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A 7-year operative laparoscopy experience in private practice
August 2004, Vol. 11, No. 3 Supplement TheJournalof the American Association of Gynecologic Laparoscopists
section was performed in 3 out of 5 patients; two women delivered vaginally. Corzclusiorz. Our experience suggests that laparoscopic procedures performed either in the first or in the second trimester of pregnancy are safe and effective for both mother and fetus. However, such conclusion is contingent upon the skill and the experience of the surgical team as well as the adequacy of laparoscopic and anesthesiologic techniques.
99. What is a Complication in Total Laparoscopic Hysterectomy? IK Orbuch, H Reich. Study Objective. To define what is a complication in total laparoscopic hysterectomy (TLH). Desigrz. Retrospective review. Sett#zg. University medical center. Patierzts. Seventy-six patients (76 women). Irzterverztiorz. Total laparoscopic hysterectomy. Measuremerzts arzd Ma#z Results. Total laparoscopic hysterectomy was performed for uterine leiomyoma in 66% of the patients. 41% of patients (30 patients) underwent prior laparotomy. Uterus ranged in weight from 53-2783 g (average 498.3 g). Mean EBL was 230 cc's. One patient developed a 9 cm infected hematoma on postoperative day 10. One patient required conversion to laparotomy secondary to large blood loss. One enterotomy and one rectal perforation were noted intraoperative, both successfully repaired intraoperative. Ureteral obstruction was discovered intraop in three patients with subsequent successful intraoperative repair. One cystotomy was noted intraoperative with intraoperative repair. Two cuff collections were noted postoperative successfully treated with antibiotics. Corzclusiorz. Major complications should be defined as problems that remain unrecognized resulting in postoperative sequela or compromising the patient. We include one pelvic abscess and one conversion to laparotomy as complications (2.7%). If we included problems that occurred and were fixed during these surgeries (i.e. enterotomy, ureter obstruction, and cystotomy), our rate would be 11.8%. If they are recognized, most complications during TLH can be corrected by laparoscopic surgery. Bladder and ureters can be assessed by including cystoscopy in the procedure. Rectum and rectosigmoid can be assessed by filling with blue dye and underwater exam. Bleeding can be evaluated by looking underwater at low pressure while irrigating. Thus, early recognition of intraoperative problems can lead to reparation and restoration of normal function and anatomy minimizing sequela.
100. A Prospective Randomized Trial of Closing Laparoscopic Trocar Wounds by Transcutaneous versus Subcuticular Suture or Adhesive Papertape 0 Buchweitz, P WOlfing, L Kiesel. University of MOnster, MOnster, Nordrhein Westfalen, Germany. Study Objective. Several methods for closure of trocar wounds are known in laparoscopic surgery. The choice of technique (mostly transcutaneous or subcuticular suture or
adhesive papertape) is often based on the surgeon's personal experience. The objective of this trial was to assess the impact of these closure methods on potential complications of wound healing, cosmetic outcome, and patient satisfaction. Desigrz. Prospective randomized analysis. Sett#zg. University hospital. Patierzts. Sixty consecutive patients undergoing operative laparoscopy. Irzterverztiorz. 5-mm port site incisions were closed with either subcuticular or transcutaneous absorbable sutures (4-0 polyglactin 910) or with adhesive papertape. Measuremerzts arzd Ma#z Results. Postoperative complications, pain, and patient satisfaction with scars were evaluated at 3-month follow-up postoperatively using a questionnaire. Each patient served as her own control. Dissatisfying results were reported significantly more frequently after subcuticular sutures (p <.05). Assessment of patient satisfaction with cosmetic outcome on a visualanalog scale revealed significantly better results after transcutaneous skin closure than with other approaches (p <.05). Adverse wound healing (e.g. infection, dehiscence) were observed most frequently in the subcuticular suture group. In addition, the rate of painful scars was highest with this technique. Corzclusiorz. The transcutaneous closure with absorbable suture material seems to be the most suitable technique for closure of laparoscopic port site incisions.
