A novel modification of conventional laparoscopic myomectomy using manual assistance for multiple uterine myomas

Objectives

To evaluate the efficacy and feasibility of finger-assisted laparoscopic myomectomy for multiple myomas.

Study design

A total of 565 patients with symptomatic myomas underwent finger-assisted laparoscopic myomectomy between January 2006 and March 2011 to remove multiple myomas at our center. Laparoscopic myomectomy technique was modified, and involved the insertion of two fingers into the vagina to elevate the uterus, while one or two fingers of the other hand were inserted into the abdomen through a suprapubic 15-mm trocar port for palpation of small myomas, which did not distort the uterine contour.

Results

The mean (SD; range) patient age was 38.26 years (5.84; 25–48 years). The diameter of the largest myoma in each case was 6.13 cm (1.21; 4–15 cm). The total number of myomas enucleated in the initial enucleation was 2228. There were 597 additional myomas enucleated with finger-assisted guidance. The mean diameter of the additionally enucleated myomas was 1.1 cm (range, 0.2–2.5 cm), which was significantly smaller than those of the initially enucleated myomas (p = 0.002). The mean operative time was 97.1 min (30.2; 35–180 min). The decrease in postoperative hemoglobin concentration was 1.6 g/dL (0.7; 0.4–3.2 g/dL). During the operation, no patients required a blood transfusion. Six patients developed postoperative fever. There was no occurrence of bowel or urinary tract injury. The mean postoperative hospital stay was 3.2 days (0.9; 2–6 d). All procedures were successfully completed without the need for laparotomy.

Conclusions

Finger-assisted laparoscopic myomectomy is a feasible and safe approach in the surgical treatment of multiple myomas.     

Impact of a program of physiotherapy and health education on the outcome of obstetric fistula surgery

Objective

Surgery is the only successful treatment for most obstetric fistulae. The present study measured the impact of a structured program of pre- and postoperative physiotherapy and health education on the outcome of surgery for obstetric fistula.

Methods

We compared the postoperative outcomes of 2 consecutive groups of women with obstetric fistulae who were recruited and followed-up by 2 local nongovernmental organizations at a hospital in Tanguiéta, Benin. The first group of women (n = 99) had fistula repair using standardized techniques. The second group (n = 112) had a standardized surgical approach plus a structured program of pre- and postoperative health education and physiotherapy.

Results

The program had a significant positive impact on recovery in general and on urinary incontinence in particular. After physiotherapy, the odds of recovery were 2.72 times greater for women in the physiotherapy group than for control patients, and the probability of postoperative stress incontinence was considerably higher for patients in the control group than for those in the physiotherapy group (P < 0.001).

Conclusion

A structured program of health education and physiotherapy by experienced nurses and physiotherapists improves the likelihood of a successful outcome after surgical repair of obstetric fistula.     

Laparoscopic appendectomy performed during pregnancy by gynecological laparoscopists

Objective

To evaluate the safety, feasibility, and pregnancy outcomes of laparoscopic appendectomy (LA) during pregnancy.

Study design

A retrospective review of eight pregnant women who underwent LA from January 2007 to December 2008.

Results

The median age of the patients and median parity were 29.5 years (range, 25–34 years) and 0 (range, 0–1), respectively. The median operating time of LA was 22.5 min (range, 15–40 min). The median length of hospital stay was 3 days (range, 2–4 days). There was no maternal or fetal mortality or morbidity, conversion to laparotomy, or uterine injury. Seven women delivered seven healthy infants. One patient chose to have an elective abortion in another hospital. The histopathological diagnoses of the resected appendices were of acute appendicitis.

Conclusion

LA performed by gynecologic laparoscopists in pregnant women is safe, feasible, and effective.     

Transvaginal repair of complex and complicated vesicovaginal fistulae

Objective

To document the experience at a tertiary referral hospital in India with managing complex and complicated vesicovaginal fistulae (VVF) by the transvaginal route, and to document the complications and the long-term outcome of the patients.

