Effect of two different modalities of hysterectomy on wound infection and wound dehiscence in obese patients

This research intended to investigate the influence of the operation of both kinds of hysterectomies in the risk of wound infection and the degree of wound dehiscence. Both of them were open field and laparoscope. In this research, we looked into four databases: PubMed, Web of Science, Embase and Cochrane Library. Research was conducted on various operative methods for hysterectomy in obese patients between 2000 and October 2023. Two independent investigators performed an independent review of the data, established the inclusion and exclusion criteria, and managed the results with Endnote software. It also evaluated the quality of the included literature. Finally, the data were analysed with RevMan 5.3. This study involved 874 cases, 387 cases received laparoscopy and 487 cases received open access operation. Our findings indicate that there is a significant reduction in the rate of post-operative wound infection among those who have received laparoscopy compared with who have received open surgical procedures (odds ratio [OR], 0.04; 95% confidence interval [CI], 0.01-0.15; p < 0.001); There was no statistical difference between the rate of post-operative wound dehiscence and those who received laparotomy compared with those who received open surgical procedures (OR, 0.33; 95% CI, 0.10-1.11; p = 0.07); The estimated amount of blood lost during the operation was less in the laparoscopy group compared with the open procedure (mean difference, -123.72; 95% CI, -215.16 to -32.28; p = 0.008). Generally speaking, the application of laparoscopy to overweight women who have had a hysterectomy results in a reduction in the expected amount of bleeding during surgery and a reduction in the risk of post-operative wound infections.

Iatrogenic Bladder Injury During Laparoscopic Hysterectomy: A Case Report and Discussion of Anatomic Variations

Hysterectomy, one of the most common surgical procedures performed in women worldwide, assumes a very important role in the definitive management of diverse gynecologic conditions. This case report presents a compelling instance of an iatrogenic bladder perforation that occurred during laparoscopically assisted vaginal hysterectomy in a 47-year-old woman with a high body mass index, extensive surgical history, and postural orthostatic tachycardia syndrome. Despite considerable preoperative planning and the use of minimally invasive techniques, the occurrence of physician-induced bladder perforation highlights the significance of understanding anatomical relationships and variations. The patient's previous abdominal surgeries including two cesarean sections, appendectomy, and cholecystectomy likely contributed to scar formation and adhesions, making dissection challenging. The case report and following discussion delve into anatomical variations, as well as the diagnosis and management of iatrogenic bladder injuries. The presented case serves as a valuable addition to the literature, contributing insights into the challenges and considerations surrounding urinary tract injuries during hysterectomy. This paper aims to review current research and guide practicing obstetricians and gynecologists in the management of intraoperative bladder injuries.

Surgical Site Infection in Laparoscopic Hysterectomy versus Abdominal Hysterectomy in Gynecological Disease(s): An Overview

Objective

Surgical site infection (SSI) is an unsettled complication seen in any surgery. The aim of this study is to assess the rate of postoperative SSIs between total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH). Can the rate of SSI be reduced with the use of a laparoscopic mode of hysterectomy over abdominal?

Materials and Methods

It was a retrospective comparative study. The study was conducted in the obstetrics and gynecology department at a tertiary care center from June 2016 to March 2020. A total of 300 patients who underwent hysterectomy either via laparoscopic or abdominal route were included in the study. They were subdivided into two groups: a total of 167 underwent TLH (Group 1) and 133 had TAH (Group 2). The results were compared. It included the age and body mass index of the patient, indication of surgery, size of the uterus, intraoperative blood loss, postoperative SSIs, duration of hospital stay, and readmission rates.

Results

It was found a high rate of SSI in TAH (82.4% vs. 17.6%, P < 0.001, Cramer's V-0.18), the operative time taken (75 ± 25 min vs. 128 ± 52 min, P < 0.001), and the mean blood loss during TLH (110 ± 30 ml vs. 160 ± 116 ml, P < 0.001) was found significant for patients. The hospital stay after TLH was found to be significantly shorter (4 ± 2.47 days vs. 7 ± 2.43, P < 0.001).

Conclusion

TLH has improved the psychological, physical, and financial burden on the health care department. Thus, it has proved a preferred route over TAH.

A Comparison between Total Abdominal Hysterectomy versus Total Laparoscopic Hysterectomy

Objectives

To compare the operative and postoperative outcomes of total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH).

Materials and Methods

In this retrospective comparative study, we reviewed all hysterectomies performed in the Al-Karak Governmental Hospital in Al-Karak, Jordan, from September 2018 to July 2022. We enrolled 129 patients who underwent hysterectomy. The patients were divided into the TLH (n = 39) and TAH (n = 90) groups. Patient data were accessed through hospital records and analyzed using SPSS 25.0.

Results

The most common indication for TLH was uterine fibroid, and that for TAH was abnormal uterine bleeding, although the specimen weights were comparable. There was no significant between-group difference in the patient's demographics. Although the TLH group had longer operative time, the hospital stay was shorter and there were no reported cases of wound infection. The estimated blood loss was significantly lower in the TLH group than in the TAH group, but there was no difference between the two groups in terms of blood transfusion requirement and postoperative hemoglobin level.

Conclusion

TLH and TAH had comparable overall outcomes in the Al-Karak Governmental Hospital. However, TLH was superior to TAH in terms of blood loss, and patients with TLH recovered faster without postoperative wound infection.

Omentum Mimicking as a Vaginal Prolapse in a Delayed Vaginal Cuff Dehiscence

A rare consequence of hysterectomy is vaginal vault dehiscence, which commonly occurs five to seven weeks after the procedure. Its frequency ranges from 0% to 7.5%. The incidence of delayed dehiscence is rare. The small bowel is the organ that prolapses most frequently, but other organs and multi-organ prolapses have also been documented. Due to potential catastrophes such as intestinal ischemia, blockage, and perforation, transvaginal protrusion of abdominal viscera is an emergency. A laparoscopic approach facilitates a thorough evaluation of the abdominal contents and provides assistance in challenging circumstances where the contents are not reducible.

