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P495 Total laparoscopic hysterectomy a case report of a modified technique
S554
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
P494 Total laparoscopic hysterectomy (TLH) using the Ligasure 5 mm sealer/divider system and the Hohl uterine manipulator
detection of the ureter. First step uterine coagulation reduces the total blood loss and decreases the surgical time.
D. Seeger. Marienhospital
P496 A combination of misoprostol and estradiol for pre-operative cervical ripening in postmenopausal women: A randomised controlled trial1,2 K. Oppegaard1 , M. Lieng2 , A. Berg2 , O. Istre2 , E. Qvigstad2 , B. Nesheim2 . 1 Dept. of Gynaecology, Helse Finnmark HF, Klinikk Hammerfest, 2 The Woman’s Clinic, Oslo University Hospital Ullev˚ al
Objectives: This study was undertaken to assess safety and efficacy of total laparoscopic hysterectomy using the Ligasure bipolar diathermy system for vessel sealing/tissue dividing and the Hohl uterine manipulator in routine practice. Patients and Methods: In a retrospective study, medical records of 112 patients who underwent total laparoscopic hysterectomy (TLH) between November 2006 and October 2008 were reviewed. TLH was done due to benign uterine pathology with or without salpingo-oophorectomy. All hysterectomies were performed by using the Ligasure system (Covidien Inc.), the Hohl uterine manipulator for elevation of the uterus and the Image 1 HD endoscopy video platform (Storz Inc.). Demographic data, mean operating time, uterine weight, change in hemoglobin concentration, rate of conversion to abdominal approach and intra-/ postoperative complications were analyzed. Results: The mean age of the patients was 47±6.55 years, the body mass index 25.8±3.0 kg/m2 , the mean operating time was 84.5±15.2 min, the mean uterine weight 246.3±174.2 g. Hemoglobin decreased a mean of 1.5±0.7 g/dl by postoperative day 1. One patient converted to laparotomy because of severe adhesions, no postoperative complications were observed. Conclusions: Total laparoscopic hysterectomy using the Ligasure system and the Hohl uterine manipulator appears to be a safe method of surgery with less intraoperative bleeding. The use of the Hohl manipulator simplifies the TLH procedure. P495 Total laparoscopic hysterectomy a case report of a modified technique C. Vasile1 , P. Litta2 , M. Vasile3 . 1 Hospital Mirano Venice Italy, 2 University of Padova Italy, 3 Clinic Hospital 5 University of Timisoara Romania Laparoscopic hysterectomy was first performed by Reich in 1989 and within the last decades became a widely performed procedure. The benefits of the laparoscopic route including less postoperative discomfort and shorter recovery determined a constant development of laparoscopic instruments and techniques. Disadvantages of monopolar energy, the limits of bipolar coagulation and the frequent changes of instruments during LPS procedure emphasize the benefits of the Harmonic Scalpel allowing to perform dissection and coagulation with a minimal thermal side effect for surrounding tissues. Coagulation of uterine arteries at the beginning of the procedure inverting the conventional hysterectomy times may result a semplified more rapid technique with less blood loss. We present a case report of a total laparoscopic hysterectomy performed for fibromatosis by Harmonic Scalpel with Litta modified technique. The weight of the uterus was 580 gr. No intra or post operative complications occurred. The operative time was 130 min (utersu was extracted by the vagina usign hemisection as electric morcellation was not available) The patient hospital stay was 3 days. The Harmonic Scalpel is a versatile device which allows cutting and coagulation without changes of the instrument and contributes to have a more clean and smoke free surgical field, reducing operation time. Its minimal thermal side effects on the surrounding tissues may determine a more rapid healing with less postoperative discomfort. Total inverted laparoscopic hysterectomy using the modified LITTA technique consists of the coagulation of the uterine pedicle at the beginning of the intervention after the dissection of the vesicouterine peritoneum. The dissection of the anterior leaf of the broad ligament preserving the posterior leaf permits a better