Methods

The medical records of 102 patients with complex or complicated VVF who underwent transvaginal surgical repair during 2000-2009 were reviewed retrospectively.

Results

The mean age of the patients was 24 years and the mean duration of urinary incontinence was 3 years (range 6 months to 12 years). The patients were followed up for a median of 48 months. In total, 78 patients had obstetric fistulae, 20 patients had surgical (gynecologic) fistulae, and 4 patients had postradiation fistulae. The overall success rate for the transvaginal approach was 86.3%. Fourteen patients remained incontinent despite the surgical repair. Early failure of the repair was observed in 11.8% of the patients and delayed failure in 2.0%. Postoperative complications included stress urinary incontinence (9.8%), urge urinary incontinence (7.8%), dyspareunia (5.9%), and chronic labial pain (2.0%).

Conclusion

The transvaginal approach to the repair of complex and complicated VVF gives good long-term results with low complication rates.     

Pelvic exenteration: Impact of age on surgical and oncologic outcomes

Objective

To evaluate whether preoperative age impacts surgical outcomes, complication rates, and/or recurrence in women undergoing pelvic exenteration.

Methods

All women who underwent a pelvic exenteration for any gynecologic indication at our institution from 1993 to 2010 were included. Women were stratified into groups based on age in years (young: ≤ 50, middle: 51–64, and senior: ≥ 65). Baseline characteristics, surgical outcomes, early (< 60 days) and late (≥ 60 days) postoperative complications, and recurrence/survival outcomes were ascertained. Fisher's exact test or Kruskal–Wallis test was performed. Kaplan–Meier survival curves were compared.

Results

161 patients were included (58 young, 62 in the middle, and 41 senior). Women in the young group predominately had a diagnosis of cervical cancer (82.8%) while women in the senior group primarily had a diagnosis of vulvar or vaginal cancer (70.7%). Senior women were also more likely to have hypertension (p < 0.0001) and pulmonary disease (p = 0.040). Operative time was significantly shorter for women in the senior group (8.5 h) compared with the middle (9.5 h) and young group (10.1 h) (p = 0.0089). There were no significant differences in early or late complications when stratified by age. The overall survival did not differ between age groups (p = 0.3760).

Conclusion

Although hypertension and pulmonary disease were more frequent in the senior age group, duration of surgery, blood loss, length of hospital stay and complication rates did not increase with age. Advanced chronological age should not be considered a contraindication to a potentially curative surgical procedure.     

The role and timing of palliative medicine consultation for women with gynecologic malignancies: Association with end of life interventions and direct hospital costs

Objective

Aggressive care interventions at the end of life (ACE) are reported metrics of sub-optimal quality of end of life care that are modifiable by palliative medicine consultation. Our objective was to evaluate the association of inpatient palliative medicine consultation with ACE scores and direct inpatient hospital costs of patients with gynecologic malignancies.

Methods

A retrospective review of medical records of the past 100 consecutive patients who died from their primary gynecologic malignancies at a single institution was performed. Timely palliative medicine consultation was defined as exposure to inpatient consultation ≥ 30 days before death. Metrics utilized to tabulate ACE scores were ICU admission, hospital admission, emergency room visit, death in an acute care setting, chemotherapy at the end of life, and hospice admission < 3 days. Inpatient direct hospital costs were calculated for the last 30 days of life from accounting records. Data were analyzed using Fisher's Exact, Mann–Whitney U, Kaplan–Meier, and Student's T testing.

Results

49% of patients had a palliative medicine consultation and 18% had timely consultation. Median ACE score for patients with timely palliative medicine consultation was 0 (range 0–3) versus 2 (range 0–6) p = 0.025 for patients with untimely/no consultation. Median inpatient direct costs for the last 30 days of life were lower for patients with timely consultation, $0 (range 0–28,019) versus untimely, $7729 (0–52,720), p = 0.01.

Conclusions

Timely palliative medicine consultation was associated with lower ACE scores and direct hospital costs. Prospective evaluation is needed to validate the impact of palliative medicine consultation on quality of life and healthcare costs.     

Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: A randomized controlled trial

Objective

To investigate whether gum chewing affects the return of bowel function after complete staging surgery for gynecologic malignancies.

Methods

A total of 149 patients undergoing abdominal complete surgical staging for various gynecological cancers were randomized into a gum-chewing group (n = 74) or a control group (n = 75). The patients chewed sugarless gum three times from the first postoperative morning until the first passage of flatus. Each chewing session lasted 30 min. Total abdominal hysterectomy with systematic pelvic and para-aortic lymphadenectomy was performed on all patients as part of complete staging surgery. Groups were compared in terms of time to first bowel movement time, first flatus and feces pass time, postoperative analgesic and antiemetic drug requirement, postoperative oral intake tolerance, mild ileus symptoms and hospital stay.

Results

The mean time to flatus (34.0 ± 11.5 vs. 43.6 ± 14.0 h; p < 0.001), mean time to defecation (49.6 ± 18.7 vs. 62.5 ± 21.5 h; p < 0.001), mean time to bowel movement (41.5 ± 15.7 vs. 50.1 ± 15.9 h; p = 0.001), mean time to tolerate diet (4.0 ± 0.8 vs. 5.0 ± 0.9 days; p < 0.001), mean length of hospital stay (5.9 ± 1 vs. 7.0 ± 1.4 days; p < 0.001) were significantly reduced in patients that chewed gum compared with controls. Mild ileus symptoms were observed in 27 (36%) patients in the control group compared to 11(14.9%) patients in the gum-chewing group [relative risk, 2.4; 95% confidence interval, 1.2–4.5; p = 0.004]. Severe symptoms were observed in two patients (2.7%) in the control group.

Conclusions

Gum chewing early in the postoperative period following elective total abdominal hysterectomy and systematic retroperitoneal lymphadenectomy hastens time to bowel motility and ability to tolerate feedings. This inexpensive and well-tolerated treatment should be added as an adjunct in postoperative care of gynecologic oncology.     

Comparison of robotic-assisted vs conventional laparoscopy for extraperitoneal paraaortic lymphadenectomy

Objective

To evaluate the perioperative outcomes of robotic-assisted extraperitoneal paraaortic lymphadenectomy for locally advanced cervical cancer and to compare to a previous series of patients from our institution undergoing the same procedure by conventional laparoscopy.

Methods

17 patients with locally advanced cervical cancer (FIGO stages IB2, IIA2 and IIB–IVA) underwent pretherapeutic extraperitoneal paraaortic lymphadenectomy by robotic-assisted laparoscopy. Perioperative outcomes including age, BMI, FIGO stage, operating time, blood loss, complications and length of hospital stay were compared to a series of 83 patients from our institution undergoing the same procedure by conventional laparoscopy.

Results

The median values for operating time and hospital days for the robotic-assisted and conventional laparoscopy groups were 150 vs. 150 min and 2 vs 2 days, respectively. In the robotic group, blood loss was lower (90 vs 20 ml, p < 0.05) and more aortic nodes were removed (14 vs 17 nodes, p < 0.05). Docking time was 7 min (range 3–15). There were no intraoperative complications. There were no differences for postoperative complications (17.6% vs 8.4%).

Conclusion

Robotic-assisted and conventional laparoscopy provide similar perioperative outcomes other than lower blood loss and higher number of aortic nodes removed (both without clinical impact) in robotic patients for the performance of extraperitoneal paraaortic lymphadenectomy in patients with locally advanced cervical cancer. We believe that robotic surgery is an additional tool to perform the same surgical procedure.

Highlights

Robotic-assisted and conventional laparoscopic extraperitoneal paraaortic lymphadenectomy provide similar perioperative outcomes.     

A retrovesical approach for the laparoscopic repair of vesicouterine fistulas

Objective

To report the initial experience with laparoscopic repair of vesicouterine fistulas (VUFs) at Shiraz University of Medical Sciences, Shiraz, Iran.

