The effect of prophylactic antibiotics on pelvic infection following vaginal hysterectomy

The effect of prophylactic penicillin and streptomycin on postoperative pelvic infection and hospital stay following vaginal hysterectomy was studied. 92 patients received 600,000 U procaine pencillin plus .5 gm streptomycin 12 hours prior to operation and every 8 hours following operation for 3 days. 8 patients allergic to penicillian received 1 gm cephaloridine rather than penicillian and streptomycin. 100 patients undergoing vaginal hysterectomy received no prophylactic antibiotics. Morbidity caused by pelvic infection was significantly reduced (p less than .01) from 19 to 1% and urinary tract infection decreased from 6 to 2% when prophylactic antibiotics were employed. Total postoperative morbidity was decreased from 37 to 8% (p less than .01) and postoperative hospital stay was reduced from 6.3 to 5 days (p less than .002) when prophylactic antibiotics were administered.     

Tubal ligation by colpotomy incision.

A five-year review of colpotomy tubal ligation performed on 585 patients within a private-practice setting in Columbus, Georgia, is analyzed. Operative time averaged under 30 minutes, and average hospital stay was less than 3 days. The major postoperative complication rate was less than 2%. The patient population is reviewed as to age, parity, previous contraception, and medical indications for sterilization. Surgical technique is discussed, and several suggestions are made, A follow-up of subsequent gynecologic procedures and the interval following colpotomy is then presented.     

Laparoscopic myomectomy: feasibility and safety—a retrospective study of 762 cases

The objective of this retrospective study of a case series was to evaluate patients with symptomatic uterine myomas managed by laparoscopic myomectomy—the clinical features, operative techniques, and intraoperative and postoperative morbidity. The subjects consisted of a total of 762 women who underwent endoscopic surgery for uterine leiomyomas at a private advanced endoscopy and assisted reproductive technology centre over a 13-year period. Data were collected on baseline clinical characteristics, details of surgery, intraoperative and postoperative complications, and hospital stay. A total of 1,375 myomas were removed; the most common indication was infertility (50.9%), and the majority of myomas (49.52%) were intramural. The mean duration of surgery was 95 min, and the average blood loss was 250.5 ml. The average hospital stay was 1.3 days. Major complications included an unexplained postoperative death and one laparotomy for postoperative bleeding. We conclude that laparoscopic myomectomy is a relatively safe procedure. Most cases can be completed by a laparoscopic approach, and the remaining may require a laparoscopic-assisted myomectomy. The risk of complications is comparable to that with the open procedure, whereas morbidity and length of hospital stay are much lower.     

The effect of accelerated rehabilitation on recovery after surgery for ovarian malignancy

BACKGROUND: In patients undergoing colonic surgery the postoperative hospital stay has been reduced from 8-12 days to 2-4 days with multimodal rehabilitation programs. The aim of this study was to evaluate the postoperative outcome after surgery for ovarian malignancy with conventional care compared to fast-track multimodal rehabilitation. METHODS: Seventy-two consecutive patients receiving conventional care (group 1) were compared with 69 consecutive patients receiving multimodal, fast-track rehabilitation with a planned care program including continuous epidural analgesia, early oral feeding and mobilization (group 2) in the same department. Outcome was postoperative hospital stay and morbidity during the first postoperative month. RESULTS: Median age was 63 years (group 1) and 62 years (group 2). Median postoperative hospital stay was reduced from 6 days in group 1 (mean 7.3) to 5 days in group 2 (mean 5.4) (p < 0.05). There was no difference in the overall complication rate, although severe medical complications were reduced in group 2 (14% versus 2%; p < 0.01). Readmission rate was 10% in group 1 and 3% in group 2 (p > 0.05). CONCLUSIONS: The concept of fast-track multimodal rehabilitation appears to be beneficial in patients operated for ovarian malignancy, as hospital stay and medical morbidity are reduced.     

Use of Ligasure bipolar diathermy system in vaginal hysterectomy.

The use of Ligasure, a computer-controlled bipolar diathermy system is proven beneficial in a wide range of surgical procedures. This study was to evaluate its application to vaginal hysterectomy. Over forty patients underwent vaginal hysterectomy with (n = 32) or without (n = 12) Ligasure using standard surgical techniques. The main diagnoses, the age of patients, time for surgery, hospital stay and estimated blood loss during operation were compared. The average operating time was shorter in the Ligasure vaginal hysterectomy group (30 mins (24-48) P < 0.05), the estimated blood loss was less in the Ligasure hysterectomy group (39 mins (25-60) P < 0.05), and the hospital stay was shorter in the Ligasure hysterectomy group (1.2 days (1-2) vs 3 days (3-5) P < 0.05). There were no postoperative complications or re-admissions in either group. Vaginal hysterectomy using Ligasure reduced operating time and blood loss, and therefore shortened hospital stay.     

