Laparoscopic-assisted Vaginal Hysterectomy Research Articles

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at The Time of Uterosacral Ligament Suspension

Study Objective The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension (USLS). Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program database. Patients or Participants We included all patients who underwent USLS and concurrent vaginal or laparoscopic hysterectomy from 2010 to 2017. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. Interventions We compared 30-day complication rates in patients who underwent vaginal versus laparoscopic hysterectomy at the time of USLS. Measurements and Main Results We compared groups using chi-squared analysis and students t-test for categorical and continuous variables, respectively. Stepwise backward multivariate logistic regression was used to identify independent predictors of experiencing complications. The cohort was comprised of 3,349 patients who underwent vaginal hysterectomy with USLS and 484 who underwent laparoscopic hysterectomy with USLS. Patients who underwent the vaginal approach were older (58.3 vs 50.9 years), more likely to have hypertension, and to undergo concurrent minor urogynecologic procedures such as midurethral sling or colporrhaphy. Patients in the laparoscopic group had higher BMI and were more likely to smoke. Groups were otherwise similar. Patients who underwent the vaginal approach had a significantly higher rate of complications than the laparoscopic group for all complications (11.4% vs 6.4%, OR 1.9, 1.3-2.8, p=0.0005) as well as serious complications-only (5.6% vs 3.1%, OR 1.8, 1.1-3.1, p=0.02). After controlling for confounding variables on multivariate logistic regression, vaginal hysterectomy at the time of USLS remained a significant predictor of all complications (OR 2.0, 1.4-2.9, p=0.001), as well as serious complications (OR 2.1, 1.2-3.7, p=0.009). Conclusion In this large national cohort, after adjusting for known medical and surgical risk factors, vaginal hysterectomy at the time of USLS was associated with a higher complication rate than the laparoscopic route of surgery. The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension (USLS). Retrospective cohort study. American College of Surgeons National Surgical Quality Improvement Program database. We included all patients who underwent USLS and concurrent vaginal or laparoscopic hysterectomy from 2010 to 2017. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. We compared 30-day complication rates in patients who underwent vaginal versus laparoscopic hysterectomy at the time of USLS. We compared groups using chi-squared analysis and students t-test for categorical and continuous variables, respectively. Stepwise backward multivariate logistic regression was used to identify independent predictors of experiencing complications. The cohort was comprised of 3,349 patients who underwent vaginal hysterectomy with USLS and 484 who underwent laparoscopic hysterectomy with USLS. Patients who underwent the vaginal approach were older (58.3 vs 50.9 years), more likely to have hypertension, and to undergo concurrent minor urogynecologic procedures such as midurethral sling or colporrhaphy. Patients in the laparoscopic group had higher BMI and were more likely to smoke. Groups were otherwise similar. Patients who underwent the vaginal approach had a significantly higher rate of complications than the laparoscopic group for all complications (11.4% vs 6.4%, OR 1.9, 1.3-2.8, p=0.0005) as well as serious complications-only (5.6% vs 3.1%, OR 1.8, 1.1-3.1, p=0.02). After controlling for confounding variables on multivariate logistic regression, vaginal hysterectomy at the time of USLS remained a significant predictor of all complications (OR 2.0, 1.4-2.9, p=0.001), as well as serious complications (OR 2.1, 1.2-3.7, p=0.009). In this large national cohort, after adjusting for known medical and surgical risk factors, vaginal hysterectomy at the time of USLS was associated with a higher complication rate than the laparoscopic route of surgery.

