Laparoscopic Supracervical Hysterectomy Research Articles

Laparoscopic Hysterectomy Route, Resource Use, and Outcomes: Change After Power Morcellation Warning.

To examine changes in utilization of different types of laparoscopic hysterectomy, as well as their associated resource use and surgical outcomes, after the U.S. Food and Drug Administration (FDA) safety statement in April 2014 regarding power morcellation. We retrospectively analyzed data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement Program and identified 145,746 women undergoing hysterectomy for benign indications. We measured use of laparoscopic supracervical hysterectomy compared to total laparoscopic hysterectomy (including laparoscopic-assisted vaginal hysterectomy) in these patients, as well as operative time, surgical setting (inpatient vs outpatient), length of stay, and 30-day surgical outcomes (wound complication, medical complication, reoperation, and readmission). We used an interrupted time series analysis to examine the association between FDA warning and changes in utilization and outcomes of laparoscopic hysterectomy. After adjusting for patient characteristics and background trends in practice, use of laparoscopic supracervical hysterectomy was significantly lower in the postwarning than prewarning period (odds ratio [OR]=0.49, 95% CI 0.45-0.53), whereas use of total laparoscopic hysterectomy was not affected (OR 1.01, 95% CI 0.96-1.06). Overall, after an initial reduction, use of laparoscopic hysterectomy (laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy combined) increased over time in the postwarning period (adjusted OR of utilization for each calendar quarter elapsed=1.03, 95% CI 1.02-1.03). After the FDA warning, operative time for laparoscopic supracervical hysterectomy increased by 11.45 minutes (95% CI 6.22-16.69), whereas the decreasing trend in the likelihood of inpatient stay for total laparoscopic hysterectomy was attenuated (OR for each calendar quarter elapsed=0.92 in prewarning period, 95% CI 0.91-0.93; and 0.97 in postwarning period, 95% CI 0.97-0.98). There was no significant change in 30-day surgical outcomes after the FDA warning. Rates of laparoscopic supracervical hysterectomy fell in association with power morcellation safety warnings, whereas rates of other laparoscopic hysterectomies continued to rise. There was no change in patient outcomes among laparoscopic hysterectomies.

Dual Compartment Surgery for Pulmonary Endometriosis

A 46-year-old black woman with a history of endometriosis presented with right-sided sciatica, right shoulder pain, and persistent cough. She had a history of severe endometriosis and myomas with previous laparoscopic supracervical hysterectomy and bilateral salpingectomy performed at an outside facility 1 year earlier. Three weeks before presentation, she had a spontaneous right pneumothorax, which was managed with a tube thoracostomy. Transvaginal ultrasound showed bilateral endometriomas, and a repeat computed tomographic scan indicated a recurrent right apical pneumothorax.

A multipurpose uterine/vaginal manipulator for laparoscopic urogynecologic procedures.

The use of an appropriate uterine manipulator is key to various laparoscopic gynecologic procedures. Adequate uterine manipulation is important for total or supracervical laparoscopic hysterectomies, laparoscopic sacrocolpopexy as well as laparoscopic repair of vaginal vault prolapse. While several uterine manipulators are available to choose from, their use may be specific to certain procedures and their cost may vary as well. This video aims to provide an introduction to a multipurpose, reusable uterine/vaginal manipulator that can be used for laparoscopic supracervical hysterectomy, laparoscopic sacrocolpopexy, laparoscopic hysteropexy as well as laparoscopic repair of vaginal vault prolapse. The video highlights the user-friendly, easy-to-clean, reusable, multipurpose uterine/vaginal manipulator. The manipulator is designed for an efficient combination of laparoscopic urogynecologic procedures and supracervical hysterectomy.

