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Single-Port Laparoscopically Assisted-Transumbilical Ultraminilaparotomic Myomectomy (SPLA-TUM)
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S95–S132 301
Open Communications 17dLaparoscopy (3:56 PM d 4:01 PM)
Patient and Hospital Factors Associated with Route of Hysterectomy in British Columbia Chen I, Lisonkova S, Allaire C, Williams C, Yong P, Joseph KS. Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada Study Objective: To examine temporal trends and patient and hospital factors associated with routes of hysterectomy in British Columbia. Design: Hospital admission, operating room, and emergency room data were linked to conduct a retrospective cohort study of routes of hysterectomy. Logistic regression modeling with mixed effects was used to estimate adjusted odds ratios (AOR) and 95% confidence intervals (CI) for patient factors and hospital characteristics. Setting: Eight hospitals in the Vancouver Coastal Health and Providence Health service areas in British Columbia, Canada. Patients: 4372 consecutive women who had elective hysterectomy for benign gynaecologic indications from 2007 to 2011. Intervention: Abdominal, vaginal, and laparoscopic hysterectomy. Measurements and Main Results: Abdominal hysterectomies decreased from 58.4% in 2007 to 47.7% in 2011; vaginal hysterectomies decreased from 27.5% to 21.1%; and laparoscopic hysterectomies increased from 14.2% to 31.2% (p\0.001 for all trends). Patient factors associated with laparoscopic hysterectomy were young age (AOR=4.59, CI 2.10-10.0 for \30 vs. 40-49 years), indication of pain (AOR=2.08, CI 1.53-2.83) or prolapse (AOR=3.28, CI 2.14-5.03), absence of fibroids (AOR=0.37, CI 0.29-0.46), absence of concurrent ovarian (AOR=0.71, CI 0.58-0.86) or prolapse (AOR=0.50, CI 0.29-0.85) procedure, rural residence (AOR=1.89, CI 1.28-2.78), and higher socioeconomic status (AOR=0.58, CI 0.46-0.74 for lowest vs. highest quintile). Patient factors associated with vaginal hysterectomy included older age (AOR= 1.75, CI 1.05-2.92), prolapse indication (AOR= 34.4, CI 21.1-56.3), and concurrent procedure for prolapse (AOR= 1.68, CI 1.07-2.64). After adjustment for patient characteristics, urban hospital location was associated with laparoscopic hysterectomy (AOR= 22.2, CI 2.6-192.3). No differences were seen in need for intensive care, return to emergency room, or rehospitalisation. Conclusion: The proportion of minimally invasive hysterectomies has increased significantly in recent years. Vaginal hysterectomies are associated with patient clinical factors, while laparoscopic hysterectomies are associated with clinical, sociodemographic, and hospital characteristics.
302
S95
wound closure. Evaluations were recorded at 3, 6 and 12 months following wound closure. Intervention: The surgical technique entailed the placement of deep sutures in the subcutaneous fat. Additionally, a subcuticular (subdermal) suture was placed. For topical closure with Prolene, the running subcuticular was placed by taking horizontal bites through the dermis. Topical wound closure with LeukosanÒ SkinLink was performed according to the manual. Measurements and Main Results: Both methods of wound closure scored equally high on the visual analogue scale for cosmetic evaluation at the 3-, 6and 12-month follow-ups as assessed by the patient, surgeon and the blinded observers. Conclusion: The results from our study show that the new wound closure device was comparable to the standard method of suturing in all aspects investigated. The new wound closure device represents a valid alternative to traditional suturing for large or small wounds leaving patients and surgeons with an additional non-invasive option. Practical implementions of the method in minimal invasive surgery were estabished. 303
Open Communications 17dLaparoscopy (4:08 PM d 4:13 PM)
Single-Port Laparoscopically Assisted-Transumbilical Ultraminilaparotomic Myomectomy (SPLA-TUM) Lee JH,1 Kim JY,1 Lee DH,1 Eom JM.2 1Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; 2Obstetrics and Gynecology, National Medical Center, Seoul, Republic of Korea Study Objective: The aim of this study is to describe the surgical technique and our initial experience with single-port laparoscopically assisted transumbilical ultraminilaparotomic myomectomy (SPLA-TUM).
