Pilot study assessing robotic laparoscopic hysterectomy and patient outcomes

STUDY OBJECTIVE: To examine the operative variables and complications associated with robotic-assisted total laparoscopic hysterectomy. DESIGN: Canadian Task Force classification II-1. SETTING: Gynecology service affiliated with a major cancer center in Southern California. PATIENTS: Twenty women with a benign gynecologic condition. INTERVENTION: Robotic-assisted total laparoscopic hysterectomy. Patient status was evaluated in terms of operative morbidity, length of surgery, anesthesia time, estimated blood loss, and hospital stay. MEASUREMENTS AND MAIN RESULTS: Mean operative time was 3.2 hours, and anesthesia time was 4 hours. Mean estimated blood loss was 81 mL, and patient postoperative hospital stay was 2 days. The complication rate in this study was low. The surgical procedure was converted to a laparotomy and abdominal hysterectomy in two patients because of poor visualization during robotic-assisted surgery. CONCLUSIONS: While the number of patients and nonrandomized nature of this single-institution experience are insufficient to draw any definitive conclusions regarding potential treatment efficacy, the patient postoperative stay and low complication rates suggest that this procedure is feasible and promising. Additional study comparing the efficacy and cost of robotic laparoscopic hysterectomy with standard laparoscopic hysterectomy with a larger patient population is warranted.     

Vaginoplasty with Interceed absorbable adhesion barrier for complete squamous epithelialization in vaginal agenesis

OBJECTIVE: The purpose of this study was to present our experiences of an innovative surgical approach for vaginal agenesis with the use of Interceed absorbable adhesion barrier (Ethicon) to achieve a satisfactory neovagina. STUDY DESIGN: The current study involved 10 subjects who were diagnosed with vaginal agenesis. After the creation of a vaginal tunnel, a mold that had been wrapped with Interceed was placed in the neovagina. RESULTS: No operative and postoperative complications were encountered. The duration of the operation was < or =30 minutes, and blood loss was minimal. The postoperative hospital stay was only 2 days. Epithelialization of the neovagina was achieved 1 to 4 months after the operation, and all patients were satisfied with the outcome. The neovagina that was created with this procedure was not much different from the normal adult vagina as far as histologic and physiologic conditions are concerned. CONCLUSION: This innovative surgical procedure may be a potential alternative approach for the therapy of vaginal agenesis with the use of the absorbable adhesion barrier Interceed with excellent results.     

An evaluation of the resident learning curve in performing laparoscopic supracervical hysterectomies as compared with patient outcome: five-year experience

STUDY OBJECTIVE: To compare surgical and postoperative results after laparoscopic supracervical hysterectomy between the first 2 cases and last 2 cases performed by each senior resident. DESIGN: Retrospective, case-control study (Canadian Task Force classification II-B). SETTING: University hospital. PATIENTS: Two hundred six women underwent laparoscopic supracervical hysterectomy. INTERVENTIONS: Charts were reviewed to determine length of surgery, operative and postoperative complications, and other surgical values. A comparison was made between the first 2 and last 2 cases of 25 chief residents. MEASUREMENTS AND MAIN RESULTS: There was no statistically significant difference between the first 2 and last 2 patients of each resident in terms of age, indication for surgery, uterine mass, ethnicity, body mass index, or parity. There was a significant decrease in the mean time of the first 2 cases versus the last 2 cases: 201.4 minutes versus 137.2 minutes (p <.001). There was no significant difference in blood loss, change in hematocrit, length of hospital stay, and surgical or postoperative complications. CONCLUSIONS: Laparoscopic supracervical hysterectomy is a technically challenging procedure that nevertheless can be learned quickly with rapid improvement in operative time and without undue risk to the patient. Since initially presenting these data in 2003, the senior residents are now getting twice the amount of exposure to this surgery. In addition, these data now include residents who were exposed to this type of surgery as junior residents. Although residents are beginning to have increased experience in performing laparoscopic supracervical hysterectomy before their chief year, there is still a significant difference in operative time from the initial 2 procedures to the last 2 procedures completed by a chief resident.     