Abnormal Vaginal Cytology after Total Laparoscopic Hysterectomy in Patients with Cervical Intraepithelial Neoplasia

To explore the incidence of abnormal vaginal cytology after total laparoscopic hysterectomy for the treatment of cervical intraepithelial neoplasia 3, we retrospectively analyzed the medical records of patients treated at NHO Shikoku Cancer Center (Japan) in 2014-2019. The cases of 99 patients who underwent a laparoscopic (n=36) or open (n=63) hysterectomy and postoperative follow-up were examined. Abnormal vaginal cytology was detected in 13.9% (5/36) of the laparoscopic-surgery (LS) group and 14.3% (9/63) of the open-surgery (OS) group. A vaginal biopsy was performed at the physicians' discretion; one LS patient and six OS patients were diagnosed with vaginal intraepithelial neoplasia. The cumulative incidence of abnormal vaginal cytology at 3 years post-hysterectomy was 21.4% (LS group) and 20.5% (OS group), a nonsignificant difference. A multivariate analysis showed that age > 50 years was the only independent risk factor for abnormal vaginal cytology among the covariates examined including age; body mass index; histories of vaginal delivery, abdominal surgery, and smoking; and surgical approach (hazard ratio 8.11; 95% confidence interval 1.73-37.98; p=0.01). These results suggest that the occurrence of abnormal vaginal cytology after a hysterectomy may not be influenced by the laparoscopic procedure but is associated with older age.

Clinical analysis of acute postoperative pain after total laparoscopic hysterectomy for adenomyosis and uterine fibroids - a prospective observational study

OBJECTIVE

To investigate the outcome of total laparoscopic hysterectomy (TLH) and postoperative pain characteristics and compare the pain severity after TLH for adenomyosis or uterine fibroids.

METHODS

This prospective observational study collected 101 patients received TLH for adenomyosis (AD group) including 41 patients were injected goserelin (3.6 mg) 28 days before TLH, while other adenomyosis patients received TLH without preoperative treatment, and 113 patients received TLH for uterine fibroids (UF group). Pain scores were evaluated at different time sites from operation day to postoperative 72 h using the numeric rating scale. Clinical data were collected from clinical record.

RESULTS

Operative time and anaesthetic time were longer in the AD group than those in the UF group (66.88 ± 8.65 vs. 64.46 ± 7.21, p = 0.04; 83.95 ± 10.05 vs. 79.77 ± 6.88, p < 0.01), severe endometriosis was quite more common in AD group (23.76% vs. 2.65%, p < 0.01). Postoperative usage of Flurbiprofen in AD group were more than that of UF group (15.48 ± 38.00 vs. 4.79 ± 18.16, p = 0.02). Total pains and abdominal visceral pains of AD group were more severe compared with UF group in motion and rest pattern at several time sites, while incision pain and shoulder pain were similar. The total postoperative pains after goserelin preoperative treatment in AD group were less than that without goserelin preoperative treatment (p < 0.05). The levels of serum NPY, PGE2 and NGF after laparoscopic hysterectomy of adenomyosis reduced with GnRH agonist pretreatment.

CONCLUSIONS

Acute postoperative pain for adenomyosis and uterine fibroids showed considerably different severity, postoperative total pain and abdominal visceral pains of TLH for adenomyosis were more severe compared with uterine fibroids. While patients received goserelin before laparoscopic hysterectomy of adenomyosis suffered from less severity of postoperative total pain than that without goserelin preoperative treatment.

Diagnosis of Appendiceal Neuroendocrine Tumors Following Incidental Appendectomy During Benign Gynecologic Laparoscopic Surgeries: A Case Series

Gastrointestinal neuroendocrine tumors, although relatively rare, are one of the most common appendiceal neoplasms. Patient symptoms can range from asymptomatic to acute appendicitis, and these tumors are often diagnosed after histopathological evaluation. This case series describes five separate cases of appendiceal neuroendocrine tumors diagnosed by histopathological review following incidental appendectomy during benign gynecologic laparoscopic surgeries at a single multispecialty group. Each case had a preoperative diagnosis of chronic pelvic pain. Intraoperatively, the appendix appeared scarred, adhered, or nodular. Two patients required a right laparoscopic hemicolectomy for the management of the appendiceal neuroendocrine tumor. As a result of these findings, it is recommended that the appendix be routinely evaluated during gynecologic surgeries and, if abnormal in appearance, appendectomy should be performed. Additionally, laparoscopic gynecologic surgeons should receive appendectomy training to aid with the early diagnosis and treatment of appendiceal neuroendocrine tumors.

Complications of Total Laparoscopic Hysterectomy in a Tertiary Care Center

Introduction Laparoscopic hysterectomy is a standard practice in developed countries and corporate setups in India but is a relatively new practice in government institutions; surgical audits are rarely done in our institutions. This study aims to determine the complications of total laparoscopic hysterectomy (TLH) in a tertiary care center in India. Methods This was a retrospective record review of patients admitted to the Obstetrics and Gynecology department of Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), Odisha, India. Data were collected from case sheets of patients who underwent TLH, operated on between January 2018 and May 2022. Demographic and clinical data were extracted and analyzed. Results Of the 223 consecutive patients, 12 (5.3%) were converted to laparotomy. The mean age of patients was 44.34 years (±5.457), with a mean BMI of 24.24 kg/m² (±2.181). The mean surgical duration was 1.895 hr (±0.487), with a mean blood loss of 140 ml and an average hospital stay of 3.25 (±0.821) days. Duration of surgery, blood loss, and hospital stay decreased with the surgeon's increasing experience. Reoperation was not needed in any case. Complications were recorded in about 18 (8.07%) cases. Also, major complications were less. Conclusion Total laparoscopic hysterectomy is a less invasive and safe alternative to total abdominal hysterectomy, offering the benefits of minimally invasive surgery, and is also ideal for candidates unsuitable for vaginal hysterectomy.

