of vaginal cuff closure by vaginal route on patients submitted to TLH. During the period between January 2013 to December 2015 total number of 64 laparoscopic hysterectomy were performed in our clinic. TLH and vaginal vault closure was performed as described by Ghezzi for all patients. The length of cuff closure time and the frequency of vaginal cuff-related complications were measured. Mean age was 48.1 (38-71) years, mean parity was 2.6 (1-9). Most ranked indications for hysterectomy were abnormal uterine bleeding and symptomatic leiomyoma. Average cuff closure time was 6 (2-17) minute. In average 24 (2-36) month follow-up there were no vaginal vault dehiscence. Transvaginal vaginal cuff closure seems to be safe, easy and effective for total vaginal hysterectomy. Using vaginal route can significantly reduce the length of closure time. This technique has comparable complication rates with endoscopic suturing techniques.

Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy

BACKGROUND

To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy.

METHODS

A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay.

RESULTS

A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates.

CONCLUSIONS

This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.

The impact of abdominal and laparoscopic hysterectomies on women's sexuality and psychological condition

Objective:

To investigate whether there were any differences in the quality of life, sexual function, and self-esteem of patients who underwent total laparoscopic hysterectomy (TLH) (n=42) and total abdominal hysterectomy (TAH) (n=42).

Materials and Methods:

All premenopausal patients who underwent TLH or TAH because of benign uterine disorders were enrolled. The sexual function and quality of life status were assessed preoperatively and 6 months postoperatively using three standardized validated questionnaires: the Arizona Sexual Experiences Scale (ASEX), the Symptom Checklist-90-Revised (SCL-90-R), and the Rosenberg Self-Esteem Scale (RSES).

Results:

Preoperative ASEX, SCL-90-R and RSES scores were not different among the hysterectomy subgroups. The postoperative SCL-90-R scores were also not different among the hysterectomy subgroups. The postoperative RSES scores were significantly lower (p<0.05) than the preoperative scores for all procedures (indicating improved self-esteem) but did not differ among the groups. The postoperative ASEX scores were significantly decreased (p<0.01) as compared with the preoperative scores (indicating improved sexual function). When the average score of each item of the ASEX score was compared in both groups, significant differences were observed in sexual drive and arousal in the laparoscopy group (p<0.01).

Conclusion:

Women undergoing TLH for benign uterine disease may have better outcomes related to certain sexual function parameters than women undergoing TAH.

Total laparoscopic hysterectomy: Analysis of the surgical learning curve in benign conditions

OBJECTIVE

To assess the learning curve for total laparoscopic hysterectomy.

METHODS

This study was a retrospective analysis of the learning curve for two surgeons during their first 257 consecutive cases of total laparoscopic hysterectomy at a teaching hospital. Patients were divided sequentially into groups comprising the first 75 patients, the next 75, and the final 107 patients. Age, body mass index, gestational parity, indications for laparoscopic hysterectomy, previous pelvic surgery, operating time, haemoglobin decline, complications, need for transfusion, and length of hospital stay were evaluated.

RESULTS

The mean operating time for total laparoscopic hysterectomy reduced significantly from 76.2 min to 68.9 min (p = 0.001) between the first and second 75-patient groups. Linear regression analysis showed a plateau was reached on the learning curve after 71-80 cases. The rate of all complications started at 8% in the first group of 75 patients, reduced to 6.7% in the next group, and decreased further in the final group to 4.7%. The decline was not statistically significant (p = 0.6). The difference in the need for transfusion was statistically significant between the first 75 patients and the second group of 75 (p = 0.04). Conversion from laparoscopy to laparotomy was required in five patients, four in the early group and one in the final group. Age, body mass index, parity, previous pelvic surgery, decline in haemoglobin, and length of hospital stay were similar among the three groups.

CONCLUSIONS

A plateau in the learning curve for TLH was reached after the first 75 cases. We can infer that there is a learning curve for TLH as confirmed by the decrease in operating time (accompanied by no change in complications) correlated to gain in experience. On the other hand, one should not disregard the fact that laparoscopy is not a complication-free surgery and achievement of the learning curve does not exclude complications. Gynaecological surgeons can perform TLH securely during the learning curve.

Laparoscopic Versus Open Hysterectomy for Benign Disease in Women with Giant Uteri (≥1500 g): Feasibility and Outcomes

STUDY

OBJECTIVE

To evaluate perioperative outcomes and complications of laparoscopic hysterectomy (LH) in women with giant uteri (≥1.5 kg) compared with open abdominal hysterectomy (AH), which is considered the reference.

DESIGN

A retrospective analysis of prospectively collected data (Canadian Task Force Classification II-2).