A value-based evaluation of minimally invasive hysterectomy approaches

BackgroundWith surgical care contributing to the rising healthcare costs around the globe, quantifying the value of surgical modalities is critical to pushing healthcare systems in the direction of greater sustainability. The purpose of this study was to assess and compare the value of minimally invasive hysterectomy approaches, as defined by operative outcomes and patient satisfaction relative to direct hospital costs.MethodsSequential mixed methods; retrospective chart review of all women (N = 2689) ≥ 18 years old who underwent hysterectomy for benign conditions from 2011 through 2013 at a suburban hospital in Maryland, USA; a mail survey of the same population was administered in June to October 2015. Procedures included laparoscopic supracervical hysterectomy (LSH), robotically assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy (TLH), laparoscopically assisted vaginal hysterectomy (LAVH), total vaginal hysterectomy (TVH), and laparoscopic retroperitoneal hysterectomy (LRH), a procedure that incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin. We estimated the value of each procedure by dividing quality over direct hospital costs, where quality was quantified by creating a summary composite score of the average operating time, estimated blood loss, complication and conversion rates, and patient satisfaction.ResultsThe majority of LRH and RALH procedures were performed by high-volume surgeons, while the majority of LSH and TVH procedures were performed by low-volume surgeons. RALH had the highest postoperative complication rate (11.4%; p < .0001). TVH had the highest intraoperative complication rate (9.6%; p < .0001) but lowest postoperative complication rate (1.8%; p < .0001). LRH had the shortest operating time (71.2 min; p < .0001) and lowest intraoperative complication rates (2.1%; p < .0001). LRH and TVH were the least costly ($4061 and $6416, respectively), while RALH was the most costly ($9354). LRH had the highest combined patient satisfaction score, followed by RALH, while TLH, LAVH, TVH, and LSH averaged similar scores.ConclusionLRH, TVH, and LAVH yielded the highest value scores; LSH, TLH, and RALH yielded the lowest. Healthcare costs continue to escalate, in large part due to innovations in medical technology. For healthcare stakeholders seeking to control costs without sacrificing quality, it is critical to operationalize the value of varying surgical techniques, including measures of surgeon experience, operative outcomes, costs, and patient satisfaction.

68: Surgical site infection after laparoscopic hysterectomy

To compare 30-day risk of deep/organ space and superficial incisional surgical site infections (SSI) by sub-type of laparoscopic hysterectomy. To report on additional risk factors for SSI following laparoscopic hysterectomy. Using the American College of Surgeons National Surgical Quality Improvement Program’s Database, we identified women undergoing laparoscopic hysterectomy between 2012-2014 using CPT codes. Women were stratified into 3 groups by type of hysterectomy: total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and laparoscopic supracervical hysterectomy (LSCH). Group comparisons were made using ANOVA and X2 test. Univariate analysis was performed using Student’s t-test, X2 test or Fisher’s exact test. Significant variables on univariate analysis were included in a stepwise backward multivariable logistic regression to identify independent risk factors for SSI. A total of 52,786 women were included. Mean (±SD) age and BMI were 49 ± 12years and 31 ± 8kg/m2; 74% were white. There were 31,070 (59%) hysterectomies classified as TLH, 14,796 (28%) were LAVH, and 6,920 (13%) were LSCH. Mean operative times were shortest for LAVH, and longest for LSCH (130 ± 63 mins and 154 ± 79 mins, respectively; p < 0.001). The 30-day deep/organ space SSI was lower for LSCH (0.6%) than for TLH (1.0%) or LAVH (1.1%) (p = 0.001), but there was no difference in occurrence of superficial incisional SSI: 0.8%, 0.8%, and 0.8% for TLH, LAVH, and LSCH, respectively (p=0.54). On univariate analysis, type of hysterectomy, increasing age, race, smoking, diabetes, preoperative steroid use, dialysis, gynecologic malignancy, ASA class, operative time, peri-operative transfusion, hospital length of stay and wound classification were associated with deep/organ space SSI. On multivariate analysis after controlling for confounders, LSCH remained independently associated with a decreased risk of deep/organ space SSI (aOR 0.59, 0.42-0.83). Conversely, relative to women who were discharged within 24hrs, women admitted for greater than 1 day had a 2-fold increase in deep/organ space SSI (aOR 2.13 (1.56-2.91). Asian race (aOR 1.89, 1.28-2.77), smoking (aOR, 1.45, 1.18-1.79), gynecologic malignancy (aOR, 1.42, 1.05-1.91), perioperative transfusion (aOR 1.94, 1.26-2.99), preoperative steroid use (aOR 1.83, 1.08-3.10), dirty/infected cases (aOR 26.04, 7.31-92.73), and preoperative dialysis (aOR 4.11, 1.20-14.06), were independently associated with increased odds for deep/organ space SSI. Smoking (aOR 1.29, 1.02-1.65) and length of stay greater than 1 day (aOR 1.62, 1.16-2.25) increased the risk of superficial incisional SSI. Laparoscopic supracervical hysterectomy is associated with a decreased risk of deep/organ space SSI compared to other sub-types of laparoscopic hysterectomy. Same-day discharge is protective against SSI.

