Laparoscopic Hysterectomy For Benign Pathology Research Articles

VNOTEsHC : Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopic for large uteri: study protocol for a multicentre randomised controlled trial.

In France, 62,000 hysterectomies are performed per year, 70% of which are benign. The choice of approach (laparotomy, laparoscopy or vaginal route) is particularly important in the case of large uterus (> 280g) which are associated with a higher risk of complications. The current data are not sufficient to favour one or other approach. A new medical device, the vNOTES (Natural Vaginal Orifice Transluminal Endoscopy System), offers the advantage of both laparoscopic and vaginal route for pelvic surgery. To demonstrate the superiority in terms of intraoperative and postoperative complications of the use of a natural orifice transluminal endoscopic hysterectomy system (vNOTES) versus laparoscopic hysterectomy for benign pathologies on estimated large volume uteri (>280g). A randomised, double-blind, superiority trial will be performed at five hospital centres. Women with benign uterine pathology requiring hysterectomy and with a large uterus (> 280g) will be randomised to receive either laparoscopic or vNOTES hysterectomy. The primary outcome will be the occurrence of intraoperative and postoperative complications within 6 weeks of surgery. Secondary outcomes will be conversion during surgery, duration of surgery and hospitalisation, postoperative pain, postoperative complications, resumption of sexual life and satisfaction with the surgical team. 248 women will be randomised. This trial will provide a better understanding of the approach to large uteri optimise the care of these thousands of women undergoing hysterectomy. This trial will evaluate the vNotes for large uteri.

Benefits of AirSeal System in Laparoscopic Hysterectomy for Benign Condition: A Randomized Controlled Trial

To compare the AirSeal insufflation system with the standard insufflation system for postoperative abdominal pain after laparoscopic hysterectomy for benign pathology. Randomized controlled trial. Teaching Hospital La Conception, Marseille, France, February 2018 to July 2020. A total of 80 patients scheduled for a laparoscopic hysterectomy for benign pathology (40 per group). Laparoscopic hysterectomy using the AirSeal insufflation system with a pneumoperitoneum between 8 and 10 mm Hg compared with the standard insufflation system with a pneumoperitoneum between 12 and 15 mm Hg. The primary end point was abdominal pain at 6 hours after the end of surgery, assessed by a Simple Numerical Scale from 0 to 10. The secondary end points were intraoperative (operating time and difficulty of the surgery felt by the operator), early postoperative (intensity of abdominal and scapular pain at H0 [end of surgery], H2 [two hours after the end of surgery, H12 [twelve hour after the end of surgery], H24 [twenty four hours after the end of surgery], H48 [fourty eight hours after the end of surgery]), and late postoperative (late postoperative complication, estimated time to return to normal life, and overall patient satisfaction assessed by the SF-12 general health survey). The median values for abdominal pain were not different between the 2 groups at 6 hours (AirSeal group median, 0; interquartile range, 2 vs standard laparoscopy group median, 1; interquartile range, 2; p = .41). The abdominal and scapular pain values were similar in both groups at all postoperative times. There were no differences between the groups regarding secondary end points. Use of the AirSeal insufflation system with low-pressure pneumoperitoneum in laparoscopic hysterectomy for a benign indication did not reduce postoperative abdominal and scapular pain.

The effects of CO2 pneumoperitoneum at different temperature and humidity on hemodynamic and respiratory parameters and postoperative pain in gynecological laparoscopic surgery: A prospective randomized controlled study

BackgroundIt is recommended to heat and humidity CO2 in laparoscopic surgery to prevent postoperative pain and hypothermia but information about its effects on hemodynamic and respiratory parameters is limited. We aimed to investigate the effects of standard and heated-humidified CO2 on hemodynamic and respiratory parameters, body temperature and pain in healthy patients. MethodsOne hundred patients who underwent total laparoscopic hysterectomy for benign pathology were divided into two groups: Group CD (cold-dry) patients were administered standard CO2, while Group HH (heated-humidified) patients were administered 95% humidified insufflation at 37 °C. Hemodynamic and respiratory parameters, body temperature, pain score and blood count parameters were recorded. ResultsA total of 96 patients were included in the study, taken from the 100 patients. Group HH (n:47) had only higher systolic blood pressure at 75, mean blood pressure at 50 and 55 and a lower heart rate between 15 and 45 min (p:0.049, 0.037, 0.013 respectively). Pain score, morphine consumption, end-tidal CO2 and arterial blood gas values were not different between the groups, with only body temperature from 40 min and minimum value being significantly higher (at a difference of 0.86–1.04 °C) in Group HH. Postoperative leukocyte, neutrophil and NLR (neutrophil-leukocyte ratio) were found to be higher in this group (p < 0.05). ConclusionIt has been found that both standard and heated-humidified CO2do not constitute a problem in terms of hemodynamic and respiratory parameters in healthy patients. The heated-humidified CO2group had only a higher core body temperature and inflammatory response. Trial registrationNCT04508387.