SETTING

An academic research center.

PATIENTS

All consecutive women who underwent hysterectomy for uteri weighing ≥1500 g (total = 51) between 2000 and 2015 were analyzed. Twenty-seven (53%) patients had been scheduled for the laparoscopic approach (LH), whereas 24 (48%) had been scheduled for AH.

INTERVENTIONS

Hysterectomy ± mono/bilateral salpingo-oophorectomy.

MAIN OUTCOME MEASURES

Perioperative details, incidence, severity, and type of complications were analyzed according to surgical approach (AH vs LH). We also evaluated the trends over time in terms of perioperative outcomes.

RESULTS

AH was associated with a shorter operative time (97.5 vs 160 minutes, p = .004) compared with LH. Blood loss (200 vs 225 mL, p = .21) and the decrease in postoperative hemoglobin (-1.2 vs -1.1, p = .89) were similar between AH and LH. Intra- and postoperative complications were similar between the 2 groups; however, hospital stay was significantly shorter in the LH group (median = 3 days vs 1 day, p < .001). A significant trend toward a progressive increase in the use of the minimally invasive approach was registered through the years (p = .001). Parallel to this increase, we observed a significant reduction in terms of length of stay. Moreover, a decrease in the total number of complications, mainly because of a decrease in the rate of early minor events, was observed through the years.

CONCLUSIONS

Our experience shows that LH can be considered a feasible procedure, even in cases of uteri ≥1.5 kg, with significant advantages over open surgery in terms of postoperative hospital stay.

Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy

PURPOSE

Total laparoscopic hysterectomy (TLH) in the case of endometriosis may be extremely challenging. Our aim has been to analyze perioperative details and complications of TLH in women with vs. women without endometriosis.

METHODS

Consecutive women who underwent TLH for endometriosis (endometriosis group) were compared with consecutive patients who had TLH for other conditions (controls) in terms of perioperative outcomes. Patients in the endometriosis group were analyzed, according to the severity of the disease.

RESULTS

One-hundred and twelve women in the endometriosis group, 29 (25.9 %) with minimal-mild, and 83 (74.1 %) with moderate-severe stage disease (rAFS score), respectively, were compared with 572 controls. Conversion rate was 0.8 vs. 0.5 % (P = 0.51), and median operative time was 75 vs. 55 min (pxxx = x) in the endometriosis group vs.

CONTROLS

Intraoperative complications were similar between groups (P = 0.56). Postoperative complications occurred in 10 (12.3 %) women in the endometriosis group vs. 12 (3.3 %) among the controls (P = 0.002). The severity of complications according to Clavien-Dindo classification system was higher in the endometriosis group (Clavien-Dindo >2: 7.5 vs. 1.9 %). The risk of organ lesions, urinary lesions, postoperative complications, and severe adverse events was significantly higher in women with moderate-severe endometriosis vs.

CONTROLS

No differences between patients with minimal-mild endometriosis and controls were found.

CONCLUSION(S)

TLH in the case of endometriosis is associated with longer operative time and an almost fourfold increase in the risk and severity of complications compared with controls. In particular, the adjunctive risk of adverse events is specific for moderate/severe-stage disease but not for minimal/mild endometriosis.

Uterine Sarcomas in Patients Undergoing Surgery for Presumed Leiomyomas: 10 Years' Experience

STUDY OBJECTIVE

To find the incidence of sarcomas in patients undergoing surgery for presumed leiomyomas.

DESIGN

Retrospective study (Canadian Task Force classification II-3).

SETTING

Paul's Hospital, Centre for Advanced Laparoscopy and Infertility, Kochi, India.

PATIENTS

All women who underwent total laparoscopic hysterectomy (TLH), laparoscopic myomectomy (LM), and hysteroscopic myomectomy (HM) at Paul's Hospital for presumed leiomyomas from January 1, 2004 to December 31, 2014 that were then diagnosed as sarcomas on histopathologic examination.

INTERVENTIONS

TLH, LM, and HM.

MEASUREMENTS AND MAIN RESULTS

A total of 2678 patients underwent TLH, LM, and HM at Paul's Hospital for presumed leiomyomas from January 1, 2004 to December 31, 2014. Five patients were diagnosed as leiomyosarcoma and 3 patients as endometrial stromal sarcoma on histopathologic examination. Women's ages ranged from 12 to 53 years. Histopathologic diagnosis of leiomyosarcoma was made in 3 patients from the TLH group and 2 patients from the myomectomy group. Two patients from the TLH group and 1 patient from the myomectomy group were diagnosed as endometrial stromal sarcoma on histopathologic examination. The incidence of uterine sarcomas (leiomyosarcoma and endometrial stromal sarcoma) in patients undergoing surgery for presumed leiomyomas was found to be .29% (1 in 335 patients) in our study.

