Advanced Gynecologic Laparoscopy in a Fast-Track Ambulatory Surgery Center

Background/Objectives:

It has been shown that major gynecologic laparoscopy is safe in hospital ambulatory settings, but there is little data to suggest the same in freestanding ambulatory surgery centers. This study evaluates the safety and efficacy of advanced gynecologic laparoscopic surgery using a fast-track model in freestanding ambulatory surgery centers and discusses our institution protocols.

Methods:

Retrospective, multicenter review was conducted of major gynecologic surgeries from August 1^st 2010 to September 30^th 2011 in 3 surgical centers with one primary surgeon. All patients were treated for symptomatic uterine leiomyomas and/or endometriosis. Primary outcome measures were unplanned admissions and discharge within 23 hours.

Results:

One hundred and thirty-four patients underwent major laparoscopic gynecologic surgery with a total of 160 procedures: 77 stage IV endometriosis treatment including 7 disk excisions of endometriosis from the large bowel, 3 ureteroneocystostomies and 1 partial bladder resection, 38 myomectomies, and 34 hysterectomies including 12 modified radical hysterectomies. The overall unplanned admission rate was 4.5%. One hundred and thirty-one patients (97.7%) were discharged within 24 hours after surgery. Three patients (2.2%) were transferred to the hospital postoperatively: 1 patient for observation of postoperative anemia and 2 patients for postoperative fever. Three patients (2.2%) were admitted to the hospital after discharge: 1 patient for postoperative ileus, 1 patient for postoperative fever, and 1 patient with septic pelvic thrombophlebitis. These postoperative issues all resolved without complication, and all patients had an uneventful follow-up.

Conclusions:

With appropriate resources and an experienced surgeon, advanced laparoscopic surgery can be safely performed in a fast-track ambulatory surgery center with a high rate of discharge within 23 hours and low unplanned readmission rate.     

A Comparison of Single-, Two- and Three-Port Laparoscopic Myomectomy

Background and Objective:

A recent FDA safety communication has discouraged the use of a power morcellator for myoma extraction and has called for a change in surgical techniques for myomectomy. The objective of this study was to compare surgical outcomes of laparoscopic single-, two-, and conventional three-port myomectomy and to evaluate the feasibility of contained manual morcellation for uterine myoma.

Methods:

This retrospective study was a review and analysis of data from 191 consecutive women who underwent single-, two-, or three-port myomectomy for the management of uterine myoma from January 1, 2009, through December 31, 2014.

Results:

The 3 study groups did not differ demographically. Apart from operative time, the single- and two-port groups showed operative outcomes comparable to those of the multiport group. The single-port group had significantly longer operative times (P = .0053) than the two- and three-port groups. However, in the latter half of the single-port cases, the operative time was similar to those in the three-port group. The two-port surgery group showed a consistent operative time without a learning period.

Conclusion:

Single- or two-port myomectomy with transumbilical myoma morcellation is feasible and safe, with outcomes comparable to those of three-port myomectomy. These results suggest the potential for minimally invasive management of symptomatic uterine myoma, without the use of a power morcellator.     

Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience

Objective

To evaluate the feasibility and safety of combined uterine artery embolization (UAE) using embosphere and surgical myomectomy as an alternative to radical hysterectomy in premenopausal women with multiple fibroids.

Materials and methods

Mid-term clinical outcome (mean, 25 months) of 12 premenopausal women (mean age, 38 years) with multiple and large symptomatic fibroids who desired to retain their uterus and who were treated using combined UAE and surgical myomectomy were retrospectively analyzed. In all women, UAE alone was contraindicated because of large (>10 cm) or subserosal or submucosal fibroids and myomectomy alone was contraindicated because of too many (>10) fibroids.

Results

UAE and surgical myomectomy were successfully performed in all women. Myomectomy was performed using laparoscopy (n = 6), open laparotomy (n = 3), hysteroscopy (n = 2), or laparoscopy and hysteroscopy (n = 1). Mean serum hemoglobin level drop was 0.97 g/dL and no blood transfusion was needed. No immediate complications were observed and all women reported resumption of normal menses. During a mean follow-up period of 25 months (range, 14–37 months), complete resolution of initial symptoms along with decrease in uterine volume (mean, 48%) was observed in all women. No further hysterectomy was required in any woman.

