Complications of hysteroscopic surgery: predicting patients at risk

OBJECTIVE: To determine the frequency of operative complications and whether they can be predicted by specific patient characteristics or type of hysteroscopic procedure. METHODS: We collected demographic and medical history information on 925 women who had hysteroscopies from 1995 through 1996. We compared differences in rates of operative complications of specific hysteroscopic procedures. Operative complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia, hemorrhage (500 mL or more), bowel or bladder injury, inability to dilate the cervix, and procedure-related hospital admissions. RESULTS: Operative complications occurred in 25 (2.7%) of 925 hysteroscopies. Excessive fluid absorption was the most frequent complication. Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4-7 times higher odds for operative complications. CONCLUSION: Complications during hysteroscopic surgery are rare. Among hysteroscopic procedures, myomectomies and resections of uterine septa have significantly higher rates of complications, especially excessive fluid absorption. Meticulous fluid management might limit the number of serious complications of these higher-risk procedures.     

Laparoscopic surgery in women with endometrial cancer: the learning curve

OBJECTIVE: The aim of this study was to assess the effect of increasing surgeons's experience in the laparoscopic surgery of women with endometrial cancer (EC) on the surgical outcome of these patients. STUDY DESIGN: Data were obtained from a prospectively collected database of 108 patients two oncolaparoscopic centers in Czech Republic who underwent laparoscopically assisted surgical staging (LASS) from April 1996 to March 2001. Patients were arranged in chronological order and divided into three groups, based on the date of their surgery. The three groups were compared in patient characteristics and surgical outcome using one-way analysis of variance (ANOVA) and Wilcoxon rank sum test. SETTING: Department of Obstetrics and Gynecology, Endoscopic Training Center, Baby Friendly Hospital Kladno, Czech Republic. RESULTS: The three groups were similar in patient characteristics. Operative times for laparoscopic staging with pelvic lymphadenectomy (LN) decreased significantly from mean of 156.3 min for group 1 to 142.8 min for group 3 (P < 0.05). In cases LASS with pelvic lymphadenectomy was significant increase in the number lymph nodes harvested (12.4 for group 1, 13.9 for group 2, and 15.4 for group 3, P < 0.05). In cases LASS without lymphadenectomy was not significant difference in operating time, estimated blood loss, rate of conversion to laparotomy, operative complications, and length of hospital stay among the compared groups. The number of patients who underwent para-aortic lymphadanectomy was too small (n = 22), and their distribution was asymmetrical for comparison. CONCLUSION: A learning curve is demonstrated in the LASS of women with endometrial cancer. With increasing surgeon's team experience, there is significant decrease in operative time for staging with pelvic lymph node dissection and increase in the number of pelvic lymph nodes removed. The para-aortic lymphadenectomy (PALN) was found to be more challenging than pelvic lymphadenectomy.     

重视宫腔镜手术的安全性

宫腔镜检查是诊断宫腔内病变的有效手段,应用于临床已有半个世纪.宫腔镜手术已有近20年的历史,如今宫腔镜子宫内膜息肉切除术(TCRP)、宫腔镜子宫肌瘤切除术(TCRM)、宫腔镜子宫中隔切除术(TCRS)和宫腔镜子宫内膜去除术(EA)都是标准术式.尽管一直有相关并发症的零星报道,但多数文献报道均认为宫腔镜安全、有效、简单、微创 [1-4].近几年来,我国宫腔镜术中死亡的事件时有发生,在我国宫腔镜应用日趋普及,并由诊断发展到手术治疗之际,强调其安全性,强化安全意识,趋利除弊,将有利于宫腔镜临床应用的健康发展.     