47: Power morcellation in laparoscopic sacrocervicopexy with supracervical hysterectomy: a retrospective review of uterine pathology

To review uterine pathology of patients undergoing laparoscopic supracervical hysterectomy with electromechanical (power) uterine morcellation and sacrocervicopexy for uterovaginal prolapse. This retrospective cohort study used the electronic medical record to review the cases of 182 patients undergoing laparoscopic supracervical hysterectomy with uterine power morcellation and sacrocervicopexy performed by a single high-volume gynecologic surgeon at our institution between January 1, 2012 and December 31, 2017. Uterovaginal prolapse was the primary indication for surgery for all patients included. The electronic medical record was reviewed to determine demographic and operative variables, pathology reports, and any post-operative complications. Of the 182 patients undergoing this procedure, the mean age was 63.4 years (standard deviation: 9.73). 5.0% had a post-operative complication (3 with incisional cellulitis, 3 with trocar incision site herniation, 1 with urinary retention requiring an emergency department visit, 1 with severe constipation requiring disimpaction, and 1 with perforation of the cecum from a concurrent rectopexy performed by colorectal surgery requiring re-operation). No patient had a complication directly related to uterine power morcellation or uterine pathology. The median uterine mass was 55.5 grams (interquartile range: 38.8 - 81.0). 49.9% of patients had leiomyomas noted in the pathology report, 40.7% had adenomyosis, 11.5% had uterine polyps, and 4.4% had endometrial hyperplasia (4 with simple hyperplasia without atypia, 1 with simple hyperplasia with focal atypia, 1 with complex hyperplasia without atypia, and 1 with complex hyperplasia with focal atypia). None of the patients with endometrial hyperplasia had reported abnormal uterine or postmenopausal bleeding and as such had not had endometrial sampling prior to surgery. 100% of patients had at least one follow up visit with the surgeon. While there has been extensive examination of the use of uterine power morcellation in benign minimally invasive hysterectomy, there is minimal data specifically focusing on its use for patients whose primary indication for hysterectomy is uterovaginal prolapse. While our sample is limited to a single institution, our data suggests that malignant pathology may be even rarer than that found in hysterectomy for other benign indications. These variations should be considered when making decisions about the use of uterine power morcellation.

Feasibility of myomatous tissue extraction in laparoscopic surgery by contained in – bag morcellation: A retrospective single arm study