Clinical feasibility of absorbable gelatin film adhesion barrier (GM142 "TENALEAF®") in gynecological laparoscopic surgery: Safety assessment for first-in-human use and surgical video

AIM

To evaluate the safety and operability of the GM142 (TENALEAF®, Medical Division, Gunze Limited, Tokyo, Japan) adhesion barrier applied in patients undergoing surgery for benign gynecologic disease.

METHODS

This multicenter open study enrolled 34 patients from November 2018 to October 2019.

RESULTS

The primary outcome was the incidence of adverse events (AE) within 12 weeks postoperatively. None of the 30 patients completing the study experienced a life-threatening AE. Thirteen patients (43.3%) suffered 30 mild or moderate AE in total. No intestinal obstruction (0/30) was observed, with the sample size justified by the AdSpray® trial (8/61 patients with AE). No gelatin-specific Immunoglobulin E (IgE) antibodies were induced in the patients. The adhesion barrier could be easily inserted (even via trocar) and positioned. After malfunctions were reported in six patients, the instructions for use were updated for trocar use.

CONCLUSION

This study showed the safety and clinical feasibility GM142 as an adhesion barrier.

Safety of Three-Dimensional versus Two-Dimensional Laparoscopic Hysterectomy during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has resulted in a significant decrease in the number of surgical procedures performed. Therefore, it is important to use surgical methods that carry the lowest possible risk of virus transmission between the patient and the operating theater staff.

AIM

Safety evaluation of three-dimensional (3D) versus two-dimensional (2D) laparoscopic hysterectomy during the COVID-19 pandemic.

METHODS

44 patients were assigned to a prospective case-control study. They were divided either to 3D (n = 22) or 2D laparoscopic hysterectomy (n = 22). Fourteen laparoscopic supracervical hysterectomies (LASH) and eight total laparoscopic hysterectomies (TLH) were performed in every group. The demographic data, operating time, change in patients' hemoglobin level and other surgical outcomes were evaluated.

RESULTS

3D laparoscopy was associated with a significantly shorter operating time than 2D. (3D vs. 2D LASH 70 ± 23 min vs. 90 ± 20 min, p = 0.0086; 3D vs. 2D TLH 72 ± 9 min vs. 85 ± 9 min, p = 0.0089). The 3D and 2D groups were not significantly different in terms of change in serum hemoglobin level and other surgical outcomes.

CONCLUSIONS

Due to a shorter operating time, 3D laparoscopic hysterectomy seems to be a safer method both for both the surgeon and the patient. Regarding terms of possible virus transmission, it may be particularly considered the first-choice method during the COVID-19 pandemic.

Role of enhanced recovery after surgery in total laparoscopic hysterectomy

Introduction:

Enhanced recovery after surgery (ERAS) principles is an evidence-based surgical management approach that requires cooperation across various medical specialties. In this study, we applied ERAS principles in total laparoscopic hysterectomy (TLH) and the post-operative outcomes like post-operative pain, nausea and vomiting, opioid requirement, day of discharge, and any other complaints were studied.

Methods:

The study was conducted in a private healthcare setup in Jodhpur, Rajasthan, India. In this non-randomised controlled study 103 patients who underwent TLH over a period of 1 year were alternatively allocated to the study group and the control group. There were 51 patients in the study group in whom ERAS principles were applied and 52 patients in control group in whom traditional post-operative care was given.

Results:

Post-operative nausea and vomiting and opioid requirement were significantly reduced in the study group (P < 0.05). The post-operative pain was similar in both groups. The majority of patients in study group were discharged within 24 h as compared to the routine discharge after 48 h.

Conclusion:

Following ERAS principles in TLH results in decrease in post-operative nausea and vomiting, post-operative opioid requirement and hospital stay. Hence, the ERAS principles should be the standard practice in TLH even in a developing country setup.

Change in the trend of surgical treatment and staging of lymph nodes in endometrial cancer - results of the Oncogynecology Center, Department of Gynecology and Obstetrics, University Hospital Brno and Masaryk University in the years 2012-2021

INTRODUCTION

In the last decade, the view of endometrial cancer has shifted enormously, and the surgical approach or lymph node staging has changed significantly. We are presenting these changes with the University Hospital Brno Oncogynecology centers results in the years 2012-2021 in the actual national and European guidelines context.

METHODS

The retrospective unicentric observational study, national and European guidelines review.

RESULTS

In the observation period, 715 endometrial cancer patients were treated in our clinic, and 636 of them underwent surgical treatment (89%). Concerning lymph node staging, firstly, there is a clear trend of expanding lymphadenectomy to the paraaortic area, followed by the sentinel node bio-psy introduction in the years 2018-2019, and finally, the complete transition to this method as the main staging procedure in 2021, when this examination was performed in 73% of surgeries, even with high-risk cancers limited to the uterus. Within the sentinel node bio-psy expansion, a gradual decrease in laparotomy approach (maximum 41% in 2016, 18% in 2021), and blood loss (2012-2019 median 100 mL, with a decrease to 50 mL in 2020-2021) was evident. A hospitalization length stabilized at a median of 5-6 days.

CONCLUSIONS

Surgical treatment of endometrial cancer has become a minimally invasive procedure for the majority of patients, the average blood loss and hospitalization length have decreased. Sentinel node bio-psy has become the preferred lymph node staging method.

Sodium Bicarbonate Sub-Diaphragmatic Irrigation Relieves Shoulder Pain After Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study Objective

To determine whether sub-diaphragmatic irrigation with sodium bicarbonate would relieve post-laparoscopic shoulder pain (PLSP) after total laparoscopic hysterectomy.

