Laparoscopic Hysterectomy For Benign Conditions Research Articles

Impact of chlorhexidine and povidone-iodine antiseptic solutions on the cervicovaginal microenvironment during laparoscopic hysterectomies: a pilot study

The use of chlorhexidine gluconate (CHG) as surgical preparation solution has been advocated due to reduced bacterial loads compared with povidone-iodine (PI). We aimed to investigate changes to the vaginal microenvironment among patients who had laparoscopic hysterectomy and were surgically prepped using 4% CHG compared to 7.5% PI. Premenopausal women who underwent laparoscopic hysterectomy for benign conditions and were prepped with either CHG or PI per surgeon’s choice were enrolled. Vaginal swabs and cervicovaginal lavages were collected prior to vaginal preparation and at 4–6 week post-operative visits for microbiome (α and β diversity, bacterial relative abundances, vaginal pH) and immune marker analyses (protein profiles and concentrations). Antimicrobial activity of clinical CHG and PI formulations were tested in vitro using minimal inhibitory and bactericidal concentration assays. Between February 2021 and June 2022, 41 patients were enrolled. Seven patients either withdrew consent or met exclusion criteria for vaginal bleeding. Thirty-four patients had pre-operative samples collected; 13 patients were lost to follow-up. A total of 21 patients with longitudinal samples of pre- and post-operative collection contributed to this study: 13 in the CHG group and 8 in the PI group. Prior to surgery, 75–77% of women in both groups exhibited Lactobacillus dominance. PI did not change overall vaginal microbiome profiles; however, CHG impacted Lactobacillus iners-dominant profiles, shifting to other lactobacilli (50%) or dysbiotic anaerobes (33%). Lactobacillus crispatus-dominant profiles, which are optimal for vaginal health, were not impacted by either antiseptic solution. In vitro assays further confirmed higher susceptibility of L. iners to CHG solution compared to other vaginal lactobacilli species. Pro-inflammatory cytokines or chemokines were not increased in the CHG or PI group. Our study suggests that CHG does not increase the rate of post-operative vaginal dysbiosis, or genital inflammation compared to PI. Species-specific effects of CHG on vaginal lactobacilli and its clinical impact require further investigation.

Apical support after laparoscopic hysterectomy for benign conditions: a randomized controlled trial comparing vaginal cuff closure techniques

Apical support after laparoscopic hysterectomy for benign conditions: a randomized controlled trial comparing vaginal cuff closure techniques

Personalising the risk of conversion from laparoscopic to open hysterectomy in benign conditions: Development and external validation of risk prediction models.

To develop and validate novel prediction models to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions. Retrospective cohort study. English NHS Hospitals between 2011 and 2018. 68752 women undergoing laparoscopic hysterectomy for benign conditions. We developed two multivariable logistic models using readily available clinical information, one for the pre-operative setting and another for operative decision-making using additional surgical information, using 2011-2016 data in five regions (24806 women). We validated them (a) temporally in the same regions using 2017-2018 data (12438 women); (b) geographically in the same time-period using data from three different regions (22024 women); and (c) temporally and geographically using 2017-2018 data in three different regions (9484 women). Conversion from laparoscopic to open hysterectomy. Conversions occurred in 6.8% (1687/24806) of hysterectomies in the development group, and in 5.5% (681/12438) in the temporal, 5.9% (1297/22204) in the geographical and 5.2% (488/9484) in the temporal and geographical validation groups. In the development cohort, the area under the receiver operating characteristic curve values for the pre-operative and operative models were 0.65 and 0.67, respectively. In the validation cohorts the corresponding values were 0.65 and 0.66 (temporal), 0.66 and 0.68 (geographical) and 0.65 and 0.68 (temporal and geographical), respectively. Factors predictive of conversion included age, Asian ethnicity, obesity, fibroids, adenomyosis, endometriosis and adhesions. Adhesions were the most predictive (odds ratio 2.54, 95% confidence interval 2.22-2.90). The models for predicting conversions showed acceptable performance and transferability. Novel tool to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions.

