Abdominal hysterectomy: relationship between morbidity and surgical technique

Elective cesarean section without urethral catheterization

AIM

To determine the feasibility and safety of carrying out elective lower-segment cesarean section without urethral catheterization.

METHODS

A prospective comparative study was carried out at a private hospital in Colombo, Sri Lanka. A pilot study involving 50 women was carried out to measure the volume of urine obtained at the beginning and at the end of cesarean section, using an indwelling catheter. In the main study, surgery was carried out without urethral catheterization on 344 women who had voided within the previous hour.

RESULTS

The mean volume of urine collected at the beginning and at the end of surgery was 25.5 and 42.8 mL, respectively. This volume was calculated to be accommodated in spheres of 4.0 and 4.6 cm in diameter, respectively. In the main study, 73% had the bladder distended to a level <3 cm from the lower cut edge of the rectus sheath. In the remaining 27% it was above this level, but covered completely by Doyen's retractor. There were no cases of accidental cystotomy. The difference in the mean time taken for surgery in the two groups was not significant (P=0.30). Distress catheterization was required in two (0.58%). The rest voided after a mean of 8.76 h (SD=2.37). The majority (68.2%) voided in the toilet. The difference in the urinary infection rates between the two groups (6%vs 0.58%) was statistically significant (P <0.05).

CONCLUSIONS

Cesarean section without urethral catheterization does not compromise the safety or ease of surgery. It reduces the risk of urinary infection.

Prospective comparison of indwelling bladder catheter drainage versus no catheter after vaginal hysterectomy

OBJECTIVE

This study compares the postoperative outcomes of patients in whom indwelling bladder catheterization or no catheter was used after vaginal hysterectomy.

STUDY DESIGN

One hundred women undergoing inpatient vaginal hysterectomy were randomly assigned to have an indwelling Foley catheter for 24 hours or no catheter after the procedure. Data regarding postoperative morbidity were recorded, and a clean voided urine specimen for urinalysis and culture was obtained 48 hours and 2 weeks after surgery.

RESULTS

The study groups were similar with respect to demographics and surgical indications. Two patients in the catheterized group required recatheterization after the catheters were removed. None of the subjects in the no-catheter group required a catheter. There was a significantly higher incidence of fever in the catheter group. No differences were found in the incidence of positive urine cultures between the study groups at 48 hours (8 vs 14, p = 0.227) and 2 weeks (6 vs 1, p = 0.111), respectively.

CONCLUSION

Indwelling catheterization appears unnecessary after routine vaginal hysterectomy. However, catheter placement for 24 hours does not contribute significantly to postoperative morbidity.

Surgical complications of obese patients with endometrial carcinoma

Sixty-seven patients had exploratory laparotomy for stage I and II (occult) adenocarcinoma of the endometrium. Acute surgical complications were analyzed in obese and in normal-weight patients. Compared to normal-weight patients, obese patients had significantly higher rates of wound infection and wound dehiscence, longer operating time, greater blood loss, and longer hospital stay. Wound infection and wound dehiscence were significantly related to postoperative anemia.

Careful surgical technique can reduce infectious morbidity after cesarean section

A total of 635 consecutive cesarean sections performed in private practices during the past 20 years are reviewed. In the course of this 20 year period, we have tried to alter gradually our surgical technique used for this procedure to conform to the principles of surgery developed by Halsted. The study is divided into three periods of time to examine the results of changes in technique. With the use of the standard definition of febrile morbidity (temperature of greater than or equal to 100.4 degrees F during any two 24-hour periods after the first postoperative 24 hours) the postoperative morbidity rate was 15% during 1967 to 1973, 5.4% during 1974 to 1979, and 0.7% during the period 1980 through 1986. Prophylactic antibiotics were used with decreasing frequency. It was clear that the reduction in morbidity was the result of the modifications in surgical technique.

Pelvic laparotomy without an indwelling catheter. A retrospective review of 949 cases

A retrospective review of 949 cases of pelvic laparotomy without an indwelling catheter was conducted. Contrary to traditional beliefs, this study found that the use of an indwelling catheter was not necessary to assure either adequate exposure during operation or satisfactory voiding in the postoperative period. Various prophylactic steps included staff attention to the preoperative and postoperative voiding needs of patients and occasional bladder needling during operation. These efforts resulted in a low (22.1%) postoperative distress catheterization rate with no complications if needling was done. Urinary infection rates ranged from less than 1% for patients who did not require distress catheterization to 3.9% for a comparative population of patients who had an indwelling catheter during and after operation. Abstaining from the use of an indwelling catheter was also associated with lower cost and greater patient satisfaction.

Knot security of synthetic absorbable suture material; a comparison of polyglycolic acid and polyglactin-910

To compare the knot reliabilities of two kinds of synthetic absorbable suture material, twelve different knots commonly used in surgical practice were tested. Twenty tests were performed on each knot, i.e., ten with Dexon-S (uncoated) and ten with Vicryl (coated). The knots made with Dexon-S were found to slip less frequently, to be significantly stronger, more consistent, and more reproducible than those made with Vicryl. It was concluded that uncoated Dexon-S is superior to coated Vicryl with respect to know reliability. The practical implications of these findings for surgical performance are discussed. It is emphasized that surgeons should be more aware of the relationship of the holding power of surgical knots to not only the knot-typing technique but also the kind of suture material used.

Single dose of tinidazole in prophylaxis of infections following hysterectomy

A single dose of 2 g tinidazole was given preoperatively to 70 patients undergoing elective hysterectomy; 76 patients served as controls. One patient in the drug therapy group and 10 in the control group had a temperature of 38 degrees C at some time after the first postoperative day. One patient in the tinidazole group and seven among the controls had abscess formation. The differences between the tinidazole and the control groups were highly significant. This simple prophylactic procedure reduced treatment costs and minimised infection following hysterectomy.