101. A 7-Year Operative Laparoscopy Experience in Private Practice T Brown, ML Moore, M Cohen. Advanced Women's Health Institute, Denver, Colorado. Study Objective. To review the learning curve and complication rate in gynecologic endoscopic procedures performed in a private practice setting. Desigrz. Prospective observational study. Sett#zg. Private practice. Patierzts. One thousand one hundred seventy-four women underwent consecutive surgeries, all laparoscopic, with the exception of two open abdominal cases. Irzterverztiorz. Operative laparoscopy. Measummerzts arzd Ma#z Results. An audit of all operative laparoscopy cases in the Advanced Women's Health Institute prospective surgical database (February 1997 through March 2004) was conducted. Data collected included operation type, operating time, estimated blood loss, uterine size, tissue weight, intraoperative complications, and postoperative complications. Operations included 253 laparoscopic supracervical hysterectomy (LSH) (21.5%); 166 LSH with adnexectomy (14.2%); 279 laparoscopic myomectomies (23.8 %); 216 laparoscopic myomectomies with ablation of endometrium (18.4%); 86 cases of pelvic reconstruction (7.3%); 67 cases of endometriosis (5.7%); 31 laparoscopic oophorectomies (2.6%); 21 tubal surgeries (1.8%); 17 classic intrafascial supracervical hysterectomy (CISH) (1.4%); 14 ovarian cystectomies (1.2%); 12 cases of lysis of adhesions (1.0%); 6 uterosacral plications (0.6%);
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Oral Presentations
2 total laparoscopic hysterectomies (0.2%); and 1 LSC oophoropexy. Major complications were analyzed by surgery type. There were a total of 36 major complications (3%) and 81 minor complications (6.9%). Major complications included excessive blood loss requiring transfusion (3); return to the OR (1); bowel perforation (4); cystotomy (8); ureteral injury (1); peritonitis (2); acute and delayed postoperative hemorrhage (10); open abdominal conversion (4); and pulmonary embolus or deep vein thrombosis (3). Minor complications included urinary tract infection (35); transient nerve paresthesia (9); wound infection (7); bladder atony (8); vaginal infection (6); fever (6); hematoma (5); incisional hernia (2); dehydration (2); and pneumonia (1). Conclusion. Complication rates for operative laparoscopy in a private practice paralleled that reported of tertiary university based practices.
102. A Multicenter Study of Laparoscopic Uterine Suspension for Pain Relief 1Cp Perry, 2JB Presthus, 3A Nieves Gonzalez. 1Birmingham, Alabama; 2Edina, Minnesota; 3University Women's Services, Chattanooga, Tennessee. Study Objective. To assess the efficacy of the UPLIFT laparoscopic uterine suspension procedure in alleviating pain in women with a retroverted uterus, the duration of the pain relief, and operative or postoperative complications associated with the procedure. Design. Prospective cohort study conducted between May 1998 and November 2000. Setting. Three private gynecologic practices. Patients. Sixty-two women (average age 29 years, range 17-48 years) with a retroverted uterus and chronic pelvic pain (defined as pain lasting greater than 6 months) with moderate to severe dysmenorrhea, and/or dyspareunia. Intervention. Laparoscopic uterine suspension with the UPLIFT procedure as developed by Carter. Fifty-five women (88%) had either endometriosis and/or adhesions at the time of uterine suspension, and virtually all were treated at the time of the UPLIFT procedure. Measurements andMain Results. Patients were asked to rate their pelvic pain, dysmenorrhea, and dyspareunia on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, preoperatively and again at 4 weeks and 3, 6, and 12 months postoperatively. The average follow-up time was 10.2 months (range .2-14.9 months). The mean scores for pelvic pain decreased from 7.3 to 3.7 at 12 months (n = 46). Dysmenorrhea decreased from 7.8 to 4.4 (n = 39), and dyspareunia decreased from 8.0 to 3.3 (n = 41). There were five minor intraoperative adverse events. Conclusion. Laparoscopic uterine suspension with the UPLIFT procedure results in significant long-term pain reduction in women. The results were especially encouraging given that the women in the study all experienced severe dysmenorrhea and/or dyspareunia, rated as 6 or more on a scale from 0-10.