Conclusion

In premenopausal women with multiple fibroids, the two-step procedure is safe and effective alternative to radical hysterectomy, which allows preserving the uterus. Further prospective studies, however, should be done to determine the actual benefit of this combined approach on the incidence of subsequent pregnancies.     

MRI评估子宫肌瘤患者行腹腔镜下肌瘤剔除术的可行性

目的探讨MRI评估子宫肌瘤患者行腹腔镜下肌瘤剔除术的可行性。方法回顾性分析2019年1月至2019年12月于我院收治的60例子宫肌瘤患者临床资料,根据2011年FIGO新的子宫肌瘤分类标准对子宫肌瘤分类,测量子宫肌瘤大小及数目,按照临床及腹腔镜下子宫肌瘤剔除术的适应症标准,筛选符合腹腔镜下子宫肌瘤剔除术的病例,计算MRI对腹腔镜下子宫肌瘤剔除术的排除率、手术率。结果本研究中60例患者经MRI检查,病灶单发者19例,多发者41例,子宫肌瘤病灶数目共计119个,其中112个位于子宫体,5个位于子宫颈,阔韧带2个;其中6-7型子宫肌瘤55个,3-5型子宫肌瘤48个,0-2型子宫肌瘤5个,混合型6个,特殊类型5个。最终符合腹腔镜下子宫肌瘤剔除术手术标准者25例,排除者35例,手术率为41.67%,排除率为58.33%。结论MRI能对子宫肌瘤患者行腹腔镜下肌瘤剔除术的可行性进行评估,筛选适宜手术的患者,且能为临床医师行腹腔镜下肌瘤剔除术提供影像学基础。     

腹腔镜下核除子宫肌瘤后两种缝合方法的临床探讨

目的研究分析采用两种缝合方法对于腹腔镜下核除子宫肌瘤的临床治疗效果。方法该择该院2011年12月—2013年12月收治140例子宫肌瘤患者作为研究对象,将所有患者按照随机数字法分为观察组和对照组两组,每组各70例。对照组患者在摘除肌瘤之后采用间断缝合术,观察组患者采取连续缝合子宫术。对比观察两组患者在手术时间、术中出血量、疼痛恢复时间、出院时间以及排气时间情况的比较。结果观察组患者在手术时间、术中出血量以及疼痛恢复时间均明显短于对照组,差异有统计学意义（P〈0.05）。两组患者在出血时间、排气时间情况的差异无统计学意义（P〉0.05）。结论对于腹腔镜下核除子宫肌瘤后采取连续缝合子宫术能够有效缩短手术时间,降低术中出血量,值得临床推广运用。     

Comparison of Robotic,Laparoscopic, and Abdominal Myomectomy in a Community Hospital

Background and Objectives:

To evaluate the operative outcomes between robotic, laparoscopic, and abdominal myomectomies performed by a private gynecologic oncology practice in a suburban community hospital.

Methods:

The medical records of 322 consecutive robotic, laparoscopic, and abdominal myomectomies performed from January 2007 through December 2009 were reviewed. The outcomes were collected from a retrospective review of patient medical records.

Results:

Records for 14/322 (4.3%) patients were incomplete. Complete data were available for 308 patients, including 169 (54.9%) abdominal, 73 (23.7%) laparoscopic, and 66 (21.4%) robotic-assisted laparoscopic myomectomies. Patients were similar in age, body mass index, parity, and previous abdominopelvic surgery. Median operative time for robotic surgery (140 min) was significantly longer (P<.005) compared to laparoscopic (70 min) and abdominal (72 min) myomectomies. Robotic and laparoscopic myomectomies had significantly less estimated blood loss and hospital stay compared to abdominal myomectomies. There was no significant difference in complications or in the median size of the largest myoma removed between the different modalities. However, the median aggregate weight of myomas removed abdominally (200g; range, 1.4 to 2682) was significantly larger than that seen laparoscopically (115g; range, 1 to 602) and robotically (129g; range 9.4 to 935). Postoperative transfusion was significantly less frequent in robotic myomectomies compared to laparoscopic and abdominal myomectomies.

Conclusion:

While robotic-assisted laparoscopic myomectomies had longer operative times, laparoscopic and robotic-assisted laparoscopic myomectomies demonstrated shorter hospital stays, less blood loss, and fewer transfusions than abdominal myomectomies. Robotic myomectomy offers a minimally invasive alternative for management of symptomatic myoma in a community hospital setting.     