Bipolar resectoscope: the future perspective of hysteroscopic surgery

The objective of this study is to prove the effectiveness and security of bipolar resectoscope in hysteroscopic surgery. A clinic-based, prospective, non-randomised trial was conducted in Centro Florence di Chirurgia Ambulatoriale, Florence, Italy. One hundred fifty-seven women with endocavitary uterine pathologies, such as myoma, polyp, uterine septum and endometrial hyperplasia, were included in the study. Myomectomy, polypectomy, metroplasty and endometrial ablation have been done through the use of Karls Storz 26 Fr bipolar resectoscope and Autocon II 400 high-frequency unit with parameters standard selected 180 (in effect 4) for cut and 120 (in effect 4). The main outcome measures are the current flow, distension media, tissue alteration, bleeding during resection, visibility and cost. Cutting power and coagulations appears sensibly better in comparison with monopolar resection, thanks to plasma effect. The vision during resection is not disturbed by the presence of the technical characteristics of the instruments. Results in terms of time of surgery, intra-operatory bleeding and complete removal of the pathology were better compared with traditional monopolar resection. There were no complications with bipolar resection thanks to use of saline solution as distention media. The bipolar resectoscope presents some advantages in comparison with the monopolar such as: better cut and coagulation by plasma effect of bipolar current, minor risks with the use of saline solution, lower alterations of the tissue, less bleeding during resection, better visibility and reduced cost.     

Learning curve for hysteroscopic sterilisation: lessons from the first 80 cases

The present report looks at the first 80 patients of Essure sterilisation performed by a surgeon with experience in operative hysteroscopy. The results show that the procedure is well tolerated under local anaesthesia with or without sedation, and that devices can be successfully placed in 90% of cases. Surgical time is reduced with increased experience, and successful placement increased by improving visibility within the endometrial cavity (cycle timing).     

The long learning curve of gynaecological cancer surgery: an argument for centralisation

Objective To study the development of surgical performance of an unchanging surgical team over 13 years.
Design Prospective, observational study.
Setting A university hospital, The Netherlands.
Participants Three hundred and eight women who underwent surgical treatment for early cervical cancer.
Interventions Radical hysterectomy and pelvic lymphadenectomy between 1 January 1984 and 31 December 1996.
Results The surgical procedure and indication for treatment remained unchanged during the study period. This applied also to the surgical team. The women's age increased significantly during the study years, as was the case with the number of nodes removed. The depth of infiltration by the tumour increased steadily throughout the study, but this failed to reach statistical significance. The distribution of FIGO stages, percentage of positive lymph nodes, radicality of the surgical margins and post-operative morbidity remained the same. Overall, the five year survival rate was 83%; for women with negative nodes 91%, and for women with positive nodes 53%. Survival tended to improve during the course of the study, but this was not statistically significant. Blood loss during surgery decreased consistently during the whole study period, from a mean of 1515 mL at the beginning of the study to a mean of 1071 mL at the end (   P < 0.0001  ). The operating time also diminished significantly by 8 minutes per year (   P < 0.0001  ). In 1985 the average operating time was 270 minutes, compared with 187 minutes in 1996.
Conclusions These findings indicate that it takes a long time to acquire skill in the surgical treatment of early cervical cancer. Centralisation of relatively infrequent operations for cancer should be encouraged.     

Post fellowship training in "new-to-them" surgical techniques: assessment of learning curve characteristics

Objective

To evaluate surgically related quality outcomes during the learning curve for board-certified or board-eligible gynecologic oncologists developing “new-to-them” surgical techniques.

Methods

The study design was a retrospective review of patients with endometrial cancer clinically limited to the uterus and/or cervix undergoing TLH-BSO or TAH-BSO, aortic and pelvic lymphadenectomy(APLNDx), peritoneal washings with/without omentectomy from May 1996 to April /2006. A “senior” surgeon taught three board-certified or board-eligible gynecologic oncologists a “new-to-them” technique to perform both TLH-BSO and TAH-BSO with APLNDx using argon beam coagulation and endoscopic staplers in patients with early-stage endometrial cancer. The main outcome measures were: a) length of surgery; b) surgical measures, e.g. lymph node count; and c) peri-operative morbidity. A comparison of outcomes with the “senior” surgeon was undertaken. The learning curve characteristics were analyzed by ANOVA and curve estimate analysis.

