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Operative laparoscopy: American Association of Gynecologic Laparoscopists, 1993 membership survey
1993 Membership Survey levy et al
Operative Laparoscopy: American Association of Gynecologic Laparoscopists, 1993 Membership Survey Barbara S. Levy, M.D., Jaroslav F. Hulka, M.D., Herbert B. Peterson, M.D., and Jordan M. Phillips, M.D. Abstract
The American Association oF Gynecologic Laparoscopists" 1993 membership survey on operative laparoscopy had 1205 respondents reporting 80,031 procedures. Diagnostic laparoscopy remains the most common procedure, followed by adhesiolysis and laparoscopically assisted vaginal hysterectomy. This survey was particularly designed to chronicle the rate of complications as increasingly complex laparoscopic procedures are performed.
The A m e r i c a n A s s o c i a t i o n of G y n e c o l o g i c Laparoscopists (AAGL) began collecting survey data from its members in 1988 in an effort to document trends in the distribution and complications of operative endoscopic procedures in the United States. In 1993 it was the intent to maintain a format similar to the previous surveys so that direct comparisons could be made.', 2 Additional information regarding energy sources, specific methods of hemostasis, and abdominal entry was also collected for future use. This report documents trends in operative laparoscopy procedures and complications reported retrospectively by AAGL members.
Additional information regarding complications of more complex endoscopic procedures and specific techniques was requested by the Board of Trustees. Therefore questions were added documenting the types of energy sources and equipment being used by the members. The survey was mailed to 6878 A A G L members and included questions on operative laparoscopies performed by those clinicians from January 1, 1993, through August 31, 1993. It should be noted that this survey was based on the immediately preceding 8 months in an effort to collect more meaningful and timely data.
Results The Questionnaire
Of the 6878 questionnaires mailed, 1205 (18%) were returned. All but 29 respondents (1176) reported performing operative laparoscopy in the study period. These 1176 reported performing a total of 80,031 procedures: 23,091 diagnostic laparoscopies and 7243 laparoscopic sterilizations. Excluding these two p r o c e d u r e s resulted in 49,697 o p e r a t i v e
A survey questionnaire was prepared by the A A G L Research and Survey Committee; it was reviewed and modified by the Continuing Medical Education Committee and the Board of Trustees. The wording and format of the 1993 survey were similar to the 1988 and 1991 surveys, but not identical.
301
August
1994, Vol. 1, No. 4, Part 1 The Journal of the American Association of Gynecologic Laparoscopists
laparoscopy procedures (Figure 1). Because the study period for the survey was 8 months, however, the total number of procedures estimated to have been performed during the 12 months from January 1, 1993, to December 31, .1993, was 74,545 (49,697 x 1.5), a 32% increase from the number reported in 1991. Translating data from an 8-month reporting period into a 12-month estimate allows us to compare figures from 1993 with those from surveys in 1991 and 1988 (Table 1). Compared with 1991, in 1993 there was a substantial increase in the percentage of total operative laparoscopies in which laparoscopically assisted vaginal h y s t e r e c t o m y was p e r f o r m e d , 5.0% and 18.1%, respectively. Similarly, the percentage of the total in which salpingo-oophorectomy was performed increased, 5.9% and 10.5%, respectively. Figure 2 presents the complications reported in 1993. No deaths occurred, but the numbers of bowel and urinary tract injuries were substantially greater in 1993 than in 1991. Complication rates for 1993 are difficult to compare directly with those from 1991 because the corn-
plications reported in 1993 may have been associated with diagnostic laparoscopies or with laparoscopic sterilization, whereas those in 1991 were associated only with operative laparoscopy. When we estimate the complication rate for 1993 using only operative laparoscopies (49,697) in the denominator, we are likely overestimating, as some complications from diagnostic or sterilization procedures may be included in the n u m e r a t o r but not the d e n o m i n a t o r . Conversely, when we include all procedures reported in the 8-month period in 1993 (80,031) in the denominator, we are likely to underestimate the complication rate substantially. In either case, the rates of bowel and urinary tract injuries appear to have increased substantially from 1991 to 1993 (Table 2). Postoperative hospitalization for longer than 24 hours reflects the increase in long and complex procedures. Figure 3 shows the rate of bowel injuries with sharp cannula insertion (closed technique) versus open laparoscopy (Hasson technique). Clearly the open technique does not prevent all bowel injuries.
