Two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy: A novel approach in difficult laparoscopic hysterectomy

Association of maximum uterine diameter with postoperative complications in laparoscopic supracervical hysterectomy: A retrospective cohort study

OBJECTIVE

To determine the maximum uterine diameter threshold associated with an elevated risk of complications following laparoscopic supracervical hysterectomy (LSH).

METHODS

This was a retrospective cohort study from a single tertiary referral center. We enrolled patients who underwent LSH for benign indications at our hospital between January 2013 and June 2023. The primary outcome was the occurrence of surgical complications within the 30-day timeframe of hysterectomy. The covariate included the year of the procedure, patient age, body mass index, parity, American Society of Anesthesiologists classification, comorbidities, history of previous abdominal and pelvic surgery, and preoperative anemia, blood loss, surgical time, hospital stay and pathology. The exclusion criteria comprised those who underwent hysterectomy for malignancy, individuals who underwent total vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy, and those with missing data on uterine maximum diameter, study outcomes, or covariates.

RESULTS

We included a final sample of 120 patients, revealing a median uterine diameter of 9.12 cm, with 9.2% experiencing complications. The median uterine weight among 40 patients was 275 g. Receiver operating characteristic (ROC) curve analysis suggested a potential cutoff of 11.55 cm for predicting complications, with an area under the ROC curve of 0.67. Multivariate logistic regression confirmed a significant association between uterine diameter exceeding the cutoff and increased complication risk (OR 33.925, 95% CI: 2.294-501.690, P = 0.0103). A correlation (r = 0.762, P < 0.001) between uterine weight and diameter indicated the latter's suitability for preoperative assessment of uterine weight.

CONCLUSION

The maximum uterine diameter with an optimal cutoff of 11.55 cm was associated with increased complication risk.

Hysterectomy and ovarian cystectomy using natural orifice transluminal endoscopic surgery: An initial experience at Tzu Chi General Hospital

OBJECTIVES

The objective of this study is to report our initial experience with patients undergoing transvaginal natural orifice transluminal endoscopic surgery (NOTES).

MATERIALS AND METHODS

From September 2016 to December 2016, patients who were not virgins and did not have pelvic inflammation or obliteration of the cul-de-sac who underwent NOTES hysterectomy or ovarian cystectomy (OC) were included in the study.

RESULTS

Transvaginal NOTES was performed smoothly in six patients, two patients (mean age 35 years, mean body mass index [BMI] 25) received an OC and four patients (mean age 49 years, mean BMI 27) underwent a hysterectomy. One patient with a hysterectomy received concurrent adhesiolysis. The mean surgical times were 74 and 75 min and blood loss was 50 and 87.5 ml in the OC and hysterectomy groups, respectively. One patient with a hysterectomy had a postoperative fever with 38°C last for 2 days. Pain scores were 0 at 48 h postoperatively in both groups.

CONCLUSION

Transvaginal NOTES is a feasible and safe technique for hysterectomy and OC in our patients and those in previous reports. This procedure was minimally invasive with no scars on the abdomen as well as little pain.

Two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy: An initial experience

OBJECTIVE

To report our initial experience with and the short-term outcomes of two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy (LESS-CLSH).

MATERIALS AND METHODS

A retrospective case study included 40 women who underwent LESS-CLSH from January 2014 to December 2016 at Buddhist Tzu Chi General Hospital. Uterine specimens were extracted through contained manual morcellation with a tissue pouch. The first phase was LESS supracervical hysterectomy and conization of the internal orifice of the cervix. The second phase was transvaginal cervical conization and cylinderization. Women with a uterus diameter of >12 cm, a broad ligament myoma, or severe pelvic adhesion were categorized into a difficult group, and others were categorized into a nondifficult group.

RESULTS

The difficult group required more time and had more blood loss than the nondifficult group. The mean surgical time was 187.2 ± 33.9 and 139.1 ± 20.7 min, and the mean blood loss was 533.3 ± 333.3 and 225.3 ± 168.2 mL in the difficult and nondifficult groups, respectively. The overall visual analog scale (VAS) pain scores at 0-4, 24, and 48 h after surgery were 7.1 ± 1.9, 4.2 ± 1.6, and 2.3 ± 1.5, respectively; no difference in the VAS pain scores, pain relief score, and hospitalization duration was observed between the two groups. Minor surgical complications or adverse events on follow-up were noted. Three months after surgery, the diameter and thickness of the cervix were decreased by approximately 0.5 and 1.0 cm, respectively.

CONCLUSION

LESS-CLSH is a minimally invasive, safe, and feasible approach, even for difficult laparoscopic hysterectomy. Contained manual morcellation enables more controlled specimen removal than morcellation only.

How the silent mentor program improves our surgical level and safety and nourishes our spiritual life

We briefly share our experience of using the silent mentor program in the Medical Simulation Center (MSC) of Tzu Chi University (TCU), Hualien, Taiwan, to improve our minimally invasive surgical level and patient's safety. The silent mentor program, established in 2000 by the Department of Anatomy of TCU, is a pioneering clinical skill training program based on unembalmed bodies. This program provides three valuable advantages for surgery. The first is the comprehensive understanding of the deep or rarely observed but crucial structures of the human body, which is normally difficult to achieve in living humans. The second is gaining the first experience of a novel procedure or surgery on silent mentors rather than on living humans, which is essential for young surgeons to begin their careers. The third is evaluating the safety and feasibility of a novel surgical method. In addition to surgical techniques, the most valuable point of the program is the humane ceremonies conducted for silent mentors to nourish our soul. After the workshop, all the incision wounds on every silent mentor were carefully checked and sutured in the same manner as in closing surgical wounds in a patient. Subsequently, encoffining, cremation, and thanksgiving ceremonies were solemnly held, in the hope that the medical students or trainees would imperceptibly understand their responsibility to society and the silent mentor's expectations. The Asia-Pacific Association for Gynecologic Endoscopy and Minimally Invasive Therapy, or the Taiwan Association for Minimally Gynecology Therapy, or both can consider initiating a regular silent mentor program in the MSC of TCU. It is not only intended to improve the skills of surgeons but also to allow them to participate in the interactive ceremony and thus refresh their humanitarian knowledge.