Effects of Obesity on Peri- and Postoperative Outcomes in Patients Undergoing Robotic versus Conventional Hysterectomy

Study ObjectiveTo assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the outcomes.DesignCohort study.SettingProspectively collected data from 3 Swedish population-based registers.PatientsWomen undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity.InterventionsIntraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH).Measurements and Main ResultsOut of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio [aOR]) 1.4; 95% confidence interval [CI], 1.1–1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2–2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2–15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4–124.7 and VH: 17.1; 95% CI, 3.5–83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4–40.5; aOR 8.5; 95% CI, 2.5–29.5; and aOR 5.8; 95% CI, 1.5–22.8, respectively) in women with obesity.ConclusionThe use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.     

Hysterectomy trends over a 9-year period in an endoscopic teaching center

Objective

To investigate trends in the performance of hysterectomy at a single certified endoscopic teaching center.

Methods

Data were collected retrospectively from 953 patients who underwent hysterectomy between 2002 and 2010 for benign indications at UKSH, Germany. Preoperative risk scores were assigned to patients.

Results

The most frequent indications for hysterectomy were uterine myoma, adenomyosis, prolapse, endometrial hyperplasia, menstrual disorders, and endometriosis. The shortest operating time was recorded for vaginal hysterectomy (VH) and the longest for laparoscopically assisted VH (LAVH). The average uterine weight was highest for abdominal hysterectomy (AH) and lowest for VH. The major postoperative complication rate was 11.8% for laparoscopic supracervical hysterectomy (LSH) and 23.5% for AH. The highest intraoperative complication rate occurred with AH (46.4%) and the lowest with total laparoscopic hysterectomy (TLH; 3.6%). The minor postoperative complication rate was 5.9%. The mean preoperative score was 1.09 ± 1.51 for AH, 0.75 ± 0.96 for VH, 1.04 ± 1.30 for LSH, 1.0 ± 1.40 for LAVH, and 1.38 ± 1.52 for TLH.

Conclusion

Laparoscopic hysterectomies have become more common and were associated with decreased complication rates, despite the higher preoperative risk score of these patients.     

Association of Race/Ethnicity with Surgical Route and Perioperative Outcomes of Hysterectomy for Leiomyomas

Study ObjectiveTo evaluate the associations among race/ethnicity, route of surgery, and perioperative outcomes for women undergoing hysterectomy for uterine leiomyomas.DesignRetrospective cohort study.SettingMultistate.PatientsWomen who underwent hysterectomies for leiomyomas from the American College of Surgeons National Surgical Quality Improvement Program database, 2014 to 2017.InterventionsNone. Exposures of interest were race/ethnicity and route of surgery.Measurements and Main ResultsRacial/ethnic variation in route of surgery and perioperative outcomes. Propensity score matching was employed to control for possible confounders. We identified 20 133 women who underwent nonemergent abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or vaginal hysterectomy (VH) for leiomyomas. We defined minimally invasive hysterectomy (MIH) as LH or VH. Black women were more likely to have open surgery (AH vs MIH adjusted odds ratio [aOR], 2.22; 95% confidence interval [CI], 2.07–2.38; AH vs VH aOR, 1.79; 95% CI, 1.54–2.08; AH vs LH aOR, 2.27; 95% CI, 2.13–2.44) than white women. Likewise, Hispanic women were more likely to have open surgery (AH vs MIH aOR, 1.76; 95% CI, 1.58–1.96; AH vs LH aOR, 1.82; 95% CI, 1.61–2.00) than white women. Black women were more likely to experience any complication after hysterectomy (AH aOR, 1.54; 95% CI, 1.31–1.80; VH aOR, 1.65; 95% CI, 1.02–2.68; LH aOR, 1.37; 95% CI, 1.13–1.66) than white women. Hispanic women were less likely than white women to experience major complications after VH (aOR, 0.28; 95% CI, 0.08–0.98). Compared with white women, the mean length of stay was longer for black women who underwent AH or LH. The mean total operation time was higher for all minority groups (except for Asian/other undergoing AH) regardless of surgical approach.ConclusionWomen of minority race/ethnicity were more likely to undergo abdominal rather than MIH for leiomyomas. Even when controlling for route of surgery, they were more likely to experience perioperative complications.     