Methods

Between June 2012 and February 2013, 2 patients with a history of multiple cesarean deliveries had a diagnosis of VUF confirmed by cystography and cystoscopy. The fistulas were repaired laparoscopically via a retrovesical approach to minimize manipulation of the bladder.

Results

The operative times were 160 minutes and 180 minutes. Excellent laparoscopic visualization and magnification together with the presence of a catheter in the fistula tract allowed meticulous dissection in the retrovesical space between the bladder and the uterus, and resection of the fistula tract with minimal manipulation of the bladder, obviating the need for a large cystotomy. A postoperative cystogram at 4 weeks showed complete resolution of the VUF in both patients. There was no recurrence of the fistula and the patients remained symptom-free during the follow-up period.

Conclusion

Laparoscopic VUF repair with a retrovesical approach is an effective technique with successful outcome. This approach provides excellent exposure to a poorly accessible area in the retrovesical space. Longer follow-up periods are needed to evaluate the likelihood of VUF recurrence with this technique.     

Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap

Introduction

Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap offers a relatively novel means to restore symmetry and functionality after extirpative gynecologic or oncologic procedures. We sought to assess the success rates and morbidity in a large series of consecutively treated patients.

Methods

We performed a retrospective review of 59 consecutive cases of lotus petal flaps performed at a single institution to more accurately assess success and complication rates.

Results

We identified 80 flaps performed among the 59 patients between September 1, 2008 and March 30, 2013. The median (range) age was 59 years (24–89) and the median (range) BMI was 27 kg/m² (19–34). The indications for vulvar/perineal excision were as follows: 39 (66.1%) vulvar carcinoma or melanoma, 12 (20.3%) vulvar dysplasia, 5 (8.5%) colorectal disease and 3 (5.1%) cases of hidradenitis suppurativa. The mean defect area, determined by post-fixation pathology specimen was 29 cm². Medical or surgical complications occurred in 36% of patients of which superficial wound separation was the most common (15%). There were no cases of complete flap loss, but partial loss occurred in 7 (8.8%) cases. 3 (5.1%) patients required re-operation prior to discharge with one case requiring skin grafting. Delayed surgical revision was required in 4 patients for partial flap loss (2) or stricture/stenosis (2).

Conclusion

The lotus petal flap is safe for use in gynecologic reconstruction, with acceptable short- and long-term complication rates. Previous reports of smaller series likely underestimate the risk of complications through case selection.     

Compliance rates and outcomes associated with a restrictive transfusion policy in gynecologic oncology patients

Objectives

Blood products are scarce but essential medical resources. Initially transfusions showed increased perioperative complications, prolonged hospitalizations, and higher mortality. Recently developed restrictive transfusion policies have not shown those adverse affects in critically ill patients. Hospitals adopted these policies to guide blood product administration. The objective of this study is to determine compliance with a restrictive transfusion policy in gynecologic oncology patients.

Methods

A retrospective chart review of gynecologic oncology patients undergoing transfusion with packed red blood cells (pRBCs) from 12/2008 to 9/2011 was performed. Cancer type and stage, surgical procedure, hemoglobin values, pRBC transfusions, intraoperative blood loss, and postoperative complications were collected. Each transfusion was classified as compliant or noncompliant.

Results

A total of 582 patients requiring 2,276 blood transfusions were identified. The mean age was 55.9 years. Ovarian and endometrial cancers were the most common malignancies. Gynecologic oncologists were 81.1% compliant with the restrictive transfusion policy; 59.0% of transfusions were secondary to exceptions. Noncompliant transfusions were commonly given on the day of surgery when intraoperative blood loss was < 1500 cc and for asymptomatic anemia. Only 64.7% of the transfusions were ordered in single unit increments. There was no significant difference in postoperative infections, thrombotic events, and mortality between compliant and noncompliant transfusions.

Conclusion

The majority of gynecologic oncology patients receive transfusions compliant with the restrictive transfusion policy. Morbidity and mortality are not increased with a restrictive transfusion policy. Efforts to improve compliance should focus on limiting transfusions when the hemoglobin is ≥ 7 g/dL and transfusing in single pRBCs unit increments.     