PurposeTo evaluate the feasibility of using contained endobags (Morsafe®) in the retrieval of the specimen during laparoscopic surgeries in presumably benign myomatous pathology. Material and methodsWe conducted a retrospective single center case – control study on 239 patients, between 01.05.2014 and 31.12.2017 for uterine myomata, presumed to be benign. The analyzed parameters were the method for contained specimen retrieval, the time of bag manipulation, practicability of action and the perioperative complications rate. The present work has been reported in accordance with the STROCSS criteria and guidelines [1]. Resultsthe main laparoscopic interventions were myomectomy (n = 148 cases) and LASH (laparoscopic supracervical hysterectomy) (n = 68 cases), LASH with bilateral salpingectomy (n = 7), LASH and bilateral adnexectomy (n = 3), LTH (laparoscopic total hysterectomy) (n = 3), LTH and bilateral adnexectomy (n = 1), radical LTH with lymphonodectomy (n = 2), LTH with bilateral salpingectomy (n = 1) and adenomyomectomy (n = 6).In 3 cases using contained closed bags, there was an evidence of malignancy in the pathological sections: leiomyosarcoma (n = 1) and endometrial carcinoma (n = 2).There were no adverse events and no intra – or postoperative bag – induced complications. Regarding the intraoperative duration, the time of bag introduction was about 7 min, and morcellation approximately 12 min. Conclusionin – bag morcellation through endobag (Morsafe®) proved to be a safe laparoscopic method in retrieval of myomatous tissue, potentially reducing the risk of dissemination and thereby improving the patients' safety avoiding spreading of benign disease and malignancy, but preserving the benefits of minimally invasive surgery. The advantages concerned not only the operating time and costs, but also the safety aspects in case of malignancy. As the system can help to reduce risk of cell dissemination it could also reduce the risk in case of occult malignancy.

Value-based assessment of hysterectomy approaches.

AimBy evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin.MethodsRetrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high‐volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic‐assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic‐assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH.ResultsTotal vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic‐assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest.ConclusionUnderstanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality‐cost framework, the LRH approach as performed by high‐volume laparoscopic specialists emerged as having the highest calculated value.

The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy

ObjectivesDetermining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management. MethodsPatients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed. ResultsTotal lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff. ConclusionLaparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.

Occult uterine malignancy during laparoscopic supracervical hysterectomy.

To estimate the incidence of occult uterine malignancies during laparoscopic supracervical hysterectomy (LSH). Retrospective cohort study based on archival data (2010-2016) of the Department of Gynecology and Oncology, Jagiellonian University. Medical records of 696 women, who underwent LSH were analyzed. Two occult sarcomas (2/696; 0.29%, 0.003, 95% CI: 0.001 to 0.01), including one case of low-grade endometrial stromal sarcoma (ESS) with co-occurring atypical endometrial hyperplasia (AH) and one case of high-grade ESS were found postoperatively. One case of invasive primary fallopian tube cancer (1/696; 0.14%, 0.001, 95% CI: 0.00 to 0.008) and additional three cases of AH (3/696; 0.57%, 0.004, 95% CI: 0.001 to 0.013) were also identified. No case of EC was documented. One hundred sixty nine (24.3%) women of 696 had an endometrial sampling prior LSH including these with ESS. We did not observe worsening of the prognosis and all patients with confirmed malignancy are still alive and free from recurrence in 2-5 years of observations. Most commonly the occult malignancy would have not been recognized if the surgery had not been conducted. When appropriate diagnostics is conducted, rare incidents of malignant tissue morcellation should not be considered as a professional misconduct but as a possible adverse event. Patients should be informed about the risk of malignancy according to available estimations and that endometrial sampling cannot eliminate such a risk. A consensus regarding safe indications, required diagnostics, and justifiability of mandatory use of contained morcellation for LSH should be developed.

Mesh Exposure After Robot-Assisted Laparoscopic Pelvic Floor Surgery: A Prospective Cohort Study

To prospectively evaluate the mesh exposure rate after robot-assisted laparoscopic pelvic floor surgery for the treatment of female pelvic organ prolapse (POP) in a large cohort. Prospective observational cohort study (Canadian Task Force classification II-2). Two large teaching hospitals with a tertiary referral function for pelvic floor disorders. Patients with symptomatic POP and simplified POP quantification (S-POP) stage ≥2. Patients with a history of mesh repair or concomitant insertion of a tension-free vaginal tape were excluded. Robot-assisted laparoscopic sacrocolpopexy or robot-assisted laparoscopic supracervical hysterectomy with a sacrocervicopexy. A blinded vaginal examination with the aid of a transparent speculum was performed to look for mesh-related complications. Mesh exposures were described following the International Urogynecological Association/International Continence Society classification system. One hundred and ninety-two patients were included, of whom 166 (86.5%) were seen for follow-up examination. The median duration of follow-up was 15.7 months (range, 8.2-44.4 months). Two vaginal mesh exposures (1.2%) were detected, both of which were treated in the outpatient clinic. One patient without any complaints had a suture exposure, which was removed in the outpatient clinic. The safety of the use of mesh in pelvic floor surgery is a matter of debate owing to the occurrence of mesh-related complications. Based on the current literature, mesh-related complications seem to be lower in transabdominal mesh surgery than in transvaginal mesh surgery. In this study, a low mesh exposure rate was observed in robot-assisted abdominal pelvic floor surgery for POP.