Open Communications 17dLaparoscopy (4:02 PM d 4:07 PM)
A Randomized, Controlled Study Comparing the Cosmetic Outcome of a New Wound Closure Device with Prolene Suture Closing Caesarean Wounds Juergens S, Buchweitz O, Moeller C, Nugent W, Krueger E, Nugent A, Biel P, Bazargan M. Gynecological Surgery, Tagesklinik Altonaer Strasse, Hamburg, Germany Study Objective: A prospective, randomised study was conducted to compare the wound closure performance and cosmetic outcome of caesarean section wounds closed with traditional Prolene suture or a new wound closure device (LeukosanÒ SkinLink). Design: Prospective randomized clinical trial. Setting: - Aim of this study was to compare a new wound closure device (LeukosanÒ SkinLink) with standard suture for its cosmetic outcome after surgery - Caesarean sections were chosen as this is a common yet challenging surgery with no agreed standard on operative techniques and materials to be used for wound closure. - Practical implementions of the method in minimal invasive surgery were estabished. Patients: Sixty-one patients referred to primary section were allocated to wound closure with either LeukosanÒ SkinLink or Prolene suture. Cosmetic outcome as the primary measure was evaluated by the patient, the surgeon as well as by independent examiners blinded to the method of
Design: Prospective observational study. Setting: A university hospital and a tertiary care center. Patients: Fifteen women with symptomatic subserosal or superficial intramural myomas (% 8 cm) underwent SPLA-TUM from July 2012 to August 2012. Intervention: SPLA-TUM. Measurements and Main Results: The patients’ mean age, parity, body mass index, and number of previous abdominal surgeries were 35.3 5.3 years, 0.5 0.8, 21.5 3.0 kg/m2, and 0.4 0.7, respectively. The mean operating time, hemoglobin change, return of bowel activity, and length of hospital stay were 64.9 9.5 minutes, 1.2 0.5 g/dL, 32.8 3.5
S96
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S95–S132
hours, and 3.1 0.4 days, respectively. Because SPLA-TUM did not provide a satisfactory surgical field, SPLA-TUM was converted to singleport laparoscopic myomectomy in one woman (6.7%). There were no surgical or wound complications. Conclusion: SPLA-TUM, which was designed by integrating the surgical techniques of single-port laparoscopy and laparotomy, can reduce the operating time compared with SP-LM by permitting comfortable suturing and reliable knotting while maintaining the advantages of single-port laparoscopy. SPLA-TUM is a feasible alternative in selected patients with symptomatic myoma. 304
Open Communications 17dLaparoscopy (4:14 PM d 4:19 PM)
Predictive Factors for Laparoscopic Conversion to Laparotomy and Associated Outcomes Mack-Deberardinis L,1 Dion M,2 Morosky C.3 1Obstetrics and Gynecology, University of Connecticut Integrated Residency Program, Farmington, Connecticut; 2University of Connecticut School of Medicine, Farmington, Connecticut; 3Obstetrics and Gynecology, The Hospital of Central Connecticut, New Britain, Connecticut Study Objective: Laparoscopic surgery has multiple benefits to the patient when compared to laparotomy; however, laparoscopic conversion to laparotomy may be associated with increased complications compared to laparotomy alone. The aims of this study were to identify predictive factors for conversion, and to evaluate the associated outcomes when compared to planned laparotomy. Design: We performed a retrospective case-control study of all patients who underwent conversion from January 1, 2007 to December 31, 2011. Laparoscopy and laparotomy control patients were matched to each conversion case in a 2 to 1 ratio. Setting: Community-based, university-affiliated teaching hospital. Patients: All laparoscopic oophorectomies and hysterectomies converted to laparotomy were included. Robotic surgeries and malignancies were excluded. Control patients were matched for type of surgery and when possible pathologic diagnosis. Intervention: Laparoscopy controls were compared to conversion cases to identify predictive factors for conversion including body mass index (BMI), uterine weight, and number of prior