Open Communications 7--Urogynecology 103. Is the Use of Mesh Always Necessary for the Laparoscopic Treatment of Genital Prolapse? JB Dubuisson, S Jacob, JM Wenger. Hopitaux Universitaires De Geneve, Geneve, France. Study Objective. To assess the efficacy of a new management for the laparoscopic treatment of genital prolapse, restricted to the use of mesh to some patients with damaged fasciae. We modified our protocols after evaluation of the results of a personal publication (2003) with a too high rate of mesh erosion (8.7%) among 115 patients treated with laparoscopic lateral suspension using mesh. Design. Retrospective analysis of 29 consecutive cases of genital prolapse treated laparoscopically. Setting. Tertiary care gynecologic center in a university hospital. Patients. Twenty-nine women (ages 35-75 years) with stage II and III genital prolapse according to the POPQ classification. All the candidates for laparoscopy were included. Intervention. After the cleavage of the vesicovaginal septum, plications of the pubocervical fascia were performed using nonabsorbable sutures. After the cleavage of the rectovaginal septum and the visualization of the levator ani muscles, the muscles were approximated and the uterosacral ligaments were attached to the fascia and to the torus uterinum using nonabsorbable sutures. In most of the cases, the sutures were sufficient to treat the descent of the pelvic organs. At this point, the mobility of the uterus (or vaginal vault) was tested. When it persisted and the fasciae seemed too damaged, a lateral suspension using a polyester mesh was associated to the procedure, according to our already published technique. Measurements and Main Results. The laparoscopic procedure was successfully completed in all 29 patients without complications. Only 7 meshes were placed (24.1%). Out of 29 patients who completed surgery and follow-up, 28 (96%) reported a relief of their symptoms and an improvement in quality of life. Objective data noted an excellent anatomic result in 27 women (93%). Conclusion. The use of mesh is not always necessary for the laparoscopic treatment of genital prolapse. The procedure using sutures and apposition of the pelvic fasciae defects are efficient in most cases. Only cases indicating overly damaged fasciae or hypermobility of the uterus after placation need the use of mesh.
104. Feasibility of Performing Nonsurgical Radiofrequency Energy Tissue MicroRemodeling in Women with Stress Urinary Incontinence Using Oral and Local Anesthesia 1jp Lenihan, 2p Palacious, 1M Sotomayor. 1Tacoma Women's Specialists, Tacoma, Washington; 2National Institute of Nutrition and Medical Sciences, Tlalpan, Mexico. Study Objective. To assess the feasibility of performing nonsurgical radiofrequency energy (RF) tissue microremodeling in women with stress urinary incontinence (SUI) using oral and local anesthesia.
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section was performed in 3 out of 5 patients; two women delivered vaginally. Corzclusiorz. Our experience suggests that laparoscopic procedures performed either in the first or in the second trimester of pregnancy are safe and effective for both mother and fetus. However, such conclusion is contingent upon the skill and the experience of the surgical team as well as the adequacy of laparoscopic and anesthesiologic techniques.
99. What is a Complication in Total Laparoscopic Hysterectomy? IK Orbuch, H Reich. Study Objective. To define what is a complication in total laparoscopic hysterectomy (TLH). Desigrz. Retrospective review. Sett#zg. University medical center. Patierzts. Seventy-six patients (76 women). Irzterverztiorz. Total laparoscopic hysterectomy. Measuremerzts arzd Ma#z Results. Total laparoscopic hysterectomy was performed for uterine leiomyoma in 66% of the patients. 41% of patients (30 patients) underwent prior laparotomy. Uterus ranged in weight from 53-2783 g (average 498.3 g). Mean EBL was 230 cc's. One patient developed a 9 cm infected hematoma on postoperative day 10. One patient required conversion to laparotomy secondary to large blood loss. One enterotomy and one rectal perforation were noted intraoperative, both successfully repaired intraoperative. Ureteral obstruction was discovered intraop in three patients with subsequent successful intraoperative repair. One cystotomy was noted intraoperative with intraoperative repair. Two cuff collections were noted postoperative successfully treated with antibiotics. Corzclusiorz. Major complications should be defined as problems that remain unrecognized resulting in postoperative sequela or compromising the patient. We include one pelvic abscess and one conversion to laparotomy as complications (2.7%). If we included problems that occurred and were fixed during these surgeries (i.e. enterotomy, ureter obstruction, and cystotomy), our rate would be 11.8%. If they are recognized, most complications during TLH can be corrected by laparoscopic surgery. Bladder and ureters can be assessed by including cystoscopy in the procedure. Rectum and rectosigmoid can be assessed by filling with blue dye and underwater exam. Bleeding can be evaluated by looking underwater at low pressure while irrigating. Thus, early recognition of intraoperative problems can lead to reparation and restoration of normal function and anatomy minimizing sequela.