Design

Randomized double-blinded trial.

Setting

Teaching hospital.

Patients

Seventy patients undergoing total laparoscopic hysterectomy (TLH) for benign indications.

Intervention

We randomly allocated patients to intervention or control groups where sodium bicarbonate containing flushing liquid or normal saline was irrigated sub-diaphragm before sewing.

Measurement & Main Results

The primary outcome was PLSP following surgery measured by a numerical rating scale (NRS) (0 = no pain; 10 = worst pain imaginable). Secondary outcomes were abdominal incisional and visceral pain, analgesic use, and sodium bicarbonate related side effects. The incidence of PLSP in intervention group was significantly lower than that in control group (P < 0.05). Contrarily, incisional and visceral pain was similar in both groups (P = 0.1). The consumption of rescue analgesics in the intervention group was lower than that in the control group. Side effects were comparable in both study groups.

Conclusion

Sub-diaphragmatic irrigation with sodium bicarbonate could effectively reduce shoulder pain, but not abdominal incisional and visceral pain, in patients undergoing TLH without an increase in side effects.

Registration information

Clinical trial registry number: http://www.chictr.org.cn/ (ChiCTR2100041765).

Registration findings

http://www.chictr.org.cn/showproj.aspx?proj=66721 Link to clinical trial page and data repository: http://www.medresman.org.cn/pub/cn/proj/projectshshow.aspx?proj=2992.

Underdiagnosis of early cervical cancer with an invisible cervical transformation zone in an elderly patient: A case report

The treatment of cervical intraepithelial neoplasia (CIN) can result in under- or overtreatment. The current report describes a case of undertreatment of a cervical tumor. A 72-year-old woman was preoperatively diagnosed with CIN3. Following surgery, the final diagnosis of the excised specimen was keratinizing squamous cell carcinoma that measured 2.5 cm in size. The exocervical margin and deep margin were negative. The patient received adjuvant therapy with concurrent chemoradiotherapy and never had disease recurrence. In elderly patients, making an accurate preoperative diagnosis based on specimens from cervical biopsies with or without colposcopy is difficult. MRI may be an accurate preoperative indicator of early cervical tumor, although some studies have demonstrated that MRI has a limitation with respect to its diagnostic ability. Other studies have reported that it is necessary to perform conization prior to hysterectomy. Physicians must reconsider the determined preoperative diagnosis of an early cervical tumor and establish standard guidelines for deciding when to use surgical treatment in elderly patients.

Barbed Suture in Total Laparoscopic Hysterectomy: A Comparative Study of the Safety in Vaginal Cuff Closure with that of Polyglactin 910 Suture

OBJECTIVES

To evaluate whether the use of barbed sutures during laparoscopic hysterectomy for vaginal cuff closure has reduced the surgical difficulty and incidence of post-operative complications as compared to polyglactin 910 suture.

MATERIALS AND METHODS

This is a randomized comparative study conducted at a tertiary care hospital and research institute where 100 patients were divided into two groups (50 each) and underwent vault closure using barbed suture/Polyglactin 910. Data collected include demographic details, indication for surgery, mean suturing time, degree of surgeon difficulty, and the incidence of postoperative complications when followed up to 12 weeks and were compared statistically using Chi square test and Independent-t test.

RESULTS

The use of barbed suture has significantly reduced the suturing time (5.39 min vs. 6.9 min, P < 0.0001) and surgical difficulty. The incidence of minor complications is similar to that of polyglactin 910. There were no cases of vaginal cuff dehiscence or bowel obstruction reported in our study.

CONCLUSION

With the advantages of reduced suturing time and technical difficulty, and incidence of complications similar to conventional suture material, barbed sutures are to be considered as an excellent alternative to conventional suture materials.

Implementation of Total Laparoscopic Hysterectomy As the Default Technique and Lessons Learnt

Introduction Concerns about surgical complications and the paucity of surgical audits have been named as reasons for the slow implementation of total laparoscopic hysterectomy (TLH) in New Zealand and Australia, despite a majority of gynaecologists who would like to offer this less-invasive approach to their patients. Material and methods This study aims to assess the implementation of TLH as the default method of hysterectomy at a private institution in the Waikato region of New Zealand, and to identify factors related to the perioperative complications and to the failure to accomplish the above procedure laparoscopically in an unselected population. We present 1,287 cases collected over fourteen years with an emphasis on demographics, outcomes, indications for surgery, laparoscopic completion of the surgical procedure and perioperative major complications. Results One hundred and fifty patients (11.7%) were nulliparous and 378 patients (29.4%) had a history of the previous laparotomy. The mean theatre time and SD was 144.84 ± 20.48 min; the mean blood loss was 137.24 ± 69 mL; the mean hospital stay was 2.07 ± 0.31 days; the median uterine weight was 177 g and the biggest uterus removed laparoscopically weighed 1,510 g. Twelve cases were converted to laparotomy (0.93%). The uterine weight had a statistically significant association with the conversion rate. The main indications for surgery were menorrhagia and/or recurrent dysmenorrhoea in 662 patients (51.4%) and fibroid uterus in 228 patients (17.7%). Six patients (0.47%) required blood transfusions. There was a total of 74 perioperative complications (5.7%) and 16 major complications (1.24%). BMI and uterine weight had a statistically significant association with major complication rates. Seven patients (0.54%) were re-operated as a result of a complication. Conclusion The implementation of TLH as default is achievable and is a safe surgical option. BMI and uterine weight are factors associated significantly with major complications or conversion to laparotomy.

The Effect of Body Mass Index on Peri-operative Parameters of Total Laparoscopic Hysterectomy: An Institutional Experience

Objectives

Worldwide, there is an increase in the obese population and laparoscopic surgery is now becoming one of the preferred modes of surgery. Therefore, it is important to examine its feasibility and safety in overweight and obese women. The study was aimed to evaluate the effects of body mass index (BMI) on intraoperative and postoperative parameters in patients undergoing total laparoscopic hysterectomy (TLH).