laparotomies and minimally invasive surgeries. Laparotomy controls were compared to the same conversion cases to evaluate outcomes including estimated blood loss, operating time, total and individual complications. Measurements and Main Results: A total of 53 laparoscopic conversions were identified. The majority of conversions were performed for adhesions (47.2%) or mass effect (28.3%). Compared to laparoscopy controls, conversion cases had more prior laparotomies and larger uterine weight (table 1). Compared to laparotomy controls, conversion patients had a longer operating time and more organ injury complications (table 2). Table 1 Conversion versus Laparoscopy
BMI # MIS # ExLap Uterine Weight (grams)
Conversion
Laparoscopy
n=53
n=106
p-value
30.7 0.9 0.84 427
28.8 0.54 0.36 192
0.22 0.24 0.003 0.02
BMI (body mass index); # MIS (number prior minimally invasive surgeries); # ExLap (number prior laparotomies)
Conclusion: Risk factors for laparoscopic conversion to laparotomy include increased number of prior laparotomies and increased size of the pelvic pathology. Patients who are converted to laparotomy undergo longer procedures, and are at increased risk of organ damage as compared to
Table 2 Conversion versus Laparotomy
EBL (cc) OR Time (minutes) Complications Total Organ Injury Transfusion Vascular Injury
Conversion
Laparotomy
n=53
n=106
p-value
432 165
320 136
0.10 0.002
16 9 6 1
16 (15%) 3 (3%) 13 (12%) 0
0.04 0.003 1.00 0.33
(30%) (17%) (11%) (2%)
EBL (estimated blood loss); cc (cubic centimeter); OR (operating room)
planned laparotomy. Patients at high risk for conversion may benefit from planned laparotomy or robot-assisted laparoscopic surgery. 305
Open Communications 17dLaparoscopy (4:20 PM d 4:25 PM)
Complications with Myoma Screw While Using as Uterine Manipulator in Total Laparoscopic Hysterectomy Magdum AA, Padiyath HR, Puthiyidom A, Trehan N. Obstetrics and Gynecology, Sunrise Hospital, Ernakulam, Kerala, India Study Objective: Uterine manipulation plays vital role during total laparoscopic hysterectomy (TLH). We share our experience with myoma screw when it is used as sole uterine manipulator during TLH with an aim to evaluate the safety of myoma screw in terms of complications. Design: This is a retrospective analysis of women who have undergone TLH between Jan 2008 to February 2012 where myoma screw was used for uterine manipulation. Complications with use of myoma screw were documented. Setting: Tertiary care center. Patients: All women who had undergone TLH during study period were included in this study. Myoma screw is the only uterine manipulator used since January 2008 at this cneter. Intervention: 5 mm specially designed myoma screw was used as sole uterine manipulator through one of the accessory ports. For few larger uteri, whenever necessary, myoma screw position was changed to another suitable site or additional myoma screw was inserted. Measurements and Main Results: 2880 women underwent TLH during the study period where myoma screw was used as uterine manipulator. In 40% of cases uterus was larger than 20 weeks size. In 231 (8%) cases there was minor difficulty to tackle right sided pedicles of uterus. Additional trocar was inserted in 12 (0.4%) cases due to difficulty in uterine manipulation (excessively enlarged size of uterus). In 9 (0.3%) cases two myoma screws were used. In 10 cases (0.34%) there was serosal bowel injury. In 6 cases (0.2%) there was bowel injury involving complete thickness of wall which was sutured laparoscopically. There was bleeding from omental injury in one case. Bipolar coagulation was used for significant bleeding from myoma screw site in 44(1.5%) cases. Difficulty in uterine manipulation due to atrophic size of uterus was encountered in 2% of atrophic uteri. Conclusion: Myoma screw is one of the most effective and cheapest uterine manipulators for TLH. 306
Open Communications 17dLaparoscopy (4:26 PM d 4:31 PM)
Laparoscopic Management of Giant Adnexal Cysts: Technique and Initial Results Ribeiro SC, Miyahara CBdF, Tormena RA, Pamplona I, Arazawa STN, Baracat EC. Obstetrics and Gynecology, Clinics Hospital, Sao Paulo University Medical School, S~ao Paulo, SP, Brazil
