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Nerve Sparing Radical Hysterectomy Made Easy by Laparoscopy
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S1–S49
S13
Outcomes by Type of Hysterectomy and Category By Hysterectomy Type No Prev Major Inc-Close Mean LOS minutes (N=577) No Vag Del (%) Abd OR BMI Mean(SD) Min.(SD) No Complication (%) No Readmit (SD) Mean(SD) LAVH (N=411) VH (N=68) TAH (N=63) TLH (N=14) Mini-Lap (N=21) p Value for Hyst Type By Category (N=577) Category 1 (N=140) Category 2 (N=280) Category 3 (N=157) p Value Categories
116 (28%) 1 (2%) 35 (56%) 9 (64%) 15 (71%) \0.0001
209 (51%) 55 (81%) 27 (43%) 4 (29%) 12 (57%) \0.0001
31.1 30.0 32.1 32.4 32.3 0.29
(6.5) (6.8) (6%) (8.5) (8.4)
121 (48) 70 (25) 144 (63) 156 (62) 229 (63) \0.0001
389 (94.6%) 62 (91%) 54 (86%) 13 (93%) 21 (100%) 0.0001
400 (97.8%) 65 (97%) 61 (97%) 14 (100%) 20 (95%) 0.89
1135 (718) 1420 (672) 3955 (1818) 1645 (1199) 1414 (558) \0.0001
0 (0%) 81 (29%) 95 (61%) \0.0001
108 (77%) 141 (50%) 58 (37%) \0.0001
25.8 (2.8) 31 (4.8) 36 (8.1) \0.0001
96 (43) 122 (54) 146 (61) \0.0001
132 (94%) 263 (94%) 144 (92%) 0.6
136 (97%) 273 (99%) 151 (96%) 0.28
1218 (1137) 1392 (1095) 1941 (1494) \0.0001
reviewed by one of six gynecologists. Follow up was from two to fourteen months at time of abstract submission. Our categorization system uses four data points: Body Mass Index (BMI), number of vaginal deliveries, number of previous major abdominal surgeries, clinical uterine size. Outcomes by Type of Hysterectomy and Category Types of hysterectomies performed: Laparoscopic Assisted Vaginal Hysterectomy (LAVH), Vaginal Hysterectomy (VH), Total Abdominal Hysterectomy (TAH), Total Laparoscopic Hysterectomy (TLH), Minilaparotomy (Mini-lap), Laparoscopic Supracervical Hysterectomy (LSH). Categorizing Benign Hysterectomy Body Mass Index
Vaginal Del (#)
Major Abd OR
Clinical Uterine Size (weeks)
1 or more
\/= 1
> / = 12
Category
1
> 30
Category
21 24 22 23
30-40
31 32 33 35 37 38 36 34
> 40
Category
0 2-3 > 12 \ 18
>3 > / = 18 > / = 18
> 40 > 40 > 40 30 - 40
0
>3 >3 >3 2-3
> / = 18 > / = 18 > 12 \ 18
Between types of hysterectomy we see a statistical difference in incision to close time, complication rates and length of stay (LOS). Between categories we see a statistical difference in incision to close time and LOS. Conclusion: Continued education, along with providing expert surgical mentoring has improved the non-open hysterectomy rate while maintaining safety and excellent use of resources in a large multispecialty group. Preoperative categorizing of hysterectomy can help determine time required for surgery and expertise of surgical assistance needed. We will review our system in more detail during presentation as well as types of complications and re-admissions. 36
Open Communications 3dHysterectomy (11:54 AM d 12:00 AM)
Development of Minimally Invasive Gynecologic Surgery Program without Robotics in Community Hopsital Stanley CJ. Division of Minimally Invasive Gynecologic Surgery, Florida Hospital Waterman, Tavares, Florida Study Objective: To demonstrate that a service line devoted to Minimally Invasive Gynecologic Surgery (MIGS) procedures could be enhanced,
without robotics, in such a manner that improves volume and is safe, effective, and fiscally responsible. Design: Review of year to year, 2009-2011, data in terms of number of cases involving advanced minimally invasive techniques prior to and after intitiation of intensive teaching program led by hospital based instructor. Setting: Suburban 220 bed community hospital in Central Florida. Patients: 1,256 women undergoing gynecologic procedures for benign indications from July of 2009 through July 2011. Intervention: In July of 2010, a surgeon trained in advanced minimally invasive gynecologic surgery (MIGS) initiated a program based in a community hospital with the goal of increasing the rate of advanced minimally invasive procedures, both endoscopic and vaginal, by teaching/ assisting the staff surgeons on all major cases. Benchmarks were as follows: Volume of total major