Objectives: To compare the impact of 1000 micrograms of selfadministered vaginal misoprostol versus self-administered vaginal placebo on pre-operative cervical ripening after two weeks pretreatment with estradiol vaginal tablets in postmenopausal women prior to day-care operative hysteroscopy. Design: Randomised double blind placebo controlled sequential trial. The boundaries for the sequential trial were calculated on the primary outcomes of a difference of cervical dilatation ≥1 mm, with the assumption of a type 1 error of 0.05 and a power of 0.95. Setting: Norwegian university teaching hospital. Population: Sixty-seven postmenopausal women referred for daycare operative hysteroscopy. Methods: The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before day-care operative hysteroscopy. All women had administered a 25 microgram vaginal estradiol tablet daily for 14 days prior to the operation. Main outcome measures: Primary efficacy outcome: pre-operative cervical dilatation at hysteroscopy (difference between misoprostol and placebo group). Secondary efficacy outcomes: difference in dilatation at recruitment and before hysteroscopy, number of women who achieve a pre-operative cervical dilatation ≥5 mm, acceptability, complications and side-effects. Funding sources: No pharmaceutical company was involved in this study. Research grants from the regional research board of Northern Norway and from Helse Øst funded the study. Results: The mean cervical dilatation was 5.7 mm (SD 1.6) in the misoprostol group and 4.7 mm (SD 1.5) in the placebo group, the mean difference in cervical dilatation being 1.0 mm (95% CI 0.2– 1.7). In the misoprostol group, 88% achieved a cervical dilatation of ≥5 mm compared with 59% in the placebo group. One woman (3%) who received misoprostol was difficult to dilate compared to seven (21%) who received placebo. In the misoprostol group, 13 women (39%) reported mild to moderate lower abdominal pain, compared to 8 women (24%) in the placebo group. Two women in the misoprostol group (6.1%) experienced light pre-operative bleeding. Most women did not experience misoprostol-related sideeffects. All the women managed to take the estradiol tablets and misoprostol capsules as prescribed. The majority (91%) of women found self-administered vaginal misoprostol the evening before day care hysteroscopy, after pre-treatment with vaginal estradiol tablets for 14 days, to be acceptable. There were two complications (uterine perforations), one in each treatment group. Conclusions: One thousand micrograms of self-administered vaginal misoprostol 12 hours prior to day care hysteroscopy, after 14 days pre-treatment with vaginal estradiol, has a significant cervical ripening effect compared with placebo in postmenopausal women. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before day care hysteroscopy is safe and highly acceptable, although a small proportion of women experienced lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is cheap and easy to use. Reference(s) [1] European Clinical Trials Database Number: 2007-004083-52. [2] ClinicalTrials.gov Number: NCT00572819.
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
P494 Total laparoscopic hysterectomy (TLH) using the Ligasure 5 mm sealer/divider system and the Hohl uterine manipulator
detection of the ureter. First step uterine coagulation reduces the total blood loss and decreases the surgical time.
D. Seeger. Marienhospital
P496 A combination of misoprostol and estradiol for pre-operative cervical ripening in postmenopausal women: A randomised controlled trial1,2 K. Oppegaard1 , M. Lieng2 , A. Berg2 , O. Istre2 , E. Qvigstad2 , B. Nesheim2 . 1 Dept. of Gynaecology, Helse Finnmark HF, Klinikk Hammerfest, 2 The Woman’s Clinic, Oslo University Hospital Ullev˚ al
Objectives: This study was undertaken to assess safety and efficacy of total laparoscopic hysterectomy using the Ligasure bipolar diathermy system for vessel sealing/tissue dividing and the Hohl uterine manipulator in routine practice. Patients and Methods: In a retrospective study, medical records of 112 patients who underwent total laparoscopic hysterectomy (TLH) between November 2006 and October 2008 were reviewed. TLH was done due to benign uterine pathology with or without salpingo-oophorectomy. All hysterectomies were performed by using the Ligasure system (Covidien Inc.), the Hohl uterine manipulator for elevation of the uterus and the Image 1 HD endoscopy video platform (Storz Inc.). Demographic data, mean operating time, uterine weight, change in hemoglobin concentration, rate of conversion to abdominal approach and intra-/ postoperative complications were analyzed. Results: The mean age of the patients was 47±6.55 years, the body mass index 25.8±3.0 kg/m2 , the mean operating time was 84.5±15.2 min, the mean uterine weight 246.3±174.2 g. Hemoglobin decreased a mean of 1.5±0.7 g/dl by postoperative day 1. One patient converted to laparotomy because of severe adhesions, no postoperative complications were observed. Conclusions: Total laparoscopic hysterectomy using the Ligasure system and the Hohl uterine manipulator appears to be a safe method of surgery with less intraoperative bleeding. The use of the Hohl manipulator simplifies the TLH procedure. P495 Total laparoscopic hysterectomy a case report of a modified technique C. Vasile1 , P. Litta2 , M. Vasile3 . 