Comparison of prevalence of hypoactive sexual desire disorder (HSDD) in women after five different hysterectomy procedures

Objective

The advantages of the various methods used for hysterectomy are currently a topic of debate, and there is particular controversy over whether the cervix should be left in situ or not. The aim of this study was to compare the prevalence of hypoactive sexual desire disorder (HSDD) after five different hysterectomy procedures.

Study design

The Brief Profile of Female Sexual Function (B-PFSF) score was measured to compare postoperative prevalence of HSDD after the different surgical procedures. The questionnaire was sent to 590 women who had undergone hysterectomy between 2002 and 2007 for benign conditions. The following procedures were performed: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopy-assisted vaginal hysterectomy (LAVH), laparoscopic supracervical hysterectomy (LASH), and total laparoscopic hysterectomy (TLH).

Results

A total of 304 questionnaires returned and 258 were found to be eligible for analysis. The mean follow-up intervals were 2 years for women after LASH and TLH and 3 years for women after AH, VH, and LAVH. The women in the AH group were significantly older than those in the LASH group, and the women in the VH group were significantly older than those in the LASH or TLH groups. The median B-PFSF score was highest at 26 in women after LASH, 25 in women after TLH, 23 in women after LAVH, 23.5 in women after VH, and 21 in women after AH. There were no statistically significant differences between the groups.

Conclusions

No differences were observed using the B-PFSF score with regard to the prevalence of HSDD after hysterectomy, irrespective of the surgical technique used.     

Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database

Study ObjectiveThe objective of this study was to describe perioperative outcomes of minimally invasive sacrocolpopexy (MISCP) based on 4 different routes of concurrent hysterectomy: vaginal (VH), laparoscopic-assisted (LAVH), laparoscopic supracervical (LSCH), and total laparoscopic (TLH).DesignThis was a retrospective cohort study. A secondary analysis of the 2006–2015 National Surgical Quality Improvement Program (NSQIP) database was performed analyzing women who underwent concurrent hysterectomy with MISCP based on Current Procedural Terminology (CPT) codes. We excluded open abdominal hysterectomies. We compared outcomes between VH, LAVH, LSCH, and TLH including operative time, length of hospital stay, a composite outcome of 30-day postoperative adverse events, readmission, or reoperation. A logistic regression model was used to correct for pre-identified potential confounding variables. A minimum detectable effect analysis was planned.SettingHospitals participating in the NSQIP program.PatientsWomen who underwent hysterectomy with MISCP.InterventionsNot applicable.Measurement and Main ResultsA total of 524 women underwent hysterectomy with MISCP including VH in 31 (5.9%), LAVH in 40 (7.6%), LSCH in 322 (61.5%), and TLH in 131 (25%). The VH group had a higher incidence of ≥4 concurrent CPT codes (71% vs 27% in other groups, p = .03). Operative times differed significantly between groups (p < .01): TLH had the shortest operating time (171.43 ± 83.77 minutes). There were no significant differences in length of hospital stay, rate of reoperation, 30-day readmission, or the composite outcome (p = .8). Route of hysterectomy was not associated with increased composite outcome on adjustment for confounders (adjusted odds ratio [OR] 1.1, 95% CI 0.3–3.99, p = .88). A minimum detectable effect analysis indicated that this study population had 80% power to detect an OR of 5.07 or greater between the different routes of hysterectomy during concomitant MISCP for the composite 30-day outcome.ConclusionRegardless of route of concurrent hysterectomy, MISCP is associated with low rates of 30-day complications, reoperation, and readmission.     