CONCLUSION

Over a period of 10 years (2004-2014), the incidence of uterine sarcomas in patients undergoing surgery for presumed leiomyomas was found to be .29% in our study.

Identifying the Rate-Limiting Step in Total Laparoscopic Hysterectomy in a Training Hospital

STUDY OBJECTIVE

To identify the lengthiest step of total laparoscopic hysterectomy (TLH) in a teaching hospital and to determine which clinical factors affect the duration of this step.

SETTING

The University of Louisville Hospital.

DESIGN

Single institution retrospective case series.

METHODS AND MAIN RESULTS

This is a retrospective chart and video review that included 135 benign, elective TLHs performed at The University of Louisville. TLH was divided into 5 steps: (1) insertion of laparoscopic ports and adhesiolysis to restore normal anatomy; (2) identification of the ureter and resection of adnexal structures to transection of the round ligament; (3) transection of the round ligament to transection of the uterine artery; (4) lateralization of the uterine vessel pedicle to completion of colpotomy; and (5) completion of vaginal cuff closure. The random intercept and slope model was used to identify the lengthiest step of TLH, and the backward elimination procedure was used to evaluate which clinical factors affected this step. Mean ± SD total length of TLH was 81 ± 30 min. The lengthiest step was colpotomy, with a mean duration of 24 ± 13 min. Uterine weight significantly increased the length of time required for colpotomy (p = .001). The primary energy source (ultrasonic scalpel vs monopolar hook) used to perform colpotomy did not influence the length of time (p = .539 vs p = .583). Uterine weight (p < .001) and adhesiolysis (p = .003) significantly increased the total time of TLH.

CONCLUSIONS

At a teaching institution where surgeries are performed by residents and fellows, colpotomy is the lengthiest step of TLH and is influenced by uterine weight. This finding may reflect the training levels of the surgeons performing these cases and the learning curve associated with a challenging surgical skill. Further research should focus on simulation models and/or tools for colpotomy that may result in greater efficiency in the operating room.

Laparoscopic Hysterectomies: Our 10 Years Experience in a Single Laparoscopic Center

STUDY OBJECTIVE

To evaluate the association between outcomes of laparoscopic hysterectomy with respect to clinical factors, intraoperative variants, and post-operative complications.

DESIGN

The study conducted was retrospective (Canadian Task Force Classification II-1).

SETTING

The set used in this study was a gynecological laparoscopic centre.

PATIENTS

The present study included 858 women who underwent laparoscopic hysterectomies with or without bilateral/unilateral salpingo-oophorectomy, from December 2004 to May 2014.

INTERVENTIONS

Eight hundred and sixteen patients underwent total laparoscopic hysterectomy, 14 patients underwent subtotal laparoscopic hysterectomy, 20 patients underwent laparoscopic-assisted vaginal hysterectomy, and 8 patients underwent laparoscopic radical hysterectomy with bilateral pelvic lymph node dissection.

MEASUREMENTS AND MAIN RESULTS

All surgeries were performed by the same surgeon, using the same surgical technique. The medical records were reviewed, and data were collected with respect to age, indications, type of surgery performed, intraoperative variants, and post-operative complications. Patient average age was 44.9 ± 6.2 years. Most common indication for benign TLH was leiomyoma of 54.4 %. Indications for laparoscopic radical hysterectomy were early stage endometrial cancer (n = 5) and early stage cervical cancer (n = 3). The maximum uterine size operated on was from 20-26 weeks, 4.9 % (n = 42). 9.7 % had previous abdominopelvic surgery. Fifty three % underwent unilateral/bilateral salpingo-oophorectomy. Conversion rate was 0.93 % (n = 8). The minimum and maximum operating time during the total study period was 20 min-2 h. The major complication rates were 0.9 % (n = 8). The hospital stay was not more than 2 days.

CONCLUSION

In our experience of 858 laparoscopic hysterectomies, 850 were done for benign indications, and 8 done for malignancies. TLH can be performed more safely and under vision, with less blood loss, early post-operative recovery, less post-operative infection, and less complication rate.

Major laparoscopic surgery under regional anesthesia: A prospective feasibility study

BACKGROUND

Laparoscopic surgeries have attained the status of a gold standard for most of the abdominal pathology; we therefore performed this study to assess feasibility and safety of major laparoscopic surgeries like laparoscopic cholecystectomy (LC) and laparoscopic assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) under regional anesthesia that is combined spinal epidural anesthesia (CSE) with normal pressure pneumoperitoneum using intrathecal fentanyl with bupivacain.