1 Hospital Mirano Venice Italy, 2 University of Padova Italy, 3 Clinic Hospital 5 University of Timisoara Romania Laparoscopic hysterectomy was first performed by Reich in 1989 and within the last decades became a widely performed procedure. The benefits of the laparoscopic route including less postoperative discomfort and shorter recovery determined a constant development of laparoscopic instruments and techniques. Disadvantages of monopolar energy, the limits of bipolar coagulation and the frequent changes of instruments during LPS procedure emphasize the benefits of the Harmonic Scalpel allowing to perform dissection and coagulation with a minimal thermal side effect for surrounding tissues. Coagulation of uterine arteries at the beginning of the procedure inverting the conventional hysterectomy times may result a semplified more rapid technique with less blood loss. We present a case report of a total laparoscopic hysterectomy performed for fibromatosis by Harmonic Scalpel with Litta modified technique. The weight of the uterus was 580 gr. No intra or post operative complications occurred. The operative time was 130 min (utersu was extracted by the vagina usign hemisection as electric morcellation was not available) The patient hospital stay was 3 days. The Harmonic Scalpel is a versatile device which allows cutting and coagulation without changes of the instrument and contributes to have a more clean and smoke free surgical field, reducing operation time. Its minimal thermal side effects on the surrounding tissues may determine a more rapid healing with less postoperative discomfort. Total inverted laparoscopic hysterectomy using the modified LITTA technique consists of the coagulation of the uterine pedicle at the beginning of the intervention after the dissection of the vesicouterine peritoneum. The dissection of the anterior leaf of the broad ligament preserving the posterior leaf permits a better
Objectives: To compare the impact of 1000 micrograms of selfadministered vaginal misoprostol versus self-administered vaginal placebo on pre-operative cervical ripening after two weeks pretreatment with estradiol vaginal tablets in postmenopausal women prior to day-care operative hysteroscopy. Design: Randomised double blind placebo controlled sequential trial. The boundaries for the sequential trial were calculated on the primary outcomes of a difference of cervical dilatation ≥1 mm, with the assumption of a type 1 error of 0.05 and a power of 0.95. Setting: Norwegian university teaching hospital. Population: Sixty-seven postmenopausal women referred for daycare operative hysteroscopy. Methods: The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before day-care operative hysteroscopy. All women had administered a 25 microgram vaginal estradiol tablet daily for 14 days prior to the operation. Main outcome measures: Primary efficacy outcome: pre-operative cervical dilatation at hysteroscopy (difference between misoprostol and placebo group). Secondary efficacy outcomes: difference in dilatation at recruitment and before hysteroscopy, number of women who achieve a pre-operative cervical dilatation ≥5 mm, acceptability, complications and side-effects. Funding sources: No pharmaceutical company was involved in this study. Research grants from the regional research board of Northern Norway and from Helse Øst funded the study. Results: The mean cervical dilatation was 5.7 mm (SD 1.6) in the misoprostol group and 4.7 mm (SD 1.5) in the placebo group, the mean difference in cervical dilatation being 1.0 mm (95% CI 0.2– 1.7). In the misoprostol group, 88% achieved a cervical dilatation of ≥5 mm compared with 59% in the placebo group. One woman (3%) who received misoprostol was difficult to dilate compared to seven (21%) who received placebo. In the misoprostol group, 13 women (39%) reported mild to moderate lower abdominal pain, compared to 8 women (24%) in the placebo group. Two women in the misoprostol group (6.1%) experienced light pre-operative bleeding. Most women did not experience misoprostol-related sideeffects. All the women managed to take the estradiol tablets and misoprostol capsules as prescribed. The majority (91%) of women found self-administered vaginal misoprostol the evening before day care hysteroscopy, after pre-treatment with vaginal estradiol tablets for 14 days, to be acceptable. There were two complications (uterine perforations), one in each treatment group. Conclusions: One thousand micrograms of self-administered vaginal misoprostol 12 hours prior to day care hysteroscopy, after 14 days pre-treatment with vaginal estradiol, has a significant cervical ripening effect compared with placebo in postmenopausal women. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before day care hysteroscopy is safe and highly acceptable, although a small proportion of women experienced lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is cheap and easy to use. Reference(s) [1] European Clinical Trials Database Number: 2007-004083-52. [2] ClinicalTrials.gov Number: NCT00572819.