Predictive Factors for Morcellation during Total Laparoscopic Hysterectomy: A Cohort Study

ObjectivesOur objective was to identify predictors of morcellation during a total laparoscopic hysterectomy (TLH).MethodsA retrospective cohort study (Canadian Task Force classification II-2) taking place in a university hospital center in Quebec, Canada. Participants were women undergoing a TLH for a benign gynaecologic pathology from January 1, 2017, to January 31, 2019. All women underwent a TLH. If the uterus was too voluminous to be removed vaginally, surgeons favoured in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed before surgery by ultrasound or magnetic resonance imaging to predict morcellation.ResultsA total of 252 women underwent a TLH and the mean age was 46 ± 7 (30–71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17–1572) ± 272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least 1 leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥250 vs. <250 grams; OR 3.7 [CI 1.8 to 7.7, P < 0.01]), having ≥ 1 leiomyoma (OR 4.1, CI 1.0 to 16.0, P = 0.01) and leiomyoma of ≥5 cm (OR 8.6, CI 4.1 to 17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis.ConclusionsUterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.     

Can total laparoscopic hysterectomy replace total abdominal hysterectomy? A 5-year prospective cohort study of a single surgeon's experience in an unselected population

Total laparoscopic hysterectomy (TLH) has well-established advantages over total abdominal hysterectomy in benign gynaecology. We evaluated the outcome of a single surgeon who offered TLH as the default surgical procedure for all non-vaginal hysterectomies in an unselected gynaecology clinic population. TLH was offered as the default method of hysterectomy for patients from September 1, 2006, and data were collected up to August 31, 2011. Data were collected on indication for surgery, previous surgery, pelvic pathology, intraoperative findings, uterine weight and/or size, complications and conversion to open hysterectomy. Primary outcomes were the proportion of hysterectomies performed laparoscopically, complications and conversion rates. A total of 173 hysterectomies were performed; 18 (10 %) were total abdominal hysterectomy (TAH), 17 (10 %) were vaginal hysterectomies (VH), and 138 (80 %) were TLH. TLH rates increased from 51 % in year 1 to 100 % in years 3, 4 and 5 for women that elected for laparoscopic approach. The median uterine weight for TLH increased each year from 110 g (range 58–209 g) in year 1 to 240 g (range 70–584 g) in year 5. All patients were deemed suitable for laparoscopic approach irrespective of the uterine size and comorbidities by year 3 with only a single conversion in year 4. There were 11 major surgical complications: VH 0 (0 %), TAH 1 (5.6 %) and TLH 10 (7.2 %) and three (2.2 %) conversions to laparotomy. Once a surgeon's laparoscopic expertise plateaus, TLH can be offered to patients as the default procedure for non-vaginal hysterectomy in an unselected UK population with benign disease.     

Outpatient Laparoscopic Hysterectomy for Large Uteri

ObjectiveTo determine the incidence of perioperative complications associated with laparoscopic hysterectomies performed for very large uteri on an outpatient basis.MethodsA retrospective chart review of consecutive women who underwent total laparoscopic (TLH) or supracervical laparoscopic (LSH) hysterectomy with uterine weight ≥ 500 grams. Clinical, demographic, and surgical characteristics were ascertained. Deviation from a normal intraoperative/perioperative course and readmission rate were assessed. Complications were graded by Dindo morbidity scale. Surgical characteristics and complications were compared between TLH and LSH groups using Chi2 tests for categorical and unpaired t tests for continuous variables. Logistic regressions were performed to identify specific risk factors.ResultsTLH and LSH were performed in 113 (25.3%) and 333 (74.7%) cases, respectively, with no differences in baseline characteristics between the groups. Median uterine weight was 786 gm (range: 500–4500). Mean operative time was 27 minutes longer in the TLH group: 186.5 ± 58.6 vs. 159.6 ± 53.8 minutes for LSH (P < 0.0001). Life threatening complications (Dindo's grade IV morbidity) occurred in 0.7%. Surgical intervention requiring general anesthesia (IIIB) occurred in 0.45% of cases. Visceral injury was limited to 6 (1.3%) cases of cystotomy. The rate of vascular injury was 0.22%. Conversion to laparotomy occurred in 3.4% of cases. 92.8% of patients were discharged on post-operative day zero, with 1.1% readmission rate. There was no association between perioperative morbidity and patient/surgical characteristics.ConclusionLaparoscopic hysterectomy is a viable option for women with very large uteri. Same day discharge of clinically stable patients can be safely implemented.     