Materials and methods

A retrospective data analysis was conducted over a period of two years among women who underwent TLH. Data were grouped as per their BMI into Normal, Overweight, and Obese groups. Baseline demographic and clinical characteristics, intraoperative outcomes including operative time, estimated blood loss, hemoglobin difference, the need for blood transfusion, conversion to laparotomy, uterine weight, intraoperative and postoperative complications, postoperative pain, duration of hospital stay, and readmission were noted.

Results

Baseline demographic characteristics were similar in all three groups. Operative time was comparable among the groups. However, a weak positive correlation was found between operative time and total BMI value, which was statistically significant (p = 0.039). For every 1 kg/m2 increase in BMI, operative time increased by 2.35 minutes. Other intraoperative parameters were comparable among all the groups except hemoglobin difference, which was significantly higher in obese women. Postoperative parameters were similar among all groups.

Conclusion

Total laparoscopic hysterectomy is a safe, efficient, and feasible surgical approach in higher BMI groups. This approach provides advantages over open surgery of early recovery, short hospital stay, and less postoperative pain to obese women.

Removing the large uterus without morcellation - The Colpo-V incision for specimen extraction at hysterectomy

BACKGROUND

Hysterectomy is the most commonly performed benign gynaecological surgery. Recently, the rates of minimally invasive hysterectomy have fallen due to the banning of mechanical morcellation techniques that rendered minimal invasive gynaecology surgeons unable to extract large uteri from the relatively small colpotomy incisions.

AIMS

This study aims to share our experience in utilising Colpo-V incision to remove large uterine specimens transvaginally and report its success and complication rates to promote a minimal invasive approach in patients with large uteri without the need to perform large abdominal incisions or transabdominal morcellation.

METHODS

This is a prospective case series study in which women with large uteri and|or narrow vaginal canal underwent total laparoscopic hysterectomy and a subsequent posterior vaginal wall incision (Colpo-V) to facilitate the intact extraction of the uterus through the vagina. Patients were seen in the clinic six weeks after the surgery for post-operative assessment and documentation of late complications.

RESULTS

Seventeen women underwent the procedure, and the intact extraction of the specimen was successful in 16 out of the 17 cases (94%). No major complications were encountered during or after the procedure.

CONCLUSION

Colpo-V incision is a simple and effective technique for the intact extraction of larger uterine specimens at hysterectomy.

Predictive factors of the need to morcellate in total laparoscopic hysterectomy

BACKGROUND

Specimen extraction is a major challenge in total laparoscopic hysterectomy (TLH) and tissue morcellation may be needed to extract a large uterus.

AIMS

The study aims to determine preoperative factors that could predict the need for uterine morcellation in TLH, and also find the best cut-off values of each measured parameter leading to optimum sensitivity and specificity.

MATERIALS AND METHODS

This was a cross-sectional study of women from August 2019 to May 2020 who underwent TLH, with or without salpingo-oophorectomy in our department. We performed bimanual exams preoperatively to estimate the uterine size and recorded the uterine ultrasonographic dimensions and myoma size in myomatous uteri. Receiver operating characteristic (ROC) were used to establish cut-offs that maximised the sensitivity and specificity of each factor in predicting the need for morcellation. Poisson regression was used to calculate the relative risks (RR) of each cut-off.

RESULTS

One hundred and sixty-two women were recruited in the study. ROC curves demonstrated maximum sensitivities and specificities with a cross-sectional area of 36.5 cm² , the largest leiomyoma dimension of 40 mm, uterine length of 10 cm, and bimanual uterine size of 13 weeks. Multiple modified Poisson regression revealed that the strongest predictors of morcellation were the largest leiomyoma diameter of >40 mm (RR: 3.58), the uterine cross-sectional area of >36.5 cm² (RR: 6.38), and uterine size in the bimanual exam of >13 weeks pregnancy (RR: 3.57).

CONCLUSION

The largest leiomyoma diameter, uterine cross-sectional area, and size on a bimanual exam can all be used to predict needing morcellation preoperatively in TLH.

Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden

INTRODUCTION

The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume.

MATERIAL AND METHODS

All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses.

RESULTS

TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9).

CONCLUSIONS

RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.

Unidirectional Barbed Suture Versus Polyglactin 910 Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy

Introduction and objective

Laparoscopic suturing of the vaginal cuff and knotting is the most challenging step in total laparoscopic hysterectomy (TLH) and requires surgical skill. The objective of this study was to compare the efficacy and safety of unidirectional barbed suture (V-Loc^TM 180; Covidien, Mansfield, MA) with the conventional polyglactin 910 suture (coated Vicryl; Covidien) for vaginal cuff closure in patients with benign uterine diseases undergoing total laparoscopic hysterectomy.

Methods 

A prospective observational study was carried out at the department of obstetrics and gynecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, for two years. A total of 109 patients with benign uterine diseases planned for TLH were included in the study. Laparoscopic vaginal cuff closure was performed with the unidirectional barbed suture (V-Loc) in 44 patients and with the standard polyglactin 910 suture (Vicryl) in 65 patients. The primary outcome measure was vaginal cuff closure time. Secondary outcome measures included total operative time, blood loss, average number of stitches, postoperative pain perception, duration of hospital stay, vaginal cuff-related complications, and dyspareunia.

Results

Demographic variables and baseline characteristics were similar in both groups except for body mass index (BMI). The mean vaginal cuff closure time was significantly less in the V-Loc group (8.84 ± 2.18 min) than in the Vicryl group (11.66 ± 1.74 min) (p = <0.01). Mean operative time was comparable in both groups (V-Loc group - 109.36±33.02 and Vicryl group - 108.49±40.48; p = 0.91). Other intraoperative parameters, such as blood loss and number of stitches in cuff closure, and postoperative characteristics, such as pain score, duration of hospital stay, vaginal cuff-related complications (vault cuff dehiscence, hematoma, or abscess), and dyspareunia, were comparable in both the groups.