TABLE 1. Comparison of Three AAGL Surveysof Operative Laparoscopies 1993
1991
1988
Indication or Procedure
No.
%
No.
%
No.
%
Endometrial implantsa Lysis of extensive adhesions Ovarian cyst Laparoscopic uterosacral nerve ablation for pelvic pain Ectopic pregnancy Salpingo-oophorectomy Hydrosalpinx Laparoscopically assisted vaginal hysterectomy Myomectomy Pelvic abscess Other Total procedures Total number of respondents
7168 17,503 NA
9.6 23.5 --
15,532 11,942 7393
27.5 21.1 13.1
13,336 8224 5075
36.1 22.3 13.7
6002 7232 7834 3993
8.1 9.7 10.5 5.4
4612 4620 3313 2533
8.2 8.2 5.9 4.5
4457 1914 NA 1358
12.1 5.2 -3.7
13,470 4,161 888 6,294 74,545 1176
18.1 5.6 1.2 8.4 100.0
2846 2,296 436 1,013 56,536 878
5.0 4.1 0.8 1.8 100.0
NA 1,102 265 1,197 36,928 880
-3.0 0.7 3.2 100.0
aln 1988 and 1991 the question referred to management of endometrial implants. In 1993 it referred to management of stage III or IV endometriosis. The total number of procedures reported in 1993 was 80,031 ; however, this included 23,091 diagnostic laparoscopies and 7423 tubal sterilizations. These were excluded to be comparable with the surveys in 1991 and 1988, which did not include these procedures. With these exclusions, the total for 8 months of reporting in 1993 was 49,697. To make the 1993 estimates, which were based on a reporting period of 8 months, comparable with 1991 and 1988 estimates, which were used on a reporting period of 12 months, the number of procedures reported for 1993 was multiplied by 1.5. - - -- not asked.
302
1993 Membership Survey Levy et al
Ectopic pregnancy Lysis of ext adhesions Endom stage III or IV
Luna for pelvic pain Pelvic abscess Uterine myomas
Hydrosalpinx Lap assist vag hyst
Salpingo-oophorectomy VTL Diagnostic laparoscopy Other
TOTAL CASESREPORTED
TOTAL CASES REPORTED
80,031 FIGURE 1. The number of procedures for conditions managed by laparoscopy only.
TABLE 2. Comparison of Complications Associated With Operative Laparoscopy in 1993 and 1991 Complication
Hospitalization >24 hrs Hospital readmission Unintended laparotomy Hemorrhage Transfusion for hemorrhage Bowel or urinary tract injury Nerve injury Death
1993 Rat~1000 a (rat~1000 b)
1991 Rat~1000
59.2 (36.7) 5.2 (3.2) 13.6 (8.5) 12.8 (7.9) 5.1 (3.2) 8.9 (5.5) 0.5 (0.3) 0.0 (0.0)
30.3 4.2 8.9 6.8 2.7 2.8 0.5 1.8/100,000 procedures
aRate/1000 procedures excluding diagnostic laparoscopies and laparoscopic sterilizations from the denominator, to make this denominator comparable with the one used for 1991. However, with this rate, the numerator for the 1993 estimate may include some complications that resulted from diagnostic or sterilization procedures. To the extent that this is the case, the rate may be an overestimate. bRate/1000 procedures including diagnostic laparoscopies and laparoscopic sterilizations in the denominator. Because diagnostic and sterilization procedures were not included in the denominator in 1991 and because they make up a large percentage (38%) of the total number of procedures in the denominator in 1993, this rate is likely to be a substantial underestimate.
303
August 1994, Vol. 1, No. 4, Part 1 TheJournalof the AmericanAssociationof GynecologicLaparoscopists
Fata/outcome Nerve injury Injury to ureter Injury to bladder Bowel injury Transfusion for hemor. Readrnission for cornp. > 500 ml blood loss Unintended laparotomy Hosp > 24 hrs postoper.
500
0
1,000
1,500
2,000
2,500
3,000
3,500
TOTALCASESREPORTED 80,031 FIGURE2. The numberof patientswho had complicationsin 1993.