A randomized controlled trial of early versus "traditional" postoperative oral intake after major abdominal gynecologic surgery

OBJECTIVE: The purpose of this study was to compare early oral intake and the traditional timing of feeding after major gynecologic surgery and the effects on the length of hospital stay. STUDY DESIGN: Gynecologic oncology and urogynecology patients who underwent major abdominal gynecologic surgery were prospectively randomized to 1 of 2 groups. The traditional feeding group (group A, 49 patients) received nothing by mouth until documentation of bowel function. They were then advanced slowly to solid diet. The patients allocated to the early feeding regimen (group B, 47 patients) began clear fluids on the first postoperative day. Once 500 mL of clear fluid was tolerated, they received a regular diet. The groups were compared with regard to length of hospital stay, postoperative day that solids were tolerated, and the incidence of adverse effects. Statistical analyses were performed with the chi(2) test, the Fisher exact test, the Student t test, and analysis of variance. RESULTS: The demographic characteristics of the 2 groups were similar. There was a statistically significant reduction in the length of hospital stay for those patients on the early feeding regimen. The median length of stay for group A was 6.0 days and for group B was 4.0 days (P =.0001). There was no difference in the incidence of emesis, ileus, or other postoperative complications between the 2 groups. CONCLUSION: Early postoperative dietary advancement after major abdominal gynecologic surgery results in a decreased length of hospital stay and appears to be safe, with no increased adverse effects.     

Conservative treatment for prostatorectal or urethrorectal perforation during transurethral surgical procedures

From 7 March 1989 to 16 December 1989, we experienced 2 prostatorectal and 2 urethrorectal perforations during transurethral surgical procedures at the National Taiwan University Hospital (3 cases) and Tz'u-Chi General Hospital (1 case). All 4 patients were men. Their ages ranged from 57 to 76 years with a mean of 66 years. All 4 complications were identified immediately. Neither a transrectal/suprapubic immediate (or staged) direct suturing, nor a colostomy/cystostomy was needed in our series. Instead, we introduced a rectal tube coated with gauze soaked in Betadine and vaseline, which fit tightly into the rectum for an average of 4 days (range from 3 to 5 days). A 22-Fr three-way indwelling Foley catheter with continuous normal saline irrigation was also applied for 7 to 14 days (9.5 days on average). Nothing by mouth started immediately after the operation (range from 3 to 7 days; 5.3 days on average). All 4 patients were discharged in good condition with a mean postoperative stay of 14 days (range from 11 to 18 days). No prostatorectal or urethrorectal fistula were found during an average follow-up period of 13.5 months (range from 10 to 17 months).     

Laparoscopic-assisted vaginal hysterectomy: A case control comparative study with total abdominal hysterectomy

We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels. Of 81 women who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, 19 who underwent each procedure were chosen for inclusion in the study. Patients were matched in a case control manner for age, weight, diagnosis, and uterine weight. All 38 hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were performed. The average surgery time for LAVH was 144 minutes and for TAH 98 minutes, a significant difference (p<0.005). There were no significant differences between estimated blood loss and change in hemoglobin from preoperative levels to postoperative day 1 levels between the groups. Women having TAH reported significantly more pain after their release from the hospital. There was no significant difference in pain during hospitalization apparently because patients who had TAH self-medicated to maintain acceptable levels. That group in fact used an average of 436 mg meperidine during their hospital stay, significantly more than the 197 mg used by the LAVH group (p<0.005). The length of stay was 2.125 days for LAVH and 3.542 days for TAH (p<0.001). On a scale of 1 to 10 (10 being complete normal activity) the activity level of women undergoing LAVH was 9.2 by day 14 compared with 6.4 for those having TAH (p<0.005). By the sixth postoperative week the latter group reported an activity level of only 8.5, indicating that the ability to function is much more severely limited after TAH than LAVH.     

