Major Gynaecological Surgery Research Articles

Laparoscopic Repair of Large Ventral Hernia Following Abdominal Radical Hysterectomy for Cervical Cancer

Background: Incisional hernia is a common complication after a major abdominal gynecologic operation. Laparoscopic repair with a mesh prosthesis is a surgical modality of choice as an alternative to conventional open repair. Case: A 52-year-old woman underwent radical abdominal surgery in 2001 because she had cervical cancer. An abdominal mass had developed since 2008, measuring 8×8×4 cm. Abdominal computed tomography scanning performed at the current presentation of this patient confirmed that she had an incisional hernia at the midline of the abdominal wall. Laparoscopic hernioplasty was performed using an intraperitoneal prolene mesh and suture fixation. Results: The patient had an uneventful recovery. No recurrence has occurred as noted on outpatient follow-up. Conclusions: Laparoscopic repair of incisional hernia has been accepted as a safe and effective method. The current authors took advantage of this surgical modality to treat this patient. The desired outcome was achieved to address her large incisional hernia. (J GYNECOL SURG 30:32)

Balloon aortic valvuloplasty (BAV) as a bridge to aortic valve replacement in cancer patients who require urgent non-cardiac surgery.

BackgroundBalloon aortic valvuloplasty (BAV) is a percutaneous treatment option for severe, symptomatic aortic stenosis. Due to early restenosis and failure to improve long term survival, BAV is considered a palliative measure in patients who are not suitable for open heart surgery due to increased perioperative risk. BAV can be used also as a bridge to surgical or transcatheter aortic valve implantation (TAVI) in haemodinamically unstable patients or in patients who require urgent major non-cardiac surgery.Patients and methods.We reported on 6 oncologic patients with severe aortic stenosis that required a major abdominal and gynaecological surgery. In 5 cases we performed BAV procedure alone; in one patient with concomitant coronary artery disease we combined BAV and percutaneous coronary intervention (PCI).ResultsWith angioplasty and BAV we achieved a good coronary artery flow and an increase in aortic valve area without any periprocedural complications. After the successful procedure, we observed a hemodynamic and symptomatic improvement. As a consequence the operative risk for non-cardiac surgery decreased and the surgical treatment of cancer was done without complications in all the 6 cases.ConclusionsBAV can be utilized as a part of a complex therapy in severe aortic stenosis aimed to improve the quality of life, decrease the surgical risk for major non-cardiac surgery or as a bridge to surgical or transcatheter aortic valve implantation.

Oliguria after prophylactic ureteric stenting in gynaecological surgery—a report of three cases and review of the literature

Ureteric injury is one of the most serious complications of gynaecological surgery. Use of prophylactic preoperative bilateral ureteric stents to reduce ureteric injury is established in colorectal surgery and becoming commonplace in complex gynaecological surgery. The safety of the procedure has been questioned due to reports of stent-induced complications including a rare but serious phenomenon of stent-induced transient obstructive oligo-anuria termed reflex anuria, a response to manipulation and irritation of the ureters. A retrospective case-note review of patients who had bilateral ureteric stents placed prior to gynaecological surgery at Salford Royal Hospital, UK, from 2007 to 2011 was performed to identify cases of oligo-anuria post-stenting, which were not related to hypovolaemia, nephrotoxic drugs or a radiologically evident obstruction. All patients had their stents removed immediately at the end of surgery before leaving the operating theatre. Three out of 439 patients (0.7 %), who had preoperative bilateral ureteric stents, developed post-operative oligo-anuria despite relatively normal radiological assessment. In these three cases outlined below, one self-resolved, and two required urgent re-stenting to relieve obstruction. Use of ureteric stents for major gynaecological surgery can expedite intraoperative identification of the ureters to help reduce accidental ureteric injury but can directly cause complications. These three cases have contributed to knowledge of the complications of ureteric stents during major gynaecological surgery. Awareness of reflux anuria as a possible root cause of post-operative acute renal failure is important for guiding appropriate and timely management to preserve renal function.