METHODS

In a zonal government hospital, 50 patients were selected prospectively for LC and LAVH/TLH, under normal pressure (12 mmHg) pneumoperitoneum and under CSE over a span of fifteen months. Injection bupivacaine (0.5%) and 20 μg of fentanyl were used for spinal anesthesia. Plain bupivacaine (0.5%) was used for epidural anesthesia.

RESULTS

We successfully performed the operations in 48 patients without major complications. CSE was converted to general anesthesia in two patients due to distressing shoulder tip pain. Age varied between 25 and 70 years. Duration of operation time (skin to skin) was between 50 and 170 min. Five patients had urinary retention and one developed localized pruritis. There was no incidence of respiratory depression, aspiration or headache.

CONCLUSION

Laparoscopic surgeries with normal pressure CO2 pneumoperitoneum are feasible and safe under CSE. Incidence of postoperative shoulder pain was minimal due to use of intrathecal fentanyl and complications were less and easily manageable.

Comparison of total laparoscopic hysterectomy and abdominal hysterectomy

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.

Iatrogenic uterine perforation and bowel penetration using a Hohlmanipulator: A case report

INTRODUCTION

Adequate exposure is a vital factor in total laparoscopic hysterectomy, and uterine manipulators have been used in achieving that. The Hohl uterine manipulator has been considered to be one of the safer manipulators. Beside adequate exposure, it is associated with lower intraoperative complications. However, we report a case of iatrogenic uterine rupture with the Hohl manipulator which also caused bowel penetration.

PRESENTATION OF CASE

A 52-year-old woman with endometrial hyperplasia was scheduled for total laparoscopic hysterectomy. Prior to entering into the abdomen, the Hohl uterine manipulator was introduced into the uterine cavity without force. During the laparoscopic exploration, we noted that the tip of the Hohl manipulator had perforated the posterior uterine fundus and penetrated the bowel. Therefore, laparotomy was performed, and the bowel injury was repaired by a colorectal surgeon.

DISCUSSION

The Hohl uterine manipulator is safe and easy to use, and is associated with decreased intraoperative injuries. However, the complications observed due to the improper use of an uterine manipulator can overshadow any advantages of manipulator. In the present report, we describe a case of uterine perforation and bowel penetration caused by the Hohl uterine manipulator during total laparoscopic hysterectomy, which required conversion to laparotomy. The cause for this complication is associated with improper usage of the uterine manipulator.

CONCLUSION

Uterine manipulator may cause uterine perforation and bowel penetration at the beginning of the hysterectomy procedure. These types of complications can be prevented by proper application of the Hohl manipulator into the uterus under direct pelvic visualization.

Comparison of the use of LigaSure, HALO PKS cutting forceps, and ENSEAL tissue sealer in total laparoscopic hysterectomy: a randomized trial

STUDY OBJECTIVE

There are many instruments with different energy modalities or with different properties that are available for use in total laparoscopic hysterectomy. The aim of the study was to compare the use of LigaSure (Valleylab, Boulder, CO), HALO PKS cutting forceps (Gyrus-ACMI, Maple Grove, MA), and ENSEAL tissue sealer (SurgRx, Inc. Redwood City, CA) in total laparoscopic hysterectomy with respect to operation time and blood loss as main outcomes. Perioperative complications, return of gastrointestinal activity, and hospitalization time were assessed as secondary outcomes.

DESIGN

Randomized prospective study (Canadian Task Force classification I).

SETTING

Adana Numune Training and Research Hospital.

PATIENTS

Forty-five patients with the indication of hysterectomy were randomized into 3 groups for total laparoscopic hysterectomy. Patients with malignancies, having 3 or more previous abdominal surgeries, a uterus larger than 12 weeks of gestation, and who had to undergo additional surgical procedures during the same operation were excluded.

INTERVENTIONS

Total laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Operations were completed in all 15 patients in the LigaSure and HALO PKS Cutting Forceps groups with the planned instruments. In 2 patients in the ENSEAL group, bleeding could not be controlled with ENSEAL, and additional instruments were used. One patient in the ENSEAL group had bladder injury. The mean operation time and blood loss were 52.4 ± 12.8, 51.86 ± 14.11, and 55.7 ± 15.7 minutes (p > .05) and 138 ± 54.3, 118 ± 63.3, and 218 ± 115.9 mL (p < .05) in the LigaSure, HALO PKS, and ENSEAL groups, respectively. Changes in hemoglobin/hematocrit levels, return of gastrointestinal activity, and hospitalization time did not differ between groups.

CONCLUSION

These 3 novel bipolar platforms had similar results in total laparoscopic hysterectomy. These instruments were not determined to be independent predictors of operating time and amount of blood loss.