A Comparative Study Of Surgical Outcome In Different Approaches For Hysterectomy

Introduction: Globally, hysterectomy has been the commonest gynecologic surgery since a long time. One of the most remarkable innovations in surgery has been the changeover from laparotomy to laparoscopy. The first reported laparoscopic hysterectomy was in 1989 by Harry Reich, for endometriosis. As laparoscopic procedure has various important advantages over laparotomy, it has become a preferred surgical method. But open hysterectomy or laparoscopic hysterectomy has been chosen based on various factors and the surgeon's experience and skill. Earlier hysterectomies were done in conventional way at Kathmandu University Hospital. But Laparoscopic assisted vaginal hysterectomy and total laparoscopic hysterectomy were started from 2011 and 2015 respectively.
 Method: This retrospective study was undertaken to compare the demographic parameters, operative particulars, postoperative outcomes including complications of different hysterectomy approaches done from 2011 to 2018 at Kathmandu University Hospital.
 Result: A total of 756 hysterectomy cases with 461 of open hysterectomy and 295 of laparoscopic hysterectomy were done in over 8 years. There was no significant difference in mean age of patients who underwent different types of hysterectomies (46.29±6.50 and 45.52±8.15 years, p=0.6829). There was significant increase in Brahmin/Chhetri caste seeking laparoscopic hysterectomy (p=0.0001) and significant decrease in other janajati caste undergoing laparoscopic hysterectomy (p=0.0004). The indications of different type of hysterectomy were almost comparable; with fibroids/adenomyosis (49.7%) followed by abnormal uterine bleeding (19.7%) were common indications. Laparoscopic hysterectomies have significantly increased since 2016. There were significant differences in operating time, blood loss and hospital stay between open and laparoscopic hysterectomy cases with 143.63±43.25 vs 67.56±25.75 minutes, 294.78±51.37 vs 470.24±102.99 ml and 2.61±0.66 vs 5.64±0.69 days respectively (all p<0.0001). There were 30 major complications in open and 10 in laparoscopic hysterectomy respectively with 9 minor complications in both. Eleven laparoscopy cases (3.7%) had to be converted to laparotomy.
 Conclusions: Laparoscopic hysterectomies are possible with equivalent advantages. A good laparoscopic experiences for surgeons and a careful selection of the cases are the obligatory prerequisites.

Comparison of laparoscopy-assisted vaginal hysterectomy as endoscopic single-station surgery and conventional laparoscopic hysterectomy\u2014surgical effects on safety and quality of life

BackgroundTo extend the benefits of minimally invasive surgery, an increasing enthusiasm has emerged for the laparo-endoscopic single-site surgery (LESS). The idea of LESS is to allow inserting multiple laparoscopic instruments through only one umbilical incision instead of multiple abdominal incisions.MethodsSixty patients from three different centers in Germany were randomized (1:1) to conventional laparoscopic hysterectomy (n = 31) or LESS hysterectomy (n = 29). The study focused in particular on the safety and efficacy of both techniques.ResultsThe mean operative time was comparable in both groups (68.2 vs 73.6 min., p = 0.409; 95% CI − 18.69–7.12). No differences were seen regarding estimated blood loss (p = 0.915; 95% CI − 21.02–18.88), intra- and postoperative complications (p = 0.944), and wound infection rates (p = 0.944). Patients within the LESS group experienced significantly less pain in the first 24 h postoperatively (p = 0.006); the pain scores at 3, 5, 7 days and 2 months postoperatively were comparable.ConclusionLESS hysterectomy is a reliable and safe option in gynecologic surgery. Compared to conventional laparoscopic hysterectomy, LESS surgery demonstrated comparable surgical properties in regard to blood loss, duration of surgery, and intra-/postoperative complications. Notably, patients undergoing LESS hysterectomy experienced some less pain postoperatively.

Identifying the superior surgical procedure for endometrial cancer: A protocol of network meta-analysis.

Background:Endometrial cancer (EC) is one of the most common gynecologic tumors, with a high incidence in developed countries. Although the overall prognosis is good, some women have invasive tumors, the risk of recurrence, and death is high. The common surgical methods used in EC are total-abdominal hysterectomy (TAH), total-vaginal hysterectomy (TVH), laparoscopic-assisted vaginal hysterectomy (LAVH), and total-laparoscopic hysterectomy (TLH) including both conventional and robotically assisted.Methods:The literature search was performed in The Cochrane Central Register of Controlled Trials, PubMed, Web of Science, and Embase. The randomized controlled trials (RCTs) will be included. The search date is until June 2019. The risk of bias of included RCTs was assessed by 2 investigators according to the Cochrane Collaboration's tool. Network meta-analysis will be conducted by R software.Results:This study is ongoing and the results will be submitted to a peer-reviewed journal for publication.Conclusion:This network meta-analysis will provide clinical staff with current and reliable information on the best surgical approach for EC. Ethical approval is not applicable, since this is a network mate-analysis based on published articles. The protocol has been registered on PROSPERO under the number CRD42019128094.

