Unintended Laparotomy Research Articles

The “July Phenomenon” and Unintended Laparotomy

The “July Phenomenon” and Unintended Laparotomy

One hundred cases of laparoscopic subtotal hysterectomy using the PK and Lap Loop systems

Study objective To evaluate the safety and short-term outcomes of laparoscopic subtotal hysterectomy using the PK and Lap Loop systems. Design Prospective observational study (Canadian Task Force classification II-2). Setting Princess Royal University and Chelsfield Park Hospitals, Kent, UK. Patients One hundred women who underwent laparoscopic subtotal hysterectomy for menorrhagia from February 2003 through July 2004. Intervention The procedure was performed using the Plasma Kinetic (PK) system to seal the vascular pedicles and the Lap Loop system to separate the uterus at the level of the internal os. The uterus was removed from the abdominal cavity mainly by morcellation or posterior colpotomy. Measurements and main results Of 100 patients, 59 were operated on as outpatients. Mean patient age was 44.6 years, median parity was 2, mean body mass index was 26.8, and mean duration of symptoms was 4 years. Clinically, the uterus was enlarged in 70 patients, and preoperative ultrasound scanning suggested the presence of uterine myomas in 42 patients. In addition to hysterectomy, 47 patients had concomitant pelvic surgery. The mean total operating time was 45.5 minutes, and mean estimated blood loss was 114 mL. The overall major complication rate was 2%; two patients required blood transfusion after surgery. There were no bowel or urinary tract injuries, unintended laparotomy, return to operating room, or anesthetic complications. At follow-up, all patients were satisfied with surgery. Conclusion Laparoscopic subtotal hysterectomy using the PK and Lap Loop systems for treatment of therapy-resistant menorrhagia is safe, can be performed as an outpatient procedure, and is associated with reduced operating time and high patient satisfaction.

Risk Factors for Conversion to Laparotomy During Gynecologic Laparoscopy

Study Objective To identify risk factors and short-term outcomes associated with conversion from laparoscopic surgery to laparotomy. Design Case control study (Canadian Task Force classification II-2). Setting Large urban, academic medical center. Subjects All 2530 gynecologic laparoscopies, including those converted to laparotomy. Intervention Laparoscopic surgery. Measurements and Main Results Statistical analysis was performed to compare risk factors in converted versus nonconverted cases. Multiple logistic regression analysis was performed using variables found to be significant on univariate analysis. Of 2530 laparoscopies identified, 159 (6.3%) were converted to laparotomy; 323 were selected by random number assignment from the remaining cases for the control group. The following factors were significantly associated with unintended laparotomy (OR; 95% CI): surgeon inexperience (2.43; 1.38, 4.17), level of laparoscopic complexity (3.19; 1.20, 5.10), body mass index greater than 30 kg/m 2 (2.45; 1.40, 4.41), suspicion of malignancy (17.45; 7.32, 43.57), history of laparotomy (1.34; 1.02, 1.78), presence of adhesions (2.30; 1.37, 3.76), and intraoperative technical difficulty (17.86; 7.32, 43.57). When stratified by level of complexity, experience in laparoscopy does not appear to confer protection during level 1 laparoscopic procedures (0.42; 0.12, 1.37) but does significantly reduce the frequency of conversion during level 2 procedures (0.39; 0.72, 0.93). Age, parity, bowel injury, vascular injury, and history of pelvic inflammatory disease and endometriosis did not increase the risk of conversion. Compared with controls, patients who were converted experienced significantly greater blood loss (p <0.001), longer operating room time (p <0.001), and longer hospital stay (p <0.001). Conclusion All women undergoing laparoscopy should be counseled that unintended laparotomy is a known risk and has additional morbidity over laparoscopy alone. Less-experienced surgeons attempting complicated procedures significantly increase the risk of conversion.