Conclusions

The unidirectional barbed suture significantly reduces vaginal cuff closure time. It is a safe, effective, and well-tolerated alternative to conventional Vicryl suture for vaginal cuff closure in TLH without increasing the risk of postoperative vaginal complications particularly where affordability is not an issue and resources are accessible.

Total laparoscopic hysterectomy in combination with dilation and evacuation of an 18-week-sized uterus with gestational trophoblastic neoplasia: a novel treatment approach

Gestational trophoblastic disease is a spectrum that includes complete and partial hydatidiform moles, invasive mole, choriocarcinoma, and placental site trophoblastic tumor. Although most cases of gestational trophoblastic neoplasia occur after a molar pregnancy, it can develop after any pregnancy. Suction curettage remains the standard first-line management in a molar pregnancy in patients desiring fertility. However, hysterectomy is a reasonable option in patients that do not desire to preserve fertility. Hysterectomy for gestational trophoblastic neoplasia can be difficult because of the enlarged uterus and prominent uterine vasculature. Traditionally, hysterectomy for gestational trophoblastic neoplasia is usually performed via laparotomy. In this article and accompanying video, we describe and illustrate a minimally invasive technique that demonstrates a safe and feasible laparoscopic removal of an enlarged uterus and illustrates alternative extraction techniques to avoid laparotomy in hysterectomy for gestational trophoblastic disease. In this case, a combination of laparoscopic transection of the vascular pedicles followed by dilation and evacuation was used before colpotomy. The addition of dilation and evacuation allowed us to reduce the overall size of the uterus and remove it intact through the vagina with minimal bleeding, avoiding unnecessary laparotomy. This allowed the patient to have an improved postsurgical recovery experience with minimal blood loss compared with standard laparotomy for gestational trophoblastic neoplasia.

Surgical outcomes of conventional laparoscopic and robotic-assisted hysterectomy

INTRODUCTION

The aim of the present study was to compare surgical outcomes of total laparoscopic hysterectomy with those of the robotic approach using the da Vinci Xi system.

METHODS

Patients who underwent hysterectomy with da Vinci Xi for early endometrial cancer or benign indications from 2018 to 2019 were selected. The control group consisted of patients who underwent conventional laparoscopy.

RESULTS

A total of 300 patients were included in the study. The mean duration of surgery differed significantly (p = 0.025) between those who underwent laparoscopy (125.01 ± 76.168) and robotic-assisted surgery (142.96 ± 82.657 min). Blood loss, median hospital stay, intraoperative and postoperative complications were similar in both groups. No statistical difference was observed in the subgroups with a body mass index of more than 30 kg/m² or more than 40 kg/m² concerning the duration of surgery or the surgical outcome.

CONCLUSION

The da Vinci Xi did not improve surgical outcomes in patients who underwent hysterectomy by trained laparoscopists and takes more time than conventional laparoscopy when performed in patients of normal weight.

Risk Factors for Surgical Treatment of Endometrial Cancer Using Traditional and Laparoscopic Methods

Surgical treatment is the most important part of therapy for endometrial cancer. The aim of the study was to define factors having the most significant impact on surgical treatment of endometrial cancer when using traditional and laparoscopic methods. In the study, we evaluated 75 females who were treated for endometrial cancer via laparoscopic surgery in 2019 and used a historical control of 70 patients treated by laparotomy in 2011. The evaluated risk factors included the method of surgery, type of lymphadenectomy, patient's age, various obesity parameters, histological grading, cancer clinical staging, pelvic dimensions, previous abdominal surgeries, comorbidities, and number of deliveries. The duration of hospitalization, operation time, loss of hemoglobin, and procedure-related complications were used as parameters of perioperative outcomes. Multivariable linear regression analysis confirmed the following factors as being predictors of worse perioperative outcomes: laparotomy, abdominal obesity (waist circumstance and waist-to-hip ratio), range of lymphadenectomy, prior abdominal surgeries, and larger pelvic dimensions. Abdominal obesity is a significant risk factor in the treatment of endometrial cancer. Laparotomy continues to be utilized frequently in the management of endometrial cancer in Poland as well as elsewhere, and adopting a minimally invasive approach is likely to be beneficial for patient outcome.

Outcomes of Total Laparoscopic Hysterectomy: A Single-Surgeon Experience of Initial 50 Cases

Introduction

In this study, we reported a single surgeon experience of total laparoscopic hysterectomy (TLH) in terms of intraoperative and early postoperative outcomes and complications. In addition, we compared our results with published literature for a reevaluation of complications and outcomes.

Material and methods

This present prospective study was conducted on 50 patients who underwent TLH due to benign causes. Patients diagnosed with abnormal uterine bleeding (AUB), uterine fibroids, and post-menopausal bleeding (PMB) were included in this analysis. Patients were discharged after 24 hours of surgery if there were considered fit for discharge. The patients' age, co-morbidities, size of the uterus, additional procedure along with TLH, and postoperative complications were collected and analyzed. The follow-up period was three months, done on the tenth day after surgery, the thirtieth day, and then at three months.

Results

The mean age of our patients was 46.42±5.01 years. The major indication of hysterectomy was fibroids diagnosed in 27 (54.0%) patients and AUB in 18 (36.0%) patients. Out of 50, 10 (20.0%) patients had a previous cesarean section, and 4 (8.0%) had a bilateral tubal ligation (BTL). Mean surgery duration was 124.26±44.74 minutes. Mean hospital stay was 2.18±0.39 days. Total complications occurred in five (10.0%) patients, ureteric injury in one (2.0%) patient, port-site infections in 2 (4.0%), and vault infections in 2 (4.0%) patients.