100. A Prospective Randomized Trial of Closing Laparoscopic Trocar Wounds by Transcutaneous versus Subcuticular Suture or Adhesive Papertape 0 Buchweitz, P WOlfing, L Kiesel. University of MOnster, MOnster, Nordrhein Westfalen, Germany. Study Objective. Several methods for closure of trocar wounds are known in laparoscopic surgery. The choice of technique (mostly transcutaneous or subcuticular suture or
adhesive papertape) is often based on the surgeon's personal experience. The objective of this trial was to assess the impact of these closure methods on potential complications of wound healing, cosmetic outcome, and patient satisfaction. Desigrz. Prospective randomized analysis. Sett#zg. University hospital. Patierzts. Sixty consecutive patients undergoing operative laparoscopy. Irzterverztiorz. 5-mm port site incisions were closed with either subcuticular or transcutaneous absorbable sutures (4-0 polyglactin 910) or with adhesive papertape. Measuremerzts arzd Ma#z Results. Postoperative complications, pain, and patient satisfaction with scars were evaluated at 3-month follow-up postoperatively using a questionnaire. Each patient served as her own control. Dissatisfying results were reported significantly more frequently after subcuticular sutures (p <.05). Assessment of patient satisfaction with cosmetic outcome on a visualanalog scale revealed significantly better results after transcutaneous skin closure than with other approaches (p <.05). Adverse wound healing (e.g. infection, dehiscence) were observed most frequently in the subcuticular suture group. In addition, the rate of painful scars was highest with this technique. Corzclusiorz. The transcutaneous closure with absorbable suture material seems to be the most suitable technique for closure of laparoscopic port site incisions.
101. A 7-Year Operative Laparoscopy Experience in Private Practice T Brown, ML Moore, M Cohen. Advanced Women's Health Institute, Denver, Colorado. Study Objective. To review the learning curve and complication rate in gynecologic endoscopic procedures performed in a private practice setting. Desigrz. Prospective observational study. Sett#zg. Private practice. Patierzts. One thousand one hundred seventy-four women underwent consecutive surgeries, all laparoscopic, with the exception of two open abdominal cases. Irzterverztiorz. Operative laparoscopy. Measummerzts arzd Ma#z Results. An audit of all operative laparoscopy cases in the Advanced Women's Health Institute prospective surgical database (February 1997 through March 2004) was conducted. Data collected included operation type, operating time, estimated blood loss, uterine size, tissue weight, intraoperative complications, and postoperative complications. Operations included 253 laparoscopic supracervical hysterectomy (LSH) (21.5%); 166 LSH with adnexectomy (14.2%); 279 laparoscopic myomectomies (23.8 %); 216 laparoscopic myomectomies with ablation of endometrium (18.4%); 86 cases of pelvic reconstruction (7.3%); 67 cases of endometriosis (5.7%); 31 laparoscopic oophorectomies (2.6%); 21 tubal surgeries (1.8%); 17 classic intrafascial supracervical hysterectomy (CISH) (1.4%); 14 ovarian cystectomies (1.2%); 12 cases of lysis of adhesions (1.0%); 6 uterosacral plications (0.6%);
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Oral Presentations
2 total laparoscopic hysterectomies (0.2%); and 1 LSC oophoropexy. Major complications were analyzed by surgery type. There were a total of 36 major complications (3%) and 81 minor complications (6.9%). Major complications included excessive blood loss requiring transfusion (3); return to the OR (1); bowel perforation (4); cystotomy (8); ureteral injury (1); peritonitis (2); acute and delayed postoperative hemorrhage (10); open abdominal conversion (4); and pulmonary embolus or deep vein thrombosis (3). Minor complications included urinary tract infection (35); transient nerve paresthesia (9); wound infection (7); bladder atony (8); vaginal infection (6); fever (6); hematoma (5); incisional hernia (2); dehydration (2); and pneumonia (1). Conclusion. Complication rates for operative laparoscopy in a private practice paralleled that reported of tertiary university based practices.