Closed 7L'~Pl~r°sc°p
~
~ / / / / / / / ~
Open Laparoscopy - 1.2% Bowel Injuries Closed Lapamscopy - 0.15% Bowel Injuries
FIGURE3. Openversusclosedlaparoscopies. 304
OpenL~l;ag~°sc°py
J
-~ No::s%wer
1993 Membership Survey Levyet al
700 600 500 400 300 200 100
0
0
1-10
11-20
>20
#LAV/-/S TOTAL N = 1205
FIGURE 4. The number of LAVHs performed by each surgeon reporting two or more major complications over 8 months according to their surgical experience.
procedures (Figure 4). This may reflect the tendency to approach more difficult, complex cases as surgeons gain more experience. The findings suggest the need for better documentation of the complications associated with complex laparoscopic procedures. To this end, we have initiated a National Registry of Complications. We started the registry in the hope that our colleagues will use it to help improve our collective ability to maximize the safety of operative laparoscopy.
Discussion and Conclusion
The number and complexity of operative laparoscopic procedures have risen dramatically in the past 5 years. The most striking findings of the 1993 survey are the substantial increases in the number and percentage distribution of laparoscopically assisted vaginal hysterectomies, and the increase in bowel and urinary tract injuries. These findings may well be related, but because complication rates for laparoscopically assisted vaginal hysterectomy were not specifically assessed, our findings must be interpreted with caution. Clearly, not all major organ injuries are avoidable even with open laparoscopy and meticulous technique. The higher rate of bowel injury reflects the performance of open laparoscopy in difficult cases in women with several prior abdominal incisions. Although a learning curve may well exist for advanced endoscopic procedures, the number of complications goes up as surgeons do more than 20
References
1. Peterson HB, Hulka JF, Phillips JM: American Association of Gynecologic Laparoscopists' 1988 membership survey on operative laparoscopy. J Reprod Med 35:587-589, 1990 2. Hulka JF, Peterson HB, Phillips JM, et ah Operative laparoscopy: American Association of Gynecologic Laparoscopists' 1991 membership survey. J Reprod Med 38:569-571, 1993
305
Operative Laparoscopy: American Association of Gynecologic Laparoscopists, 1993 Membership Survey Barbara S. Levy, M.D., Jaroslav F. Hulka, M.D., Herbert B. Peterson, M.D., and Jordan M. Phillips, M.D. Abstract
The American Association oF Gynecologic Laparoscopists" 1993 membership survey on operative laparoscopy had 1205 respondents reporting 80,031 procedures. Diagnostic laparoscopy remains the most common procedure, followed by adhesiolysis and laparoscopically assisted vaginal hysterectomy. This survey was particularly designed to chronicle the rate of complications as increasingly complex laparoscopic procedures are performed.
The A m e r i c a n A s s o c i a t i o n of G y n e c o l o g i c Laparoscopists (AAGL) began collecting survey data from its members in 1988 in an effort to document trends in the distribution and complications of operative endoscopic procedures in the United States. In 1993 it was the intent to maintain a format similar to the previous surveys so that direct comparisons could be made.', 2 Additional information regarding energy sources, specific methods of hemostasis, and abdominal entry was also collected for future use. This report documents trends in operative laparoscopy procedures and complications reported retrospectively by AAGL members.
Additional information regarding complications of more complex endoscopic procedures and specific techniques was requested by the Board of Trustees. Therefore questions were added documenting the types of energy sources and equipment being used by the members. The survey was mailed to 6878 A A G L members and included questions on operative laparoscopies performed by those clinicians from January 1, 1993, through August 31, 1993. It should be noted that this survey was based on the immediately preceding 8 months in an effort to collect more meaningful and timely data.
Results The Questionnaire
Of the 6878 questionnaires mailed, 1205 (18%) were returned. All but 29 respondents (1176) reported performing operative laparoscopy in the study period. These 1176 reported performing a total of 80,031 procedures: 23,091 diagnostic laparoscopies and 7243 laparoscopic sterilizations. Excluding these two p r o c e d u r e s resulted in 49,697 o p e r a t i v e
A survey questionnaire was prepared by the A A G L Research and Survey Committee; it was reviewed and modified by the Continuing Medical Education Committee and the Board of Trustees. The wording and format of the 1993 survey were similar to the 1988 and 1991 surveys, but not identical.