Effect of length of surgery on the incidence of venous thromboembolism after benign hysterectomy

Venous thromboembolism is a leading cause of morbidity and mortality postoperatively. The current venous thromboembolism risk assessment tools have not been validated in gynecologic patients. Most patients undergoing hysterectomy for benign indications will receive mechanical or pharmacologic prophylaxis based on preoperative risk assessment. However, current guidelines do not incorporate newer data that indicate additional risk of venous thromboembolism with prolonged surgery times or mode of hysterectomy. This study aimed to determine the effect of length of surgery, or operative time, on the risk of venous thromboembolism within 30 days after hysterectomy and determine whether differences in the effect of operative time exist across age, body mass index, and surgical approach. We performed a secondary analysis of prospectively collected surgical quality improvement data using the American College of Surgeons National Surgical Quality Improvement Program database, which contains demographic and perioperative information and 30-day postoperative outcomes from >500 hospitals, and targeted data files including procedure-specific risk factors and outcomes for a subset of hospitals. We analyzed patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign conditions from 2014 to 2017, identified by the Current Procedural Terminology codes. We excluded patients with cancer, patients whose surgery was not performed by a gynecologist, patients who were not in the targeted files, and patients with missing operative time or with an operative time of <30 minutes. Patients were compared with respect to the incidence of venous thromboembolism and operative time, stratified by age, body mass index, and surgical approach. Multivariable logistic regression was performed; operative time was treated as a continuous, linear variable. A total of 70,606 patients were included. The 30-day venous thromboembolism incidence was 0.4% (n=259). Patients with venous thromboembolism were more likely to be obese, have inpatient procedures, and had, on average, greater uterine weight. Hysterectomy approach was vaginal in 11,641 patients, laparoscopic in 41,557 patients, and abdominal in 17,408 patients. After adjustment, for each 60-minute increase in operative time, there was a 35% increase in the odds of venous thromboembolism (adjusted odds ratio, 1.35; 95% confidence interval, 1.25-1.45). Stratified by surgical approach, the odds of venous thromboembolism per 60-minute increase in operative time was greatest among abdominal hysterectomy (adjusted odds ratio, 1.49; 95% confidence interval, 1.35-1.65) compared with laparoscopic hysterectomy (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.38) and vaginal hysterectomy (adjusted odds ratio, 1.27; 95% confidence interval, 0.97-1.66) (P=.01). Increasing body mass index and increasing age did not modify the impact of operative time on venous thromboembolism incidence (P=.66 and P=.58, respectively). Every 60-minute increase in operative time was independently associated with a 35% increased odds of venous thromboembolism within 30 days of hysterectomy, and this risk was cumulative. Minimally invasive hysterectomy had lower odds of venous thromboembolism than abdominal hysterectomy across all time points.

Risk of complication at the time of laparoscopic hysterectomy: a prediction model built from the National Surgical Quality Improvement Program database

Although laparoscopic hysterectomy is well established as a favorable mode of hysterectomy owing to decreased perioperative complications, there is still room for improvement in quality of care. Previous studies have described laparoscopic hysterectomy risk, but there is currently no tool for predicting risk of complication at the time of laparoscopic hysterectomy. This study aimed to create a prediction model for complications at the time of laparoscopic hysterectomy for benign conditions. This is a retrospective cohort study that included patients who underwent laparoscopic hysterectomy for benign indications between 2014 and 2017 in US hospitals contributing to the American College of Surgeons - National Surgical Quality Improvement Program database. Data about patient baseline characteristics, perioperative complications (intraoperative complications, readmission, reoperation, need for transfusion, operative time greater than 4 hours, or postoperative medical complication), and uterine weight at the time of pathologic examination were collected retrospectively. Postoperative uterine weight was used as a proxy for preoperative uterine weight estimate. The sample was randomly divided into 2 patient populations, one for deriving the model and the other to validate the model. A total of 33,123 women met the inclusion criteria. The rate of composite complication was 14.1%. Complication rates were similar in the derivation and validation cohorts (14.1% [2306 of 14,051] vs 13.9% [2289 of 14,107], P=.7207). The logistic regression risk prediction tool for hysterectomy complication identified 7 variables predictive of complication: history of laparotomy (21% increased odds of complication), age (2% increased odds of complication per year of life), body mass index (0.2% increased odds of complication per each unit increase in body mass index), parity (7% increased odds of complication per delivery), race (when compared with white women, black women had 34% increased odds and women of other races had 18% increased odds of complication), and American Society of Anesthesiologists score (when compared with American Society of Anesthesiologists 1, American Society of Anesthesiologists 2 had 31% increased odds, American Society of Anesthesiologists 3 had 62% increased odds, and American Society of Anesthesiologists 4 had 172% increased odds of complication). Predicted preoperative uterine weight also had a statistically significant nonlinear relationship with odds of complication. The c-statistics for the derivation and validation cohorts were 0.62 and 0.62, respectively. The model is well calibrated for women at all levels of risk. The laparoscopic hysterectomy complication predictor model is a tool for predicting complications in patients planning to undergo hysterectomy.