Results

The mean operative times associated with learning a new technique to perform TLH-BSO with APLNDx and TAH-BSO with APLNDx were 155.39 +/− 26.32 and 102.28 +/− 34.22 min, respectively, with significant improvement after 20 cases (150.27 +/− 26.68 vs. 172.30 +/− 22.28, p = 0.030) and 30 cases (93.30 +/− 24.97 vs. 124.63 +/− 29.73, p = 0.030), respectively. Intra- and peri-operative morbidity and lymph node count were unaffected by experience.

Conclusion

While mean operative times decreased, outcome measures of surgical quality were not adversely affected during the learning curve for post-fellowship training while acquiring “new-to-them” surgical techniques. This study emphasizes the need for “senior” surgical supervision during the initial training period. The results of this study are likely transferable to fellowship-trained gynecologic oncologists learning other “new-to-them” surgical techniques and procedures.     

Treating previable twin-twin transfusion syndrome with fetoscopic laser surgery: outcomes following the learning curve.

AIMS: We have performed fetoscopic laser occlusion of chorioangiopagous vessels (FLOC) in previable pregnancies affected by twin-twin transfusion syndrome (TTTS) since 1988. Treatment outcomes obtained after the procedure's learning curve are presented and compared to those from other centers performing FLOC or other treatment methods. METHODS: A total of 100 cases of FLOC have been performed at our centers. The later 67 TTTS patients had a mean gestational age of 21.1 +/- 1.7 weeks (range 18-24.5) with a mean fundal height of 33.1 +/- 4.9 cm (range 27-44) when treated. Eighteen (27%) had failed another treatment method before FLOC. RESULTS: All 67 cases have delivered with 82% (55/67) having at least one surviving twin and 93/134 (69%) of the twins surviving overall. Thirty-eight have surviving twins, 17 have one survivor (5 neonatal and 12 fetal deaths), and 12 have none. The mean duration of pregnancy following FLOC was 9.9 +/- 5.5 weeks (range 1.0-19). Only 4 of 93 (4.3%) survivors have significant handicaps at a mean follow-up of 14.3 +/- 10.1 months (range 1.0-34). CONCLUSION: Fetoscopic laser occlusion of chorioangiopagous vessels within the vascular equator limits the duration of fetal pathophysiology in TTTS and results in neonatal outcomes superior to the modified procedure and other treatment methods.     

Total laparoscopic hysterectomy: the Brisbane learning curve

BACKGROUND: Total laparoscopic hysterectomy (TLH) is becoming more commonly used for gynaecological malignancies. AIMS: To describe our experience with TLH since its introduction to our tertiary referral centre for gynaecological cancer in 2003. METHODS: Retrospective analysis of the first 120 consecutive cases of TLH performed at our gynaecological cancer centre. Patients were divided into the first, second and third group of 40 patients. Operating time, estimated blood loss, hospital stay, conversion to laparotomy and intra- and postoperative morbidity were evaluated. Results: The three groups were similar with regard to baseline characteristics. For the entire group the mean hospital stay was 2.4 +/- 1.4 days and eight of 120 patients (6.6%) required conversion to laparotomy. Operating time, estimated blood loss and intraoperative morbidity were similar among the three groups. Postoperative morbidity was highest (25%) in the middle one-third of the patients (P = 0.022). The percentage of pelvic lymph node dissections increased from 2.5% in the first one-third of patients to 27.5% in the final one-third of patients (P = 0.003). CONCLUSIONS: TLH can be established safely in a tertiary gynaecological cancer referral centre.     

An overview of hysteroscopy and hysteroscopic surgery

Hysteroscopy allows direct visualization of the uterine and endocervical cavities. Recent innovations in endoscopic techniques have increased the accessibility of diagnostic and therapeutic procedures. However, hysteroscopic surgery should be performed by an appropriately trained gynaecologist to ensure safe practice and good patient outcomes. This review discusses the basic principles required to undertake diagnostic and operative hysteroscopic surgery, discuss the newer procedures available and highlight the current evidence behind the use of hysteroscopic surgery in the clinical setting.     