Open Communications 17dLaparoscopy (3:56 PM d 4:01 PM)
Patient and Hospital Factors Associated with Route of Hysterectomy in British Columbia Chen I, Lisonkova S, Allaire C, Williams C, Yong P, Joseph KS. Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada Study Objective: To examine temporal trends and patient and hospital factors associated with routes of hysterectomy in British Columbia. Design: Hospital admission, operating room, and emergency room data were linked to conduct a retrospective cohort study of routes of hysterectomy. Logistic regression modeling with mixed effects was used to estimate adjusted odds ratios (AOR) and 95% confidence intervals (CI) for patient factors and hospital characteristics. Setting: Eight hospitals in the Vancouver Coastal Health and Providence Health service areas in British Columbia, Canada. Patients: 4372 consecutive women who had elective hysterectomy for benign gynaecologic indications from 2007 to 2011. Intervention: Abdominal, vaginal, and laparoscopic hysterectomy. Measurements and Main Results: Abdominal hysterectomies decreased from 58.4% in 2007 to 47.7% in 2011; vaginal hysterectomies decreased from 27.5% to 21.1%; and laparoscopic hysterectomies increased from 14.2% to 31.2% (p\0.001 for all trends). Patient factors associated with laparoscopic hysterectomy were young age (AOR=4.59, CI 2.10-10.0 for \30 vs. 40-49 years), indication of pain (AOR=2.08, CI 1.53-2.83) or prolapse (AOR=3.28, CI 2.14-5.03), absence of fibroids (AOR=0.37, CI 0.29-0.46), absence of concurrent ovarian (AOR=0.71, CI 0.58-0.86) or prolapse (AOR=0.50, CI 0.29-0.85) procedure, rural residence (AOR=1.89, CI 1.28-2.78), and higher socioeconomic status (AOR=0.58, CI 0.46-0.74 for lowest vs. highest quintile). Patient factors associated with vaginal hysterectomy included older age (AOR= 1.75, CI 1.05-2.92), prolapse indication (AOR= 34.4, CI 21.1-56.3), and concurrent procedure for prolapse (AOR= 1.68, CI 1.07-2.64). After adjustment for patient characteristics, urban hospital location was associated with laparoscopic hysterectomy (AOR= 22.2, CI 2.6-192.3). No differences were seen in need for intensive care, return to emergency room, or rehospitalisation. Conclusion: The proportion of minimally invasive hysterectomies has increased significantly in recent years. Vaginal hysterectomies are associated with patient clinical factors, while laparoscopic hysterectomies are associated with clinical, sociodemographic, and hospital characteristics.
302
S95
wound closure. Evaluations were recorded at 3, 6 and 12 months following wound closure. Intervention: The surgical technique entailed the placement of deep sutures in the subcutaneous fat. Additionally, a subcuticular (subdermal) suture was placed. For topical closure with Prolene, the running subcuticular was placed by taking horizontal bites through the dermis. Topical wound closure with LeukosanÒ SkinLink was performed according to the manual. Measurements and Main Results: Both methods of wound closure scored equally high on the visual analogue scale for cosmetic evaluation at the 3-, 6and 12-month follow-ups as assessed by the patient, surgeon and the blinded observers. Conclusion: The results from our study show that the new wound closure device was comparable to the standard method of suturing in all aspects investigated. The new wound closure device represents a valid alternative to traditional suturing for large or small wounds leaving patients and surgeons with an additional non-invasive option. Practical implementions of the method in minimal invasive surgery were estabished. 303
Open Communications 17dLaparoscopy (4:08 PM d 4:13 PM)
Single-Port Laparoscopically Assisted-Transumbilical Ultraminilaparotomic Myomectomy (SPLA-TUM) Lee JH,1 Kim JY,1 Lee DH,1 Eom JM.2 1Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; 2Obstetrics and Gynecology, National Medical Center, Seoul, Republic of Korea Study Objective: The aim of this study is to describe the surgical technique and our initial experience with single-port laparoscopically assisted transumbilical ultraminilaparotomic myomectomy (SPLA-TUM).