Malignant transformation of uterine leiomyoma to myxoid leiomyosarcoma after morcellation associated with ALK rearrangement and loss of 14q

A 50 year old woman underwent laparoscopic supracervical hysterectomy because of symptomatic fibroids. Histologic examination of samples obtained after morcellation revealed typical uterine leiomyomas in all samples investigated. 28 and 47 months later, respectively, the patient presented with peritoneal spreading of nodules that were surgically removed and histologically classified as leiomyosarcoma. In 3/4 of samples obtained after morcellation copy number/SNP-array hybridization showed complex genomic alterations widely identical to the pattern characterizing the sarcoma. Therefore, we conclude that the leiomyosarcoma had unambiguously developed from one of the leiomyomas as a result of secondary genetic alterations i.e. a rearrangement of ALK and a del(14q). The case is challenging the current risk estimates for spreading of unexpected malignant uterine tumors due to power morcellation and highlights the relevance of certain genetic alterations for rare malignant transformation of uterine benign smooth muscle tumors.

Non-malignant Sequelae after Unconfined Power Morcellation

To identify the incidence of repeat surgery and subsequent findings after the performance of unconfined uterine power morcellation. A retrospective descriptive study (Canadian Task Force classification II-2). Southern California Kaiser Permanente Medical Centers. Women (N = 5154) who underwent laparoscopic supracervical hysterectomy with unconfined power morcellation. Of the 5154 cases, 279 (5.41%) underwent subsequent reoperation with a median of 24 months after index surgery. The most common clinical complaint leading to laparoscopic supracervical hysterectomy was symptomatic leiomyoma (n = 135, 48.4%) and abnormal uterine bleeding (n = 94, 33.7%). The most common indication for reoperation was a symptomatic adnexal mass (n = 87, 31.2%) followed by pelvic pain (n = 83, 29.7%). The majority (n = 128, 60.4%) of subsequent non-urogynecologic-related reoperations resulted in benign pathology. Endometriosis was the primary pathologic diagnosis in 65 of 279 (23.3%) of the reoperative cases; this was not previously documented in 86% (n = 57/65) of these cases. The overall frequency of subsequent pathology was endometriosis (65/5154, 1.26%), disseminated leiomyomatosis (18/5154, 0.35%), and new malignancy (11/5154, 0.21%). Morcellation of nonmalignant tissue is not without consequence. Pathology confirmed endometriosis was documented for the first time in 20.4% of patients who underwent a second surgery. This finding raises the suspicion that morcellation and dispersion of the uterine specimen may be associated in the development of endometriosis.

Practice Patterns and Complications of Benign Hysterectomy Following the FDA Statement Warning Against the Use of Power Morcellation