Prelaparoscopic assessment of ovarian cysts in reproductive‐age women

Ovarian cysts are a common cause of hospital admission in several countries. For this reason, and because of the increasing impact of minimal access surgery in clinical practice, a preoperative assessment that offers a reasonable degree of accuracy is necessary. While transabdominal ultrasonography has not been useful because of relatively poor resolution, the transvaginal probe increases the accuracy of ultrasonography, reducing the risk of unexpected malignancy at laparoscopy. This risk can be further reduced by thorough inspection at laparoscopy characterized by high sensitivity, and by selecting a population with a low risk of ovarian malignancy, such as women of reproductive age. Within this population, it is important to distinguish the different kinds of benign ovarian cysts. A principal ultrasonographic criterion among women of reproductive age is the persistence of the mass. Consideration of the latter feature should reduce the number of unnecessary operative laparoscopies, also reducing the number of wrong differential diagnoses. The above‐mentioned approach, associated with the use of simple ultrasonographic findings, seems to have given good reproducibility and accuracy in the differential diagnosis of ‘clear’ cysts, dermoids and endometriomas in premenopausal women. This approach should permit the preparation of suitable laparoscopic instrumentation and enable the surgeon to decide on the siting of ancillary ports, with the aim of reducing the number of unintended laparotomies and avoiding the risk of complications such as spillage in the case of unrecognized teratomas.

Complications of multipuncture laparoscopic surgery

We analyzed the complications that occurred in 1813 laparoscopic operations performed in our institution from August 1989 to August 1995. The patients' mean age was 39.3 &plusmn; 8.5 years and mean parity was 1.5 &plusmn; 1.2. The most common indication for operative laparoscopy was uterine myomas (45.8%). After the procedure, 87 women (4.8%) developed complications. The most common was subcutaneous emphysema (42, 48.3%). Other complications were unintended laparotomies, 16 (18.4%); urinary complications, 11 (12.6%); and vascular injuries, 9 (10.3%). Understanding these complications and determining how to avoid them is the only way to reduce their frequency. Prompt recognition and treatment of complications results in the most favorable outcome.

Operative laparoscopy: American Association of gynecologic Laparoscopists' 1993 membership survey

The American Association of Gynecologic Laparoscopists' 1993 membership survey on operative laparoscopy had 825 respondents reporting 45,042 procedures. The most frequent indication was pelvic pain (56% of procedures), followed by infertility (38%). There were 7382 laparoscopically assisted hysterectomies reported. Compared with 1988 and 1991 survey data, the rates of unintended laparotomy, hemorrhage, and bowel or urinary tract injury increased, but the overall complication and death rates remained essentially unchanged.

Mechanical devices for interval laparoscopic tubal sterilization in previous IUD users

This retrospective analysis was conducted to determine whether IUD users are good candidates for laparoscopic sterilization using the tubal ring and the Filshie clip. The data set used for the analysis came from international multicenter clinical trials involving 1235 women who were sterilized by the tubal ring and 1892 women sterilized by the Filshie clip. Results indicate that former IUD use is not associated with an increased risk of surgical injuries, including uterine perforation, major complications, or postoperative infections, for either of these tubal occlusion techniques. The risk of a sterilization procedure ending in technical failure (defined as switching to laparotomy and/or a tubal occlusion technique not originally planned) among tubal ring cases was greater for former IUD users than for non-IUD users. However, this may be related to a center effect. Nine of the 10 ring cases with technical difficulties were successfully switched to electrocoagulation, and the operator did not have to resort to an unintended laparotomy. The incidence of surgical difficulties among the Filshie clip cases was also higher in former IUD users, but all of these difficulties were safely overcome without changing the tubal occlusion method. These findings lead us to believe that, in general, a woman's IUD use should not generally be a reason for an experienced service provider to hesitate in performing an interval laparoscopic sterilization using a mechanical tubal occlusion technique.