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.

A case of congenital long QT syndrome, type 8, undergoing laparoscopic hysterectomy with general anesthesia

ObjectivePatients with Long QT syndrome (LQTS) P may present with torsades de pointes, ventricular tachycardia (VT), or ventricular fibrillation (VF) and are at risk of sudden cardiac death. Materials and methodsA 38 y/o female patient with uterus myoma developed VF during laparoscopic assisted vaginal hysterectomy surgery. Defibrillation was delivered and the electrocardiogram (ECG) returned to sinus rhythm after CPR. ResultsPatient survived and implantable cardioverter-defibrillator was implanted and received beta-blocker therapy. ECG obtained in out-patient clinic still showed QT interval prolongation, but revealed no prolongation few months after persistent beta-blocker therapy. LQTS type 8 (CACNA1C E768del mutation) was identified by genetic DNA sequencing study. ConclusionsPatients with concealed LQTS may have normal QT interval unless exposing to stress or specific stimuli. Unexpected ventricular arrhythmia may happen during any medical management. We should avoid triggers of QT prolongation, and get familiar with management of the episode.

Parecoxib Shortens the Duration of Acute Postoperative Pain After Laparoscopic-Assisted Vaginal Hysterectomy.

The effect of parecoxib sodium on the duration and severity of acute postoperative pain after laparoscopic-assisted vaginal hysterectomy has been inadequately studied. This randomized, controlled trial compared the effects of parecoxib, methylprednisolone, and placebo on the duration of acute postoperative pain after elective laparoscopic-assisted vaginal hysterectomy. Ninety-four eligible patients were randomized to three groups [parecoxib sodium 40 mg (Group P), methylprednisolone 1 mg/kg (Group M), and saline (Group S)]. The duration of pain during coughing [median (interquartile range)] was significantly lower in Group P than in Group M or Group S [26.0 (5.8–48.0) vs. 48.0 (30.0–55.5) vs. 48.0 (36.0–58.5) h; p = 0.025]. The duration of pain during rest was also significantly lower in Group P than in Group M or Group S [5.5 (3.8–21.0) vs. 24.0 (6.0–28.0) vs. 22.0 (5.8–36.0) h; p = 0.009]. Compared with those in Group M and Group S, the patients in Group P reported less intense visceral pain during coughing at 12 (p = 0.050) and 24 h (p = 0.009) as well as at rest at 12 h (p = 0.008). Compared with those in Group P and Group S, the patients in Group M showed lower serum C-reactive protein levels and higher blood glucose levels after surgery. No differences were noted in nausea, vomiting, length of hospital stay, wound infection, and delayed wound healing among the groups. Thus, parecoxib sodium reduces the duration and intensity of acute postoperative pain after laparoscopic-assisted vaginal hysterectomy.

Comparative Study between Laparoscopic Assisted and Traditional Vaginal Hysterectomy

Introduction: The choice of hysterectomy approach depends on the reason for hysterectomy, the overall health of the patient and surgeon’s experience. The choice of technique dictates hospital stay and healing time.
 Objective: To compare the efficacy and outcome of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) and traditional Vaginal Hysterectomy (VH).
 Materials and Method: A total of 100 patients were purposively selected for this prospective comparative study during the period of January 2011 to January 2013 in CMH, Dhaka and Hitech Multicare Hospital. Non-malignant patients undergoing LAVH and VH by the same surgeon were included in this study. Clinical variables such as operative time, operative cost, blood loss, quantity of analgesics used and hospital stay were observed in both cases for comparison. Several other variables were also observed as postoperative complications such as amount of haemoglobin decrease, rise of temperature, urinary tract infection, vault granuloma in both the cases.
 Results: There was no significant difference in terms of age, parity, body weight, uterine weight. The mean estimated blood loss in VH (100±32.8 ml) was significantly lower compared to LAVH (126.5±39.8 ml) group. Comparing the relief of post-operative pain, less analgesic was required, rapid patient recovery, and hospital stay time was less in LAVH group than VH group.
 Conclusion: LAVH is clinically beneficial in terms of less post-operative pain and less quantity of analgesia used, rapid patients’ recovery and shorter hospital stay than VH. It is useful for patients who prefer laparoscopy for cosmetic purpose.
 Journal of Armed Forces Medical College Bangladesh Vol.13(2) 2017: 29-31