Factors that Lengthen Patient Hospitalizations Following Laparoscopic Hysterectomy.

Objective:To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol.Methods:A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015.Results:Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization.Conclusion:Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.

2180 Experience of Centro Medico Nacional “20 De Noviembre“ in Robotic-assisted Hysterectomy for Large Uteri: A Case Series of 20 Women

Study Objective To determine the outcomes of robotic-assisted laparoscopic hysterectomy for benign conditions in women with large uteri. Design A prospective and recruting cases for robotic-assisted laparoscopic hysterectomy for benign indications at Centro Medico Nacional “20 de Noviembre” by one surgeon with trainning in minimally invasive and Robotic surgery between May 2016 to August 2018. Setting Centro Medico Nacional “20 de Noviembre” ISSSTE. Patients or Participants Only women with large uteri (defined as greater than 750g) were included in this study. Interventions Robotic hysterectomy. Measurements and Main Results A total of 20 women were included in the analysis: 11 patients had uterine weights 750-999g and 9 had uterine weights greater than 1000g with the largest being 1,450g. The average surgical times were 131 min (53-301 min) and 156 min (82-338 min), respectively. The average estimated blood loss was 50cc; no blood transfusions were required. There were no intra- operative conversions. There were none major intraoperative complications. There were 2 minor postoperative complications (acute urinary retention and a wound dehiscence of an umbilical port site); both were in the 750-999g group. All patients in both groups were hospitalized 0-1 days. Conclusion In skilled hands, robotic-assisted laparoscopic hysterectomy in women with large uteri is an acceptable option, associated with minimal complications.

Perioperative Duloxetine for Pain Management After Laparoscopic Hysterectomy: A Randomized Placebo-Controlled Trial

To evaluate the effect of perioperative duloxetine on pain management in patients recovering from laparoscopic hysterectomy. A randomized placebo-controlled trial. A university hospital. Of 100 patients enrolled, 80 were randomized 1:1 to receive perioperative duloxetine (n = 40) or placebo (n = 40). Patients undergoing laparoscopic hysterectomy for benign conditions from November 2017 through March 2018 received 2 doses of 60 mg duloxetine or placebo 2 hours before and 24 hours after surgery. The Quality of Recovery (QoR)-40 questionnaire was completed by participants after discharge. Study and control groups were compared in terms of questionnaire scores, opioid analgesic use, and hospital length of stay. The baseline characteristics of the groups were comparable; median total QoR-40 scores were 111 of 200 and 112 of 200 for duloxetine and the placebo group, respectively; the difference did not reach statistical significance (p = .91). Although the physical independence subcomponent of the recovery questionnaire was improved in favor of duloxetine, none of the subcomponents reached statistical difference between groups. The groups did not differ in terms of postoperative narcotic analgesic use and hospital length of stay (p >.05). Perioperative duloxetine did not reduce pain, need for narcotic analgesia, or hospital length of stay following laparoscopic hysterectomy.