Abdominal, vaginal and total laparoscopic hysterectomy: perioperative morbidity

Purpose  

The aim of our retrospective study was to assess and to compare the surgical complications of hysterectomy regarding the choice of procedure [abdominal (AH), vaginal (VH), and total laparoscopic hysterectomy (TLH)].     

Minimally Invasive Hysterectomies—A Survey on Attitudes and Barriers among Practicing Gynecologists

Study ObjectiveTo explore attitudes and hysterectomy practices among gynecologists in the United States and to identify potential barriers to offering minimally invasive hysterectomies.DesignMixed-mode (online and on-paper) survey of a random sample of 1500 practicing obstetrician-gynecologists.SettingNationwide survey in the United States.ParticipantsNonretired obstetrician-gynecologists identified through a physician list from the American Medical Association.InterventionsPostal and online survey.Measurements & Main ResultsWe received a response from 376 physicians (25.8% response rate). The average age of respondents was 47.9 years, and 87% were generalists. Participants performed on average 4 surgical cases per week and 32 hysterectomies per year, most of which were abdominal hysterectomies. When asked for preferred mode of access for themselves or their spouse, 55.5% chose vaginal hysterectomy (VH), 40.6% chose laparoscopic hysterectomy (LH), and 8% chose abdominal hysterectomy (AH). Younger physicians (<40) and high surgical volume physicians were significantly more likely to chose a laparoscopic approach and identified significantly fewer barriers for performing LH. The main barriers to performing VH were technical difficulty, potential for complications, and caseload of VH. The main barriers for performing LH were training during residency, technical difficulty, personal surgical experience and operating time. The majority of gynecologists wanted to decrease their AH rates and increase their LH rates. The most significant identified contraindications to VH were prior laparotomy, a uterus larger than 12 weeks, narrow introitus, adnexal mass, and minimal uterine descent.ConclusionsWhile a large majority of gynecologists would prefer a VH or LH for themselves or their spouse, AH remains the most common hysterectomy method in the United States. A generation gap appears to be brewing with younger gynecologist more in favor of the laparoscopic approach. More emphasis should be placed on training gynecologists in performing minimally invasive hysterectomies, given their desire to change their surgical mode of access.     

What Determines the Need to Morcellate the Uterus during Total Laparoscopic Hysterectomy?

Study ObjectiveTo identify factors associated with the need to perform uterine morcellation during total laparoscopic hysterectomy (TLH). A secondary aim was to establish new cut-offs based on uterine weight for the probability of morcellation.DesignProspective observational study (Canadian Task Force Classification II-2).SettingTertiary referral laparoscopic unit.PatientsAll women scheduled to undergo TLH in the study period were included.InterventionsAge, parity, operating time, estimated blood loss, and final uterine weight at histology were recorded. Logistic regression analysis was performed to determine the factors associated with the need to perform uterine morcellation at the time of TLH. Multiple imputation (MI) was used to impute missing values.Measurements and Main ResultsA total of 112 consecutive women underwent TLH and were included in the final analysis. In all, 56 (50%) of 112 women underwent TLH without morcellation (i.e., it was possible to deliver the uterine specimen vaginally) and 56 (50%) of 112 women underwent TLH with morcellation (i.e., it was not possible to deliver the uterine specimen vaginally and, therefore, morcellation was performed). Median age in each group was 45 and 46 years, respectively. Sixteen (70%) of 23 nulliparous women underwent morcellation compared with 40 (45%) of 89 parous women. Multivariable logistic regression analysis revealed that nulliparity (OR = 6.45, 95% CI = 1.74–23.9) and uterine weight (OR/100-g increase = 4.97, 95% CI = 2.13–11.6) increased the odds of morcellation. All 20 women with a uterine weight of at least 350 g required morcellation. Based on the MI analysis results, uterine weight was at least 350 g in 1 of 5 patients, with 99.5% of the women having uterine weight of 350 g or more that required morcellation.ConclusionNulliparity and increasing uterine weight are associated with the need to perform uterine morcellation in TLH. Studies are needed to find a reliable method for estimating uterine weight preoperatively.     