The Impact of Current Smoking on Wound Complications, A Review of the ACS NSQIP Dataset [11Q

INTRODUCTION: Smoking is a modifiable risk factor that is associated with cardiac, respiratory, and wound postoperative complications. We investigate the impact of smoking on postoperative wound complications. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset was queried for patient who underwent hysterectomy by primary CPT code from 2011 to 2014. CPT codes used included laparoscopic hysterectomy (58570-58573), laparoscopic assisted vaginal hysterectomy (58550-58554), abdominal hysterectomy (58150), vaginal hysterectomy (58260, 58261, 58290, 58291). Smoking was defined by the ACS NSQIP as individuals who have smoked cigarettes within the previous twelve months leading up to surgery. Univariate analysis was used to assess 30 day postoperative wound complications. Wound complications included: superficial surgical site infection (SSI), deep SSI, organ space SSI and wound disruption. RESULTS: There were significant differences between number of wound complications and relative risk for smokers compared to non-smokers undergoing hysterectomy. The relative risk for superficial wound complication is 1.5 (p<0.05), deep surgical site infection is 1.89 (P<0.05), organ space infection is 1.59 (p<0.05), and wound disruption 1.61 (p <0.05) for smokers compared to non-smokers undergoing hysterectomy. The risk of a single complication increases by 1.56 (p<0.001) with smoking, risk of two complications increases by 2.12 (p<0.001), and the risk of having three complications increases by 4.88 (p<0.001). CONCLUSION: Smoking at the time of hysterectomy greatly increased the risk of wound complications. Future studies should investigate the amount of time from smoking cessation to surgery required to decrease the risk of wound complications.

Comparative Study of Laparoscopic Assisted Vaginal Hysterectomy versus Vaginal Hysterectomy as Regards Blood Loss: Randomized Control Trial

Objective: A comparative research study conducted to evaluate and asses blood loss issues between laparoscopic assisted vaginal hysterectomy and vaginal hysterectomy.Patients and Methods: A prospective randomized controlled research study trial to investigate blood loss and other surgical and clinical outcomes in comparison between VH and LAVH.Results: No statistically significant difference was displayed between the research study groups concerning demographic parameters (age, BMI, parity uterine size) with p values= 0.224, 0.845, 0.296, 0.175 prospectively. No statistically significant difference between the research study groups concerning preoperative hemoglobin with p value =0.379. However, postoperative Hb was statistically significantly greater within VH research group than within LAVH research group with p value =0.021. Hemoglobin reduction was statistically significantly lower within VH than within LAVH with p value <0.001.Conclusion: our research group came to the conclusion that vaginal hysterectomy has a shorter operative time as well as less postoperative bleeding leading to lower Hb and Hct drop. Therefore it is better to conduct vaginal hysterectomy when surgically possible.

