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Total laparoscopic hysterectomy: Technical aspects and results
August 2003, Vol. 10, No. 3 Supplement
TheJournal of the American Association of Gynecologic Laparoscopists
Both nursing staffs were in-serviced about outpatient LSH. The anesthesia group and nursing staff at Center B were asked to assign specific staff but declined. Data was collected prospectively for patient demographics, indication for LSH, surgery time, discharge outcome, and patient satisfaction. A total of 285 outpatient LSH were performed form March 1, 1999 through February 28, 2003 (Center A= 157, Center B = 128). There were no differences with respect to age, parity, indication, preoperative uterine size, or surgical time. LSH was outpatient more often at Center A than Center B (87.5% v 66.2%, p<0.01). Fewer compazine suppositories were needed after discharge form Center A (0.41/pt v0.68/pt, p<0.01). Patients gave the operating room staff and excellent rating more often at Center A (80.9% v 66.7% p<0.01). The recovery room at Center A also had a higher patient satisfaction rating (67.4% v 57.1%, p<0.01). Fewer anesthesiologists cared for patients at Center A (4 v 29, P<0.01). Conclusion. A center dedicated to excellence in outpatient LSH has better outcomes than one that does not.
134. Total Laparoscopic Hysterectomy: Technical Aspects and Results Vl Kulakov, LV Adamyan, SI Kiselev. Research Centre for Obstetrics, Gynecology & Perinatology, Moscow, Europe Russian Federation.
Objective. To evaluate the technical benefits and results of total laparoscopic hysterectomy (TLH). Design. Retrospective analysis of 1180 cases of intrafascial TLH for uterine myoma and/or adenomyosis. Setting. Department of Operative Gynecology of the Research Centre for Obst., Gyn., & Perinatology. Patients. The patients were aged 42.4+2.5 yrs. Average uterine size was 12.2 weeks, uterine weight--511 g). Large myomas (20-24 weeks of gestation) were present in 184 cases, localization of fibroids in the lower uterine segment or intraligan~entous was documented in 35% of cases. In 214 patients associated gynecologic conditions were present, providing process-specific distortion of pelvic anatomy. Interventions. Intrafascial TLH was performed without preliminary dissection of the ureters; with ligation of the ascendent branch of uterine artery prior to adnexal pedicles; dissection of the posterior leaf of broad ligament and uterosacrals; cutting of vessels and circular transection of pelvic fascia and vaginal walls together with uterosacral-cardinal complex. McCall culdoplasty was performed for prevention of the vaginal stump prolapse in 23.7% of cases; Burch colposuspension--for urinary incontinence in 9 patients. Measurements and Main Results. All procedures were done laparoscopically with no conversions to other approach. The only vaginal manipulation was morcellation, sometimes consuming as much as a half of total operating time (av. 80.2+11.3 min.). Blood loss did not exceed 140 ml, no intra- or postoperative complications occurred. Conclusion. Laparoscopic intrafascial technique provides preservation of pelvic support, safety for life-important
structures and control over blood loss even in patients with distorted pelvic anatomy.
135. Total Vaginal Cuff Disruptions Associated with Total Laparoscopic Hysterectomy for Endometriosis AG Santomauro, RZ Mansano. Bridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut. From January 2000 through April 2003, one surgeon performed 75 Laparoscopic hysterectomies. During the last 3 months, three cases of total vaginal cuff disruption occurred despite no significant change in technique. Cardinals, uterosacral and cuff were transected with 500 micron Elmed unipolar needle at 40 W low pure cutting current. Cuffs were closed with interrupted figure 8 sutures 0 Polysorb using Endostich. Two disruptions occurred during intercourse 6 to 7 weeks post op after examination revealed a healed cuff. Each was associated with post coital bleeding, pain, and serosanguinous discharge and in one case small intestine prolapse. The third occurred 3 weeks after surgery following heavy vaginal bleeding but no intercourse. In two cases extensive dissection through dense endometriosis and vesicouterine and rectovaginal adhesions was performed either sharply or with monopolar current. One case had previous bipolar electrocantery of cul de sac endometriosis. Two were closed vaginally and normal tissue was described. One was closed at laparotomy by a covering physician who debrided necrotic tissue. The presence of endometriosis and the surgery required to eradicate it or lyse its dense adhesions in the vesicovaginal or rectovaginal spaces are factors predisposing to vaginal cuff disruption. Compromise of tissue vitality may be associated with figure 8 sutures for tissue approximation and electrocantery for hemostasis or dissection. Suturing wide margins of healthy tissue using interrupted sutures and minimizing cuff electrocautery many reduce this complication in these cases.