Vesicoureteral Injury during Benign Hysterectomy: Minimally Invasive Laparoscopic Surgery versus Laparotomy

Study ObjectiveThe findings of previous studies have been inconsistent as to whether benign hysterectomy via minimally invasive laparoscopic surgery increases the risk of vesicoureteral injury when compared with laparotomy. The objectives of our study were to (1) examine the rate of vesicoureteral injury on benign hysterectomy by the surgical approach and (2) compare the risk of vesicoureteral injury specifically between minimally invasive laparoscopic and abdominal hysterectomy on a populational level.DesignRetrospective population-based observational study.SettingThe National Inpatient Sample.PatientsA total of 501 110 women who had undergone hysterectomy for benign gynecologic disease between January 2012 and September 2015 were included as follows: total abdominal hysterectomy (TAH, n = 284 365 [56.7%]), total laparoscopic hysterectomy (TLH, n = 60 410 [12.1%]), abdominal supracervical hysterectomy (Abd-SCH, n = 55 655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n = 45 620 [9.1%]), total vaginal hysterectomy (TVH, n = 34 865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH, n = 20 195 [4.0%]).InterventionsA comprehensive risk assessment for vesicoureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing was used to compare (1) TLH versus TAH and (2) LSC-SCH versus Abd-SCH with generalized estimating equations. In a sensitivity analysis, gynecologic disease−specific injury risk and vaginal route−specific injury risk (LAVH vs TVH) were assessed.Measurements and Main ResultsVesicoureteral injury was reported in 1045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas LSC-SCH had the lowest (0.10%) (p <.001). TLH (0.13%) had the highest ureteral injury rate, whereas TAH had the lowest (0.04%) (p <.001). In propensity score inverse probability of treatment weighing models, compared with TAH, TLH was associated with an increased risk of ureteral injury (odds ratio [OR] 3.95, 95% confidence interval [CI] 2.03−7.67, p <.001) but not bladder injury (OR 1.04, 95% CI 0.57−1.90, p = .897). Risk of ureteral injury was particularly high when TLH was performed for endometriosis (OR 6.15, 95% CI 1.18−31.9, p = .031) or for uterine myoma (OR 4.15, 95% CI 2.13−8.11, p <.001). In contrast, for supracervical or vaginal hysterectomy, minimally invasive laparoscopic approaches were not associated with an increased risk of vesicoureteral injury (LSC-SCH vs Abd-SCH: OR 0.62, 95% CI 0.19−1.98, p = .419; LAVH vs TVH: OR 1.21, 95% CI 0.63−2.33, p = .564).ConclusionThe risk of vesicoureteral injury on benign hysterectomy is low overall regardless of hysterotomy modalities but varies widely with the surgical approach. Compared with TAH, TLH may be associated with an increased risk of ureteral injury.     