Comparison between hyperbaric Bupivacaine and hyperbaric Bupivacaine plus Fentanyl intrathecally in major gynaecological surgeries

Background: Subarachnoid block is commonest anaesthetic technique used for most gynaecological surgeries. Local anaesthetic agents have traditionally been used for this, but with the discovery of opioid receptors in spinal cord in substantia gelatinosa. Possibility of synergism between opioids & local anaesthetics co-administered intrathecally has been explored for various lower abdominal surgeries. Aims & Objective: To study was to compare effect of intrathecal bupivacaine with bupivacaine, fentanyl mixture to assess safety and efficacy, peri –operative hemodynamic stability postoperative pain relief in major gynecological surgeries. Materials and Methods: 60 female patients with American society of anaesthesiologists (ASA) grade I OR II were divided in two groups after matching. Group BF received inj. Bupivacaine 15 mg (0.5%) 3 ml + inj. Fentanyl 25 mcg, (50 mcg/ml), 0.5 ml and Group B: (inj. Bupivacaine 15 mg (0.5%) 3 ml + Normal Saline (0.5 ml), total volume was 3.5 ml in each group. Spinal anaesthesia was given with conventional technique. Results: Duration of sensory block and effective analgesia was prolonged while there was no change in duration of motor block with intrathecally bupivacaine with fentanyl as compared to inj. Bupivacaine alone. Conclusion: Intrathecal Fentanyl as an adjuvant to bupivacaine improves quality of block with longer duration of sensory block & prolongs duration of effective analgesia.

Effect of Paracetamol Intravenous Infusion on Duration and Quality of Spinal Blockade in Patients Undergoing Major Gynaecological Surgeries: A Prospective, Randomised, Double-Blinded, Placebo-Controlled Study

Effect of Paracetamol Intravenous Infusion on Duration and Quality of Spinal Blockade in Patients Undergoing Major Gynaecological Surgeries: A Prospective, Randomised, Double-Blinded, Placebo-Controlled Study Effective pain management is an important component of post-surgical care. For pain relief after major gynecological surgeries, particular attention has been paid to NSAIDs and paracetamol. Paracetamol (acetaminophen) is one of the most commonly used antipyretic analgesics for the symptomatic treatment of acute pain and fever. This study was conducted with the primary aim of evaluating the effect of intravenous paracetamol infusion on the onset and duration of sensory-motor blockade in patients undergoing elective major gynecological surgeries under spinal anesthesia.

Advanced gynecologic laparoscopy in a fast-track ambulatory surgery center.

Background/Objectives:It has been shown that major gynecologic laparoscopy is safe in hospital ambulatory settings, but there is little data to suggest the same in freestanding ambulatory surgery centers. This study evaluates the safety and efficacy of advanced gynecologic laparoscopic surgery using a fast-track model in freestanding ambulatory surgery centers and discusses our institution protocols.Methods:Retrospective, multicenter review was conducted of major gynecologic surgeries from August 1st 2010 to September 30th 2011 in 3 surgical centers with one primary surgeon. All patients were treated for symptomatic uterine leiomyomas and/or endometriosis. Primary outcome measures were unplanned admissions and discharge within 23 hours.Results:One hundred and thirty-four patients underwent major laparoscopic gynecologic surgery with a total of 160 procedures: 77 stage IV endometriosis treatment including 7 disk excisions of endometriosis from the large bowel, 3 ureteroneocystostomies and 1 partial bladder resection, 38 myomectomies, and 34 hysterectomies including 12 modified radical hysterectomies. The overall unplanned admission rate was 4.5%. One hundred and thirty-one patients (97.7%) were discharged within 24 hours after surgery. Three patients (2.2%) were transferred to the hospital postoperatively: 1 patient for observation of postoperative anemia and 2 patients for postoperative fever. Three patients (2.2%) were admitted to the hospital after discharge: 1 patient for postoperative ileus, 1 patient for postoperative fever, and 1 patient with septic pelvic thrombophlebitis. These postoperative issues all resolved without complication, and all patients had an uneventful follow-up.Conclusions:With appropriate resources and an experienced surgeon, advanced laparoscopic surgery can be safely performed in a fast-track ambulatory surgery center with a high rate of discharge within 23 hours and low unplanned readmission rate.

