Predictive factors of the need to morcellate in total laparoscopic hysterectomy

Adverse outcomes related to morcellation in Total Laparoscopic Hysterectomy

OBJECTIVE

This study aimed to comprehensively evaluate the complications associated with morcellation in Total Laparoscopic Hysterectomy (TLH) procedures, providing evidence-based insights to enhance patient safety and surgical efficacy.

DATA SOURCES

A comprehensive literature search was conducted using multiple databases, including PubMed, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. The inclusion criteria were Studies that focused on morcellation and morcellation-related complications were included. The risk of bias in the included studies was assessed using established evaluation scales.

METHODS OF STUDY SELECTION

Thirteen studies investigating complications associated with morcellation in TLH (Total Laparoscopic Hysterectomy) were included in this review.This review covers intraoperative blood loss, length of hospital stay, loss of bag integrity, mean uterine specimen and weight, morcellation time, operation time, and TLH morcellation complications.

TABULATION, INTEGRATION, AND RESULTS

The selected studies covered different approaches and aspects related to this procedure, providing valuable insights into the factors associated with complications and efficacy of the technique in various clinical settings.This review highlights the importance of evaluating and considering complications associated with morcellation in TLH.

CONCLUSION

The findings of this review provide valuable insights into complications associated with morcellation in TLH. Clinicians could use this information to make informed decisions, implement safe protocols, and improve patient care. Addressing these complications will enhance the safety and efficacy of morcellation for TLH. Ethical Compliance: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Predictive factors for morcellation during total laparoscopic hysterectomy: a cohort study

OBJECTIVE

Our objective was to identify predictors of morcellation during total laparoscopic hysterectomy (TLH) DESIGN: Retrospective cohort study (Canadian Task Force classification II-2) SETTING: University Hospital Center in XXX PARTICIPANTS: Women undergoing a TLH for a benign gynecologic pathology form January 1st 2017 to January 31st 2019 INTERVENTION: All women underwent a TLH. If the uterus was to voluminous to be removed vaginally, surgeons favored in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed prior to surgery by ultrasound or MRI in order to predict morcellation.

MAIN RESULTS

A total of 252 women underwent a TLH and the mean age was 46±7 (30-71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17-1572)±272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least one leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥250 versus <250 grams; OR 3.7 (CI 1.8-7.7, P < 0.01), having ≥ 1 leiomyoma (OR 4.1, CI 1.0-16.0, P = 0.01) and a leiomyoma of ≥5 cm (OR 8.6, CI 4.1-17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis.

CONCLUSION

Uterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.

Facilitating method for removal of the large uterus after laparoscopic hysterectomy: Vaginal vault vertical incision

BACKGROUND

In patients with a large uterus, an important part of the laparoscopic hysterectomy operation time is the phase of removing the uterus from the abdomen.The development of techniques that will shorten the morcellation time is the key to reducing the total operation time.

AIM

To evaluate the effect of vaginal cuff vertical incision in accelerating removal of the large uterus in laparoscopic hysterectomy.

METHODS

This study was performed with patients who underwent total laparoscopic hysterectomy. In the study group, a vertical incision was performed in the middle of the posterior vaginal stump before the vaginal removal of the larger uterus (weighing more than 500 g). The control group consisted of patients who underwent vaginal morcellation after conventional colpotomy. Patients in both groups were matched in terms of uterine weights +/-50 g and the same vaginal morcellation technique was applied to all patients.

RESULTS

In patients who underwent a vertical incision procedure, the time to remove the uterus from the abdomen (17.55±2.53 min vs 26.62±4.72 min, p<0.001) and the total operation time (130.81±12.83 min vs.143.29±13, 15 min, p = 0.001) was statistically significantly less than the patients without vertical incision. There was no difference between the groups in terms of intraoperative complications, drop in hemoglobin levels, time to flatus, postoperative 6th,24th hour visual analog score and length of hospital stay.

CONCLUSIONS

The vertical incision procedure reduces the time to remove the large uterus from the abdomen after laparoscopic hysterectomy and, accordingly, the total operation time. This procedure may be the preferred method before vaginal morcellation, especially in large uterus.

A consensus-based core feature set for surgical complexity at laparoscopic hysterectomy

BACKGROUND

There are no current standardized and accepted methods to characterize the surgical complexity of a laparoscopic hysterectomy. This leads to challenges when trying to understand the relationship between the patient and the surgical features and outcomes. The development of core feature sets for laparoscopic hysterectomy studies would enable future trials to measure the similar meaningful variables that can contribute to surgical complexity and outcomes.

OBJECTIVE

The purpose of this study was to develop a core feature set for the surgical complexity of a laparoscopic hysterectomy.

STUDY DESIGN

This was an international Delphi consensus study. A comprehensive literature review was conducted to identify the features that were reported in studies on laparoscopic hysterectomy complexity. All the features were presented for evaluation and prioritization to key experts in 3 rounds of online surveys. A priori consensus criteria were used to reach agreement on the final outcomes for inclusion in the core feature set.

RESULTS

Experts represented North America, South America, Europe, Africa, Asia, and Oceania. Most of them had fellowship training in minimally invasive gynecologic surgery. Sixty-four potential features were entered into round 1. Experts reached a consensus on 7 features to be included in the core feature set. These features were grouped under the following domains: 1) patient features, 2) uterine features, and 3) nonuterine pelvic features. The patient features include obesity and other nonobesity comorbidities that alter or limit the ability of a surgeon to perform the basic or routine steps in a laparoscopic hysterectomy. The uterine features include the size and presence of fibroids. The nonuterine pelvic features include endometriosis, ovarian cysts, and adhesions (bladder-to-uterus, rectouterine pouch, and other adhesions).

CONCLUSION

Using robust consensus science methods, an international consortium of experts has developed a core feature set that should be assessed and reported in all future studies that aim to assess the relationship between the patient features and surgical outcomes of laparoscopic hysterectomy.