Open Communications 17dLaparoscopy (4:02 PM d 4:07 PM)
A Randomized, Controlled Study Comparing the Cosmetic Outcome of a New Wound Closure Device with Prolene Suture Closing Caesarean Wounds Juergens S, Buchweitz O, Moeller C, Nugent W, Krueger E, Nugent A, Biel P, Bazargan M. Gynecological Surgery, Tagesklinik Altonaer Strasse, Hamburg, Germany Study Objective: A prospective, randomised study was conducted to compare the wound closure performance and cosmetic outcome of caesarean section wounds closed with traditional Prolene suture or a new wound closure device (LeukosanÒ SkinLink). Design: Prospective randomized clinical trial. Setting: - Aim of this study was to compare a new wound closure device (LeukosanÒ SkinLink) with standard suture for its cosmetic outcome after surgery - Caesarean sections were chosen as this is a common yet challenging surgery with no agreed standard on operative techniques and materials to be used for wound closure. - Practical implementions of the method in minimal invasive surgery were estabished. Patients: Sixty-one patients referred to primary section were allocated to wound closure with either LeukosanÒ SkinLink or Prolene suture. Cosmetic outcome as the primary measure was evaluated by the patient, the surgeon as well as by independent examiners blinded to the method of
Design: Prospective observational study. Setting: A university hospital and a tertiary care center. Patients: Fifteen women with symptomatic subserosal or superficial intramural myomas (% 8 cm) underwent SPLA-TUM from July 2012 to August 2012. Intervention: SPLA-TUM. Measurements and Main Results: The patients’ mean age, parity, body mass index, and number of previous abdominal surgeries were 35.3 5.3 years, 0.5 0.8, 21.5 3.0 kg/m2, and 0.4 0.7, respectively. The mean operating time, hemoglobin change, return of bowel activity, and length of hospital stay were 64.9 9.5 minutes, 1.2 0.5 g/dL, 32.8 3.5
S96
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S95–S132
hours, and 3.1 0.4 days, respectively. Because SPLA-TUM did not provide a satisfactory surgical field, SPLA-TUM was converted to singleport laparoscopic myomectomy in one woman (6.7%). There were no surgical or wound complications. Conclusion: SPLA-TUM, which was designed by integrating the surgical techniques of single-port laparoscopy and laparotomy, can reduce the operating time compared with SP-LM by permitting comfortable suturing and reliable knotting while maintaining the advantages of single-port laparoscopy. SPLA-TUM is a feasible alternative in selected patients with symptomatic myoma. 304
Open Communications 17dLaparoscopy (4:14 PM d 4:19 PM)
Predictive Factors for Laparoscopic Conversion to Laparotomy and Associated Outcomes Mack-Deberardinis L,1 Dion M,2 Morosky C.3 1Obstetrics and Gynecology, University of Connecticut Integrated Residency Program, Farmington, Connecticut; 2University of Connecticut School of Medicine, Farmington, Connecticut; 3Obstetrics and Gynecology, The Hospital of Central Connecticut, New Britain, Connecticut Study Objective: Laparoscopic surgery has multiple benefits to the patient when compared to laparotomy; however, laparoscopic conversion to laparotomy may be associated with increased complications compared to laparotomy alone. The aims of this study were to identify predictive factors for conversion, and to evaluate the associated outcomes when compared to planned laparotomy. Design: We performed a retrospective case-control study of all patients who underwent conversion from January 1, 2007 to December 31, 2011. Laparoscopy and laparotomy control patients were matched to each conversion case in a 2 to 1 ratio. Setting: Community-based, university-affiliated teaching hospital. Patients: All laparoscopic oophorectomies and hysterectomies converted to laparotomy were included. Robotic surgeries and malignancies were excluded. Control patients were matched for type of surgery and when possible pathologic diagnosis. Intervention: Laparoscopy controls were compared to conversion cases to identify predictive factors for conversion including body mass index (BMI), uterine weight, and number of prior laparotomies