Vault prolapse occurrence after total laparoscopic hysterectomy and total abdominal hysterectomy performed for benign indications, is there a difference? A systematic review of the literature

Aim: To systematically review published data on vault prolapse occurrence after total laparoscopic hysterectomy versus abdominal hysterectomy for benign uterine pathology. Materials and Methods: Medline and PubMed were searched for clinical studies reporting on vault prolapse occurrence after laparoscopic or abdominal hysterectomy. The studies included were randomized and non-randomized clinical trials reporting on the occurrence of vaginal vault prolapse as a long-term complication of either abdominal or laparoscopic hysterectomy for nonmalignant conditions. Results: The search yielded only one study reporting on vaginal cuff prolapse after laparoscopic assisted vaginal hysterectomy (LAVH) or total abdominal hysterectomy (TAH). The additional articles that were retrieved using the ‘search for related articles’ function as well as from references of eligible studies were 581. Of these, 473 studies were excluded by title, 45 by abstract, 32 by full text, seven for which the full text could not be retrieved, and 24 by language. For this study two groups of women were followed up after LAVH (n=150) and TAH (n=146). No statistically significant difference in the likelihood of vault prolapse was revealed between the two groups (p = 0.592).Conclusion: In the literature, various measures are recommended to avoid vaginal vault prolapse such as the suspension of the vaginal apex to the cardinal and uterosacral ligament or to the sacrospinous ligaments at the time of hysterectomy. More studies are needed with a greater number of cases and longer follow up to assess whether abdominal or laparoscopic hysterectomy is more appropriate to prevent vaginal vault prolapse.

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.

02: A county hospital experience with determining route of hysterectomy: can we safely increase the minimally invasive hysterectomy rate?

The aim of this study is to review a county hospital’s practice pattern and compare the perioperative outcomes in patients who did or did not receive the recommended surgical route for hysterectomy (vaginal, laparoscopic or abdominal) using a recent evidence-based clinical decision tree algorithm to evaluate the surgical approach. (Figure 1). A retrospective case series was performed on women aged 18 or older who underwent a hysterectomy at a county hospital from January to December 2017. Exclusion criteria included malignancy, planned concomitant bowel or hernia surgery, or cesarean hysterectomy. Information collected included demographic information, risk factors for adhesive disease, estimated uterine size, adequate uterine descensus, operative route performed, and surgical complications such as blood loss, length of stay and readmission. An evidence-based algorithm was applied to the preoperative characteristics of our patients to assess whether we could have offered different route of hysterectomy. Patients were assigned to the appropriate match group when the recommended and the actual surgery did or did not match. STATA software was used for the statistical analysis. Chi-square, T test and ANOVA were used to calculate p values when appropriate. A total of 246 patients were included in the analysis, 89 (36%) had a total vaginal hysterectomy (TVH), 84 (34%) had a total laparoscopic hysterectomy (TLH) or laparoscopic assisted vaginal hysterectomy (LAVH), and 73 (30%) had a total abdominal hysterectomy (TAH). Conversion rate from laparoscopic to abdominal was 5%, mean uterine weight was 362 (SD=217) grams with most patients having severe adhesive disease. After applying the algorithm, 15% of patients recommended to have a TVH had a more invasive surgical route (p<0.0001) and 40% of patients recommended to have a TLH/LAVH had a different surgical route, half had a TVH and the other half underwent a TAH (p< 0.0001). Patients with pelvic pain, history of endometriosis, and larger estimated uterine size were more likely to match into the recommended surgery type (p<0.04). 100% of the patients underwent the recommended surgical type when the algorithm suggested the TAH approach. (Figure 2). After adjusting for actual surgery performed, we found no difference in length of stay, blood loss, transfusion, UTI, readmission to the hospital within 60 days, and presence of adhesive disease between the matching and the non-matching surgery group (Figure 3). Our hospital’s minimally invasive hysterectomy rate is 70%. Applying the algorithm may significantly increase this number to 83%. After adjusting for the surgery performed, perioperative morbidity was not different if the surgery did or did not match with the algorithm recommendation in our cohort.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Laparoscopically-assisted vaginal hysterectomy in patient with bicorporeal uterus: a case report

Introduction: Hysterectomy is one of the most common gynecological procedures. In the general population, the prevalence of uterine malformations is reported to be 6.7% and the incidence of a bicorporeal uterus among all congenital uterine anomalies is reported to be 11.1%.

Predictors of 30-day morbidity after hysterectomy for benign disease.