Laparoscopic Hysterectomy for Benign Pathology Does Not Yield More Perioperative Complications than Abdominal or Vaginal Hysterectomies: Our Experience in Introducing Laparoscopic Hysterectomy.

Objectives:Total laparoscopic hysterectomy (TLH) is increasing as a substitute for total abdominal hysterectomy (TAH) and total vaginal hysterectomy (TVH) with the growing prevalence of laparoscopic surgery. The aim of this study is to assess perioperative complications of the chosen hysterectomy techniques performed for benign indications when started performing TLH. This was retrospective cohort study. This study was conducted at Nagahama City Hospital.Materials and Methods:There were 176 patients who underwent hysterectomy for benign indications from 2013 to 2016. Perioperative and postoperative outcomes were compared for the three different hysterectomy approaches laparoscopic; abdominal; and vaginal. Data were analyzed using the t-test or Chi-square and Fisher's exact test.Results:TAH, TLH, and TVH were performed on 118 patients (67.0%), 32 (18.2%), and 26 (14.8%), respectively. Operation time was significantly longer for the TLH group than for the TAH and TVH groups. Blood loss was lower for the TVH and TLH groups than for the TAH group. Three days after surgery, C-reactive protein was lower in the TVH group than in the TAH group. The average uterus size in the TAH group was larger than in the TVH and TLH groups. Patients undergoing TLH experienced fewer perioperative complications than patients in the TAH and TVH groups; however, this difference was not statistically significant.Conclusion:TLH for benign pathology does not yield more perioperative complications than TAH or TVH. However, vaginal hysterectomy is the least invasive approach. The final choice for the route of hysterectomy depends on many factors, including body mass index, uterus size, and experience of the gynecologist.

2336 Unidirectional Barbed Versus Polyglactin 910 Suture for Laparoscopic Vaginal Cuff Closure - A Prospective Comparative Study

Study Objective We compared the use of unidirectional barbed sutures and conventional vicryl sutures for vaginal cuff closure during total laparoscopic hysterectomy. The aim of our study is to evaluate whether the use of unidirectional barbed suture (V-Loc) for vaginal cuff closure is associated with a decrease in vault closure time, operative time, blood loss, and other intraoperative and postoperative complications compared to polyglactin 910 (Vicryl) in patients undergoing total laparoscopic hysterectomy for benign pathology. Design Prospective comparative study. Setting The study conducted at the department of Obstetrics & Gynaecology at AIIMS, Rishikesh from July 2018 to December 2018. Patients or Participants A total of 60 women participated in the study; 30-30 in each group. Interventions All 60 women underwent total laparoscopic hysterectomy due to benign pathology of uterus, vault closure was done with unidirectional barbed suture (v-Loc) in 30 women and with polyglactin 910 (vicryl) in another 30 patients. Measurements and Main Results The mean vault closure time was significantly less with barbed suture (8.84 min) than vicryl group (12.27 min). The mean number of stitches taken was more in barbed suture group (7.46) than vicryl group (7.09), though the difference was not statistically significant. No statistically significant differences were found in operative time, or postoperative outcomes, such as vaginal cuff dehiscence, infectious complications, and the presence of granulation tissue. Conclusion The efficacy and safety of unidirectional barbed suture is comparable to the conventional vicryl sutures. Barbed sutures can be safely used to reduce procedure time and surgical difficulty.

Barbed Suture versus Conventional Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy: Randomized Controlled Clinical Trial

Study ObjectiveTo determine the surgical time, suture time, presence of postoperative dyspareunia, and complications that occur after closing the vaginal cuff with a barbed suture compared with conventional suture. DesignA randomized, controlled clinical trial (Canadian Task Force classification I). SettingPrivate gynecologic clinic in Medellin, Colombia. PatientsOne hundred fifty women who underwent total laparoscopic hysterectomy for benign pathology. InterventionsThe patients underwent total laparoscopic hysterectomy with intracorporeal closure of the vaginal cuff and were randomized to 2 groups, 1 using a barbed suture (V-Loc 90; Medtronic/Covidien, New Haven, CT) and 1 using polyglactin 910 (coated Vicryl suture; Ethicon/Johnson & Johnson, New Brunswick, NJ). Measurements and Main ResultsThe total operative time, closing time of the vaginal vault, presence of complications in the cuff, and incidence of postoperative dyspareunia were recorded. The patients were evaluated at a postoperative office visit 2 weeks after the procedure and by telephone interview at 24 weeks. Seventy-five patients were included in the barbed suture group and 75 patients in the polyglactin 910 group. The average time to complete the suture of the vaginal cuff was 12.01 minutes (± 5.37 standard deviation) for the barbed suture group versus 13.49 minutes (± 6.48) in the polyglactin 910 group (95% confidence interval, –.44 to 3.4; p = .130). Blood loss was 31.56 ± 22.93 mL in the barbed suture group versus 30.82 ± 21.75 mL in the polyglactin 910 group (95% confidence interval, –7.95 to 6.47; p = .840). The frequency of postoperative events such as hematoma, cellulitis, cuff dehiscence, fever, emergency consultation, and hospitalization was not statistically significant between groups. No statistically significant difference was found regarding deep dyspareunia at 24 postoperative weeks. ConclusionNo differences were found in surgical time or frequency of adverse events when comparing patients after vaginal cuff closure with barbed suture versus polyglactin 910.