In November 2014, the US Food and Drug Administration (FDA) issued a black box warning against the use of power morcellation for excision of uterine fibroids to decrease the risk of disseminating malignant cells and worsening survival outcomes of patients with unexpected malignant neoplasms. After the FDA statement was issued, studies showed decreased rates of minimally invasive surgery and increased rates of open abdominal hysterectomy. However, there are limited and controversial data on the association of these changed rates with 30-day hysterectomy complications. To assess changes in the rates of 30-day major and minor complications of hysterectomy for benign gynecologic indications following the FDA-issued statement. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database and included 603 hospitals participating between January 1, 2013, and December 31, 2015. Thirty-day posthysterectomy complications were compared before and after the FDA-issued warning. Women who underwent hysterectomy for benign gynecologic indications (n = 75 487), including hysterectomies with indication of uterine fibroids (n = 25 571), were included. Complication rates and procedure distributions between the periods were compared with χ2 tests and multivariable logistic regression controlling for patient and operative factors. Major and minor 30-day complication rates before (from 2013 through the first quarter of 2014) and after (from the fourth quarter of 2014 through 2015) the FDA-issued warning. Of 75 487 women (mean [SD] age, 47.8 [10.7] years) who underwent hysterectomy for benign gynecologic indications, 32 186 (42.6%) were treated before and 43 301 (57.4%) after the FDA-issued warning. Non-Hispanic white women comprised most (59.4%) of the total population, followed by African American women (15.1%). Overall, major and minor complications remained stable before and after the FDA-issued warning. By contrast, among a subset of 25 571 women (33.9%) who underwent hysterectomy for uterine fibroids, major complications significantly increased after the FDA-issued warning from 1.9% to 2.4% (adjusted odds ratio [OR], 1.23; 95% CI, 1.04-1.47; P = .02), and minor complications significantly increased from 2.7% to 3.3% (adjusted OR, 1.21; 95% CI, 1.04-1.40; P = .01). In this subgroup, the rate of open abdominal surgery increased from 37.2% to 43.0%, and the rate of minimally invasive surgery (total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, and laparoscopic-assisted vaginal hysterectomy) decreased from 56.1% to 49.7% (P < .001). Major and minor 30-day complication rates among women undergoing hysterectomy for uterine fibroids increased following the FDA-issued statement. This increased risk corresponding with a decreased use of minimally invasive surgery should be balanced against the potential harms of morcellation during a shared decision-making process between clinician and patient. Regulatory bodies and medical societies should consider these findings when issuing relevant communications.

Tubal Ectopic Pregnancy 12 Weeks after Laparoscopic Supracervical Hysterectomy and Tubal Ligation

Introduction: Since 1895, at least 67 ectopic pregnancies have been reported in patients previously subjected to hysterectomy. Most of them were abdominal or vaginal total hysterectomies. Only four cases of ectopic pregnancies in patients who had undergone hysterectomies have been reported after a laparoscopic supracervical hysterectomy (LSH), with three of them having occurred years after surgery. Case Report: A 40-year-old white Caucasian woman was admitted to the emergency room with acute abdominal pain for 20 min, 12 weeks after LSH and tubal ligation. Rapid examination using ultrasounds scan did not show free liquid in the abdomen, and initially, the cause of pain was not identified. However, the patient became unstable and 4 h after symptom presentation, a second ultrasound scan revealed a significant amount of free liquid in the abdomen. Quantification of β-HCG confirmed the suspicion of a ruptured tubal ectopic pregnancy.Conclusions: Ectopic pregnancy is one of the conditions to be considered in differential diagnosis of abdominal pain in women of child-bearing age. To the best of our knowledge, this is the first report of an ectopic pregnancy occurring as early as 3 months after LSH and tubal ligation

15: A prospective randomized, controlled, blinded trial of pre-operative acupuncture in the management of pain in gynecologic surgery