301
August
1994, Vol. 1, No. 4, Part 1 The Journal of the American Association of Gynecologic Laparoscopists
laparoscopy procedures (Figure 1). Because the study period for the survey was 8 months, however, the total number of procedures estimated to have been performed during the 12 months from January 1, 1993, to December 31, .1993, was 74,545 (49,697 x 1.5), a 32% increase from the number reported in 1991. Translating data from an 8-month reporting period into a 12-month estimate allows us to compare figures from 1993 with those from surveys in 1991 and 1988 (Table 1). Compared with 1991, in 1993 there was a substantial increase in the percentage of total operative laparoscopies in which laparoscopically assisted vaginal h y s t e r e c t o m y was p e r f o r m e d , 5.0% and 18.1%, respectively. Similarly, the percentage of the total in which salpingo-oophorectomy was performed increased, 5.9% and 10.5%, respectively. Figure 2 presents the complications reported in 1993. No deaths occurred, but the numbers of bowel and urinary tract injuries were substantially greater in 1993 than in 1991. Complication rates for 1993 are difficult to compare directly with those from 1991 because the corn-
plications reported in 1993 may have been associated with diagnostic laparoscopies or with laparoscopic sterilization, whereas those in 1991 were associated only with operative laparoscopy. When we estimate the complication rate for 1993 using only operative laparoscopies (49,697) in the denominator, we are likely overestimating, as some complications from diagnostic or sterilization procedures may be included in the n u m e r a t o r but not the d e n o m i n a t o r . Conversely, when we include all procedures reported in the 8-month period in 1993 (80,031) in the denominator, we are likely to underestimate the complication rate substantially. In either case, the rates of bowel and urinary tract injuries appear to have increased substantially from 1991 to 1993 (Table 2). Postoperative hospitalization for longer than 24 hours reflects the increase in long and complex procedures. Figure 3 shows the rate of bowel injuries with sharp cannula insertion (closed technique) versus open laparoscopy (Hasson technique). Clearly the open technique does not prevent all bowel injuries.
TABLE 1. Comparison of Three AAGL Surveysof Operative Laparoscopies 1993
1991
1988
Indication or Procedure
No.
%
No.
%
No.
%
Endometrial implantsa Lysis of extensive adhesions Ovarian cyst Laparoscopic uterosacral nerve ablation for pelvic pain Ectopic pregnancy Salpingo-oophorectomy Hydrosalpinx Laparoscopically assisted vaginal hysterectomy Myomectomy Pelvic abscess Other Total procedures Total number of respondents
7168 17,503 NA
9.6 23.5 --
15,532 11,942 7393
27.5 21.1 13.1
13,336 8224 5075
36.1 22.3 13.7
6002 7232 7834 3993
8.1 9.7 10.5 5.4
4612 4620 3313 2533
8.2 8.2 5.9 4.5
4457 1914 NA 1358
12.1 5.2 -3.7
13,470 4,161 888 6,294 74,545 1176
18.1 5.6 1.2 8.4 100.0
2846 2,296 436 1,013 56,536 878
5.0 4.1 0.8 1.8 100.0
NA 1,102 265 1,197 36,928 880
-3.0 0.7 3.2 100.0
aln 1988 and 1991 the question referred to management of endometrial implants. In 1993 it referred to management of stage III or IV endometriosis. The total number of procedures reported in 1993 was 80,031 ; however, this included 23,091 diagnostic laparoscopies and 7423 tubal sterilizations. These were excluded to be comparable with the surveys in 1991 and 1988, which did not include these procedures. With these exclusions, the total for 8 months of reporting in 1993 was 49,697. To make the 1993 estimates, which were based on a reporting period of 8 months, comparable with 1991 and 1988 estimates, which were used on a reporting period of 12 months, the number of procedures reported for 1993 was multiplied by 1.5. - - -- not asked.