70岁以上患者妇科恶性肿瘤的手术治疗

目的：观察70岁以上的老年妇科恶性肿瘤患者者耐受手术治疗的情况,方法：收集我院1983年9月至1999年6月期间,70岁以上接受盆腔局限性和广泛性手术治疗的全部生殖器恶性肿瘤患者,共57例,分析不同年龄和手术方式对预后的影响。结果：57例患者的平均年龄73．5岁,其中34例接受了广泛性手术治疗,23例接受了局限手术治疗。41例（71．9％）术前合并各种内科疾病,术后18例（31．6％）出现一般并发症,6例（10．5％）发生严重并发症,比较70－75岁组和＞75岁组之间,手术方式,平均住院日,以及术前和术后并发症等因素无明显差别。与局限性手术组相比较,6例严重并发症患者均发生在广泛性手术组,后者术后住院日较前者延长1倍多,结论：经过周密的术前准和术后观察处理,70岁以上的妇科恶性肿瘤患者能够耐受广泛性手术治疗。     

Uterine morcellation during vaginal hysterectomy: apropos of a series of 216 prospective cases

OBJECTIVE: The purpose of this study was to compare the surgical outcomes of women undergoing vaginal hysterectomy with and without morcelation. PATIENTS AND METHOD: Between December 1999 and December 2000, 216 women underwent vaginal hysterectomy without laparoscopic assistance at the Department of Gynecology of H?tel-Dieu hospital in Paris. The patients were divided into two groups: 114 of them underwent vaginal hysterectomies with morcelation whereas 102 underwent vaginal hysterectomies without morcelation. The two groups were compared as to demographic data, total complications, operative time, hospital stay length and peri-operative hemoglobin concentration change. RESULTS: Although women undergoing morcelation were significantly younger (mean 49 versus 52, p = 0.01) and less parous (mean 1.9 versus 2.3, p = 0.03), there were no significant differences in other surgical or anesthetic risks factors, including weight, BMI, nulliparity and preexisting surgical diseases. Mean uterine weight was significantly greater in those undergoing morcelation (331 versus 110 g, p < 0.001); operative time was increased in the group which had undergone morcelation (331 versus 110 g, p < 0.001). There were no significant differences between the two groups with respect to peri-operative hemoglobin concentration change or hospital stay length. Finally, the rate of surgical complication was similar in the two groups (17.5 versus 21.5%). CONCLUSION: Although vaginal hysterectomy requires an increase in operative time, morcelation at the time of vaginal hysterectomy is safe and facilitates the vaginal removal of enlarged uteri without increasing peri-operative morbidity.     

Laparoscopic Davydov or laparoscopic transposition of the peritoneal colpopoeisis described by Davydov for the treatment of congenital vaginal agenesis: the technique and its evolution

INTRODUCTION: The laparoscopic Davydov is described. The data concerning the surgery and the postoperative course are reported at the same time as the data concerning the anatomical and sexological results. PATIENTS AND METHODS: The surgery includes three steps: (i) cleavage under laparoscopic guidance, (ii) peritoneovestibular stitch by perineal approach, (iii) making the vaginal vault with the laparoscope. The cleavage can be performed in front of the fascia interposed between the bladder and the rectum or behind it. A nymphoplasty can be added to the colpopoeisis. RESULTS: Between February 1996 and March 2003 we operated on 28 patients affected by congenital vaginal agenesis using the laparoscopic Davydov technique. Two peroperative complications occurred (urinary tract injuries during the first step: laparoscopic management) and two postoperative complications (intraperitoneal migration of the mould and vesicovaginal fistula managed successfully with the laparoscope for the first one and trough laparotomy for the second one). Four re-operations (incision and dilation) were necessary. The length of the neovagina was, at the last assessment, 7.2 +/- 1.3 cm. The Female Sexual Function Index was 26.5 +/- 5.6 vs. 27.9 +/- 4.5 in a control cohort. In the patients whose cleavage was performed behind the fascia (13 cases vs. 15) no complication occurred, no re-operation was necessary, the length of the neovagina was 7.0 +/- 0.7 cm and the FSFI was 26.3 +/- 5.9. DISCUSSION AND CONCLUSION: The laparoscopic Davydov is, if the dorsal approach is used for the cleavage, an easy to make operation (operating time: 90 +/- 29 minutes) with a short hospital stay. The postoperative care is simple (vaginal mould useless). Heterosexual activity with penile penetration can start early (6 to 8 weeks). The level of satisfaction is high. Laparoscopic Davydov procedure may be considered a good alternative to the more complex ones (as Vecchietti's technique) or to the more dangerous ones (sigmoid colpoplasty).     

Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy

OBJECTIVE: We compared operative time, length of hospital stay, postoperative recovery, return to work, and costs for women undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy. STUDY DESIGN: A prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy (n = 24) versus abdominal hysterectomy (n = 24) was carried out in a tertiary care setting. The main outcome variables were operative time, length of hospital stay, and return to work. Secondary outcomes were postoperative pain and return to normal activity as determined by weekly visual analog scales and daily diary. Hospital costs were calculated. RESULTS: The laparoscopically assisted vaginal hysterectomy group had longer operative times (median and quartiles, laparoscopically assisted vaginal hysterectomy 180 [139, 225] minutes vs abdominal hysterectomy 130 [97, 155] minutes), lower requirements for postoperative intravenous analgesia (patient-controlled analgesia pump, median and quartiles: laparoscopically assisted vaginal hysterectomy 22.1 [15.9, 23.5] hours, abdominal hysterectomy 36.7 [26.2, 45.0] hours), shorter length of hospital stay (median and quartiles, laparoscopically assisted vaginal hysterectomy 1.5 [1.0, 2.3] days, abdominal hysterectomy 2.5 [1.5, 2.5] days), and quicker return to work (Kaplan-Meier analysis, P =.03). Both procedures had similar hospital costs (P =.21). CONCLUSION: Laparoscopically assisted vaginal hysterectomy appears to allow patients a more rapid postoperative recovery and an earlier return to work with hospital costs similar to those of abdominal hysterectomy.     

Single-port versus conventional laparoscopic salpingectomy in tubal pregnancy: a comparison of surgical outcomes

Objective

To compare the surgical outcomes of single-port laparoscopic salpingectomy (SPLS) and conventional laparoscopic salpingectomy for the surgical treatment of tubal pregnancy.

Study design

From January to June 2009, patients with tubal pregnancy were assigned to two surgical groups: SPLS and conventional laparoscopic salpingectomy. Surgical outcomes, including operative time, postoperative haemoglobin drop, hospital stay and complications, were compared prospectively. For SPLS, a novel multichannel port was made using a wound retractor and a surgical glove.

Results

In total, 60 patients were enrolled in the study (30 in the SPLS group and 30 in the conventional group). All operations were completed successfully. No significant difference was observed between the two groups in terms of mean operative time (52.6 ± 16.1 min vs 46.8 ± 16.2 min; p = 0.174), mean difference between pre- and postoperative haemoglobin (1.7 ± 0.8 g/dl vs 1.8 ± 1.0 g/dl; p = 0.636), or mean postoperative hospital stay (2.4 ± 0.5 days vs 2.4 ± 0.9 days; p = 1.000). No complications were encountered in either group, and there was no conversion to conventional laparoscopy in the SPLS group.

Conclusion

SPLS has comparable surgical outcomes to conventional laparoscopic salpingectomy for the surgical treatment of tubal pregnancy in terms of operative time, hospital stay and complication rates. However, further studies are needed to evaluate the merits expected of single-port laparoscopic surgery, such as cosmetic advantage and decreased pain in patients.     

Laparoscopic myomectomy for fibroids penetrating the uterine cavity: is it a safe procedure?