Gynecological diseases in rural India: A critical appraisal of indications and route of surgery along with histopathology correlation of 922 women undergoing major gynecological surgery.

Objective:The aim of the study was to generate baseline data for indications of gynecological surgeries, and to assess route of surgery and histopathology correlation in women undergoing major gynecological surgery in a rural tertiary level teaching hospital in India.Materials and Methods:Surgical indications, route of surgery and histopathology findings were reviewed and analyzed retrospectively, in 922 patients (≥35 years age) who underwent gynecological surgery at Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India from January 1, 2011 to May 31, 2013.Results:Of 922 surgeries, 65 had malignancy (7%). Pelvic organ prolapse (POP) (32.3%) and leiomyoma uterus (29%) were two most common benign indications for hysterectomy. Ovarian tumors were present in 13% (25% of these were malignant). Postmenopausal bleeding (PMB) was seen in 5.5% (55% of these were malignant).Conclusions:All except 10% surgeries were done in the absence of definite histopathology diagnosis that is dysfunctional uterine bleeding (n = 42 [45%]), chronic pelvic pain/severe dysmenorrhea (n = 34 [36%]) and recurrent PMB (n = 17 [19%]). Majority of surgeries had histopathological correlation except for six cases (0.6%) of malignancy, which were missed on initial work-up. Majority of the surgeries were done abdominally. In rural areas of developing countries poverty, lack of regular follow-up, resource constraints and lack of technical skills (with respect to laparoscopic/robotic surgeries) pose major challenge in providing quality health care.

Risk Management of Obese Women Undergoing Major Gynaecological Surgery

Obesity is a big problem which is growing. Thus clinicians and surgeons are likely to treat obese patients more frequently. Obesity can affect medical practice in a number of ways. In order to protect ourselves from potential litigation, we need to focus on risk management efforts on creating a safe environment for patients of all sizes. The aim of our study was to review the risk management strategies of obese women prior to surgery, perioperatively and following surgery. We then identified the strategies and have brought them forward in our article.

Cost‐effectiveness of hysterectomy for benign gynecological conditions: a systematic review

The objective of this study was to assess the cost-effectiveness of hysterectomy performed for benign indications. Hysterectomy remains the most common major gynecological operation in the Western world. Rates of hysterectomy have not declined as expected with the introduction of new treatment options. Furthermore, use of laparoscopic techniques varies widely within the Nordic countries. We designed a systematic review in a University Central Hospital. The sample included all published studies regarding the cost-effectiveness of hysterectomy performed for benign indications (n=1666). Medline, Cochrane Library, PsycINFO, CINAHL, and Nursing databases were searched. Inclusion criteria were the availability of pre- and post-intervention health-related quality of life measures (HRQoL) and data on costs. HRQoL, costs, and cost-effectiveness of treatment were the main outcome measures. Studies (n=24) focused on treatment of symptomatic fibroids (n=8), treatment of heavy menstrual bleeding (n=10), various surgical techniques (n=5) and the effect of various indications for hysterectomy (n=2). Follow-up periods varied from 4months to over 10years. SF/RAND-36 or EQ-5D measures and societal cost perspective were most commonly used. Only 11 studies used individual patient data. HRQoL following hysterectomy was generally good but costs were high. The cost-effectiveness depended on indication, age, and duration of follow-up. The cost-effectiveness of hysterectomy has been surprisingly poorly studied. Conclusions are difficult to draw due to different study designs, indications, follow-up times, and HRQoL instruments used. Rates of hysterectomy have declined less than expected with the introduction of new treatment modalities. Costs of surgery are high. Laparoscopic hysterectomy seems to be the least cost-effective, although further data from original patient cohorts with long-term follow-up are needed.

