Minimally invasive hysterectomy for benign indications: an update

Ergonomic learning curves on gynecological laparoendoscopic single-site (LESS) surgery

BACKGROUND

Few previous studies have introduced general techniques to overcome the "chopstick effect" in laparoendoscopic single-site surgery (LESS). We aim to investigate and highlight the key ergonomic methodologies for gynaecologic LESS based on the surgeon's hands-on performance.

METHODS

The first author surgeon A reviewed and analyzed the LESS procedures performed by herself and how she taught surgeon B from January 2021 to April 2022. The procedures were classified based on technical difficulty and learning periods, and the hands-on technical skills of LESS module were evaluated.

RESULTS

Surgeon A conducted 580 LESS procedures, which were divided into the novice (n = 48) and intermediate (n = 33) periods, and the remaining cases were included in the routine period. We formed a special ergonomic LESS operating methodology: Maintain good LESS laparoscopic spatial sensation, keep hand-eye coordination, well cooperation between the main surgeon and the assistant; Experienced multiport laparoscopy surgery (MPS) skills, improve basic LESS technique: grasp, lift, transfer, place, blunt separating, coagulation and cutting. Coordination location, orientation, movements, and flexion or extension of shoulders, arms, elbow, wrist and finger joints; Maintain strength, tension and ambidexterity postures with joint and muscular efforts to control instruments. Surgeon B learned the above experiences by performing 39 LESS procedures under the guidance of surgeon A.

CONCLUSION

This educational research sheds light on the common challenges faced in LESS and presents the importance of ergonomic hands-on performance skills in improving surgical outcomes, which could serve as a guide for future training and education in LESS.

Malnutrition is Associated with Poor Postoperative Outcomes Following Laparoscopic Hysterectomy

Background:

Malnutrition continues to be pervasive among the general population, with rates as high as 50% of patients undergoing surgical procedures. Data is limited about women undergoing surgery for non-malignant gynecologic indications (generally elective laparoscopic hysterectomies, after failed conservative measures). With the significant increase in benign gynecologic surgery, it is of the upmost importance that surgeons optimize modifiable risk factors for patients undergoing laparoscopic hysterectomy. The purpose of this study is to identify the impact of malnutrition on postoperative outcomes in patients undergoing laparoscopic hysterectomy for benign conditions.

Methods:

A retrospective cohort study was conducted utilizing data that was collected through the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) Database. All patients that underwent laparoscopic hysterectomy for benign indications were identified. Patients with malnutrition were identified by either low albumin (≤ 3.5 g/dL), low body mass index (≤ 18.5), or 10% weight loss within 6 months. The frequency of postoperative complications was evaluated with univariate and multivariate analyses where appropriate.

Results:

Following adjustment, multivariate analysis illustrated pre-operative malnutrition to be a risk factor for the following complications: any complication, death, bleeding requiring transfusion, wound, cardiac, pulmonary, renal, thromboembolic, sepsis complications, extended length of stay, and reoperation (p ≤ 0.05 for all).

Conclusion:

Malnourished patients were at significantly higher risk of developing postoperative complications during the acute postoperative period. With elective laparoscopic hysterectomies, pre-operative evaluation and intervention for malnutrition should be considered to improve nutritional status.

The Learning Curve of Laparoendoscopic Single-Site Surgery in Benign Gynecological Diseases

OBJECTIVE

To analyze and draw the learning curve of laparoendoscopic single-site surgery (LESS) in various benign gynecological diseases, so as to provide a reference for applying this cutting-edge technique.

METHODS

A retrospective analysis of LESS was conducted. Factors influencing the LESS learning process were assessed using Cox's proportional hazards regression. The cumulative sum (CUSUM) value and the learning curve were calculated and visualized based on operation time (OT), blood loss (BL), conventional laparoscopic surgery (CLS), conversion rate (CV), and complications (CP). The CUSUM value was defined as the sum of CUSUM_OT, CUSUM_BL, CUSUM_CV, and CUSUM_CP.

RESULTS

A total of 445 cases, including adnexectomies (n = 147), ovarian cystectomies (n = 175), and myomectomies (n = 123) were analyzed. Multivariate regression analysis indicated that adhesion grade (HR, 1.462; 95% CI, 1.016-1.994; p = .045), surgical type (HR, 1.283; 95% CI, 1.042-1.429; p = .024), and surgeon CLS experience (HR, 1.372; 95% CI, 1.097-2.246; p = .012) were independent factors predicting surgeons' mastery of the LESS technique. Among gynecologists with CLS experience, the cutoff points were 17, 20, and 27 cases for adnexectomy, ovarian cystectomy, and myomectomy, respectively. For those without CLS experience, the corresponding cutoff values were 19, 27, and 35 cases.