Laparoscopic-assisted vaginal hysterectomy with bilateral oophorectomy versus total abdominal hysterectomy and bilateral salpingo-oophorectomy—Implications for gynecologic practice in the United Kingdom

A prospective, randomized study was conducted to identify differences in the perioperative outcome of patients undergoing either routine total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) or laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy (LAVH-BSO). We also assessed potential management implications, including financial differences, between the operations. Of 40 women requiring hysterectomy for a range of benign conditions, 20 underwent LAVH-BSO and 20 TAH-BSO. The respective mean operating times were 97.5 and 54 minutes. Patients in the former group required significantly less postoperative oral analgesia, 4.1 doses compared with 11.7 doses on average. The length of postoperative stay was shortened from 6 to 3.8 days on average for LAVH-BSO. The potential cost savings was 17.9% per case for LAVH-BSO compared with TAH-BSO. Thus, LAVH-BSO was a safe alternative to TAH-BSO, with less morbidity and earlier hospital discharge. Possible cost savings suggest the need for changes to current operating and inpatient hospital resources.     

Groin dissection with prevention of tissue loss and postoperative infection.

In an effort to decrease the morbidity and hospital stay associated with groin dissection for carcinoma of the vulva, 13 of 29 patients had the groin incisions left open to granulate and heal by secondary intention. In these 13 patients, the average hospital stay was 16 days, as opposed to 22 days for the more conventional closed-wound technique. The febrile morbidity was less than 1 day, and there was no major wound breakdown. The average time to complete epithelialization was 7 weeks and the cosmetic results were good.     

Preoperative hot conization of the cervix: a possible method to reduce postoperative febrile morbidity following vaginal hysterectomy.

Laboratory results indicate that the endocervix may be a source of bacterial contamination when vaginal hysterectomy is performed. In a series of 160 consecutive vaginal hysterectomies in premenopausal women, hot conization of the cervix was performed prior to the scrub with an iodophore. No preoperative antibiotics were used in this series. The postoperative febrile morbidity rate was 4.3 per cent and the average stay was 4.5 days. These results are compared with those of three other groups: (1) patients who received a three-dose parenteral prophylactic antibiotic course with the first dose two hours prior to surgery had a febrile morbidity rate of 8.6 per cent. (2) In patients who had prophylactic antibiotics for five days with the first dose given intraoperatively, the febrile morbidity rate was 10.1 per cent. (3) The febrile morbidity rate in the group with no antibiotic prophylaxis or hot conization was 49.1 per cent. Laboratory and clinical data suggest that preoperative conization may be effective in the reduction of postoperative febrile morbidity.     

No difference in length of hospital stay between laparoscopic and abdominal supravaginal hysterectomy--a preliminary study

BACKGROUND: Although a number of well-designed studies have concluded that laparoscopic hysterectomy is associated with less postoperative pain, reduced hospital stay, and shorter periods of sick leave, thus far, studies on the perioperative and postoperative outcomes of laparoscopic supravaginal hysterectomy (LSH) versus abdominal supravaginal hysterectomy (ASH) are lacking. By applying multimodal intervention program for the postoperative care of patients, the primary aim of the current study was to compare length of hospital stay, time to convalescence, and long-term patient satisfaction between LSH and ASH. METHOD: The study was conducted at the departments of Obstetrics and Gynecology, Skellefte? Hospital and Lycksele Hospital. Forty-seven consecutive women scheduled for supravaginal hysterectomy were randomly assigned to LSH or ASH. Perioperative and postoperative parameters were compared between the two groups. RESULTS: The length of the postoperative hospital stay did not differ between patients undergoing LSH and ASH, but the number of disability days was greater in the ASH group. The operating time was significantly longer in the LSH group compared with the ASH group, whereas the estimated perioperative bleeding was greater in the ASH group. At the 6-month follow-up, 87.0% of patients in the ASH group and 91.3% in the LSH group were satisfied or very satisfied with the overall result of the surgical procedure. CONCLUSION: The present study has indicated that by applying a multimodal intervention program for the postoperative care of patients undergoing supravaginal hysterectomy, the surgical procedure per se is of less importance than generally considered for the length of postoperative hospital stay and long-term patient satisfaction.     