Risk of uterine perforation during hysteroscopic surgery

STUDY OBJECTIVE: To evaluate the rate of uterine perforation during different operative hysteroscopy procedures. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: Department of Obstetrics and Gynecology, La Conception Hospital, Marseille, France. PATIENTS: One thousand nine hundred fifty-two women. INTERVENTION: Of 2116 operative hysteroscopies performed, there were 623 endometrectomies, 782 myoma resections, 422 polyp resections, 199 adhesiolyses, and 90 uterine septa sections. MEASUREMENTS AND MAIN RESULTS: Risk of perforation was evaluated according to hysteroscopic procedure. Severity of complications were also noted. In case of perforation, a management protocol was applied to prevent metabolic disorders and pelvic infections. Thirty-four perforations (1.61%) were reported. In 33 cases (97%) it was realized during the procedure and no complications occurred during follow-up. One perforation with hemorrhage was misdiagnosed during the intervention and required laparotomy. Perforation risk was higher during hysteroscopic adhesiolysis than during other procedures [endometrial ablation RR 9.39 (3.46-25.52), p <0.0001; uterine septa section RR 6.78 (0.91-50.6), p = 0.026; polyp RR 8.52 (2.60-30.80), p <0.0001 or myoma resection RR 7 (2.83-17.62), p <0.0001]. Perforation risk was comparable during endometrial ablation, uterine septa section, and polyp or myoma resection (p = 0.93). CONCLUSION: Perforation risk is higher during synechiolysis than in other indications for hysteroscopy. Severe complications are rare but may be avoided if precautions are taken.     

Prevention of intrauterine adhesions after hysteroscopic surgery

Intrauterine adhesions are the most frequent complications after hysteroscopic surgery in women of reproductive age. The prevalence of intrauterine adhesions after hysteroscopic surgery is correlated to intrauterine pathology (myoma, polyp, or adhesions). Few clinical trials have demonstrated the efficiency of barrier agents developed in order to prevent adhesions after operative hysteroscopy. Adhesion barriers are mechanic agent (intrauterine device), fluid agents (Seprafilm, Hyalobarrier) and postoperative systemic treatment (estroprogestative treatment). In this article, we evaluate the efficiency of these barrier agents for adhesion prevention in hysteroscopic surgery, undertaking a review of clinical trials published. The most frequent published studies evaluate the anatomic efficiency of antiadhesion agents after hysteroscopic surgery in order to evaluate the fertility. Data are still insufficient to evaluate them for clinical use. There is a need for other randomised controlled trials.     

Implementation of hysteroscopic surgery in The Netherlands

OBJECTIVE: This study was conducted to assess the degree of diffusion of hysteroscopic surgery in gynaecological practice in The Netherlands in order to guide further implementation. The diffusion was objectified by defining the percentage of hospitals performing hysteroscopic procedures and the number of different procedures performed per gynaecologist. STUDY DESIGN: In 2003 all Departments of Gynaecology (n=102) in The Netherlands were sent a questionnaire. The questionnaire addressed the number and type of all hysteroscopic procedures that were performed in each hospital in 2002. Data from this study were compared to previously published data from 1997. RESULTS: Responses were received from 80% of all gynaecological departments in The Netherlands. Diagnostic hysteroscopy was performed in almost all hospitals in both 1997 and 2002. The percentage of hospitals that adopted polypectomy, myomectomy and endometrial ablation increased to more than 90% in 2002. The number of teaching hospitals that integrated diagnostic hysteroscopy, polypectomy and myomectomy (procedures required for graduation) into their operative spectrum increased to 100%. CONCLUSION: This survey indicates a growing trend of the diffusion of diagnostic and "basic" therapeutic hysteroscopic procedures in The Netherlands. However, figures upon more advanced hysteroscopic surgery are less optimistic.     