302
1993 Membership Survey Levy et al
Ectopic pregnancy Lysis of ext adhesions Endom stage III or IV
Luna for pelvic pain Pelvic abscess Uterine myomas
Hydrosalpinx Lap assist vag hyst
Salpingo-oophorectomy VTL Diagnostic laparoscopy Other
TOTAL CASESREPORTED
TOTAL CASES REPORTED
80,031 FIGURE 1. The number of procedures for conditions managed by laparoscopy only.
TABLE 2. Comparison of Complications Associated With Operative Laparoscopy in 1993 and 1991 Complication
Hospitalization >24 hrs Hospital readmission Unintended laparotomy Hemorrhage Transfusion for hemorrhage Bowel or urinary tract injury Nerve injury Death
1993 Rat~1000 a (rat~1000 b)
1991 Rat~1000
59.2 (36.7) 5.2 (3.2) 13.6 (8.5) 12.8 (7.9) 5.1 (3.2) 8.9 (5.5) 0.5 (0.3) 0.0 (0.0)
30.3 4.2 8.9 6.8 2.7 2.8 0.5 1.8/100,000 procedures
aRate/1000 procedures excluding diagnostic laparoscopies and laparoscopic sterilizations from the denominator, to make this denominator comparable with the one used for 1991. However, with this rate, the numerator for the 1993 estimate may include some complications that resulted from diagnostic or sterilization procedures. To the extent that this is the case, the rate may be an overestimate. bRate/1000 procedures including diagnostic laparoscopies and laparoscopic sterilizations in the denominator. Because diagnostic and sterilization procedures were not included in the denominator in 1991 and because they make up a large percentage (38%) of the total number of procedures in the denominator in 1993, this rate is likely to be a substantial underestimate.
303
August 1994, Vol. 1, No. 4, Part 1 TheJournalof the AmericanAssociationof GynecologicLaparoscopists
Fata/outcome Nerve injury Injury to ureter Injury to bladder Bowel injury Transfusion for hemor. Readrnission for cornp. > 500 ml blood loss Unintended laparotomy Hosp > 24 hrs postoper.
500
0
1,000
1,500
2,000
2,500
3,000
3,500
TOTALCASESREPORTED 80,031 FIGURE2. The numberof patientswho had complicationsin 1993.
Closed 7L'~Pl~r°sc°p
~
~ / / / / / / / ~
Open Laparoscopy - 1.2% Bowel Injuries Closed Lapamscopy - 0.15% Bowel Injuries
FIGURE3. Openversusclosedlaparoscopies. 304
OpenL~l;ag~°sc°py
J
-~ No::s%wer
1993 Membership Survey Levyet al
700 600 500 400 300 200 100
0
0
1-10
11-20
>20
#LAV/-/S TOTAL N = 1205
FIGURE 4. The number of LAVHs performed by each surgeon reporting two or more major complications over 8 months according to their surgical experience.
procedures (Figure 4). This may reflect the tendency to approach more difficult, complex cases as surgeons gain more experience. The findings suggest the need for better documentation of the complications associated with complex laparoscopic procedures. To this end, we have initiated a National Registry of Complications. We started the registry in the hope that our colleagues will use it to help improve our collective ability to maximize the safety of operative laparoscopy.
Discussion and Conclusion
The number and complexity of operative laparoscopic procedures have risen dramatically in the past 5 years. The most striking findings of the 1993 survey are the substantial increases in the number and percentage distribution of laparoscopically assisted vaginal hysterectomies, and the increase in bowel and urinary tract injuries. These findings may well be related, but because complication rates for laparoscopically assisted vaginal hysterectomy were not specifically assessed, our findings must be interpreted with caution. Clearly, not all major organ injuries are avoidable even with open laparoscopy and meticulous technique. The higher rate of bowel injury reflects the performance of open laparoscopy in difficult cases in women with several prior abdominal incisions. Although a learning curve may well exist for advanced endoscopic procedures, the number of complications goes up as surgeons do more than 20
References
1. Peterson HB, Hulka JF, Phillips JM: American Association of Gynecologic Laparoscopists' 1988 membership survey on operative laparoscopy. J Reprod Med 35:587-589, 1990 2. Hulka JF, Peterson HB, Phillips JM, et ah Operative laparoscopy: American Association of Gynecologic Laparoscopists' 1991 membership survey. J Reprod Med 38:569-571, 1993
305