Efficacy of continuous wound infiltration of local anesthetic for pain relief after gynecologic laparoscopy

Objective

To assess the efficacy of analgesia provided by continuous ropivacaine wound infiltration after gynecologic laparoscopy.

Methods

Sixty patients who underwent gynecologic laparoscopy at Ajou University School of Medicine, Suwon, Republic of Korea, between March and May 2012 were randomized to receive either intravenous fentanyl and ketorolac infusion on demand by patient-controlled analgesia (IV PCA group, n = 31) or continuous wound infiltration of local ropivacaine (CWI group, n = 29). Postoperative pain and postoperative nausea and vomiting (PONV) were assessed via a visual analog scale. The number of patients who requested rescue analgesia was recorded.

Results

There was no significant difference in postoperative pain between the 2 groups, but more patients requested rescue analgesia in the CWI group than in the IV PCA group in 24 hours (18 versus 9 patients, respectively; P = 0.010). The PONV scores at 12 and 24 hours were, respectively, 0.28 and 0.27 in the CWI group, and 0.71 and 0.73 in the IV PCA group (P = 0.004). Nine patients requested cessation of IV PCA because of severe nausea or vomiting.

Conclusion

Continuous ropivacaine wound infiltration was found to be as effective as patient-controlled analgesia for postoperative pain relief after gynecologic laparoscopy. This technique provides good analgesia with less opioid analgesic requirement and few adverse effects.     

Learning curve analysis of the first 100 robotic-assisted laparoscopic hysterectomies performed by a single surgeon

Objective

To review the first 100 cases of robotic-assisted hysterectomy performed by an individual surgeon.

Methods

A retrospective cohort study of the first 100 consecutive patients who underwent robotic-assisted hysterectomy by a newly trained minimally invasive gynecologic surgeon was conducted. Demographic factors and short-term surgical outcome variables were abstracted from medical records. We examined univariate associations and performed multivariable modeling with linear regression, and modeled the learning curve for total operative time using power-law function.

Results

Mean age was 46 years; mean body mass index was 27.8 kg/m². Median operative time was 120 minutes; median estimated blood loss was 100 mL. On multivariable analysis, case number (β –0.296; P < 0.005) and uterine weight (β 0.330; P < 0.005) independently predicted operative time, while uterine weight (β 0.387; P < 0.005) independently predicted estimated blood loss. The point at which the slope of the case number–operative time curve crosses –1.0 is at case 28 when uncontrolled and at case 24 when controlled for other factors.

Conclusion

There was a significantly decreased operative time for robotic-assisted hysterectomies performed later in the surgeon’s learning curve. Surgical proficiency, as measured by operative time, seemed to be attained after 20–30 cases.     

A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery

Objective

To compare extra-abdominal repair of the uterine incision at cesarean delivery with in situ repair.

Methods

The present study was a double-blind randomized controlled trial conducted at a university hospital in Egypt during 2012–2013, and included women with an indication for cesarean delivery. Extra-abdominal repair was used in group 1 (n = 500) and in situ repair in group 2 (n = 500). The primary outcome measure was the surgery duration.

Results

Surgery duration was significantly longer in group 1 than group 2 (49.9 ± 2.3 minutes vs 39.9 ± 1.8 minutes; P < 0.001). More patients in group 1 than in group 2 had postoperative moderate-to-severe pain (165 [33.0%] vs 115 [23.0%]; P = 0.001) and needed additional postoperative analgesia (100 [20.0%] vs 50 [10.0%]; P < 0.001). Moreover, mean time to bowel movement was longer in group 1 than in group 2 (17.0 ± 2.7 hours vs 14.0 ± 1.9 hours; P < 0.001).

Conclusion

In situ uterine closure is more advantageous than extra-abdominal repair in terms of surgery duration, postoperative pain and need for additional analgesia, and return of bowel movement.ClinicalTrials.gov:NCT01723605     

Surgical repair of rectovaginal fistulas in patients with Crohn's disease

Objectives

To report surgical outcomes of patients who underwent rectovaginal fistula (RVF) repair with a history of Crohn's disease utilizing several reconstructive techniques.