Objective The purpose of the study was to evaluate the post-operative course and follow up of women who had undergone laparoscopic removal of intramural fibroids penetrating the uterine cavity.
Design Retrospective study.
Setting Center for Reconstructive Pelvic Endosurgery, Italy.
Population Thirty-four women with fibroids penetrating the uterine cavity.
Methods Laparoscopic myomectomy.
Main outcome measures Feasibility and safety of surgical technique, length of operation, blood loss, intra- or post-operative complications, length of hospital stay, resolution of symptoms and future obstetric outcome.
Results The mean operative time was 79 (SD 30) minutes; the mean reduction in haemoglobin was  1.1 ± 0.9 g/dL  . No intra- or post-operative complications were observed. The average post-operative stay in hospital was 54 (SD 22) hours. Nineteen (73%) out of 26 patients who had experienced symptoms prior to surgery reported resolution of these symptoms post-operatively. All patients resumed work within a mean time of 20 (SD 8) days. Among 23 of the 32 patients attempting pregnancy during the follow up period, nine (39%) conceived within one year. Seven pregnancies went to term without complications.
Conclusion The clinical results of this study suggest that laparoscopic myomectomy for intramural fibroids penetrating the uterine cavity is a safe procedure, providing well known advantages of minimal access surgery.     

Radical hysterectomy in the elderly female: a comparison to patients age 50 or younger

BACKGROUND: Longevity in the United States is increasing, therefore the knowledge of whether radical surgery can be performed on patients over age 65 with acceptable morbidity and mortality is increasingly important. A retrospective study of elderly patients undergoing radical hysterectomy was performed with a comparison to a younger cohort. METHODS: A retrospective case study of all patients over 65 years of age having undergone a radical hysterectomy for cervical cancer in one practice of gynecologic oncology was performed. Each patient was matched with two patients age 50 or younger having undergone a similar operation during the same year. No patients between July 1, 1965, and March 31, 1998, were knowingly excluded. All patients were analyzed for preexisting medical conditions, length of postoperative stay, morbidity, and postoperative mortality. RESULTS: Sixty-two patients over age 65 having undergone a radical hysterectomy and pelvic lymphadenectomy were found. These patients were matched with 124 patients age 50 or younger having undergone a radical hysterectomy during the same calendar year. No differences in operative morbidity (minor, P > 0.57; major, P > 0.93) or mortality (no deaths in either group) were found. Patients age 65 or older had more comorbidities prior to surgery than the younger cohort (minor, P < 0.001; major, P < 0.001). The mean postoperative hospital stay was significantly longer in the older cohort (P = 0.005). CONCLUSIONS: Radical hysterectomy is a safe surgical procedure in a select population of patients 65 and over. No differences in operative mortality or morbidity were found when compared to a cohort of patients age 50 or younger. However, hospital stay was longer in the older cohort.     

A Retrospective Cohort Study Evaluating Surgical Aptitude Over Time in a New Male-To-Female Penoscrotal Vaginoplasty Program

BackgroundGiven the burgeoning demand for gender affirmation surgery, there are few studies examining both surgical process variables and patient outcome variables. Knowing the learning curve for surgical teams who are beginning to perform this procedure will be important for patient safety and presurgical patient counseling as more institutions open transgender surgical programs.AimThe purpose of this study was to determine the demographics of patients pursuing penoscrotal vaginoplasty, to determine their postoperative course, and to determine a learning curve for the surgical team performing penoscrotal vaginoplasty.MethodsWe retrospectively reviewed charts of all 43 patients who underwent penoscrotal vaginoplasty from the commencement of a new male-to-female penoscrotal vaginoplasty program in March 2018 through July 2019.OutcomesPrimary outcomes included mean hemoglobin decrease from surgery and operative time. Mean time to neoclitoral sensation, length of hospital admission, complication rates, reoperation rates, length of narcotic use after surgery, and demographics were also evaluated. Associations between surgical team experience and outcomes were assessed with Spearman's rho and Cox regression, and curve-fitting procedures were applied to determine the relationship.ResultsThe mean operative time from initial incision to procedure finish was 225 minutes, and the mean decrease in hemoglobin was 3.3 g/dL. The mean time to neoclitoral sensation was 0.72 months. The time until neoclitoral sensation decreased as the surgical cases performed increased (Spearman's rho, −0.577 [P < .001]), with a power function best describing the learning curve. Operative time did not change with case number (Spearman's rho, 0.062 [P = .698]) but overall time in the operating room did (Spearman's rho, 0.631 [P < .001]). Mean length of hospital admission was 2.9 days. There were no intraoperative complications. 18 patients (42%) experienced a postoperative complication. 8 of 43 patients underwent reoperation (20%). Narcotics were used a mean of 9.5 days after surgery.Clinical ImplicationsA learning curve can be demonstrated in penoscrotal vaginoplasty for time to neoclitoral sensation and overall time in the operating room, plateauing between 30 and 40 cases.Strengths and LimitationsStrengths include assessing a learning curve for time to neoclitoral sensation, length of hospital stay, and length of postoperative narcotic use after penoscrotal vaginoplasty, which, to our knowledge, has not been reported elsewhere. Limitations include our overall low number of patients.ConclusionDespite a low number of cases, length of hospital stay was short and the postoperative complication rate was similar to that of long-standing penoscrotal vaginoplasty programs.Whynott RM, Summers K, Mickelsen R, et al. A Retrospective Cohort Study Evaluating Surgical Aptitude Over Time in a New Male-To-Female Penoscrotal Vaginoplasty Program. J Sex Med 2020;17:1787–1794.     