Conclusion

TLH is a safe procedure and can be performed with minimal complications in patients with benign uterine etiology.

Two cases of giant peritoneal inclusion cysts requiring treatment after total laparoscopic hysterectomy

Peritoneal inclusion cysts (PICs) often develop in post-operative patients. Since the incidence of adhesions is lower with laparoscopic surgery than with open surgery, PICs are less likely to occur in the former. Although post-operative adhesions or PICs rarely develop after laparoscopic surgery (such as total laparoscopic hysterectomy: TLH), we encountered two cases of giant PICs with abdominal pain after TLH. In Case 1, strong adhesion was already present when TLH was performed. Therefore, this case may have been predisposed to the development of adhesions in the abdominal cavity. However, no adhesions were observed during TLH in case 2, and there were no risk factors, such as pre-operative adhesions and endometriosis. Therefore, adhesions and PICs may develop even after TLH, and approaches need to be considered for their prevention.

Ultrasound-guided anterior and posterior quadratus lumborum block for analgesia after laparoscopic hysterectomy

Aim: Laparoscopic procedures are now preferred over open surgeries, and total laparoscopic hysterectomy is becoming increasingly popular. Quadratus lumborum (QL) block is an evolving technique for abdominal surgeries that blocks T5-L1 nerve branches. Methods: We used a combination of anterior and posterior QL block given bilaterally in two patients and evaluated perioperative opioid consumption, postoperative pain score and patient satisfaction. Results: There was reduced perioperative opioid consumption along with postoperative visual analog scale for pain over the first 24 h. Both patients appreciated the level and standard of pain relief. Conclusion: QL block is promising as a part of multimodal analgesia for laparoscopic abdominal surgeries. Further studies are needed to determine the best possible combination of different approaches to QL block.

Does Obesity and Procedure Type Increase the Risk of In-Hospital Mortality in Laparoscopic Hysterectomy: A Report From the United States Hospitals

Objectives

To assess the differences in demographics and laparoscopic hysterectomy type by comorbid obesity and to assess the risk of in-hospital mortality due to obesity and other comorbidities.

Methods

We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS, 2012-2014), and included 119,890 adult females undergoing total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and laparoscopic supracervical hysterectomy (LSH). We used a logistic regression model adjusted for confounders to assess the odds ratio (OR) of obesity on mortality in study inpatients.

Results

The majority of the inpatients were middle-age 36-50 years (83.1%) and White (67.7%). Comorbidities were seen in a higher proportion of obesity cohort with most prevalent being hypertension (53.6%) and diabetes (23.9%), followed by depression and hypothyroidism (15.8% and 15.4%, respectively). Inpatients with comorbid obesity had 4.6 times (95% CI 2.79-7.69) higher odds for in-hospital mortality compared to non-obesity cohort. There was statistically no significant association between type of laparoscopic hysterectomy and in-hospital mortality.

Conclusion

Analysis of national-level data shows that obese patients have a higher risk of in-hospital mortality by 364% compared to non-obese patients. There was no significant association between the laparoscopy procedure type and in-hospital mortality. More studies should focus on improving hospital outcomes and quality of life post-surgery in obese patients.

The Role of Preoperative and Postoperative Transversus Abdominis Plane and Rectus Sheath Block in Patients Undergoing Total Laparoscopic Hysterectomy

PURPOSE

This study was performed to assess the efficacy of a preoperative and postoperative transversus abdominis plane (TAP) and rectus sheath (RS) block compared with no TAP and RS block in patients undergoing total laparoscopic hysterectomy (TLH).

DESIGN

Prospective observational cohort study.

METHODS

From January 2014 to December 2017, 195 women undergoing TLH were categorized into three groups based on their perioperative analgesia: no TAP + RS block (n = 88), preoperative TAP + RS block + systemic analgesia (n = 68), and postoperative TAP + RS block + systemic analgesia (n = 39). We evaluated use of nonsteroidal anti-inflammatory drugs (NSAIDs) and NSAID consumption within the first 12 hours postoperatively and the numerical rating scale score at 0, 12, and 24 hours postoperatively.

FINDINGS

Women with a preoperative TAP + RS block had a significantly lower utilization rate of NSAIDs within the first 12 hours postoperatively (54.4% vs 75.0%; P = .007), lower postoperative flurbiprofen dose (45.5 vs 62.0 mg; P = .048), and lower numerical rating scale score at 12 hours postoperatively (1.63 vs 2.20; P = .002) compared with women with no TAP + RS block.

CONCLUSIONS

A preoperative TAP + RS block provided superior postoperative analgesia in patients undergoing TLH and reduced analgesic consumption during the first 12 hours postoperatively.

Total laparoscopic hysterectomy - clinical comparison of the method using two types of uterine manipulators

AIM OF THE STUDY

Comparison of two types of uterine manipulators used in total laparoscopic hysterectomy (TLH) and clinical evaluation of the method in patients in a two-year group supplemented by subjective evaluation.

DESIGN

Prospective observational study.

SETTING

Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital Brno.

MATERIAL AND METHODS

A group of patients operated in the years 2018-2019 by the TLH method using one of two types of uterine manipulators - Karl Storz HOHL (group No. 1) vs. plastic ring of Koh&#39;s manipulator (group No. 2). We compared surgical time (min), blood loss (ml), perioperative complications, length of hospital stay (days), early and late complications. We were interested in the possible influence of BMI, uterine on these parameters. Subjective evaluation of the method by patients took place before the procedure and 12 weeks after the operation with a standardized questionnaire.