Postoperative Outcomes After Robotic Versus Abdominal Myomectomy

Background and Objectives:

Differences in postoperative outcomes comparing robotic-assisted laparoscopic myomectomy (RALM) with abdominal myomectomy (AM) have rarely been reported. The objective of this study was to compare surgical, quality-of-life, and residual fibroid outcomes after RALM and AM.

Methods:

Consecutive patients who underwent RALM (n = 16) were compared with AM patients (n = 23) presenting with a uterine size of <20 weeks. Study patients participated in a telephone interview at 6 weeks and underwent a no-cost ultrasonographic examination at 12 weeks after surgery to obtain quality-of-life and residual fibroid outcomes. Medical records were reviewed to obtain surgical outcomes.

Results:

Longer operative times (261.1 minutes vs 124.8 minutes, P < .001) and a 3-fold unfavorable difference in operative efficiency (73.7 g vs 253.0 g of specimen removed per hour, P < .05) were observed with RALM compared with AM. Patients undergoing RALM had shorter lengths of hospital stay (1.5 days vs 2.7 days, P < .001). Reduction of patient symptoms and overall satisfaction were equal. RALM patients were more likely to be back to work within 1 month (85.7% vs 45.0%, P < .05). Residual fibroid volume in the RALM group was 5 times greater than that in the AM group (17.3 cm³ vs 3.4 cm³, P < .05).

Conclusion:

RALM and AM were equally efficacious in improving patient symptoms. Although operative times were significantly longer with RALM, patients had a quicker recovery, demonstrated by shortened lengths of stay and less time before returning to work. However, greater residual fibroid burden was observed with RALM when measured 12 weeks after surgery.     

腹腔镜与开腹子宫肌瘤剔除术的比较研究

目的探讨腹腔镜子宫肌瘤剔除术的安全性、可行性与临床效果。方法回顾分析2008年1月～2010年9月腹腔镜子宫肌瘤剔除术97例（腹腔镜组）与开腹子宫肌瘤剔除术90例（开腹组）的临床资料。对2组手术时间、术后血红蛋白下降值、镇痛药物使用率、住院时间、住院费用、术后病率、术后并发症、术后复发情况进行比较。结果与开腹组相比,腹腔镜组术后血红蛋白下降少[（14.3±6.4）g/L vs.（17.4±7.4）g/L,t=-3.152,P=0.002],使用镇痛药者少[4例（4.1%）vs.31例（34.4%）,χ2=28.211,P=0.000],术后住院时间短[（5.0±1.3）d vs.（6.9±1.3）d,t=-10.106,P=0.000],但手术时间长[（120.2±39.3）min vs.（99.8±36.8）min,t=3.646,P=0.000];住院费用高[（7216.0±850.9）元vs.（6531.6±875.6）元,t=5.419,P=0.000]。2组术后病率和并发症发生率差异无显著性（P〉0.05）。2组术后1个月肌瘤残留率、术后6个月后肌瘤复发率差异均无显著性（P〉0.05）。结论腹腔镜子宫肌瘤剔除术是一种安全、可行的微创手术方式,但仍有一定的局限性,并不能完全代替开腹手术。     

宫腔镜子宫粘膜下肌瘤切除术80例报告

目的:探讨宫腔镜电切术治疗子宫粘膜下肌瘤的疗效及安全性。方法:回顾分析2010年1月至2011年10月80例粘膜下子宫肌瘤患者的临床资料,其中0型26例,Ⅰ型34例,Ⅱ型20例,均行宫腔镜手术,观察患者术中情况以及术后效果、妊娠、后续药物治疗等情况。结果:80例手术均顺利完成,0型、Ⅰ型及12例Ⅱ型粘膜下子宫肌瘤均一次切除,8例Ⅱ型粘膜下肌瘤一次切除70%～80%。2例术中出血;1例术后感染;2例术后宫腔粘连。75%的残留肌瘤联合米非司酮治疗消退或脱落,不孕患者受孕率63.6%。结论:治疗粘膜下子宫肌瘤,宫腔镜电切术是较好的选择。严格掌握手术指征,提高手术质量,严密B超监测,残留肌瘤联合米非司酮治疗是提高术后疗效及手术安全性的有效措施。