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Laparoscopic hysterectomy: It is not such an expensive surgical procedure
1210
*GV p<0.00001.
Lefters Am]
+ 0.0003245*GA'
0.000003*GAý, -
R2=
99%,
Suneet P. Chauhan, MD, Everett F. Magann, MD, and John C. Morrison, MD Departmentof Obstetrics Universityof Mtsszsstppz and Gynecology, MedicalCenter,2500 N. StateSt.,Jackson,MS 39216-4505
Response declined by authors Reply To theEditors:First of all, I have verified the equation of Chauhan et al. in their letter. For each of the 27 weeks in Table VI of Moore and Cayle's article, the 50th percentile values are used. I could not verify the Moore and Cayle equation because it is based on the 791 patient values that I did not have accessto. There is no reason that these two equations should be identical, becausethey are calculated in two different ways. Disregarding the plus and minus signs momentarily, the coefficients are actually very similar, with the exception of GA'. I think this discrepancy can be attributed to a typographic error in the Moore and Cayle equation. Instead of 0.003 101, it probably should be 0.0003101. 1believe there are severalother typographic errors in the published equation. The " " for the GA coefficient --t should be "+, " there should be a "-" in front of the GAý coefficient, and the "+" for the GV coefficient should be " -. " Thus the actual equation is y 0.2108 + 0.26599*X2 0.01358*X2 + 0.0003101*x:' _ 0.000002684*x'. In summary, the published equation has four (typographic) errors. The equation proposed by Chauhan et al. is different, but their "more accurate" phrase is like comparing apples with oranges.The R2of 0.81 from the original equation (rather than their R2 of 0.99) is a better indication of the explained variance. In any event, from a practical standpoint Table VI is probably more helpful to a clinician than is either equation. Larry Sachs,PhD Schoolof AlliedMedicalProfessions, 1583 OhioStateUnzverszt)ý Per7ySt.,Columbus, OH 43210 Laparoscopic hysterectomy: It is not such an expensive surgical procedure To the Editors: We read with interest the article by Boike et al. (Boike GM, Elfstrand EP, DelPriore G, Schumock D, Holley HS, Lurain JR. Laparoscopically assisted vaginal hysterectomy in a university hospital: Report of 82 cases and comparison with abdominal and vaginal hysterectomy. Am J OBsTET GYNECOL1993; 168-.1690701) on laparoscopically assisted vaginal hysterectomy. We quite agree with their approach insofar as the place and indications for laparoscopic surgery for hysterectomy are concerned. However, we believe that laparoscopically assisted vaginal hysterectomy is not such a costly operation as they state. The increased cost involved by the use of disposable equipment and the duration of the operations prompt the following comMents.
1. Laparoscopic hysterectomy does not necessarily
April 1994 Obstet Gynecol
Bipolar instruments. disposable the use of require is ligament infundibulopelvic a the coagulation of 2 technique'simple, reliable, and reproducible and alsojust as efficient as and lesscostly than the other possibilities.' Using a completely standardized technique with laparoscopic scissorsand bipolar coagulation alone (instruments from Karl Storz-Endoscope, Tuttlingen, Germany),` 5 we have carried out 25 total hysterectomieswith no hemorrhagic complications, either during or after operation, entirely via laparoscopy up to the point the vagina is opened. 2. The time required for the operation as reported by the authors is considerably overestimated. This is due to the fact that these operations were carried out by no fewer than 29 surgeons,of whom only two had specific training in laparoscopic surgery. The average number of operations carried out by each was 2.8 :t3.2 (range I to 18). Thirteen surgeons (44.8%) carried out only one, and only 4 (13%) performed five operations or more. On our team these operations are carried out by surgeons with considerable experience in operative laparoscopy (C.C., J. B.D), and we achievea total hysterectomy,notjust with laparoscopic preparation but entirely by laparoscopy, in 2 hours. For these operations, moreover, we use just bipolar coagulation to achieve hemostasis. We believe these remarks are absolutely essential, given the very considerable advantagesof laparoscopy for hysterectomy. With laparoscopic surgery it will be possible in the fiiture to decreasethe rate of abdominal hysterectomy significantly. The indications for laparoscopy in this operation will become more clear in the next few years.
Charles Chapron, MD, jean-Bernard Dubuisson, MD, and Valirie Aubert, AID Servicede ChirurgzeGynicolopquedu Pr. Dubuisson,Chnique UniversitairePort-RoyalBaudelocque, C.H. U. CochinPori-Royal, 123, BoulevardPort-Royal,75014 Paris, France REFERENCES 1. Chapron C, Querleu D, Mage G, et al. Complications de la 1 coeliochirurgie gyn6cologique: etude multicentrique partir de 7604 coelioscopies. j Gynecol Obstet Biol Reprod 1992; 21: 207-13. 2. Reich H. Laparoscopic oophorectomy and salpingooophorectomy in the treatment of benign tubo-ovarian disease. Int j Fertil 1987; 32: 233-6. I Daniell JF, Kurtz BR, Lee JY. Laparoscopic oophorectomy: comparative study of ligatures, bipolar coagulation, and automatic stapling devices. Obstet Gynecol 1992; 80: 325-8. 4. Reich H, DeCaprio J, McGlynn F. Laparoscopic hvsterectomy. j Gynecol Surg 1989; a: 213-6. 5. Chapron C, Mage G, Pouly JL. Hvst6rectomie percoelioscopique pour pathologie benigne: techniques op&atoires. In: Encyclopeclie medico-chirurgicale. Paris: Editions Techniques, 1993,4p; Techniques chirurgicales-urologiegyn6cologie, F. r. 41-515.
Reply To the Editors: Chapron et al. raised two points about our manuscript on laparoscopically assisted vaginal hysterectomy: (1) costs and (2) time to perform the
*GV p<0.00001.