Vascular complications of laparoscopic surgery

Laparoscopic surgery as an alternative to traditional laparotomies has become an important modality in the management of gynecologic diseases; however, it is not without potential risks. Case reports describe numerous complications, including ureteral injuries, persistent ectopic pregnancies, hospital readmissions, unintended laparotomies to manage bowel or urinary tract injury, and hemorrhage. We retrospectively analyzed 195 women who underwent laparoscopic procedures to determine the frequency and severity of operative complications. Several procedures were often involved, including ablations of endometriosis and endometriomata, salpingo-oophorectomies, tubo-ovarian adhesiolyses, salpingo-salpingostomies, laser uterosacral nerve ablations, and laparoscopically assisted vaginal hysterectomies. Four major vascular complications were identified (2%), as well as one uterine perforation (0.5%) and two cases of subcutaneous emphysema (1%). There were no deaths. Three (1.5%) patients had an intraoperative laceration of the epigastric vessels during trocar placement, and one (0.5%) had a hematoma of the left common iliac vein that was self-contained. Management options included immediate laparotomy versus close observation with or without delayed laparotomy.

Laparoscopy Using a Simplified Open Technique

Laparoscopy was carried out using a simplified open method on 585 patients. In the group, 173 (29.5%) had undergone a previous laparoscopy or laparotomy, 28 (4.8%) suffered from gross obesity and 1 patient had a large umbilical hernia. Laparoscopy was diagnostic in 216 (37%) patients and operative in 369 (63%). In this series there were no technical failures or major complications; the incidence of minor complications was 2.7%. The above results seem to suggest that open laparoscopy compared to the closed method may offer the advantage of a lack of contraindications secondary to previous surgery, no risk of failure with unintended laparotomy and, possibly, decreased postoperative discomfort. A larger, randomized series to settle the controversy between closed and open laparoscopy regarding the safety differences between the two approaches may result in more widespread use of the open technique.

Laparoscopic Tubal Sterilization Under Local Anesthesia

Laparoscopic tubal sterilization has been performed under local anesthesia in the United States since 1971. Pilot studies suggested that local anesthesia was as adequate and as safe as general anesthesia. Since 1980, the senior author has performed more than 3000 outpatient laparoscopic tubal sterilizations with the silastic ring under local anesthesia. A retrospective descriptive study was conducted on 2827 cases. The technical failure rate was 0.14%. There were no unintended laparotomies due to complications. The mean operative time was 10.0 +/- 5.1 minutes. The mean anesthesia time was 23.3 +/- 6.9 minutes. The hospital cost for the patient was reduced by 68-85%. This study demonstrates that laparoscopic tubal sterilization can be performed adequately, safely, and quickly under local anesthesia.

Unintended laparotomy associated with laparoscopic tubal sterilization

Although the complication rate for laparoscopic tubal sterilization is generally low, laparotomy is sometimes necessary to complete the sterilization or manage complications. To better characterize factors that predispose women to unintended laparotomy, we analyzed data from the Collaborative Review of Sterilization. Of the 5027 women undergoing laparoscopic tubal sterilization, 12 had unintended laparotomies to manage complications, whereas 39 women had unintended laparotomies because of technical inability to complete the laparoscopic procedure. Women with prior abdominal or pelvic surgery had an increased risk of unintended laparotomy (relative risk = 10.2, 95% confidence interval = 5.3 to 19.7). Women with a history of intrauterine device use or pelvic inflammatory disease had elevated risks that were not statistically significant (relative risk = 2.2 and 1.5, respectively). Comparative studies of alternative surgical approaches for tubal sterilization are needed to formulate recommendations for women who may be at increased risk of unintended laparotomy associated with the laparoscopic approach.

Rare events associated with tubal sterilizations: an international experience.

The results from previous analyses of an international data set collected by Family Health International are reviewed in relation to the incidence, severity, risk factors, and outcomes of rare events associated with tubal sterilization. The rare events included for review, by sequence of their relationship to the tubal sterilization procedure are: luteal phase pregnancy, intraoperative complications (uterine perforation, unintended laparotomy required for completion of the laparoscopic procedure, and technical failure in tubal ring sterilization), deaths, early readmission following laparoscopic sterilization, hysterectomy after laparoscopic sterilization, and pregnancy (intrauterine and ectopic) conceived after tubal sterilization. The widespread use of this method of contraception has important public health implications, and awareness of these events will help clinicians minimize such incidences and better deal with them when they arise.