Study design

Retrospective case series of women (n = 6) with Crohn's disease surgically treated with either vaginal or rectal advancement flaps. Demographic information and data specific to Crohn's disease at the time of surgery were collected. In addition, operative reports and postoperative follow-up visits were reviewed.

Results

During the study period, six women with the diagnosis of Crohn's disease and RVF underwent surgical management. Five patients had a vaginal advancement flap (VAF) by Female Pelvic Medicine and Reconstructive Surgery and one patient was treated by the rectal advancement flap by Colorectal Surgery. The failure rate in our study population was 33% (2/6). Of note, two of the patients who had a successful VAF had a previous failure after RAF. In addition, four patients who had a repair via the transvaginal approach had a concomitant pedicled flap procedure (i.e. Martius or gracilis flap). The average follow-up for all our patients was 5 months (+/− 6.5 months). No patients failed if they received a VAF with a concomitant flap procedure.

Conclusions

This case series illustrates several techniques utilized for the repair of RVF in patients with Crohn's disease. The use of a bulbocavernosus flap during the primary repair of RVF in this patient population may be considered to bolster the rectovaginal septum.     

Single port gasless laparoscopy-assisted mini-laparotomic ovarian resection (SP-GLAMOR): Reasonable treatment for large cystic ovarian tumors with suspicion of malignancy

Objectives

Recent improvements to both optical and laparoscopic instruments have enabled the use of laparoscopic surgery for gynecological procedures as opposed to open abdominal surgery. However, laparoscopic surgery has several potential limitations, including tumor rupture, spillage, incomplete resection of lesions, and trocar insertion site metastasis in surgeries involving large ovarian masses with suspicion of malignancy.Here, we report a case series of large ovarian cystic tumors that were successfully removed by single port gasless laparoscopy assisted mini-laparotomic ovarian resection (SP-GLAMOR), the limitations of which were successfully addressed.

Methods

We reviewed the medical records of 31 women who visited St. Vincent Hospital from April 2006 until April 2011 and were diagnosed with a large cystic ovarian mass with suspicion of malignancy based on imaging studies and tumor markers. After diagnosis, all of the women underwent SP-GLAMOR.

Results

The median maximal diameter of cysts, median incision size, median surgical duration and median volume of blood loss were 20 cm (range 10.7–45 cm), 3 cm (range 2.5–4 cm), 100 min (range 45–270 min) and 100 mL (range 30–500 mL), respectively. Four cases were diagnosed as malignant disease on frozen sections obtained during the operation, and were converted to open abdominal surgery. No major complications were observed. The four patients diagnosed with malignant disease also underwent adjuvant chemotherapy. All patients were followed up to the time of this report.

Conclusions

The results of our study suggest that the SP-GLAMOR procedure is feasible, with potentially decreased perioperative morbidity and blood loss, faster recovery and better cosmetic results.     

Postoperative readmissions following ileostomy formation among patients with a gynecologic malignancy

Objectives

Ileostomy results in a relatively poorer water reabsorption and is associated with dehydration and renal injury. These problems may be exacerbated in the setting of gynecologic cancers owing to both patient and disease-related factors. We evaluated the rate and reasons for hospital readmission within 30 days of ileostomy creation in patients with a gynecologic malignancy.

Methods

We performed a retrospective review of women with gynecologic malignancies who underwent ileostomy creation between 2002 and 2013.

Results

Fifty-three patients were eligible for analysis. The mean age was 63.3 years. Most patients had ovarian cancer (86.5%). Indications for ileostomy included small bowel obstruction (45.3%), as part of primary debulking (18.9%), or treatment of an anastomotic leak (15.1%). The 30-day readmission rate was 34%. Co-morbid diseases such as hypertension (p = 0.008) and chronic kidney disease (p = 0.010) were more common among women who were readmitted. The most common reasons for readmission were dehydration (38.9%) and acute renal failure (33.3%); women readmitted for these conditions had higher average serum creatinine levels at initial postoperative discharge (1.00 mg/dL versus 0.71 mg/dL, p = 0.017) than women who did not require readmission. Readmitted women had a trend toward shorter overall survival (0.41 years versus 1.67 years, p = 0.061).