Application of a subcutaneous negative pressure drain without subcutaneous suture: impact on wound healing in gynecologic surgery

ObjectiveTo evaluate the surgical outcome of a subcutaneous negative pressure drain without subcutaneous suture on wound healing in women undergoing abdominal gynecologic surgery. Study designThe medical records of total 322 patients who underwent abdominal surgery, including cytoreductive surgery for ovarian cancer, between March 2010 and January 2013 were reviewed retrospectively. Patients were divided into two groups by the presence of subcutaneous negative pressure drains without subcutaneous suture, or suture without drainage. ResultsPatient's characteristics in the two groups were not statistically different. Among all patients, the 71 patients who had a subcutaneous wound drain achieved a higher rate of clear healing (97.2% vs. 88.8%; p=0.033): 100% vs. 98.0% (not significant) in 126 benign and 95.6% vs. 82.8% (p=0.032) in 196 malignant disease patients. In a multivariate analysis, wound drain placement was an independent prognostic factor affecting the surgical wound outcome; the disruption (OR, 0.100; 95% CI, 0.021–0.485; p=0.004) rate was significantly lower with subcutaneous negative pressure drain. Placement of a subcutaneous negative pressure drain without subcutaneous suture resulted in clinical benefit, such as shorter admission duration (median, 8 vs. 11 days; p=0.021). ConclusionsApplication of subcutaneous negative pressure drain is one of the effective and easy ways for clearer wound healing after major gynecologic surgery for malignant disease.

Characterization of breathing patterns during patient-controlled opioid analgesia

Respiratory rate is an important measurement in patient care, but accurate measurement is often difficult. We have developed a simple non-invasive device to measure respiratory movements in clinical circumstances, with minimal interference with the patient. We investigated respiratory patterns in patients receiving postoperative morphine analgesia to assess the capacity of the device to detect abnormalities. We studied subjects during self-administered opioid analgesia after major gynaecological surgery, and related the derived signals with a signal from a nasal cannula. Respiratory movement signals were transmitted wirelessly to a recorder from two encapsulated tri-axial accelerometer (RESpeck) sensors. We analysed the signals using two different sensor placements, each for 30 min. The nasal cannula signal was used to classify breathing patterns as obstructive or non-obstructed. We studied 20 patients for a mean duration of 49 min each. Breathing patterns were very variable, between and within patients. The median breathing rates ranged from 6.4 to 19.5 bpm. Breathing was partly obstructed in 10 patients, and six patients had repeated cycles of obstruction and transient recovery. In these patients, we found a consistent and statistically significant pattern of changes in chest wall movement, with increased abdominal and decreased rib cage movement during obstruction. In patients with slow respiratory rates, breath-to-breath times were highly variable. In undisturbed subjects receiving patient-controlled morphine analgesia after surgery, abnormal breathing patterns are extremely common. Cyclical airway obstruction is frequent and associated with a typical pattern of changes in chest wall movement.

Incidence Of VTE Following Genitourinary Surgery In Korea and Evidence-Based Korean Guidelines For Preventing VTE In Patients Undergoing Genitourinary Surgery