and minimally invasive surgeries. Laparotomy controls were compared to the same conversion cases to evaluate outcomes including estimated blood loss, operating time, total and individual complications. Measurements and Main Results: A total of 53 laparoscopic conversions were identified. The majority of conversions were performed for adhesions (47.2%) or mass effect (28.3%). Compared to laparoscopy controls, conversion cases had more prior laparotomies and larger uterine weight (table 1). Compared to laparotomy controls, conversion patients had a longer operating time and more organ injury complications (table 2). Table 1 Conversion versus Laparoscopy
BMI # MIS # ExLap Uterine Weight (grams)
Conversion
Laparoscopy
n=53
n=106
p-value
30.7 0.9 0.84 427
28.8 0.54 0.36 192
0.22 0.24 0.003 0.02
BMI (body mass index); # MIS (number prior minimally invasive surgeries); # ExLap (number prior laparotomies)
Conclusion: Risk factors for laparoscopic conversion to laparotomy include increased number of prior laparotomies and increased size of the pelvic pathology. Patients who are converted to laparotomy undergo longer procedures, and are at increased risk of organ damage as compared to
Table 2 Conversion versus Laparotomy
EBL (cc) OR Time (minutes) Complications Total Organ Injury Transfusion Vascular Injury
Conversion
Laparotomy
n=53
n=106
p-value
432 165
320 136
0.10 0.002
16 9 6 1
16 (15%) 3 (3%) 13 (12%) 0
0.04 0.003 1.00 0.33
(30%) (17%) (11%) (2%)
EBL (estimated blood loss); cc (cubic centimeter); OR (operating room)
planned laparotomy. Patients at high risk for conversion may benefit from planned laparotomy or robot-assisted laparoscopic surgery. 305
Open Communications 17dLaparoscopy (4:20 PM d 4:25 PM)
Complications with Myoma Screw While Using as Uterine Manipulator in Total Laparoscopic Hysterectomy Magdum AA, Padiyath HR, Puthiyidom A, Trehan N. Obstetrics and Gynecology, Sunrise Hospital, Ernakulam, Kerala, India Study Objective: Uterine manipulation plays vital role during total laparoscopic hysterectomy (TLH). We share our experience with myoma screw when it is used as sole uterine manipulator during TLH with an aim to evaluate the safety of myoma screw in terms of complications. Design: This is a retrospective analysis of women who have undergone TLH between Jan 2008 to February 2012 where myoma screw was used for uterine manipulation. Complications with use of myoma screw were documented. Setting: Tertiary care center. Patients: All women who had undergone TLH during study period were included in this study. Myoma screw is the only uterine manipulator used since January 2008 at this cneter. Intervention: 5 mm specially designed myoma screw was used as sole uterine manipulator through one of the accessory ports. For few larger uteri, whenever necessary, myoma screw position was changed to another suitable site or additional myoma screw was inserted. Measurements and Main Results: 2880 women underwent TLH during the study period where myoma screw was used as uterine manipulator. In 40% of cases uterus was larger than 20 weeks size. In 231 (8%) cases there was minor difficulty to tackle right sided pedicles of uterus. Additional trocar was inserted in 12 (0.4%) cases due to difficulty in uterine manipulation (excessively enlarged size of uterus). In 9 (0.3%) cases two myoma screws were used. In 10 cases (0.34%) there was serosal bowel injury. In 6 cases (0.2%) there was bowel injury involving complete thickness of wall which was sutured laparoscopically. There was bleeding from omental injury in one case. Bipolar coagulation was used for significant bleeding from myoma screw site in 44(1.5%) cases. Difficulty in uterine manipulation due to atrophic size of uterus was encountered in 2% of atrophic uteri. Conclusion: Myoma screw is one of the most effective and cheapest uterine manipulators for TLH. 306
Open Communications 17dLaparoscopy (4:26 PM d 4:31 PM)
Laparoscopic Management of Giant Adnexal Cysts: Technique and Initial Results Ribeiro SC, Miyahara CBdF, Tormena RA, Pamplona I, Arazawa STN, Baracat EC. Obstetrics and Gynecology, Clinics Hospital, Sao Paulo University Medical School, S~ao Paulo, SP, Brazil