Neovagina construction by combined laparoscopic-perineal sigmoid colpoplasty in a patient with Rokitansky syndrome

We created a neovagina by sigmoid colpoplasty using a combined laparoscopic-perineal approach in a 19-year-old woman with Rokitansky syndrome. Operating time was 4 hours and 45 minutes. No perioperative or postoperative complications occurred. Hemoglobin level fell by 1 g/dl. Total doses of morphine, nonsteroidal antiinflammatory drugs (NSAIDs), and paracetamol were 20 mg, 350 mg, and 28 g, respectively. Hospital stay was 7 days. The length of the neovagina was 12 cm. By comparison, in the three reported cases of laparotomic-perineal sigmoid vaginoplasty, mean operating time was 5 hours and 40 minutes; 24-hour fall in hemoglobin was 3.2 g/dl (range 2.1-4.3 g/dl); mean doses of morphine, NSAIDs, and paracetamol were 42.6 mg, 300 mg, and 40 g, respectively; mean hospital stay was 11.3 days; and length of neovaginas was 10, 12, and 12 cm. Although sigmoid colpoplasty is a reliable and reproducible technique, it requires experience in laparoscopic colonic surgery. The combined laparoscopic-perineal approach is associated with less analgesic requirement, shorter hospital stay, and similar anatomic results compared with the laparotomic-perineal approach.     

Comparison of one- and two-layer vaginal cuff closure and open vaginal cuff during laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To evaluate clinical outcomes of three surgical techniques during laparoscopic-assisted vaginal hysterectomy. DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Medical school-affiliated hospital. PATIENTS: Four-hundred twenty-seven women. INTERVENTION: By means of a computer-generated randomization code, patients were assigned immediately before operation to one of three groups according to type of surgical procedure: group 1, 147 women having one-layer closure of the vaginal cuff; group 2, 138 having two-layer closure of the vaginal cuff; and group 3, 142 having open vaginal cuff. MEASUREMENTS AND MAIN RESULTS: Patients were observed for morbidity during hospitalization, and 1 and 6 weeks and 6 months postoperatively. No significant differences were found among the groups for length of surgery, operative blood loss, postoperative hematocrit, length of hospital stay, postoperative febrile morbidity, frequency of pelvic and urinary tract infection, dyspareunia, postcoital spotting, vaginal discharge, and morbidity of the cuff (cellulitis, abscess formation, bleeding, hematoma, dehiscence). Operating time was greatest for two-layer closure. The frequency of postoperative granulation of cuff tissue and vaginal discharge was greater for group 1 than for the other two groups. CONCLUSION: Two-layer closure of the vaginal cuff during laparoscopic-assisted vaginal hysterectomy is associated with fewer instances of vaginal vault granulation and vaginal discharge than either one-layer closure or open vaginal cuff.     