The goal of the study is to evaluate if acupuncture placed for pain control pre-operatively before ambulatory laparoscopic gynecologic surgery after the induction of anesthesia improves post-operative pain and decreases the use of intra-operative and post-operative opioids. This is a blinded, prospective, randomized controlled trial. Patients were recruited by two surgeons at a single institution and were included if they were >18 years of age undergoing ambulatory laparoscopic surgery for benign gynecologic indications. Exclusion criteria included history of substance abuse or chronic pain. Patients were randomized to receive either true or sham acupuncture placed after the induction of anesthesia and prior to the start of surgery. True acupuncture was performed by a trained acupuncturist at sites on the body associated with decreasing pain while the sham was performed by the surgeon at random sites on the hands and feet. Data was collected through chart review and included post-operative pain scores and the amount of intra-operative and post-operative morphine equivalents (MEs) the patient received. Patients were sent home with logs to record the daily number of opioid tablets they took and daily pain scores. The study was powered to demonstrate a 40% decrease in post-operative opioid use. There were 102 patients in the study; 54 patients received true acupuncture and 48 received sham. There were no statistically significant differences between the groups at baseline. Most of the surgeries performed were laparoscopic supracervical hysterectomies with the indication of abnormal uterine bleeding. While all measurements of opioid use and pain scores decreased in the treatment group as compared to the sham, none of these values reached statistical significance. Intraoperatively, the true acupuncture group used 7% less ME than the sham group (p = 0.54) and post-operatively the true acupuncture group used 14% less ME than the sham in the recovery room (p = 0.22). At home, the true acupuncture group used 26% fewer acetaminophen-oxycodone tablets in the first week post-operatively than the sham group (p = 0.19) and used opioids for fewer days than the sham group, 2.7 versus 2.9 days, respectively (p = 0.44). Although the differences between groups did not reach statistical significance, the acupuncture group on average demonstrated better pain control with less intra-operative and post-operative ME usage, lower average pain scores and fewer days at home taking less opioids than the sham group. This study was not powered to show these smaller than expected differences. Further studies will need to be conducted to explore the relationship between acupuncture and pain control with gynecologic surgeries, either with larger study populations or surgeries that traditionally cause more pain such as laparotomies.

HEALTH: laparoscopic supracervical hysterectomy versus second-generation endometrial ablation for the treatment of heavy menstrual bleeding: study protocol for a randomised controlled trial

BackgroundHeavy menstrual bleeding (HMB) is a common problem affecting approximately 1.5 million women in England and Wales with a major impact on their physical, emotional, social and material quality of life. It is the fourth most common reason why women attend gynaecology outpatient clinics and accounts for one-fifth of all gynaecology outpatient referrals. Initial treatment in primary care is medical - either by means of oral or injected medication or the levonorgestrel-intrauterine system (Mirena®). If medical treatment fails then surgical treatment can be offered, either endometrial ablation (EA), which destroys the lining of the cavity of the uterus (endometrium), or hysterectomy, i.e. surgical removal of the uterus.While effective, conventional hysterectomy is invasive and carries a risk of complications due to injury to other pelvic structures. The procedure can be simplified and complications minimised by undertaking a ‘supracervical’ hysterectomy where the cervix is left in situ and only the body of the uterus removed. Recent advances in endoscopic technologies have facilitated increased use of laparoscopic supracervical hysterectomy (LASH) which can be performed as a day-case procedure and is relatively easy for the surgeon to learn.HEALTH (Hysterectomy or Endometrial AbLation Trial for Heavy menstrual bleeding) aims to address the question ‘Is LASH superior to second generation EA for the treatment of HMB in terms of clinical and cost effectiveness?’Methods/DesignWomen aged < 50 years, with HMB, in whom medical treatment has failed and who are eligible for EA will be considered for trial entry. We aim to recruit women from approximately 30 active secondary care centres in the UK NHS who carry out both surgical procedures. All women who consent will complete a diary of pain symptoms from day 1 to day 14 after surgery, postal questionnaires at six weeks and six months after surgery and 15 months post randomisation. Healthcare utilisation questions will also be completed at the six-week, six-month and 15-month time-points.DiscussionMeasuring the comparative effectiveness of LASH vs EA will provide the robust evidence required to determine whether the new technique should be adopted widely in the NHS.Trial registrationInternational Standard Randomised Controlled Trials, ISRCTN49013893. Registered on 28 January 2014.