cases; percent change in MIGS cases; and cost of program implementation. Costs were calculated using internal data and standard accounting methods. Measurements and Main Results: The majority, 85% of surgeons with gynecologic surgical privileges, took an active role in the development of the MIGS division. In the years 2009-2011, following the intitiation of the teaching program in 2010, the rate of abdominal hysterectomy fell by 39%, the rate of minimally invasive cases increased by 117%, and total gynecology cases increased by 60%. Rate of MIGS hysterectomy improved from 43% to 78% of hysterectomies. The total cost of implementation was calculated to be approximately $475,000. Conclusion: The enhancement of a MIGS service line can be achieved in a Community Hospital setting without resorting to Robotics in a cost effective manner. 37
Video Session 1dOncology (11:00 AM d 11:08 AM)
Nerve Sparing Radical Hysterectomy Made Easy by Laparoscopy Lawande A, Desai R, Puntambekar S, Puntambekar S, Telang M. Galaxy CARE Laparoscopy Institute, Pune, Maharashtra, India The most common complication of a radical hysterectomy is bladder dysfunction. To overcome this, a nerve sparing radical hysterectomy is done. The advantage of performing a nerve sparing radical hysterectomy by laparoscopy is better delineation of nerves due to the magnification enabled by a laparoscope, thus leading to better nerve preservation. Objectives: To evaluate the technical feasibility of nerve sparing radical hysterectomy performed laparoscopically. Methods: We performed laparoscopic nerve sparing radical hysterectomy in 35 patients with cancer cervix stage Ia1 and Ib1. Results: The oncological results were comparable to the conventional laparoscopic radical hysterectomy. Complete recovery of bladder functions after removal of Foleys catheter. Urodynamic studies performed after three weeks normal. Conclusion: The oncological and functional results comparable to the conventional laparoscopic radical hysterectomy. This shows that magnification enabled by laparoscope helps in better dissection and preservation of nerve anatomy.
S13
Outcomes by Type of Hysterectomy and Category By Hysterectomy Type No Prev Major Inc-Close Mean LOS minutes (N=577) No Vag Del (%) Abd OR BMI Mean(SD) Min.(SD) No Complication (%) No Readmit (SD) Mean(SD) LAVH (N=411) VH (N=68) TAH (N=63) TLH (N=14) Mini-Lap (N=21) p Value for Hyst Type By Category (N=577) Category 1 (N=140) Category 2 (N=280) Category 3 (N=157) p Value Categories
116 (28%) 1 (2%) 35 (56%) 9 (64%) 15 (71%) \0.0001
209 (51%) 55 (81%) 27 (43%) 4 (29%) 12 (57%) \0.0001
31.1 30.0 32.1 32.4 32.3 0.29
(6.5) (6.8) (6%) (8.5) (8.4)
121 (48) 70 (25) 144 (63) 156 (62) 229 (63) \0.0001
389 (94.6%) 62 (91%) 54 (86%) 13 (93%) 21 (100%) 0.0001
400 (97.8%) 65 (97%) 61 (97%) 14 (100%) 20 (95%) 0.89
1135 (718) 1420 (672) 3955 (1818) 1645 (1199) 1414 (558) \0.0001
0 (0%) 81 (29%) 95 (61%) \0.0001
108 (77%) 141 (50%) 58 (37%) \0.0001
25.8 (2.8) 31 (4.8) 36 (8.1) \0.0001
96 (43) 122 (54) 146 (61) \0.0001
132 (94%) 263 (94%) 144 (92%) 0.6
136 (97%) 273 (99%) 151 (96%) 0.28
1218 (1137) 1392 (1095) 1941 (1494) \0.0001
reviewed by one of six gynecologists. Follow up was from two to fourteen months at time of abstract submission. Our categorization system uses four data points: Body Mass Index (BMI), number of vaginal deliveries, number of previous major abdominal surgeries, clinical uterine size. Outcomes by Type of Hysterectomy and Category Types of hysterectomies performed: Laparoscopic Assisted Vaginal Hysterectomy (LAVH), Vaginal Hysterectomy (VH), Total Abdominal Hysterectomy (TAH), Total Laparoscopic Hysterectomy (TLH), Minilaparotomy (Mini-lap), Laparoscopic Supracervical Hysterectomy (LSH). Categorizing Benign Hysterectomy Body Mass Index
Vaginal Del (#)
Major Abd OR
Clinical Uterine Size (weeks)
1 or more
\/= 1
> / = 12
Category
1
> 30
Category
21 24 22 23
30-40
31 32 33 35 37 38 36 34
> 40
Category
0 2-3 > 12 \ 18
>3 > / = 18 > / = 18
> 40 > 40 > 40 30 - 40
0
>3 >3 >3 2-3
> / = 18 > / = 18 > 12 \ 18
