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A Review of Complications of Over 1000 Laparoscopic Surgeries
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S91–S135 after failed therapy by uterine artery embolization (UAE) and high-intensity focused ultrasound (HIFU). Intervention: Laparoscopic, ultrasound-guided RFVTA. Measurements and Main Results: The patient was diagnosed with a large (8.2x7.8x10.2-cm) subserosal myoma on transvaginal ultrasound in 2011. Suffering from bulk symptoms (pelvic pressure, urinary frequency, and abdominal fullness), she underwent UAE in early 2012 and HIFU in late 2012 with no relief of her symptoms. She was prescribed ulipristal acetate in the autumn of 2013 with subsequent 18% shrinkage of the myoma. Upon stopping the ulipristal acetate, the myoma grew. Laparoscopic myomectomy was rejected because of the prominent vasculature from the cervix to the myoma. When she presented to the private clinic in Texas, she had a uterine size of 20 gestational weeks and transvaginal ultrasound showed a large cervical myoma (18x11x14 cm). On laparoscopic (contact) ultrasound, the myoma measured 15x12x10 cm. She first underwent a punch biopsy of the myoma through the vagina, which evidenced endocervical tissue, followed by outpatient, laparoscopic, ultrasound-guided RFVTA with 27 overlapping ablations and no intraoperative complications. One month post procedure, the patient reported absence of pelvic pressure or bladder symptoms and less abdominal distention upon standing. She was ‘‘more than happy with the outcome so far.’’ Conclusion: Laparoscopic ultrasound-guided RFVTA can be safely performed in patients with large, vascular subserosal myomas in close proximity to the bladder. 318
Open Communications 17 - Advanced Endoscopy (4:02 PM - 4:07 PM)
A Review of Complications of Over 1000 Laparoscopic Surgeries White C, Johnston K, Niblock K. Obstetrics and Gynaecology, Antrim Area Hospital, Antrim, United Kingdom Study Objective: To review the major complication rate of laparoscopic surgery. Design: A retrospective chart review of the major complications of laparoscopic surgery over 70 months. Setting: A multi centre review of laparoscopic surgeries carried out by three experienced laparoscopic surgeons. Patients: 1021 laparoscopic surgeries in total were recorded by the three surgeons with 17 major complications identified. Measurements and Main Results: Major complication rate (CR), defined as visceral, ureteric and vascular injury was 17/1021, 1.67% (including one death from pulmonary embolism). The rate of conversion to laparotomy was 9/1021(0.88%). In 6%, complication occurred on entry, 30% intraoperatively and in 64% there was delayed recognition. Of the major complications 10/17 (58.8%) were managed laparoscopically and 41.1% (7/17) were successfully managed by the gynaecologist. The most frequently performed procedure was laparoscopic hysterectomy 39.2% (410/1021). This group also had the highest CR, 70.1% (12/17) of all major complications. Second and third commonest procedures were salpingoophorectomy 20.9%, 214/1021, CR 11.7% (2/17) and excision of endometriosis 14.2% (146/1021), CR 5.88% 1/17). Conclusion: The major complication rate is low, these rates compare favourably to rates reported in literature for open and vaginal equivalent procedures. Many major complications can be managed by the gynaecologist using a laparoscopic approach thereby avoiding the morbidity associated with laparotomy. This series reveals a higher number of complications intraoperatively versus setup phase injury,and highlights the dilemma of the ominous delayed presenting injury. 320
Open Communications 17 - Advanced Endoscopy (4:14 PM - 4:19 PM)
Successfully Removed Unfavorably Localized Myoma by Robot-Assisted Laparoscopic Myomectomy with Reduced Ports Kang SY, Chung Y-J, Choi MR, Cho HH, Kim J-H, Kim M-R. Seoul St. Mary’s Hospital, Seoul, Republic of Korea
S95
Study Objective: To evaluate the efficacy of robot assisted laparoscopic myomectomy with reduced ports for unfavorably localized myomas as an alternative of open surgery. Design: Retrospective analysis for 170 cases of robot-assisted laparoscopic myomectomy by a single operator between April 1, 2009 and October 30, 2013. Setting: Fibroid Center, Division of reproductive endocrinology in department of Obstetrics and Gynecology in general hospital. Patients: 113 patients who underwent robot-assisted laparoscopic myomectomy for unfavorably localized myomas, defined as huge deep intramural myomas which take up most of the spaces of uterus and press endometrium with being contact the endometrium, or located very close distance from the endometrium, myomas in the round or broad ligaments, and myomas on cervix. Intervention: Robot-assisted laparoscopic myomectomy with reduced ports. Measurements and Main Results: Mean age of the patients was 35.605.65 years. Among 113 cases, there were 100 cases of deep intramural myoma, 7 cases of cervical myoma, 6 cases of intraligamentary myoma. The patients have 3.913.75 myomas on average, and the mean size of the largest myoma of each patient was 7.532.18 centimeter. Mean operative time was 317.0099.84 minutes, and mean console time was 148.0065.07 minutes. Thirty six patients had surgeries for other gynecologic conditions such as pelvic endometriosis or endometrial polyps along with myomectomy at the same time. Average change of hemoglobin level compared 1 day before and after the operation was -1.541.21 g/dl. Postoperative hospital stay was 2.541.02 days on average, and all the patients recovered without any major complication. Conclusion: For patients with unfavorably localized myomas, robotassisted laparoscopic myomectomy with reduced ports could be a minimally invasive surgical option, alternative of open surgery.