Laparoscopic hysterectomy with retroperitoneal uterine artery sealing using LigaSure™: Gazi hospital experience

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of laparoscopic hysterectomy by retroperitoneal sealing of the uterine arteries with LigaSure. METHODS: Laparoscopic hysterectomy by retroperitoneal uterine artery sealing with LigaSure was performed by four-puncture laparoscopy in 50 women with various indications for hysterectomy. The mean operation time, amount of intraoperative bleeding, drop in hemoglobin concentration, weight of removed uterus, major and minor per-post operative complications, and the rate of conversion to classical abdominal approach were analyzed prospectively. RESULTS: The mean operation time was 85 min (range 60-125 min). The mean weight of removed uterus was 180 g (range 60-650 g). There was one major complication; one patient had cystotomy due to difficulty in dissecting severe adhesions because of two previous cesarean sections that were repaired laparoscopically. Only one patient converted to laparotomy because of severe bowel adhesions due to rectovaginal endometriosis. All patients were discharged on the first postoperative day. No minor complications occurred. Hemoglobin decreased a mean of 0.4 g/dl (range 0.2-1.4 g/dl) by postoperative day 1. CONCLUSION: Laparoscopic hysterectomy by retroperitoneal uterine artery sealing with LigaSure is an effective, safe, and fast procedure with less intra operative bleeding, short operation time and hospital stay.     

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.     

Comparison of uterine exteriorization and in situ repair during cesarean sections

Purpose

To compare the peri- and postoperative complication rates of two cesarean delivery techniques.

Methods

Medical records from 1,087 patients who had a cesarean delivery with regional anesthesia between 2008 and 2010 were reviewed retrospectively. Seven hundred and thirty-two patients had an in situ uterine repair, and 355 patients had an exterior uterine repair. Patients who had chorioamnionitis, preeclampsia, a bleeding disorder, or abnormal placentation were excluded from the study. The following outcomes were compared between the two groups: mean operative time, intraoperative blood loss, perioperative nausea, tachycardia, hypotension, hemoglobin level, hematocrit level, the time to the first recognized bowel movement, postoperative analgesic dose, nausea, length of hospital stay, surgical site infection rate and endometritis rate.

Results

No clinically significant differences were found between the exteriorization and in situ uterine repair groups for mean hematocrit differences, intraoperative blood loss, perioperative nausea, tachycardia, hypotension and postoperative analgesic doses. However, the mean operative time, time to the first recognized bowel movement, surgical site infection rate and length of hospital stay were significantly lower in the in situ repair group (p?Conclusion Although the techniques are similar in most scenarios, in situ uterine repair during cesarean sections appears to be more advantageous than exteriorization with respect to the mean operative time, time to the first recognized bowel movement, surgical site infection rate and length of hospital stay.     

Outpatient laparoscopic hysterectomy in a rural ambulatory surgery center

STUDY OBJECTIVE: To evaluate a cost-optimized operative technique for outpatient laparoscopic hysterectomy in a rural ambulatory surgery center focusing on shortening hospital stay and substitution of expensive disposable laparoscopic instruments with standard surgical techniques. DESIGN: Prospective feasibility and observational study (Canadian Task Force classification II-3). SETTING: Rural ambulatory surgery center in Lamar, Alabama. PATIENTS: Fifty-two women. INTERVENTION: Outpatient laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: From September 2001 through September 2003, 52 consecutive procedures with a modified classical intrafascial supracervical hysterectomy (CISH) technique without disposable instruments have been performed on patients with an average age of 42.2 years (range 25-62 years) and a follow-up of 12.5 months (range 0.4-23.6 months). Mean postoperative length of stay was 6 hours, 79 minutes (range 3 hours, 10 minutes-17 hours, 30 minutes), and overall length of stay was 11 hours, 37 minutes (range 6 hours, 45 minutes-22 hours, 50 minutes). Five patients (9.6%) stayed overnight, three for medical and two for social reasons. With an average of 2 hours, 14 minutes, the operating room time was about 1 hour longer than with disposable instruments. Health insurance reimbursement for the ambulatory surgery center was on average $1814.11. No complications occurred, and no readmission to the hospital was necessary. CONCLUSION: Outpatient laparoscopic hysterectomy is feasible and safe and can be performed cost effectively in ambulatory surgery centers, even in rural areas. Development of a protocol with patient selection, preoperative and postoperative patient teaching, caring family environment, and round-the-clock medical telephone backup is necessary.     