Long term COST-minimization analysis of robot-assisted hysterectomy versus conventional laparoscopic hysterectomy

BackgroundThe aim of this study is to carry out the economic evaluation, in term of a cost-minimization analysis that considers healthcare costs and indirect costs, of robot-assisted hysterectomy (RAH) compared with conventional laparoscopic hysterectomy (CLH) in female adults scheduled for total laparoscopic hysterectomy for benign conditions.MethodsCost-minimization analysis based on an analytic observational study of prospective cohorts with a five-year time horizon. Eligible participants were all female adults scheduled for total laparoscopic hysterectomy for benign conditions at tertiary hospital. The economic evaluation was conducted from a Spanish National Health Service and societal perspective, including healthcare costs and indirect costs. The costs are expressed in Euros from the year 2015.ResultsOne hundred sixty nine patients were analyzed, 68 in the RAH group and 101 in the CLH group. Average cost for the RAH group was €8982.42 compared to €8015.14 for the CLH group (incremental cost €967.27; p = 0.054). Healthcare cost is the most important component of total cost and represents 86.4% for the RAH group and 82.3% for the CLH group. The difference of €1169 (p = 0.01) in the average healthcare cost is mainly due to the cost of purchasing and maintaining the equipment (difference of €1206.39 in favor of RAH; p < 0.005). With regard to indirect costs, for patients in the RAH group the costs associated with loss of productivity were lower (difference of €203.42; p = 0.17), while the cost of trips to the hospital was higher (difference of €1.98; p = 0.66) in respect to CLH.ConclusionsOur findings reveal similar effectiveness between RAH and CLH, although CLH is the more efficient option from the point of view of an economic analysis based on cost-minimization.

Incidence and association factors for the development of chronic post-hysterectomy pain at 4- and 6-month follow-up: a prospective cohort study.

Chronic pain has major adverse effects on health-related quality of life and contributes to significant socioeconomic burden. Hysterectomy is a very common gynecological surgery, resulting in chronic post-hysterectomy pain (CPHP), an important pain syndrome. We conducted a prospective cohort study in 216 Asian women who underwent abdominal or laparoscopic hysterectomy for benign conditions. Demographic, psychological, and perioperative data were recorded. Postoperative 4- and 6-month phone surveys were conducted to assess the presence of CPHP and functional impairment. The incidence rates of CPHP at 4 and 6 months were 32% (56/175) and 15.7% (25/159), respectively. Women with CPHP at 4 and 6 months had pain that interfered with their activities of daily living. Independent association factors for CPHP at 4 months were higher mechanical temporal summation score, higher intraoperative morphine consumption, higher pain score in the recovery room, higher pain score during coughing and itching at 24 hours postoperatively, and preoperative pain in the lower abdominal region. Independent association factors for CPHP at 6 months were preoperative pain during sexual intercourse, higher mechanical temporal summation score, and higher morphine consumption during postoperative 24 and 48 hours. In a majority of cases, CPHP resolved with time, but may have significant impact on activities of daily living.

Study of efficacy and safety of bipolar coagulation in total laparoscopic hysterectomy

Aim: To study the efficacy and safety of bipolar coagulation in total laparoscopic hysterectomy. Methods: A single surgeon, single center, retrospective study of one year was conducted in Akola Endoscopy center from 1 May 2010 to 30th April,2011. 200 patients who underwent total laparoscopic hysterectomy for benign conditions were enrolled. Data about the surgical time, estimated blood loss, related complications and length of hospital stay were evaluated. Results: The patients who underwent TLH with bipolar coagulation in the present study, it was found that the mean operating time was 52.83+-12.28 min, mean blood loss was 40.50+-28.02 ml, post-operatively febrile morbidity was found to be in 1.5% of patients and secondary hemorrhage in 2.5% with average hospital stay around 9-10 hours. No patient required blood transfusion or re-laparotomy. There were no intra-operative or anesthetic complications and no case of hernia or mortality. Conclusion: bipolar coagulation for hemostasis used in laparoscopic hysterectomy is safe and effective.

Does prophylactic bilateral salpingectomy during pelviscopic hysterectomy increase perioperative morbidity?.