321
Open Communications 17 - Advanced Endoscopy (4:20 PM - 4:25 PM)
Uterine Pathology in Hysterectomies Performed for Treatment of Pelvic Organ Prolapse Foust-Wright C, Weinstein MM, Pilliod R, Posthuma R, Wakamatsu MM, Pulliam SJ. Obstetrics and Gynecology, Massachusestts General Hospital, Boston, Massachusetts Study Objective: To determine the rate of incidental uterine pathology in hysterectomies for pelvic organ prolapse. Design: Retrospective study from July 2008-2013 at a single institution. Setting: Female pelvic medicine and reconstructive surgery (FPMRS) division at a tertiary academic institution. Patients: All women undergoing hysterectomy for treatment of prolapse by faculty FPMRS surgeons. Intervention: Women undergoing total or subtotal hysterectomy (laparoscopic, robotic, vaginal and abdominal)for the treatment of pelvic organ prolapse by FPMRS faculty at a single institution were identified using billing data. Chart abstraction was performed including demographics, risk factors for uterine pathology, operative and pathology reports. Measurements and Main Results: Preliminary data includes 160 of 421 eligible patients. The mean age was 62y with 83%(133/160) postmenopausal. The mean BMI was 27 kg/m2 and the mean uterine weight of all specimens was 76.8g. Concerning pathology was identified in 1.8% (3/160)subjects, including complex atypical hyperplasia(CAH)(1), grade 1 endometrial adenocarcinoma(1), and low-grade B-cell lymphoma(1). 53% of hysterectomy specimens showed fibroids. No sarcomas were identified. 120(75%) had total hysterectomy and 40(25%) had supracervical hysterectomy with morcellation. One concerning pathology(CAH) was morcellated. Patients undergoing morcellation procedures were younger (57 vs. 63, p=0.001, 95%CI 2.40, 9.45) and less likely to be postmenopausal (62% vs. 88%, p=0.021, 95% CI (0.03, 0.35). Risk factors for gynecologic cancers including BMI,fibroids, tobacco, diabetes mellitus, history of pelvic radiation, ovarian cancer, breast cancer, PCOS or tamoxifen use were not significantly different between groups.
Open Communications 17 - Advanced Endoscopy (4:02 PM - 4:07 PM)
A Review of Complications of Over 1000 Laparoscopic Surgeries White C, Johnston K, Niblock K. Obstetrics and Gynaecology, Antrim Area Hospital, Antrim, United Kingdom Study Objective: To review the major complication rate of laparoscopic surgery. Design: A retrospective chart review of the major complications of laparoscopic surgery over 70 months. Setting: A multi centre review of laparoscopic surgeries carried out by three experienced laparoscopic surgeons. Patients: 1021 laparoscopic surgeries in total were recorded by the three surgeons with 17 major complications identified. Measurements and Main Results: Major complication rate (CR), defined as visceral, ureteric and vascular injury was 17/1021, 1.67% (including one death from pulmonary embolism). The rate of conversion to laparotomy was 9/1021(0.88%). In 6%, complication occurred on entry, 30% intraoperatively and in 64% there was delayed recognition. Of the major complications 10/17 (58.8%) were managed laparoscopically and 41.1% (7/17) were successfully managed by the gynaecologist. The most frequently performed procedure was laparoscopic hysterectomy 39.2% (410/1021). This group also had the highest CR, 70.1% (12/17) of all major complications. Second and third commonest procedures were salpingoophorectomy 20.9%, 214/1021, CR 11.7% (2/17) and excision of endometriosis 14.2% (146/1021), CR 5.88% 1/17). Conclusion: The major complication rate is low, these rates compare favourably to rates reported in literature for open and vaginal equivalent procedures. Many major complications can be managed by the gynaecologist using a laparoscopic approach thereby avoiding the morbidity associated with laparotomy. This series reveals a higher number of complications intraoperatively versus setup phase injury,and highlights the dilemma of the ominous delayed presenting injury. 320
Open Communications 17 - Advanced Endoscopy (4:14 PM - 4:19 PM)