CONCLUSION

The learning curve of LESS for benign gynecological diseases indicates a stepwise process, during which the surgeon's CLS experience is the key, especially in ovarian cystectomy and myomectomy. For the training of young gynecologists, CLS should be emphasized in the early stage, and LESS should be introduced gradually.

Comparison of the Effects of Total Laparoscopic Hysterectomy and Total Abdominal Hysterectomy on Sexual Function and Quality of Life

It is known that benign gynecological diseases negatively affect sexual function. For this reason, hysterectomy provides improvement in sexual function as well as symptoms such as bleeding and pain. The effects of abdominal hysterectomy (TAH) and laparoscopic hysterectomy (TLH), which are the two most common types of hysterectomy today, are not clear. In our study, we investigated the effects of TAH and TLH on sexual function and quality of life as well as intraoperative and postoperative results. In 329 TLH and 126 TAH patients, we compared both and between themselves preoperatively and postoperatively by using the standardized and validated female sexual function index (FSFI) and European quality of life five-dimension scale (EQ-5D). In conclusion, we found that both types of hysterectomy were effective in improving sexual function, and we concluded that improvement in the laparoscopy group was statistically higher. Patients who require hysterectomy for benign gynecological reasons should be informed that TLH has a more positive effect on sexual function as well as other advantages, and if the patients' main complaint is sexual dysfunction, TLH should be preferred compared to TAH.

Sexual function after total laparoscopic hysterectomy or transabdominal hysterectomy for benign uterine disorders: a retrospective cohort

The objective of this study was to evaluate changes in sexual function after total laparoscopic hysterectomy (TLH) or transabdominal hysterectomy (TAH). This retrospective cohort study included patients with benign uterine tumors that were divided into TLH group and TAH group based on the hysterectomy technique used. Baseline, intraoperative, and postoperative characteristics were compared between groups. Postoperative sexual function was assessed using the Brief Index of Sexual Functioning for Women. The TLH and TAH groups contained 119 patients (age, 51.5±6.1 years) and 126 patients (age, 50.0±4.7 years), respectively. Baseline characteristics were comparable between groups, although uterine size was larger in the TAH group (P<0.001). Compared with the TAH group, the TLH group had a longer operative time (130.0±36.2 vs 107.3±28.5 min, P<0.001), lower pain index at 24 h (2.0±1.6 vs 4.0±2.6, P<0.001), and shorter hospitalization time (5.7±1.1 vs 8.1±1.2 days, P<0.001). Many patients in the TLH and TAH groups reported decreased satisfaction with their sexual life (67.5 and 56.0%, respectively), reduced frequency of sexual activity (70.1 and 56.0%, respectively), decreased libido (67.5 and 56.0%, respectively), orgasm dysfunction (42.9 and 42.9%, respectively), and increased dyspareunia (77.9 and 85.7%, respectively). However, there was no significant difference between groups in any of the indexes of postoperative sexual function (P>0.05). Both TLH and TAH had comparable negative effects on sexual function in women treated for benign uterine tumors in China, with a decreased frequency of sexual activity, reduced libido, orgasm dysfunction, and increased dyspareunia.

The Usefulness of Immunohistochemistry in the Differential Diagnosis of Lesions Originating from the Myometrium

Uterine leiomyomas (LMs), currently the most common gynecological complaint around the world, are a serious medical, social and economic problem. Accurate diagnosis is the necessary prerequisite of the diagnostic-therapeutic process. Statistically, mistakes may occur more often in case of disease entities with high prevalence rates. Histopathology, based on increasingly advanced immunohistochemistry methods, is routinely used in the diagnosis of neoplastic diseases. Markers of the highest sensitivity and specificity profiles are used in the process. As far as LMs are concerned, the crux of the matter is to identify patients with seemingly benign lesions which turn out to be suspicious (e.g., atypical LM) or malignant (e.g., leiomyosarcoma (LMS)), which is not uncommon. In this study, we present the current state of knowledge about the use of immunohistochemical markers in the differential diagnosis of LM, atypical LM, smooth muscle tumors of uncertain malignant potential (STUMP), and LMS, as well as their clinical predictive value.