Rate of Urologic Injury with Robotic Hysterectomy

Study ObjectiveTo evaluate rates of urologic injury in patients who underwent robotic hysterectomy compared with laparoscopic, vaginal, and open hysterectomy. DesignA retrospective analysis (Canadian Task Force classification II-2). SettingHenry Ford Health System, 2013 to 2016. PatientsWomen who underwent robotic, vaginal, laparoscopic, and open abdominal hysterectomy. InterventionsRobotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, vaginal hysterectomy, and abdominal hysterectomy. Measurements and Main ResultsTo identify patients with urologic injury, a departmental database for quality improvement was searched for reported urologic injuries. In addition, patients who had urology consultation within 90 days of hysterectomy were screened for injury. A total of 3114 hysterectomies were identified by retrospective chart review. One thousand eighty-eight robotic, 782 laparoscopic, 304 vaginal, and 940 abdominal hysterectomies were analyzed for urologic complications. A total of 27 injuries were confirmed (7 during laparoscopic hysterectomy, 10 during robotic hysterectomy, 1 during vaginal hysterectomy, and 9 during abdominal hysterectomy). The overall rate of urologic injury was 0.87% with a 0.55% risk of bladder injury and a 0.32% risk of injury to the ureter. When the route of hysterectomy was taken into account, the risk of urologic injury was 0.92% for robotic hysterectomy, 0.90% for laparoscopic hysterectomy, 0.33% for vaginal hysterectomy, and 0.96% for open hysterectomy. The mean body mass index (BMI) for all patients was 32.7 kg/m2; injured patients had a mean BMI of 34.6 kg/m2, and noninjured patients had a mean BMI of 32.0 kg/m2 (p = .10). ConclusionRates of urologic injury with robotic hysterectomy are similar to those of laparoscopic hysterectomy in our population. BMI was not significantly different in patients who had urologic injuries. Surgeon volume was not associated with risk for urologic injury.

Laparoscopic supracervical hysterectomy and sacral colpopexy for pelvic organ prolapse with percutaneous surgical system: Results from a pilot study

ObjectiveThe aim of the study was to report our preliminary experience of supracervical 2 hysterectomy followed by sacral colpopexy performed with the Percuvance ™ PSS in terms of feasibility, effectiveness and safety. Study designBetween Jan 2017 and Feb 2017 10 patients affected by POP were enrolled in the present study. All patients undergoing supracervical hysterectomy followed by sacral colpo-cervicopexy with the Percuvance ™ PSS. ResultsThe reported series consisted of 10 patients undergoing supracervical hysterectomy followed by sacral colpopexy with a median age of 63 years (range 55–71 years) and a median BMI (body mass index) of 24 (range 21–26). A median operative time of 123 min (range 103–134 min) and a median estimated blood loss (EBL) of 40 ml (range 20–60 ml) were registered. No conversions to standard laparoscopy or laparotomy were required and no intraoperative complications occurred. At the discharge all patients were completely satisfied with the cosmetic result and postoperative pain control. During 3 months urogynecological follow-up no patient showed surgical anatomic failure (>2 POP-Q stage)and the degree of overall satisfaction of the cosmetic results was confirmed by the surgeon and the patient equally. ConclusionsThe PSS supracervical hysterectomy plus sacral colpopexy is a feasible and effective approach with good results in terms of operative time, cosmesis, postoperative pain and length of hospitalization.

Evaluation of the Impact of Laparoscopic Supracervical Hysterectomy for the Treatment of Adenomyosis on Pain Intensity and Patient Satisfaction

Objectives. Common symptoms of adenomyosis include pain and bleeding disorders and can severely impact a patient’s quality of life. Few studies report on the impact of hysteroscopy procedures on improving these symptoms. This study evaluates the effect of laparoscopic supracervical hysterectomy (LASH) in adenomyosis patients on pain in general, pain during intercourse, bleeding disorders and general satisfactoriness of the procedure. Methods. This prospective observational single-arm, single-center study included 256 patients treated with LASH and whose histological analysis revealed adenomyosis. Other inclusion criteria were completed family planning and no more symptom relief with conservative therapy. They completed questionnaires before and after the procedure which evaluated pain in general, pain during intercourse, bleeding disorders and general satisfactoriness of the procedure. Results. Our results showed a significant (p < 0.0001) reduction of pain (from 1261 to 428 pain points), dyspareunia (from 763 to 224 pain points) and bleeding dis-orders when compared before and after LASH treatment. Furthermore, we found a high satisfaction rate of 98.4%. Conclusion. As a minimal invasive procedure associated with low major complication rates, LASH is a qualified therapeutic choice to treat pain and bleeding disorders in adenomyosis patients with completed family planning and in where conservative therapy failed.