IntroductionVenous thromboembolism (VTE) is a major cause of morbidity and mortality after gynecologic and urologic surgeries and previously reported VTE incidence in major genitourinary surgery without VTE prophylaxis was 15-40% in Western countries. VTE is a preventable complication using thromboprophylaxis, however, pharmacologic thromboprophylaxis after major abdomino-pelvic surgery may involve serious bleeding complication. Here, we evaluated the exact incidence and risk factors of VTE following major genitourinary surgery in Korean patients and proposed evidence-based VTE prevention guidelines in such patients. MethodsIn March 2012, the committee for the development of guidelines for preventing VTE in Korea was organized by receiving recommendations from the VTE working party members in the Korean Society on Thrombosis and Hemostasis (KSTH). Using nation-wide date from Korea Health Insurance Review and Assessment Service (HIRA) from 2007 to 2011, symptomatic VTE frequencies after major genitourinary surgeries were retrospectively collected and evaluated. For the categorization of those patients by their VTE incidences, we used the methods described in AT9 guidelines (American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 9th ed.) ResultsAccording to the HIRA database, 255,324 and 85,191 patients' data were collected and evaluated their incidence of VTE and risk factors, which underwent major gynecologic and urologic surgeries, respectively. In detail, there were 87,136 hysterectomies for benign uterine diseases (76,284) and uterine cervical cancer (10,852), 168,188 oophorectomies for benign ovarian diseases (156,697) and ovarian cancer (11,491), 35,970 prostatectomies for benign prostatic hyperplasia (BPH, transurethral, 26,590) and prostatic cancer (retropubic, 9,380), 12,462 nephrectomies for renal cell cancer and 36,759 radical cystectomies for bladder cancer. As shown in Table 1, most Korean patients undergoing genitourinary surgeries were identified as very low VTE risk category. In the aspect of gynecologic cancer surgery, ovarian cancer showed highest rate of VTE incidence (1.21%, moderate risk; 0.70% deep vein thrombosis, DVT + 0.51% pulmonary embolism, PE) and cervical cancer showed 0.59% (low risk; 0.47% DVT + 0.12% PE). On the basis of these data and a literature search results, the recommendation was made by a consensus of the guideline development committee. To take the advice of outside experts, survey and review for the developed guidelines were performed by other KSTH members and the related Academic Societies. [Display omitted] ConclusionsEven when considering relatively lower incidence of VTE in Asian people than that in Western, Korean genitourinary surgery patients revealed very low incidence of VTE. As stated above, abdomino-pelvic surgery is a procedure for high risk of bleeding complications. Therefore, it is reasonable to assume that the recommendation of pharmacologic thromboprophylaxis for other gynecologic surgeries except ovarian cancer surgery should be deferred until they reveal hard evidence of higher incidence of VTE in Korea. Disclosures:No relevant conflicts of interest to declare.

Does the Trendelenburg Position Actually Make Mechanical Ventilation More Difficult? A Prospective Study of Women Undergoing Major Gynecologic Laparoscopic Surgery

Does the Trendelenburg Position Actually Make Mechanical Ventilation More Difficult? A Prospective Study of Women Undergoing Major Gynecologic Laparoscopic Surgery

A randomised prospective trial of intra‐operative oesophageal Doppler‐guided fluid administration in major gynaecological surgery

Intra-operative oesophageal Doppler monitor-guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra-operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra-operative fluid management using an oesophageal Doppler-guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra-operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5-8 [4-25]) days in the oesophageal Doppler monitor group compared with 7 (5-9 [4-42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra-operative oesophageal Doppler-guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.

The ability of bispectral index to detect intra‐operative wakefulness during isoflurane/air anaesthesia, compared with the isolated forearm technique

Clinical signs are unreliable for guiding anaesthetic administration and it is suggested that using the bispectral index can improve anaesthetic delivery. In the current study, isoflurane administration was guided to a bispectral index range of 55-60. Intra-operative responsiveness, as assessed by the isolated forearm technique, was compared with whether the bispectral index predicted/identified a patient's appropriate hand movements in response to commands. Thirty-four women underwent major gynaecological surgery with isoflurane/air and atracurium. Eleven women responded on 32 occasions with appropriate hand movements to commands given during surgery, of which the bispectral index detected 17 (sensitivity 53%). The bispectral index suggested consciousness 660 times in the absence of any movement responses (specificity 69%). The positive predictive value of the bispectral index was 3%. The median (IQR [range]) bispectral index value associated with an intra-operative response was significantly lower than that associated with eye opening after surgery: 60 (50-68 [36-83]) vs 77 (75-84 [59-90]), respectively (p = 2.25 × 10(-8)). Conversely, end-tidal isoflurane concentration was significantly higher at intra-operative response than at eye opening: 0.3 (0.3-0.4 [0.2-0.9]) vs 0.2 (0.1-0.2 [0.1-0.3]), respectively (p = 7.36 × 10(-8)). For patients who responded more than once during surgery, the bispectral index value associated with a response was not constant. No patient had recall for surgery or the taped commands, and only one could remember dreaming (a good dream). Titrating isoflurane to target a bispectral index range of 55-60 may result in an unacceptable number of patients who are conscious during surgery (albeit without recall).