To determine the 30-day morbidity rate after hysterectomy for benign disease and identify predictors of 30-day morbidity. A retrospective study was conducted among women undergoing hysterectomy for benign indications between January 1, 2010, and December 31, 2015, at Konkuk University Hospital, South Korea. Multivariable regression analysis identified independent factors for morbidity. 1609 women were included. 30-day morbidity rates were 4.5% (n=72) for the whole cohort: 7.5% (28/371), 3.2% (22/686), and 4.0% (22/552) for abdominal hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH), and vaginal hysterectomy, respectively. The most common 30-day postoperative morbidities were urinary complications (1.2%, 20/1609), wound infection (0.9%, 14/1609), and blood transfusion more than 4units (0.7%, 11/1609). In multivariate regression analysis, Charlson comorbidity index of 2 or more, operative time, and estimated blood loss were independently associated with morbidity. Propensity score-matching indicated no difference in morbidity rates for the abdominal hysterectomy and LAVH or vaginal hysterectomy groups (P=0.351), whereas the LAVH or vaginal hysterectomy groups were more strongly associated with operation time, estimated blood loss, and length of postoperative hospital stay. Comorbidity index, operative time, and blood loss were independently associated with morbidity following hysterectomy. These findings supported the preoperative optimization of comorbidities and the appropriate selection of surgical approaches.

Use of Historic Surgical Times to Predict Duration of Hysterectomy: Stratifying by Uterine Weight

To describe the accuracy of historic averages for estimating operating room (OR) time for hysterectomy among women with small and large uteri. A retrospective cohort study. Data from women who underwent abdominal, vaginal, or laparoscopic hysterectomy between 2015 and 2017 at the University of North Carolina Hospitals were analyzed. Historic and actual OR times were compared using linear regression. Patient characteristics were also evaluated to determine whether they were associated with the accuracy of predicted OR times. Nine hundred eighty-five adult women (≥18 years old) who underwent surgery for benign indications or for suspected but not biopsy-confirmed malignancy were included. Not applicable. Historic averages overestimated OR time by a median of 14 minutes (interquartile range [IQR] = -29 to 49 minutes). The OR time in women with small uteri (<250 g) was significantly more likely to be overestimated than women with large uteri (≥250 g) (median time = 21 minutes [IQR = -16 to 52 minutes] and 3 minutes [IQR = -38 to 44 minutes], respectively; p <. 001). In total laparoscopic hysterectomy and laparoscopy-assisted vaginal hysterectomy, women with uteri ≥250 g took significantly longer than hysterectomy for women with uteri <250 g (36 minutes longer [95% confidence interval, 24-50] and 95 minutes longer [95% confidence interval, 12-179], respectively; p < .001 and p = .03). Using historic averages overestimates OR time, and it is more pronounced in women with small uteri. However, there is a relatively large range of OR times, even among women with the same size uteri. This study highlights the importance of preoperative planning, and in cases in which endometriosis is expected, manually adding time to estimates is recommended.

Laparoscopic assisted vaginal hysterectomy at the clinic of gynecology and obstetrics in Novi Sad

Introduction. Laparoscopic assisted vaginal hysterectomy is a surgical procedure with uterine artery ligation followed by vaginal removal of the uterus. The first laparoscopic assisted vaginal hysterectomy was performed by Harry Reich in 1989. Material and Methods. The sample included 24 patients who underwent surgery at the Clinic of Gynecology and Obstetrics, Clinical Center of Vojvodina in Novi Sad in the period 2014 - 2017. The most common indications for laparoscopic assisted vaginal hysterectomy included mild uterine prolapse and uterine fibroids (15 patients, 62.5%). The surgery was carried out in two stages: the first, laparoscopic stage and the second, vaginal stage. The laparoscopic stage included mobilization of the bladder, ovaries and uterus to the level of uterine vessels. In the second stage, the cervix was approached vaginally and detached from the urinary bladder, after which the uterus with cervix and adnexa were removed through the vagina. Results. The average age of patients was 56.8 years; on average, the surgeries lasted 140 minutes and the mean blood loss was 190 ml. Two (8.3%) patients experienced bladder and ureteral injuries which were resolved by urologists. Laparoscopic assisted vaginal hysterectomy was the only procedure performed in 5 (20.8%) patients, whereas it was combined with anterior and/or posterior colporrhaphy in 14 (58.4%), with pelvic lymphadenectomy in 3 (12.5%) patients, and with uterine morcellation in 2 (8.3%) patients. Conclusion. There are no published controlled trials related to the use of laparoscopic assisted vaginal hysterectomy and total laparoscopic hysterectomy in Serbia. This paper presents the preliminary results of the laparoscopic assisted vaginal hysterectomy in 24 patients, comparing them with other techniques of hysterectomy conducted at the Clinic of Gynecology and Obstetrics, Clinical Center of Vojvodina in Novi Sad in the period 2014 - 2017. Laparoscopic assisted vaginal hysterectomy is a good option for surgical treatment of patient with combined pathology of genital organs.