Ureterolysis for Laparoscopic Hysterectomy

To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy. Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III). Benign gynecology department at a university hospital. Performance of ureterolysis during laparoscopic hysterectomy for benign pathology. Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. [1,2]. Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [3]. Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [4]. Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries.

Analysis of postoperative pain in robotic versus traditional laparoscopic hysterectomy.

The aim of this study was to assess postoperative pain and narcotic use in the first 23h following robotic versus traditional laparoscopic hysterectomy for benign pathology. The study design was that of a retrospective case-control study of robotic (first 100 consecutive) versus traditional (last 100 consecutive) total laparoscopic hysterectomy cases at an obstetrics and gynecology multi-institutional community practice. Patient characteristics were equivalent in both groups (age, p=0.364; body mass index, p=0.326; uterine weight, p=0.565), except for a higher number of Caucasians in the traditional laparoscopic group (p=0.017). Compared to patients who underwent robotic laparoscopic hysterectomy, those who underwent the traditional procedure had higher visual analog scale pain scores (3.1±1.5 vs. 4.6±2.4, respectively; p<0.001) and used more narcotics (27.5 vs. 35.4mg hydrocodone, respectively; p<0.05). Factors that could potentially increase pain (more procedures, more ports, total incision size, and longer operative time) were significantly higher in the robotic group, but only surgical approach, amount of narcotic, and age correlated with pain levels when evaluated with regression analysis. Complication rates were equivalent between groups. In conclusion, patients who underwent robotic assisted laparoscopic hysterectomy had statistically decreased postoperative pain scores and narcotic use than those who underwent the traditional laparoscopic approach, even when the robotic cases involved more procedures and ports and were associated with longer operative time.

GnRH Agonist Treatment before Total Laparoscopic Hysterectomy for Large Uteri

Study Objective To evaluate whether uterine shrinkage induced by gonadotropin-releasing hormone (GnRH) agonists in women with a large uterus (>14 wks) may facilitate total laparoscopic hysterectomy. Design Randomized, prospective study (Canadian Task Force classification I). Setting University-affiliated hospital. Patients Sixty-two women with symptomatic uterine myomas (size 16–20 wks). Interventions Total laparoscopic hysterectomy for benign pathology. Measurements and Main Results Before surgery, women were assigned, at a ratio of 1:1 by random selection, to receive injections of triptorelin depot 11.25 mg 3 months before surgery (group A) or no treatment (group B). Uterine volume, mean operating time, uterine weight, drop in hemoglobin, intraoperative complications, conversions to laparotomy, and hospital stay were recorded. Triptorelin decreased uterine volume, calculated by ultrasonography, by 26.5% in group A, whereas the volume remained unchanged in group B. Statistical differences were found between groups concerning uterine weight, operating time, and drop in hemoglobin level. Three patients in group B were converted to laparotomy because of uterine size. Conclusion In women with a large uterus, a 3-month preoperative course of GnRH may facilitate laparoscopic hysterectomy, decreasing uterine size, operating time, and blood loss.

Total Laparoscopic Hysterectomy for Very Enlarged Uteri

Study ObjectiveTo evaluate short-term outcome of total laparoscopic hysterectomy (TLH) performed in women with very enlarged uteri. DesignCase control study (Canadian Task Force classification II-2). SettingHospital gynecologic service. PatientsThirty-four consecutive women with very enlarged uteri. InterventionTotal laparoscopic hysterectomy for benign pathology. Measurements and Main ResultsWomen with uterine enlargement (group 1) were compared with 68 women with uteri weighing 300 g or less (group 2) who underwent TLH during the same period. Matching was based on patient age ± 2 years, surgeon (experienced senior, fellow), whether or not Burch operation was performed, and whether or not adnexectomy was performed. The groups were compared for complication rates, operating time, hospital stay, change in perioperative hemoglobin concentration, and vaginal and laparoscopic uterine morcellation. They did not differ statistically significantly in terms of indications for surgery, parity, postmenopausal status, and preoperative hemoglobin levels. No difference was seen in complication rates between groups. Operating time was significantly shorter (p <0.001) in women with smaller uteri than in those with very enlarged uteri, 108 ± 35 and 156 ± 50 minutes, respectively. The groups did not differ significantly in day 1 hemoglobin level drop, analgesia requirement (oral, intravenous opioid), time to passing gas and stool, or hospital stay. No conversion to laparotomy was required in either group. ConclusionA very enlarged uterus should not be considered a contraindication for TLH. However, it may be necessary to undertake certain surgical steps to ensure optimal exposure of the operative field and more effective and safer excision of the uterine vascular pedicle.