Ambulation of Hospitalized Gynecologic Surgical Patients

Several randomized studies have suggested that patients benefit from early ambulation after abdominal surgery. Research on possible benefits has been hampered by the lack of a quantifiable, standardized definition for adequate ambulation or any guidelines to determine the adequacy of postsurgical ambulation. Moreover, no data are available from randomized trials or other studies that quantify how much the average patient ambulates after abdominal surgery. This randomized controlled trial was designed to determine whether specific ambulation goals (goal-enhanced postoperative care) affect patient-perceived barriers to ambulation or the adequacy of in-hospital postoperative ambulation of patients who underwent major gynecology surgery. One hundred forty-six women undergoing major gynecologic surgery at an urban medical center were randomized to usual care (n = 77) or goal-enhanced postoperative care (n = 69). The primary study outcomes were the number of pedometer-recorded steps documented in the 24 hours immediately before discharge and patient-perceived barriers to ambulation. Patient-identified ambulation obstacles were assessed using a 10-question patient survey. A Mann-Whitney U test was used for group comparison. Of the 129 patients with outcome data, 8 (12%) in each group took no pedometer-recorded steps before discharge. There was no significant group difference between the median numbers of steps in the ambulation goal group and usual care group (80 vs 87 steps, respectively; P = 0.7). From a patient perspective, the most common barriers to ambulation were indwelling catheters (38.5%), intravenous poles (28%), and pain (12.5%); all 3 are modifiable. A clinically and statistically significant increase in the median number of steps taken was found for patients who underwent minimally invasive surgery (n = 143) compared with those who had a laparotomy (n = 27); P = 0.035. These data show that easily modifiable barriers to ambulation identified by patients can be quantified and have the potential to increase postoperative ambulation, improving postoperative recovery. Despite encouragement to ambulate, 12% of gynecologic surgical patients did not walk while hospitalized.

Patterns of use of hemostatic agents in patients undergoing major surgery

BackgroundAlthough a number of prohemostatic agents that are applied intraoperatively have been introduced to minimize bleeding, little is known about the patterns of use and the factors that influence use. We examined the use of hemostatic agents in patients undergoing major surgery. MethodsAll patients who underwent major general, gynecologic, urologic, cardiothoracic, or orthopedic surgery from 2000–2010 who were recorded in the Perspective database were analyzed. ResultsAmong 3,633,799 patients, hemostatic agents were used in 30.3% (n = 1,102,267). The use of hemostatic agents increased from 28.5% in 2000 to 35.2% in 2010. Over the same period, the rates of transfusion declined for pancreatectomy (−14.4%), liver resection (−15.0%), gastrectomy (−11.7%), prostatectomy (−6.6%), nephrectomy (−4.6%), hip arthroplasty (−10.4%), and knee arthroplasty (−6.6%). Over the same time period, the transfusion rate increased for colectomy (6.0%), hysterectomy (3.7%), coronary artery bypass graft (8.4%), valvuloplasty (4.2%), lung resection (1.9%), and spine surgery (1.6%). Transfusion remained relatively stable for thyroidectomy (0.2%). ConclusionsThe use of hemostatic agents has increased rapidly even for surgeries associated with a small risk of transfusion and bleeding complications. In addition to patient characteristics, surgeon and hospital factors exerted substantial influence on the allocation of hemostatic agents.

Failure to rescue after major gynecologic surgery

There is growing recognition that, in addition to occurrence of perioperative complications, the treatment of patients with complications influences outcome. We examined complications, failure to rescue (death in patients with a complication), and mortality rates for women who underwent abdominal hysterectomy. Women who underwent abdominal hysterectomy from 1998-2010 and whose data were recorded in the Nationwide Inpatient Sample were identified. Hospitals were stratified based on risk-adjusted mortality rates into 5 quintiles, and rates of complications and failure to rescue were examined. A total of 664,229 women who had been treated at 741 hospitals were identified. The overall mortality rate for the cohort was 0.17%. The risk-adjusted, hospital-level mortality rate ranged from 0-1.12%. The complication rate was 6.5% at the hospitals with the lowest mortality rates, 9.9% at the second quintile hospitals, 9.5% at both the third and fourth quintile hospitals, and 7.9% at the hospitals with the highest mortality rates. In contrast to complications, the failure-to-rescue rate increased with each successive risk-adjusted mortality quintile. The failure-to-rescue rate was 0% at the hospitals with the lowest mortality rates and increased with each successive quintile to 1.1%, 2.1%, 2.7%, and 4.4% in the hospitals with the highest mortality rates (P < .0001). For women who underwent abdominal hysterectomy, hospital complication rates correlated poorly with mortality rates; failure-to-rescue is strongly associated with in-hospital mortality rates. The treatment of complications, not the actual development of a complication, is the most important factor to use to predict death after major gynecologic surgery.