Lefters Am]
+ 0.0003245*GA'
0.000003*GAý, -
R2=
99%,
Suneet P. Chauhan, MD, Everett F. Magann, MD, and John C. Morrison, MD Departmentof Obstetrics Universityof Mtsszsstppz and Gynecology, MedicalCenter,2500 N. StateSt.,Jackson,MS 39216-4505
Response declined by authors Reply To theEditors:First of all, I have verified the equation of Chauhan et al. in their letter. For each of the 27 weeks in Table VI of Moore and Cayle's article, the 50th percentile values are used. I could not verify the Moore and Cayle equation because it is based on the 791 patient values that I did not have accessto. There is no reason that these two equations should be identical, becausethey are calculated in two different ways. Disregarding the plus and minus signs momentarily, the coefficients are actually very similar, with the exception of GA'. I think this discrepancy can be attributed to a typographic error in the Moore and Cayle equation. Instead of 0.003 101, it probably should be 0.0003101. 1believe there are severalother typographic errors in the published equation. The " " for the GA coefficient --t should be "+, " there should be a "-" in front of the GAý coefficient, and the "+" for the GV coefficient should be " -. " Thus the actual equation is y 0.2108 + 0.26599*X2 0.01358*X2 + 0.0003101*x:' _ 0.000002684*x'. In summary, the published equation has four (typographic) errors. The equation proposed by Chauhan et al. is different, but their "more accurate" phrase is like comparing apples with oranges.The R2of 0.81 from the original equation (rather than their R2 of 0.99) is a better indication of the explained variance. In any event, from a practical standpoint Table VI is probably more helpful to a clinician than is either equation. Larry Sachs,PhD Schoolof AlliedMedicalProfessions, 1583 OhioStateUnzverszt)ý Per7ySt.,Columbus, OH 43210 Laparoscopic hysterectomy: It is not such an expensive surgical procedure To the Editors: We read with interest the article by Boike et al. (Boike GM, Elfstrand EP, DelPriore G, Schumock D, Holley HS, Lurain JR. Laparoscopically assisted vaginal hysterectomy in a university hospital: Report of 82 cases and comparison with abdominal and vaginal hysterectomy. Am J OBsTET GYNECOL1993; 168-.1690701) on laparoscopically assisted vaginal hysterectomy. We quite agree with their approach insofar as the place and indications for laparoscopic surgery for hysterectomy are concerned. However, we believe that laparoscopically assisted vaginal hysterectomy is not such a costly operation as they state. The increased cost involved by the use of disposable equipment and the duration of the operations prompt the following comMents.
1. Laparoscopic hysterectomy does not necessarily
April 1994 Obstet Gynecol
Bipolar instruments. disposable the use of require is ligament infundibulopelvic a the coagulation of 2 technique'simple, reliable, and reproducible and alsojust as efficient as and lesscostly than the other possibilities.' Using a completely standardized technique with laparoscopic scissorsand bipolar coagulation alone (instruments from Karl Storz-Endoscope, Tuttlingen, Germany),` 5 we have carried out 25 total hysterectomieswith no hemorrhagic complications, either during or after operation, entirely via laparoscopy up to the point the vagina is opened. 2. The time required for the operation as reported by the authors is considerably overestimated. This is due to the fact that these operations were carried out by no fewer than 29 surgeons,of whom only two had specific training in laparoscopic surgery. The average number of operations carried out by each was 2.8 :t3.2 (range I to 18). Thirteen surgeons (44.8%) carried out only one, and only 4 (13%) performed five operations or more. On our team these operations are carried out by surgeons with considerable experience in operative laparoscopy (C.C., J. B.D), and we achievea total hysterectomy,notjust with laparoscopic preparation but entirely by laparoscopy, in 2 hours. For these operations, moreover, we use just bipolar coagulation to achieve hemostasis. We believe these remarks are absolutely essential, given the very considerable advantagesof laparoscopy for hysterectomy. With laparoscopic surgery it will be possible in the fiiture to decreasethe rate of abdominal hysterectomy significantly. The indications for laparoscopy in this operation will become more clear in the next few years.
Charles Chapron, MD, jean-Bernard Dubuisson, MD, and Valirie Aubert, AID Servicede ChirurgzeGynicolopquedu Pr. Dubuisson,Chnique UniversitairePort-RoyalBaudelocque, C.H. U. CochinPori-Royal, 123, BoulevardPort-Royal,75014 Paris, France REFERENCES 1. Chapron C, Querleu D, Mage G, et al. Complications de la 1 coeliochirurgie gyn6cologique: etude multicentrique partir de 7604 coelioscopies. j Gynecol Obstet Biol Reprod 1992; 21: 207-13. 2. Reich H. Laparoscopic oophorectomy and salpingooophorectomy in the treatment of benign tubo-ovarian disease. Int j Fertil 1987; 32: 233-6. I Daniell JF, Kurtz BR, Lee JY. Laparoscopic oophorectomy: comparative study of ligatures, bipolar coagulation, and automatic stapling devices. Obstet Gynecol 1992; 80: 325-8. 4. Reich H, DeCaprio J, McGlynn F. Laparoscopic hvsterectomy. j Gynecol Surg 1989; a: 213-6. 5. Chapron C, Mage G, Pouly JL. Hvst6rectomie percoelioscopique pour pathologie benigne: techniques op&atoires. In: Encyclopeclie medico-chirurgicale. Paris: Editions Techniques, 1993,4p; Techniques chirurgicales-urologiegyn6cologie, F. r. 41-515.
Reply To the Editors: Chapron et al. raised two points about our manuscript on laparoscopically assisted vaginal hysterectomy: (1) costs and (2) time to perform the