Successfully Removed Unfavorably Localized Myoma by Robot-Assisted Laparoscopic Myomectomy with Reduced Ports Kang SY, Chung Y-J, Choi MR, Cho HH, Kim J-H, Kim M-R. Seoul St. Mary’s Hospital, Seoul, Republic of Korea
S95
Study Objective: To evaluate the efficacy of robot assisted laparoscopic myomectomy with reduced ports for unfavorably localized myomas as an alternative of open surgery. Design: Retrospective analysis for 170 cases of robot-assisted laparoscopic myomectomy by a single operator between April 1, 2009 and October 30, 2013. Setting: Fibroid Center, Division of reproductive endocrinology in department of Obstetrics and Gynecology in general hospital. Patients: 113 patients who underwent robot-assisted laparoscopic myomectomy for unfavorably localized myomas, defined as huge deep intramural myomas which take up most of the spaces of uterus and press endometrium with being contact the endometrium, or located very close distance from the endometrium, myomas in the round or broad ligaments, and myomas on cervix. Intervention: Robot-assisted laparoscopic myomectomy with reduced ports. Measurements and Main Results: Mean age of the patients was 35.605.65 years. Among 113 cases, there were 100 cases of deep intramural myoma, 7 cases of cervical myoma, 6 cases of intraligamentary myoma. The patients have 3.913.75 myomas on average, and the mean size of the largest myoma of each patient was 7.532.18 centimeter. Mean operative time was 317.0099.84 minutes, and mean console time was 148.0065.07 minutes. Thirty six patients had surgeries for other gynecologic conditions such as pelvic endometriosis or endometrial polyps along with myomectomy at the same time. Average change of hemoglobin level compared 1 day before and after the operation was -1.541.21 g/dl. Postoperative hospital stay was 2.541.02 days on average, and all the patients recovered without any major complication. Conclusion: For patients with unfavorably localized myomas, robotassisted laparoscopic myomectomy with reduced ports could be a minimally invasive surgical option, alternative of open surgery.
321
Open Communications 17 - Advanced Endoscopy (4:20 PM - 4:25 PM)
Uterine Pathology in Hysterectomies Performed for Treatment of Pelvic Organ Prolapse Foust-Wright C, Weinstein MM, Pilliod R, Posthuma R, Wakamatsu MM, Pulliam SJ. Obstetrics and Gynecology, Massachusestts General Hospital, Boston, Massachusetts Study Objective: To determine the rate of incidental uterine pathology in hysterectomies for pelvic organ prolapse. Design: Retrospective study from July 2008-2013 at a single institution. Setting: Female pelvic medicine and reconstructive surgery (FPMRS) division at a tertiary academic institution. Patients: All women undergoing hysterectomy for treatment of prolapse by faculty FPMRS surgeons. Intervention: Women undergoing total or subtotal hysterectomy (laparoscopic, robotic, vaginal and abdominal)for the treatment of pelvic organ prolapse by FPMRS faculty at a single institution were identified using billing data. Chart abstraction was performed including demographics, risk factors for uterine pathology, operative and pathology reports. Measurements and Main Results: Preliminary data includes 160 of 421 eligible patients. The mean age was 62y with 83%(133/160) postmenopausal. The mean BMI was 27 kg/m2 and the mean uterine weight of all specimens was 76.8g. Concerning pathology was identified in 1.8% (3/160)subjects, including complex atypical hyperplasia(CAH)(1), grade 1 endometrial adenocarcinoma(1), and low-grade B-cell lymphoma(1). 53% of hysterectomy specimens showed fibroids. No sarcomas were identified. 120(75%) had total hysterectomy and 40(25%) had supracervical hysterectomy with morcellation. One concerning pathology(CAH) was morcellated. Patients undergoing morcellation procedures were younger (57 vs. 63, p=0.001, 95%CI 2.40, 9.45) and less likely to be postmenopausal (62% vs. 88%, p=0.021, 95% CI (0.03, 0.35). Risk factors for gynecologic cancers including BMI,fibroids, tobacco, diabetes mellitus, history of pelvic radiation, ovarian cancer, breast cancer, PCOS or tamoxifen use were not significantly different between groups.