Secondary hemorrhage after different modes of hysterectomy

Secondary hemorrhage after hysterectomy is rare but a life-threatening complication. The aim of this study is to estimate the cumulative incidence, patient characteristics, and potential risk factors of secondary hemorrhage after abdominal, vaginal, and laparoscopic hysterectomies. We did a retrospective observational study in which 1,623 cases of total laparoscopic hysterectomy (TLH), 963 cases of total abdominal hysterectomy (TAH), and 1,171 cases of vaginal hysterectomy (VH) were analyzed. Of the total 37 hemorrhages following hysterectomies, 23 were after TLH, 8 following VH, and 6 were after TAH. The cumulative incidence of secondary hemorrhage after any type of total hysterectomies was 0.98 %. TLH was associated with the highest risk of secondary hemorrhage (1.51 %) followed by VH (0.68 %) and TAH group (0.62 %). The relative risk of secondary hemorrhage following TLH compared to TAH and VH were 2.3 and 2.1, respectively. Both were statistically significant. The average size of the uterus in the TLH group was 516.7 g, and in the TAH and VH group, it was 140 and 142.5 g, respectively, which was statistically significant. The median time interval between hysterectomy and secondary hemorrhage was 11 days in TAH and VH group and 13 days in TLH group. Our data suggest that secondary hemorrhage is rare but may occur more often after TLH than after other hysterectomy approaches. Whether it is related to the application of thermal energy to tissues which cause more tissue necrosis and devascularization than sharp colpotomies in the TAH and VH groups is unclear. Large size of uteri, excessive use of energy source for uterine artery, and colpotomy may play a role.     

vNOTES Hysterectomy for Large Uteri: A Retrospective Cohort Study of 114 Patients

Study ObjectiveTo evaluate the outcome of hysterectomy through vaginal natural orifice transluminal endoscopic surgery (vNOTES) in cases with a large uterus.DesignA retrospective cohort study.SettingBelgian teaching hospital.PatientsWomen who underwent a vNOTES hysterectomy from March 2015 to March 2020 for benign gynecologic disease with a uterine weight of 280 g or more on pathologic examination (N = 114).InterventionsAll women underwent vaginally assisted NOTES hysterectomy. We performed a retrospective analysis of baseline patient characteristics and clinical outcomes.Measurements and Main ResultsThe mean age was 50 ± 3.5 years. Twenty-two (19%) patients were obese (body mass index ≥30 kg/m²), and 4 (3.5%) were morbidly obese (body mass index ≥40 kg/m²). Thirty-five (31%) patients were nulliparous, and 15 (13%) women had 1 or more cesarean sections in their medical history. Uterine weight varied from 281 g to 3361 g, with a mean weight of 559 ± 425 g. Mean surgical time was 63 ± 34 minutes. Surgical time was positively associated with uterine size. There were 4 complications: 3 bleeding complications in the first 24 hours after surgery and 1 minor late complication. Conversion to laparotomy for specimen extraction was performed in 1 case (conversion rate 0.9%). There were no conversions to laparoscopy. No ureteric, bladder, or intestinal injuries occurred in this case series, and there were neither life-threatening complications nor intensive care unit admissions.ConclusionThe vNOTES technique can offer a safe and effective alternative to laparoscopy or laparotomy in cases with a large to very large uterus, even if the patient has a history of cesarean section, obesity, or nulliparity. In 99% of all women in this study, hysterectomy was successfully performed through vNOTES without conversion. By making use of the advantages of endoscopic surgery, vNOTES might broaden the indications of vaginal hysterectomy. Randomized controlled trials are needed to evaluate whether vaginally assisted NOTES hysterectomy is superior to laparoscopic or abdominal hysterectomy in large uteri cases.     

Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin

Study ObjectiveTo reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin.DesignStep-by-step demonstration and explanation of technique using videos from patients.SettingGynecologic oncology unit at a university hospital.PatientA 54-year-old woman with uterine fibromatosis and metrorrhagia.InterventionTLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1].Measurements and Main ResultsLaparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature.ConclusionWe present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure.     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