The study was conducted in the Ortenau Klinikum Offenburg (Baden-Wirttemberg, Germany). Classical laparoscopic hysterectomies were performed between 2010 and 2011 and a prophylactic salpingectomy was added thereafter. The authors analysed the postoperative complications until 2013 according to the Clavien-Dindo scale in performing a logistic regression model adjusted on potential confounders. They also analysed other surgery outcomes such as operative time, duration of the hospital stay, and the blood loss during the surgery. Over 301 patients were retrieved from the records. Postoperative complication rates were not different between the two groups (13.8% versus 14.2 % patients, OR = 0.93 [0.47 - 1.84], p = 0.84). Other outcomes were also not different. Prophylactic salpingectomy performed during a laparoscopic hysterectomy for benign conditions seems to be' safe and recommended. Prospective studies especially with respect to the magnitude of the prophylactic effect are needed.

Abstract PR288

Background & Objectives: Chronic pain has major adverse effects on health-related quality of life and contributes to significant socioeconomic burden [1]. Chronic pain occurs up to 32% after hysterectomy surgery [2]. We aim to investigate the risk factors to reduce chronicity of pain. Materials & Methods: We performed prospective cohort study involving in Asian women who underwent abdominal or laparoscopic hysterectomy for benign conditions. Demographic, psychological and perioperative data were recorded. 4-month, 6-month and 12-month post-operative phone survey were conducted to assess presence of chronic post-hysterectomy pain (CPHP) and functional impairment. Potential univariate risk factors were considered using multivariate logistic regression model to assess for independent risk factors. Results: The incidence of CPHP at 4-month, 6-month and 12-month follow up were 33.9% (55/162), 17.1% (24/140) and 1.7% (2/115) respectively. Women with CPHP 4-month and 6-month had pain that interfered with their sleep and affected activities of daily living. The independent risk factors for CPHP 4-month on multivariate logistic regression were higher mechanical temporal summation score (OR1.07, p=0.0002), higher pain catastrophizing scores (0.0116) especially rumination and helplessness scores preoperatively, higher pain score at recovery room (OR1.51, p=0.0039) and when coughing 24-hours postoperatively (OR1.16, p=0.083). The independent risk factor for CPHP 6-month on multivariate logistic regression were higher mechanical temporal summation score (OR1.13, p=0.0003), higher pain catastrophizing scores (0.0179) especially rumination and helplessness scores preoperatively and higher pain score at recovery room (p=0.015). Conclusion: We concluded that majority of CPHP cases recovered with time but CPHP do have significant impact on activities of daily living. Independent risk factors for CPHP may include higher mechanical temporal summation scores and pain catastrophizing scores preoperatively and increased pain score in immediate postoperative period.

Cost Savings of Using Laparoscope for Cystoscopy Following Hysterectomy

Cost Savings of Using Laparoscope for Cystoscopy Following Hysterectomy

Incidence, risk factors and outcome of infection in a 1-year hysterectomy cohort: a prospective follow-up study

A prospective study was performed following 687 patients who underwent abdominal, vaginal and laparoscopic hysterectomy for benign conditions in Turku University Hospital. This study evaluates and compares infection after hysterectomy and determines risk factors associated with postoperative infection. Infective episodes were recorded during hospital stay, convalescence for 4 to 6 weeks at home and for 1 year of follow-up. Factors found to be statistically significant for hospital-acquired infection on univariate analysis were subsequently assessed by means of multivariate analysis. During the hospital stay 23.7% of the study population became infected, 38.1% after vaginal hysterectomy, 23.4% after abdominal hysterectomy and 3.0% after laparoscopic hysterectomy. Over half of all hospital-acquired infections were lower urinary tract infections. Infection during convalescence occurred in 19.2% of patients: 29.5% in the vaginal hysterectomy group, 17.4% in the abdominal hysterectomy group and 16.7% in the laparoscopic hysterectomy group. One year of follow-up did not find any infection directly attributable to surgery. Five factors were found to be related to in-hospital infection on multivariate analysis. These were lack of antibiotic prophylaxis, blood loss during operation, intermittent catheterization, anaemia and medication for urinary or bowel dysfunction after operation.