136. Laparoscopy as the Preferred Route for Hysterectomy in Obese Patients O Wilson. Scottsdale, Arizona.
Objective. To evaluate the safety and feasibility of Laparoscopic total or subtotal hysterectomy in obese patients. Design. Retrospective analysis of 62 obese patients (BMI >30) who underwent attempted laparoscopic total or subtotal hysterectomy. Setting. Solo practice in an urban upper-middle-class area at a private hospital. Patients. Sixty-two women in whom laparoscopic total or subtotal hysterectomy was attempted. Interventions. Attempted laparoscopic total or subtotal hysterectomy. Measurements and Main Results. Sixty-two obese women underwent attempted laparoscopic total or subtotal hysterectomy. Sixty attempts were successfully completed, 2 patients required laparotomy. No operative complications,
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TheJournal of the American Association of Gynecologic Laparoscopists
Both nursing staffs were in-serviced about outpatient LSH. The anesthesia group and nursing staff at Center B were asked to assign specific staff but declined. Data was collected prospectively for patient demographics, indication for LSH, surgery time, discharge outcome, and patient satisfaction. A total of 285 outpatient LSH were performed form March 1, 1999 through February 28, 2003 (Center A= 157, Center B = 128). There were no differences with respect to age, parity, indication, preoperative uterine size, or surgical time. LSH was outpatient more often at Center A than Center B (87.5% v 66.2%, p<0.01). Fewer compazine suppositories were needed after discharge form Center A (0.41/pt v0.68/pt, p<0.01). Patients gave the operating room staff and excellent rating more often at Center A (80.9% v 66.7% p<0.01). The recovery room at Center A also had a higher patient satisfaction rating (67.4% v 57.1%, p<0.01). Fewer anesthesiologists cared for patients at Center A (4 v 29, P<0.01). Conclusion. A center dedicated to excellence in outpatient LSH has better outcomes than one that does not.
134. Total Laparoscopic Hysterectomy: Technical Aspects and Results Vl Kulakov, LV Adamyan, SI Kiselev. Research Centre for Obstetrics, Gynecology & Perinatology, Moscow, Europe Russian Federation.
Objective. To evaluate the technical benefits and results of total laparoscopic hysterectomy (TLH). Design. Retrospective analysis of 1180 cases of intrafascial TLH for uterine myoma and/or adenomyosis. Setting. Department of Operative Gynecology of the Research Centre for Obst., Gyn., & Perinatology. Patients. The patients were aged 42.4+2.5 yrs. Average uterine size was 12.2 weeks, uterine weight--511 g). Large myomas (20-24 weeks of gestation) were present in 184 cases, localization of fibroids in the lower uterine segment or intraligan~entous was documented in 35% of cases. In 214 patients associated gynecologic conditions were present, providing process-specific distortion of pelvic anatomy. Interventions. Intrafascial TLH was performed without preliminary dissection of the ureters; with ligation of the ascendent branch of uterine artery prior to adnexal pedicles; dissection of the posterior leaf of broad ligament and uterosacrals; cutting of vessels and circular transection of pelvic fascia and vaginal walls together with uterosacral-cardinal complex. McCall culdoplasty was performed for prevention of the vaginal stump prolapse in 23.7% of cases; Burch colposuspension--for urinary incontinence in 9 patients. Measurements and Main Results. All procedures were done laparoscopically with no conversions to other approach. The only vaginal manipulation was morcellation, sometimes consuming as much as a half of total operating time (av. 80.2+11.3 min.). Blood loss did not exceed 140 ml, no intra- or postoperative complications occurred. Conclusion. Laparoscopic intrafascial technique provides preservation of pelvic support, safety for life-important
structures and control over blood loss even in patients with distorted pelvic anatomy.
135. Total Vaginal Cuff Disruptions Associated with Total Laparoscopic Hysterectomy for Endometriosis AG Santomauro, RZ Mansano. Bridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut. From January 2000 through April 2003, one surgeon performed 75 Laparoscopic hysterectomies. During the last 3 months, three cases of total vaginal cuff disruption occurred despite no significant change in technique. Cardinals, uterosacral and cuff were transected with 500 micron Elmed unipolar needle at 40 W low pure cutting current. Cuffs were closed with interrupted figure 8 sutures 0 Polysorb using Endostich. Two disruptions occurred during intercourse 6 to 7 weeks post op after examination revealed a healed cuff. Each was associated with post coital bleeding, pain, and serosanguinous discharge and in one case small intestine prolapse. The third occurred 3 weeks after surgery following heavy vaginal bleeding but no intercourse. In two cases extensive dissection through dense endometriosis and vesicouterine and rectovaginal adhesions was performed either sharply or with monopolar current. One case had previous bipolar electrocantery of cul de sac endometriosis. Two were closed vaginally and normal tissue was described. One was closed at laparotomy by a covering physician who debrided necrotic tissue. The presence of endometriosis and the surgery required to eradicate it or lyse its dense adhesions in the vesicovaginal or rectovaginal spaces are factors predisposing to vaginal cuff disruption. Compromise of tissue vitality may be associated with figure 8 sutures for tissue approximation and electrocantery for hemostasis or dissection. Suturing wide margins of healthy tissue using interrupted sutures and minimizing cuff electrocautery many reduce this complication in these cases.
136. Laparoscopy as the Preferred Route for Hysterectomy in Obese Patients O Wilson. Scottsdale, Arizona.
Objective. To evaluate the safety and feasibility of Laparoscopic total or subtotal hysterectomy in obese patients. Design. Retrospective analysis of 62 obese patients (BMI >30) who underwent attempted laparoscopic total or subtotal hysterectomy. Setting. Solo practice in an urban upper-middle-class area at a private hospital. Patients. Sixty-two women in whom laparoscopic total or subtotal hysterectomy was attempted. Interventions. Attempted laparoscopic total or subtotal hysterectomy. Measurements and Main Results. Sixty-two obese women underwent attempted laparoscopic total or subtotal hysterectomy. Sixty attempts were successfully completed, 2 patients required laparotomy. No operative complications,
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