102. A Multicenter Study of Laparoscopic Uterine Suspension for Pain Relief 1Cp Perry, 2JB Presthus, 3A Nieves Gonzalez. 1Birmingham, Alabama; 2Edina, Minnesota; 3University Women's Services, Chattanooga, Tennessee. Study Objective. To assess the efficacy of the UPLIFT laparoscopic uterine suspension procedure in alleviating pain in women with a retroverted uterus, the duration of the pain relief, and operative or postoperative complications associated with the procedure. Design. Prospective cohort study conducted between May 1998 and November 2000. Setting. Three private gynecologic practices. Patients. Sixty-two women (average age 29 years, range 17-48 years) with a retroverted uterus and chronic pelvic pain (defined as pain lasting greater than 6 months) with moderate to severe dysmenorrhea, and/or dyspareunia. Intervention. Laparoscopic uterine suspension with the UPLIFT procedure as developed by Carter. Fifty-five women (88%) had either endometriosis and/or adhesions at the time of uterine suspension, and virtually all were treated at the time of the UPLIFT procedure. Measurements andMain Results. Patients were asked to rate their pelvic pain, dysmenorrhea, and dyspareunia on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, preoperatively and again at 4 weeks and 3, 6, and 12 months postoperatively. The average follow-up time was 10.2 months (range .2-14.9 months). The mean scores for pelvic pain decreased from 7.3 to 3.7 at 12 months (n = 46). Dysmenorrhea decreased from 7.8 to 4.4 (n = 39), and dyspareunia decreased from 8.0 to 3.3 (n = 41). There were five minor intraoperative adverse events. Conclusion. Laparoscopic uterine suspension with the UPLIFT procedure results in significant long-term pain reduction in women. The results were especially encouraging given that the women in the study all experienced severe dysmenorrhea and/or dyspareunia, rated as 6 or more on a scale from 0-10.
Open Communications 7--Urogynecology 103. Is the Use of Mesh Always Necessary for the Laparoscopic Treatment of Genital Prolapse? JB Dubuisson, S Jacob, JM Wenger. Hopitaux Universitaires De Geneve, Geneve, France. Study Objective. To assess the efficacy of a new management for the laparoscopic treatment of genital prolapse, restricted to the use of mesh to some patients with damaged fasciae. We modified our protocols after evaluation of the results of a personal publication (2003) with a too high rate of mesh erosion (8.7%) among 115 patients treated with laparoscopic lateral suspension using mesh. Design. Retrospective analysis of 29 consecutive cases of genital prolapse treated laparoscopically. Setting. Tertiary care gynecologic center in a university hospital. Patients. Twenty-nine women (ages 35-75 years) with stage II and III genital prolapse according to the POPQ classification. All the candidates for laparoscopy were included. Intervention. After the cleavage of the vesicovaginal septum, plications of the pubocervical fascia were performed using nonabsorbable sutures. After the cleavage of the rectovaginal septum and the visualization of the levator ani muscles, the muscles were approximated and the uterosacral ligaments were attached to the fascia and to the torus uterinum using nonabsorbable sutures. In most of the cases, the sutures were sufficient to treat the descent of the pelvic organs. At this point, the mobility of the uterus (or vaginal vault) was tested. When it persisted and the fasciae seemed too damaged, a lateral suspension using a polyester mesh was associated to the procedure, according to our already published technique. Measurements and Main Results. The laparoscopic procedure was successfully completed in all 29 patients without complications. Only 7 meshes were placed (24.1%). Out of 29 patients who completed surgery and follow-up, 28 (96%) reported a relief of their symptoms and an improvement in quality of life. Objective data noted an excellent anatomic result in 27 women (93%). Conclusion. The use of mesh is not always necessary for the laparoscopic treatment of genital prolapse. The procedure using sutures and apposition of the pelvic fasciae defects are efficient in most cases. Only cases indicating overly damaged fasciae or hypermobility of the uterus after placation need the use of mesh.
104. Feasibility of Performing Nonsurgical Radiofrequency Energy Tissue MicroRemodeling in Women with Stress Urinary Incontinence Using Oral and Local Anesthesia 1jp Lenihan, 2p Palacious, 1M Sotomayor. 1Tacoma Women's Specialists, Tacoma, Washington; 2National Institute of Nutrition and Medical Sciences, Tlalpan, Mexico. Study Objective. To assess the feasibility of performing nonsurgical radiofrequency energy (RF) tissue microremodeling in women with stress urinary incontinence (SUI) using oral and local anesthesia.
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