Prospective Trial of Aggressive Postoperative Bowel Stimulation Following Radical Hysterectomy

INTRODUCTION: Postoperative traditional feeding protocols are not based on scientific studies, but rather on anecdotal evidence. We present the first prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy in an attempt to determine its effect on the length of hospital stay. METHODS: Twenty consecutive patients undergoing radical hysterectomy were entered onto a prospective trial of aggressive postoperative bowel stimulation, which consisted of 30 cc milk of magnesia p.o. b.i.d. starting on postoperative day 1 and biscolic suppositories q.d. starting on day 2. A clear liquid diet was begun following flatus or bowel movement and patients were discharged 12 h after tolerating a clear liquid diet. Diet was slowly advanced at home. RESULTS: Median time to flatus was 3 days, bowel movement 3 days, and clear liquid diet 3 days. Median time to discharge was 4 days. No patients developed ileus or bowel obstructions and there were no readmissions for bowel complications. Our median time to discharge of 4 days represents a 50% reduction in hospital stay compared to our previous prospective study using traditional postoperative bowel management (8 days), which was statistically significant at P = 0.001. CONCLUSION: Aggressive bowel stimulation with milk of magnesia and biscolic suppositories resulted in early return of bowel function and early discharge with no noticeable complications.     

Intestinal obstruction in patients with advanced ovarian cancer

A retrospective analysis of the management of intestinal obstruction in 31 patients with advanced ovarian carcinoma is described. Between 1981 and 1992 31 patients developed intestinal obstruction after their initial treatment. Nineteen patients underwent surgery, while the remaining 12 were treated conservatively. Careful evaluation with contrast studies of both the small intestine and colon is recommended to improve the prediction of site(s) of obstruction, and may reduce the number of unsuccessful operative procedures. Fifteen of the surgically treated patients survived for a period of 60 days or more. The majority, 13, were discharged to their homes after an average hospital stay of 24 days. Major postoperative complications occurred in three of the 19 patients. There was no surgical-related mortality. Two patients died within 30 days postoperatively (urosepsis and advanced tumor). While the median survival in the 19 surgical treated patients was 109 days (range 15–775), the conservatively treated 12 patients survived for a mean of 37 days (range 6–260). Surgical management of intestinal obstruction in selected cases is feasible and improves quality of life substantially.     

Analysis of female sterilization technics

To examine different female sterilization techniques, the cases of 846 women who were sterilized between July 1965 and December 1970 at the University of Utah Medical Center were compared for length of hospital stay, complications, and failure rates, and were followed up for at least 18 months. The most common sterilization technique was vaginal tubal ligation (365 cases). The average hospital stay for this procedure was 3.6 days with serious complications occurring at a rate of 2.6%. Postpartum tubal ligation was performed in 252 women and required an average of 1 day longer than the usual 3-day maternity hospital stay. The serious-complication rate was 2.1%. 115 patients underwent abdominal or caesarean-section tubal ligations, with their hospital stay lasting 6.0-6.8 days. Their complication rate was 4.2%. Hysterectomy was performed in 109 patients, whose average hospital stay was 8 days with a serious-complication rate of 8.0% including 1 death. There were 6 failures among the tubal ligations, 3 each with the Pomeroy and fimbriectomy techniques. The failure rates were 3% for the Pomeroy and 4.7% for the fimbriectomy. There was 1 failure among the hysterectomies. Choice of sterilization techniques depends on the individual physiological characteristics of the patient, but the Pomeroy technique through the vaginal route is suggested whenever possible.     

Tension-free vaginal tape procedure on genuine stress incontinent women with coexisting genital prolapse

OBJECTIVE: To study the efficacy of performing the tension-free vaginal tape (TVT) procedure concurrently with vaginal pelvic relaxation surgeries in the management of genuine stress incontinence with genital prolapse. MATERIALS AND METHODS: Fifty-eight women were surgically managed. Various vaginal pelvic reconstructive surgeries for prolapses were completed before the TVT procedure. Pre-operative and postoperative urodynamic studies, 1-h pad tests and symptom analysis were evaluated 1 year postoperatively. Surgical procedures and patient outcomes are discussed. RESULTS: Objective data available for 55 patients. Fifty (91%) were dry 1 year postoperatively. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies and sacrospinous ligament fixations. No major surgical complications occurred. The average blood loss was 134 ml, the average operating time for the TVT procedure was 21 min, and the average postoperative hospital stay was 3.4 days. All patients voided spontaneously with adequate volumes of postvoid residual urine before being discharged. Two patients had a recurrent prolapse. Urodynamic parameters showed no significant differences before and after the surgery, except that the parameters related to voiding dysfunction were improved in the patients with severe cystocele. De nova detrusor instability was observed in one patient. CONCLUSIONS: The tension-free vaginal tape procedure performed with concurrent vaginal pelvic relaxation surgery is safe and effective for genuine stress incontinence and pelvic prolapse. Concomitant procedures also appear to relieve bladder outlet obstructions caused by severe prolapse.     