Conclusions

Readmission rates for gynecologic oncology patients undergoing ileostomy were similar to, but higher than those previously reported in the colorectal literature. In our population, patients with preexisting cardiovascular or renal disease were at the highest risk of readmission and may benefit from preemptive strategies to decrease high ostomy output and dehydration.     

Preoperative hypoalbuminemia is an independent predictor of poor perioperative outcomes in women undergoing open surgery for gynecologic malignancies

Objective

To quantify the impact of preoperative hypoalbuminemia on 30-day mortality and morbidity after gynecologic cancer surgery.

Methods

Patients included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent any non-emergent surgery for gynecologic malignancy between 1/1/2008 and 12/31/2010 were identified. Analysis was conducted with albumin both as a dichotomous variable (< 3.5 g/dl was defined as low albumin) and as a continuous variable to determine a clinically relevant cut-off value.

Results

Of the total 3171 patients identified, 2110 had preoperative albumin levels available for analysis. In addition, 279 (13.3%) of these patients had low albumin levels.According to multivariate analysis, the low albumin group had significantly higher odds of developing one or more post-operative complications (OR-2,CI: 1.47–2.73, p < 0.0001), three or more complications (OR-4.1,CI: 2.31–7.1, p < 0.0001), surgical complications (OR-2.39,CI: 1.59–3.58, p < 0.0001), thromboembolic complications (OR-2.59,CI: 1.33–5.06, p < 0.0001), pulmonary complications (OR-4.06,CI: 2.05–8.03, p < 0.0001), or infectious complications (OR-1.84,CI: 1.26–2.69, p < 0.0001) and a higher 30-day mortality (OR-6.52,CI: 2.51–16.95, p < 0.0001). Upon subgroup analysis, this difference was not found in patients undergoing laparoscopic surgery.In patients undergoing open surgery, the probability of experiencing one or more post-operative complications increased linearly with the decrease in albumin level; however, the probability of patients experiencing three or more complications and 30-day mortality increased sharply as soon as the albumin level decreased below 3 g/dl.

Conclusion

Preoperative albumin levels < 3 g/dL identify a population of patients at a very high-risk of experiencing perioperative morbidity and 30-day mortality after open surgery.     

Comparison of total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma

Objective

To compare total laparoscopic hysterectomy (TLH) using the Hohl instrument with laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma.

Study design

231 women underwent laparoscopic hysterectomy for the treatment of symptomatic leiomyoma between January 2005 and December 2007. A total of 113 women decided to undergo complete hysterectomy with removal of the cervix (TLH group) and 118 women wished to preserve the cervix; LASH was carried out in the latter group (LASH group).

Results

No ureteral or bladder injury occurred in any of the patients. Two intraoperative complications and one postoperative complication occurred in the TLH group, while no complications occurred in the LASH group. When the TLH group was compared with the LASH group, the mean loss of hemoglobin was 1.6 ± 1.1 g/dL (95% CI 1.4–1.8) vs. 1.5 ± 1.4 g/dL (95% CI 1.2–1.7); the mean operating time was 114.0 ± 33.8 min (95% CI 107.6–120.2) vs. 116.5 ± 40 min (95% CI 109.3–124.0); and the mean uterus weight was 264.8 ± 133.6 g (95% CI 239.8–289.6) vs. 286.2 ± 209.3 g (95% CI 247.4–324.4). Hospital stay and use of analgesia in both groups were equal. No statistically significant differences were found.

Conclusions

TLH using the Hohl instrument is an option comparable with laparoscopy-assisted supracervical hysterectomy for women with uterine leiomyoma. However, the complication rates may be lower when LASH is performed.