Between types of hysterectomy we see a statistical difference in incision to close time, complication rates and length of stay (LOS). Between categories we see a statistical difference in incision to close time and LOS. Conclusion: Continued education, along with providing expert surgical mentoring has improved the non-open hysterectomy rate while maintaining safety and excellent use of resources in a large multispecialty group. Preoperative categorizing of hysterectomy can help determine time required for surgery and expertise of surgical assistance needed. We will review our system in more detail during presentation as well as types of complications and re-admissions. 36
Open Communications 3dHysterectomy (11:54 AM d 12:00 AM)
Development of Minimally Invasive Gynecologic Surgery Program without Robotics in Community Hopsital Stanley CJ. Division of Minimally Invasive Gynecologic Surgery, Florida Hospital Waterman, Tavares, Florida Study Objective: To demonstrate that a service line devoted to Minimally Invasive Gynecologic Surgery (MIGS) procedures could be enhanced,
without robotics, in such a manner that improves volume and is safe, effective, and fiscally responsible. Design: Review of year to year, 2009-2011, data in terms of number of cases involving advanced minimally invasive techniques prior to and after intitiation of intensive teaching program led by hospital based instructor. Setting: Suburban 220 bed community hospital in Central Florida. Patients: 1,256 women undergoing gynecologic procedures for benign indications from July of 2009 through July 2011. Intervention: In July of 2010, a surgeon trained in advanced minimally invasive gynecologic surgery (MIGS) initiated a program based in a community hospital with the goal of increasing the rate of advanced minimally invasive procedures, both endoscopic and vaginal, by teaching/ assisting the staff surgeons on all major cases. Benchmarks were as follows: Volume of total major cases; percent change in MIGS cases; and cost of program implementation. Costs were calculated using internal data and standard accounting methods. Measurements and Main Results: The majority, 85% of surgeons with gynecologic surgical privileges, took an active role in the development of the MIGS division. In the years 2009-2011, following the intitiation of the teaching program in 2010, the rate of abdominal hysterectomy fell by 39%, the rate of minimally invasive cases increased by 117%, and total gynecology cases increased by 60%. Rate of MIGS hysterectomy improved from 43% to 78% of hysterectomies. The total cost of implementation was calculated to be approximately $475,000. Conclusion: The enhancement of a MIGS service line can be achieved in a Community Hospital setting without resorting to Robotics in a cost effective manner. 37
Video Session 1dOncology (11:00 AM d 11:08 AM)
Nerve Sparing Radical Hysterectomy Made Easy by Laparoscopy Lawande A, Desai R, Puntambekar S, Puntambekar S, Telang M. Galaxy CARE Laparoscopy Institute, Pune, Maharashtra, India The most common complication of a radical hysterectomy is bladder dysfunction. To overcome this, a nerve sparing radical hysterectomy is done. The advantage of performing a nerve sparing radical hysterectomy by laparoscopy is better delineation of nerves due to the magnification enabled by a laparoscope, thus leading to better nerve preservation. Objectives: To evaluate the technical feasibility of nerve sparing radical hysterectomy performed laparoscopically. Methods: We performed laparoscopic nerve sparing radical hysterectomy in 35 patients with cancer cervix stage Ia1 and Ib1. Results: The oncological results were comparable to the conventional laparoscopic radical hysterectomy. Complete recovery of bladder functions after removal of Foleys catheter. Urodynamic studies performed after three weeks normal. Conclusion: The oncological and functional results comparable to the conventional laparoscopic radical hysterectomy. This shows that magnification enabled by laparoscope helps in better dissection and preservation of nerve anatomy.