Laparoscopic hysterectomy in obese women: a clinical prospective study

OBJECTIVE: To compare perioperative and postoperative outcomes of laparoscopic hysterectomy (LH) in surgical management of gynecological conditions in two groups of different weight. METHODS: A prospective comparative clinical study of 271 LH performed for disease of female pelvic organs in a group of 54 obese patients (over 30 body mass index (BMI)) and in a group of 217 non-obese patients (less than 30 BMI). The following criteria were assessed: patient characteristics, indications for surgery, previous surgery, presence of adhesions, duration of procedure, blood loss, weight of specimen, hospital stay and complications. Statistical analysis was performed using the unpaired t-test and non-parametric Chi-square test when appropriate, with a significance level of P=0.05. RESULTS: Three non-obese patients were converted to laparotomy due to operative complications. Laparoscopy in the remaining 268 patients (98.89%) was completed successfully. There was no significant difference in estimated blood loss, presence and degree of adhesions, weight of specimen, length of hospital stay and postoperative complications between women with high BMI and those with low BMI. The rate of major operative complications (5.55% versus 3.22%) was higher in the obese group. The duration of the operation was longer in obese women. However, the significance of the difference was borderline (P=0.06).     

Creation of a neovagina according to Wharton-Sheares-George in patients with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE: To introduce a simple and quick surgical alternative for creating a neovagina in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome that offers good anatomic and functional results. DESIGN: Historical report. SETTING: Tertiary center for gynecologic endocrinology. PATIENT(S): Three patients with MRKH syndrome. INTERVENTION(S): The creation of a neovagina according to Wharton-Sheares-George in patients with MRKH syndrome. MAIN OUTCOME MEASURE(S): Axis, length, and width of neovagina. RESULT(S): The George modification of the Wharton-Sheares neovaginoplasty was successfully performed in three patients. The results were excellent (normal axis and adequate length and width of neovagina), and there were no major complications. CONCLUSION(S): The George modification of the Sheares technique represents a simple, safe, and effective surgical option for creating a neovagina. The procedure is not highly complex and is therefore easy to learn and perform; no special surgical equipment is needed. Anatomic and functional results are very satisfying. Short-term hospitalization, accelerated recovery, and a rapid return to everyday life are important benefits for these young patients. These benefits also result in lower surgery-related expenses and therefore reduce the strain on the hospital's budget compared with other therapeutic options. The creation of a neovagina according to Wharton-Sheares-George might provide a satisfactory alternative for the surgical management of vaginal aplasia in patients with MRKH syndrome.     

Minilaparotomy in early stage endometrial cancer: an alternative to standard and laparoscopic treatment

OBJECTIVE: Our objective was to determine whether minilaparotomy could be a safe and feasible approach for the surgical treatment of early endometrial cancer patients and whether it could be considered a valid alternative to the laparoscopic treatment. METHODS: A pilot study of 50 consecutive patients with FIGO stage I-IV endometrial cancer undergoing surgery at our Department was performed between May and December 2001. All patients were evaluated for a minimal transabdominal approach. Exclusion criteria were considered: special histotype, poorly differentiated tumors, clinical stage >/=Ic, Ca125 >35 U/ml, BMI >30, lymph nodal involvement assessed by MRI, and severe cardiopulmonary disease precluding steep Trendelenburg position. RESULTS: Twenty-six (52%) cases were considered eligible for minilaparotomy. The mean age was 55.4 years and the mean BMI was 24.1. All patients underwent TAH, BSO, pelvic lymphadenectomy +/- omental or peritoneal biopsy. A mean number of 28 pelvic lymph nodes were removed. The mean operative time was 113.0 min and the mean intraoperative blood loss was 220.0 ml. There was 1 severe operative hemorrhage and 1 patient needed postoperative blood transfusion. No immediate complications of wound infection or separation occurred. The mean hospital stay was 3.4 days. Intra- and postoperative parameters were compared to laparotomy controls and literature data on laparoscopy, showing substantially comparable results. CONCLUSION: Minilaparotomy is a feasible alternative to the standard treatment in endometrial cancer patients. It offers the patient a cost-effective procedure that avoids many of the potential complications of standard therapy, prevents long hospital recovery periods, and accomplishes all of the important goals of standard recommendations.