宫腔镜手术治疗子宫内膜息肉的临床分析

目的　探讨宫腔镜手术治疗子宫内膜息肉的临床效果。方法　因子宫内膜息肉行各类宫腔镜手术 10 9例 ,其中绝经后子宫内膜息肉 15例、生育期子宫内膜息肉 94例。 10 9例中合并月经紊乱 84例、贫血 34例、痛经 16例、原发不孕 3例、继发不孕 2例。患者年龄 2 6～ 73岁 ,平均 (45± 9)岁 ;随访时间 3～ 2 2个月 ,平均 (12± 5 )个月。月经紊乱者在术前和术后分别填写月经失血图以评估月经血量。结果　 10 9例中 ,单纯息肉切除 35例 ,息肉切除同时浅层内膜切除 9例 ,息肉切除同时内膜切除 6 3例 ,息肉切除同时内膜剥除 2例。 84例月经紊乱者术后闭经 14例、阴道点滴出血 2 6例 ,其余 4 4例月经血量均较术前减少。 34例术前贫血患者 ,术后 1个月血红蛋白即恢复正常。 16例痛经者术后 7例症状消失、7例缓解、2例加重。 5例不孕者术后 4例妊娠。 15例绝经后患者术后无异常出血。结论　有月经改变且无生育要求者 ,息肉切除同时应行子宫内膜电切术 ,可避免息肉复发 ;需保留生育功能的患者 ,可行单纯息肉切除 ,如合并内膜息肉样增生 ,应同时行浅层内膜切除 ;绝经后患者 ,可行单纯息肉切除 ,如合并内膜息肉样增生 ,应同时行子宫内膜剥除。     

Complications of laparoscopic surgery

Laparoscopic surgery is the standard of care for many gynaecological conditions with documented benefits and excellent outcomes for patients and healthcare providers. However, in addition to the general complications associated with surgery and anaesthesia, laparoscopy poses unique complications relating to abdominal entry and surgical instrumentation. Governing bodies, representing both the surgical specialities and gynaecology, have attempted to gain consensus on the safest technique for abdominal entry to no avail. Studies comparing techniques to date are underpowered and the likelihood of high-grade evidence ever becoming available is low due to the prohibitive patient numbers and costs. This review will examine complications of laparoscopy and current recommendations from surgical training organizations for abdominal entry in laparoscopic surgery.     

Endometrial preparation with Dienogest before hysteroscopic surgery: a systematic review

Purpose

Hysteroscopic surgery is considered the gold standard for the minimal invasive treatment of many endouterine diseases such as endometrial polyps or submucous myomas. Recently, many studies have evaluated the effect of preoperative administration of a number of drugs to reduce endometrial thickness and achieve important intraoperative advantages. The purpose of this systematic review is to summarize the available evidence about the use of Dienogest, an orally administrable progestin, for endometrial preparation before hysteroscopic surgery.

Methods

All studies published on this topic and indexed on PubMed/MEDLINE, Embase or Google scholar databases were retrieved and analysed.

Results

We retrieved five studies about this topic. Considered together, the published data analyses allow us to conclude that Dienogest is effective in reducing the thickness of the endometrium, the severity of bleeding and also of operative time, with a lower number of side effects compared with other pharmacological preparations or no treatment.

Conclusion

Administration of Dienogest may be an effective and safe treatment for endometrial thinning before operative hysteroscopy. However, this conclusion is based on few reports and further studies to prove or disprove it are warranted.

     

Complications of laparoscopic surgery

Minimally invasive surgery is widely accepted as the gold standard for many gynaecological surgical procedures. The benefits to the woman, the surgeon and health care providers are well documented; however unique complications from patient positioning, abdominal entry and specific instrumentation and electrosurgery pose challenges that the surgeon must always keep in mind and address when they occur. This article presents different scenarios of complications related to laparoscopic surgery in both the immediate and post-operative times, with discussion of the management of such complications.