Improved hemostasis with plasma kinetic bipolar sealing device in the vaginal steps of laparoscopic-assisted vaginal hysterectomy

ObjectiveDuring the vaginal steps of laparoscopic-assisted vaginal hysterectomy (LAVH), excessive bleeding occurs if the vascular pedicles are not securely clamped. Accordingly, this study investigates if an advanced bipolar sealing device (PlasmaKinetics [PK] Sealer), compared to conventional sutures, could improve the efficacy and safety in the vaginal steps of LAVH. Material and methodsThe medical records of 101 women who underwent LAVH for a non-malignant condition between June 2014 and August 2017 were retrospectively reviewed. Among the women, 60 received LAVH using conventional sutures (control group), while 41 using the PK Sealer during vaginal steps (PK group). ResultsA 35% reduction (76.1 vs. 117.3 mL) in the blood loss was observed in the PK group. The natural logarithm (ln) of the blood loss was significantly lower in the PK group than in the control group (P = .045). The percentage of cases which achieved the minimal blood loss goal (<50 mL) was significantly higher in the PK group than in the control group (61 vs. 48%, P = .044). After adjusting for confounding factors, the PK group still exhibited a significantly lower ln intraoperative blood loss (OR -0.477, P = .002) than the control group. ConclusionThe PK bipolar sealing device provides a safe and effective alternative in reducing blood loss in the vaginal steps of LAVH.

Transversus Abdominis Plane Block: Comparison of Efficacy of Varying Doses of Clonidine Combined with Levobupivacaine - A Double-Blind Randomized Trail.

Background:Transversus abdominis plane block (TAP) has an evolving role in postoperative analgesia following laparoscopic-assisted vaginal hysterectomy (LAVH).Aims:This study was carried out to evaluate 75 μg and 150 μg of clonidine added to 0.25% levobupivacaine, with regard to the duration of analgesia. Our study also sought to assess the hemodynamic effects, sedation, and adverse effects.Settings and Design:This was a prospective, randomized, double-blinded, comparative study.Methods:A total number of 80 patients undergoing elective LAVH surgery under general anesthesia were randomly assigned to one of the two equal groups to receive either of the following: Group LC75 – 29 ml of 0.25% levobupivacaine plus 75 μg of clonidine diluted in 1 ml of normal saline (total 30 ml) and Group LC150 – 29 ml of 0.25% levobupivacaine plus 150 μg of clonidine diluted in 1 ml of normal saline (total 30 ml). Duration of analgesia was the primary outcome. Hemodynamic variables, sedation score, and adverse effects were secondary outcomes.Statistical Analysis:The data were analyzed with Student's t-test and Chi-square test.Results:The duration of analgesia was significantly prolonged in Group LC150 (609.18 ± 6.59 vs. 410.52 ± 7.18 min; P = 0.001). The visual analog scale score in patients who received clonidine 150 μg Group LC150 as an adjunct was significantly lower than who received 75 μg Group LC75. Significantly higher sedation score was observed in Group LC150. The incidence of bradycardia was also significant between two groups. Significantly fewer patients in Group LC150 required rescue analgesia.Conclusion:The 150 μg dose of clonidine in TAP block prolongs the duration of analgesia but with higher incidence of sedation.