Postoperative pulmonary complications after gynecologic surgery.

OBJECTIVE: Investigate the frequency of, and risks for postoperative pulmonary complications after surgery for non-malignant gynecologic disorders. METHOD: A retrospective component included medical record data for one year. A prospective component enrolled 300 patients consecutively who were scheduled for gynecologic surgeries. RESULT: Postoperative pulmonary complications occurred in 1.22% of 328 open abdominal procedures in the retrospective study, and 2.16% of 232 in the prospective study. Pooling the data yielded a frequency estimate of 1.61%. Mean hospital length of stay (pooled data) increased 1.75 days in those with postoperative pulmonary complications. Smoking was the only significant risk factor (relative risk=3.9 using pooled data). CONCLUSION: Postoperative pulmonary complications after surgery for non-malignant gynecologic disorders are infrequent but increase hospital length of stay. Smokers are at increased risk.     

Laparoscopic ureteroneocystostomy with psoas hitch

BACKGROUND AND PURPOSE: Laparoscopic extravesical ureteroneocystostomy is an infrequently described technique. Our aim is to describe five cases where we used the intracorporeal freehand suturing technique successfully for performing laparoscopic extravesical transperitoneal ureteral reimplantation with psoas hitch. We describe the preliminary results of these cases. PATIENTS AND METHODS: We performed this surgery in five female patients. Two patients had a low ureterovaginal fistula after total laparoscopic hysterectomy. The other three patients had undergone laparoscopic radical hysterectomy. RESULTS: The average surgical time was 220 minutes. The average blood loss was 150 mL. The average stay was 3 days, and the average time to starting oral intake was 12 hours. No intraoperative or postoperative complications occurred. The urinary catheter was removed after 3 weeks and the double j stent after 6 weeks. Follow-up urography showed good clearance of the kidney and ureter. There was no reflux on the postoperative cystogram. CONCLUSION: Laparoscopic extravesical ureteroneocystostomy with intracorporeal freehand suturing technique and psoas hitch is a feasible procedure in females for managing ureterovaginal fistulas after laparoscopic gynecologic surgeries. The patients need not be subjected to open surgery because this complication can be repaired laparoscopically, thus minimizing the morbidity.     

Improved management in threatened preterm labour with rapid fetal fibronectin testing

Recently, a new rapid system for fetal fibronectin (fFN) analysis (TLI(IQ)) has been developed with accuracy equal to the gold standard, ELISA (enzyme-linked immunosorbent assay) testing. The objective of this quality improvement project was to confirm that a reduction in intervention and a reduced length of stay did occur, as expected, after the testing of fFN was introduced at a tertiary referral hospital (National Women's Hospital) for women in threatened preterm labour. There was a reduction in investigation and treatment of women after fFN was introduced. The average length of stay reduced from 3.8 to 2.9 days after testing was introduced. For the women who were fFN negative, the average length of stay was 1.7 days.     

Vaginal hysterectomy: a new approach using bicoagulation forceps

This study is to assess the feasibility and outcome of vaginal hysterectomies using bicoagulation forceps. Eighty patients undergoing vaginal hysterectomy for several diagnoses were enrolled. In 40 patients, bicoagulation forceps were used for the entirety of the operation. In 19 patients, only vaginal hysterectomy was performed; in 21 patients, vaginal hysterectomy was part of surgery for pelvic floor repair. Forty control patients were operated on with the traditional technique. Data regarding intra- and postoperative complications, blood loss and duration of the hospital stay were compared. The intra- and postoperative courses were similar in both groups. Intraoperative blood loss appeared less in the Biclamp group, particularly in the vaginal hysterectomy-only subgroup, as confirmed by pre- and postoperative hemoglobin measurements. Postoperative need for pain medication was significantly lower in the bicoagulation group, as was length of postoperative hospital stay. There was one postoperative bleeding complication requiring surgical revision 12 days after the initial surgery in the bicoagulation group. Using bicoagulation forceps without sutures for routine vaginal hysterectomy is a technically feasible and safe alternative to the traditional approach. Complication rates and patient satisfaction are similar. Blood loss and need for pain medication appear to be less in the coagulation group, leading to a reduced length of hospitalization.