A new approach to simplify surgical colpotomy in laparoscopic hysterectomy

New surgical techniques and technology have simplified laparoscopic hysterectomy and have enhanced the safety of this procedure. However, the surgical colpotomy step has not been addressed. This study evaluates the surgical colpotomy step in laparoscopic hysterectomy with respect to difficulty and duration. Furthermore, it proposes an alternative route that may simplify this step in laparoscopic hysterectomy. A structured interview, a prospective cohort study, and a problem analysis were performed regarding experienced difficulty and duration of surgical colpotomy in laparoscopic hysterectomy. Sixteen experts in minimally invasive gynecologic surgery from 12 hospitals participated in the structured interview using a 5-point Likert scale. The colpotomy in LH received the highest scores for complexity (2.8?±?1.2), compared to AH and VH. Colpotomy in LH was estimated as more difficult than in AH (2.8 vs 1.4, p?<?.001). In the cohort study, 107 patients undergoing LH were included. Sixteen percent of the total procedure time was spent on colpotomy (SD 7.8 %). BMI was positively correlated with colpotomy time, even after correcting for longer operation time. No relation was found between colpotomy time and blood loss or uterine weight. The surgical colpotomy step in laparoscopic hysterectomy should be simplified as this study demonstrates that it is time consuming and is considered to be more difficult than in other hysterectomy procedures. A vaginal approach to the colpotomy is proposed to achieve this simplification.     

Surgical Outcome and Cost Comparison Between Total Vaginal Hysterectomy and Laparoscopic Hysterectomy for Uteri Weighing >500 g

Study ObjectiveTo compare surgical outcomes and overall costs of less invasive methods of hysterectomy to treat benign disease including total vaginal hysterectomy (TVH) and total laparoscopic hysterectomy (TLH) in women with a uterus weighing >500 g.DesignRetrospective review of medical records (Canadian Task Force classification III).SettingUniversity-associated hospital.PatientsOne hundred three women with a uterus weighing >500 g who had undergone either total vaginal hysterectomy (TVH) (n = 52) or total laparoscopic hysterectomy (TLH) (n = 51).Measurements and Main ResultsCost data were extracted from the hospital billing system. Patient characteristics, surgical outcomes, and hospital costs were compared between the 2 groups. Patient characteristics were similar in both groups except for a history of surgery (TVH 11.5%, and TLH 37.3%; p = .01). Insofar as surgical outcomes, mean (SD) operative time was shorter in the TVH group compared with the TLH group (110.00 [28.68] minutes vs 180.47 [51.32] minutes; p < .001), and hospital stay was longer (8.08 [0.68] days vs 7.45 [1.03] days; p < .001). Other surgical outcomes including estimated blood loss (p = .20) and decrease in hemoglobin (p = .12) did not differ between the 2 groups. Total hospital costs (converted from Korean won to US dollars) were significantly lower in the TVH group than in the TLH group ($2076.59 [$666.58] vs $2744.03 [$715.76]; p < .001).ConclusionOur data suggest that TVH is a safe and economic procedure even in women with a uterus weighing >500 g. Skilled surgeons should preferentially consider TVH for treatment of benign uterine disease, regardless of uterine size.     

Barbed Suture vs Traditional Suture in Single-Port Total Laparoscopic Hysterectomy

Study ObjectiveTo compare surgical outcomes between barbed suture and traditional suture used in repair of the vaginal vault during single-port total laparoscopic hysterectomy (TLH).DesignCase-control study (Canadian Task Force classification II-2).SettingTwo institutions.PatientsOne hundred two patients with benign uterine disease.InterventionsSingle-port TLH using barbed suture (n = 43) or traditional suture (n = 59).Measurements and Main ResultsPatient characteristics (age, body mass index, demographic data), procedures performed, uterine weight, and uterine disease were similar between the 2 study groups. There were also no differences in operative complications, conversion to other surgical approaches, operative blood loss, postoperative pain, and duration of hospital stay between the 2 groups. Use of barbed suture significantly reduced the time required for vaginal cuff suturing (11.4 vs 22.5 minutes; p < .001), as well as total operative time (92.0 vs 105.2 minutes; p = .002). Use of barbed suture is less technically demanding than traditional suture (p < .001).ConclusionUse of barbed suture in single-port TLH may aid surgeons by reducing operative time, suturing time, and surgical difficulty.