Hysterectomy in the Niger Delta of Nigeria: A Clinical Study of Indications and Outcome

Most of the women in our environment abhor hysterectomy but it remains the only option in most cases in our practice of gynaecology due to late presentation when it becomes more difficult to offer a less radical management options. This study aims to evaluate the indications, clinical characteristics and management outcome in the Niger Delta of Nigeria. This is a retrospective analysis of all Hysterectomies performed from 1st January, 2000 through 31st December, 2005 at the University of Port Harcourt Teaching Hospital. There were 170 cases of elective hysterectomy out of a total of 1025 elective major gynaecological surgeries during the study period with hysterectomy prevalence of 16.6%. The mean age of the patients was 46.5 years, 21(13.55%) of the women were nulliparous. The major indications were symptomatic uterine fibroid 55.5%, ovarian tumour 14.8% and uterovaginal prolapsed 8.4%. The surgery in 92 (59.4%) patients was performed by consultants. The crude morbidity and case fatality rates was 45.45% and 3.87% respectively. Elective hysterectomy for gynaecological condition remains a valid management option in our environment. The use of peri-operative antibiotics is advised to reduce the incidence of post-operative morbidity.

Intraperitoneal Instillation of Bupivacaine for Reduction of Postoperative Pain After Laparoscopic Hysterectomy: A Double-Blind Randomized Controlled Trial

Study ObjectiveTo evaluate the effect on postoperative pain of intraperitoneal instillation of dilute bupivacaine at the conclusion of laparoscopic hysterectomy. DesignProspective, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I). SettingTertiary care, urban, academic teaching hospital. PatientsWomen aged 18 to 65 years undergoing total or supracervical laparoscopic hysterectomy with or without salpingo-oophorectomy. InterventionRandomization to intraperitoneal instillation of bupivacaine vs normal saline solution at the conclusion of laparoscopic hysterectomy performed because of benign indications. Measurements and Main ResultsA total of 160 patients consented to participate in the study and were randomized to receive either intraperitoneal instillation of 100 mg bupivacaine in 100 mL normal saline solution or 100 mL normal saline solution alone, at the conclusion of laparoscopic hysterectomy. Sixty seven of 77 patients (87%) in the treatment group and 73 of 80 patients (91%) in the placebo group completed the study. There were no significant differences in demographic profile, indication for hysterectomy, or number of previous surgeries between the two groups. All patients were prescribed a standardized routine postoperative analgesic regimen. Pain was measured by patient self-report using a 10-cm visual analog scale (VAS) at 1, 2, 4, 6, 12, and 24 hours postoperatively. Mean VAS scores at all time points were between 2.0 and 4.3 and were highest in the first postoperative hour. VAS scores were not significantly different between the two groups at any time point. None of the measured secondary outcomes were significantly different between the bupivacaine and placebo groups, including total postoperative opioid analgesic use in morphine equivalents (23.2 mg vs 27.5 mg; p = .09), length of hospital stay in hours (23.3 vs 23.0; p = .49), patient satisfaction on a 10-cm VAS (9.0 vs 8.2; p = .12), and complication rates (9% vs 15%; p = .35). ConclusionIntraperitoneal instillation of bupivacaine at the conclusion of laparoscopic hysterectomy does not reduce postoperative pain. Opioid analgesic use, length of hospital stay, overall patient satisfaction, and complication rates are also unchanged. Self-reported postoperative pain was low in both groups after this major gynecologic surgery performed laparoscopically.