RESULTS

A total of 134 patients were enrolled in the study (75 in group 1 vs. 59 in group 2). The monitored parameters: age, BMI, operative time, blood loss and length of hospitalization did not differ statistically significantly. When comparing the individual groups with different manipulators, the total number of complications (mild difficulties, serious complications) was without statistical significance (p = 0.58), but the spectrum of symptoms was different in both groups. More than a third of the patients in the group were obese. There were more serious complications than non-obese ones, the performance was longer, however, for a small number it was statistically insignificant (p = 0.11). In patients with uterine surgery, we recorded more adhesiolysis. We did not show that previous surgery on the uterus was associated with a higher incidence of complications (p = 0.6). We did not notice any statistically significant difference in the subjective evaluation (p = 0.3).

CONCLUSION

TLH is the dominant method of uterine removal in our workplace. In a group of 134 women, we did not show a statistically significant difference in the monitored parameters. The HOHL manipulator has proved to be more user-friendly due to its technical parameters and better clarity of the operating field. Subjective evaluation of the method was positive in patients.

Perioperative outcomes of bipolar energy instruments in total laparoscopic hysterectomy

OBJECTIVES

To compare conventional and advanced bipolar energy instruments in terms of perioperative outcomes inpatients who underwent total laparoscopic hysterectomy (TLH).

MATERIAL AND METHODS

The data of 101 patients who underwent TLH between June 2017 and December 2018 for benigngynecological disorders were analyzed retrospectively. Conventional bipolar forceps (Robi forceps) were used in 37 patientsand advanced bipolar instruments (LigaSure) were used in 64 patients. Data about the characteristics of the patients, operationtime, estimated blood loss, length of hospital stay and other perioperative outcomes were compared.

RESULTS

The mean ages of the patients in the conventional bipolar and LigaSure groups were 47.6 ± 6.5 and 48.1 ± 7 years,respectively (p > 0.05). There was no statistically significant difference between the two groups with regard to all otherpatient characteristics; body mass index, parity, previous pelvic operation and indications of hysterectomy (p > 0.05). Themean operation time (41 ± 13.2 vs 37 ± 11.5 min), estimated intraoperative blood loss (70 ± 22 vs 65 ± 21 mL) and absolutechange in hemoglobin (-1.23 ± 1.12 vs -1.11 ± 1.14 g/dL) were slightly higher in the conventional bipolar group. However,there was no statistical significance with respect to these differences between the groups (p > 0.05).

CONCLUSIONS

Our findings indicate that a conventional bipolar system is as safe and effective as LigaSure, and it may beused as an alternative option for patients undergoing TLH in low-income hospitals.

Comparison of Total Laparoscopic Hysterectomy with Abdominal Total Hysterectomy in Patients with Benign Disease: A Retrospective Cohort Study

Background

The present study aimed to determine whether total laparoscopic hysterectomy (TLH) is being implemented safely and appropriately compared with abdominal total hysterectomy (ATH) in our hospital.

Methods

We retrospectively reviewed clinical records of 102 patients who underwent total hysterectomy for benign gynecological disease at Japanese Red Cross Yamaguchi Hospital from January 2017 to August 2018. We examined periods of hospital stay, operation time, blood loss, weight of the uterus, frequency of perioperative complications, and the duration from the first visit to the date of surgery. P < 0.05 was considered to be statistically significant indicated statistical significance.

Results

TLH and ATH were performed in 55 (53%) and 47 (46%) cases, respectively. The TLH group had significantly longer total operation time [133 (82-205) min vs. 87 (57-155) min, P < 0.0001], lesser blood loss [5 (5-35) g vs. 100 (10-820) g, P < 0.0001], shorter hospital stay [7 (5-14) days vs. 10 (9-26) days, P < 0.0001], and lighter uterine weight [206 (27-658) g vs. 554 (79-2284) g, P < 0.0001] than the ATH group. The frequency of perioperative complications did not differ between the two groups (3.5% vs. 8.0%, P = 0.4103).

Conclusion

TLH had a longer operation time and a lesser excised uterine weight, but it had less intraoperative blood loss, shorter hospital stay, and no difference in perioperative complication frequency when compared with ATH.

Does minimally invasive surgery reduce anxiety?

Objective:

To evaluate whether there were any differences in preoperative and postoperative anxiety in patients who underwent total laparoscopic hysterectomy (TLH) (n=37) and total abdominal hysterectomy (TAH) (n=37).

Material and Methods:

All premenopausal patients who underwent TLH or TAH because of benign uterine disorders were enrolled. Anxiety status was assessed 6 hours before and after the operation using standardized validated questionnaires: State-Trait Anxiety Inventory.

Results:

In the TAH group, the state anxiety level of the patients significantly increased, whereas there was a significant decrease in the TLH group. For the trait anxiety level, there was a statistically significant increase in the TAH group postoperatively. In the TLH group, trait anxiety levels decreased postoperatively. In the analysis of between-group differences, pre and postoperative the state anxiety level was higher in the TAH group. A statistically significant difference was determined between the groups in respect of the postoperative state anxiety levels (p<0.05), but not in the preoperative state anxiety levels (p>0.05). Statistically significant differences were determined between the groups in respect of education, occupation, and curettage rates (p<0.05).

Conclusion:

Women undergoing TLH for benign uterine disease may have lower levels of preoperative and postoperative anxiety than women undergoing TAH.

Comparison of the efficacy and safety of two advanced vessel sealing technologies in total laparoscopic hysterectomy

AIM

Adequately powered, randomized controlled studies evaluating efficacy and safety of advanced bipolar energy devices in gynecologic laparoscopic surgery are very few. We aimed to compare the two most commonly used devices in total laparoscopic hysterectomy.

METHODS

This randomized controlled trial was carried out in the department of obstetrics and gynecology in an education and research hospital. One hundred thirty-two women who underwent total laparoscopic hysterectomy for benign indications were included. Women with age younger than 18 years, suspected malignancy, stage 3-4 endometriosis and cervical/intraligamentary leiomyoma were excluded. Patients were randomized preoperatively to LigaSure or Articulating Enseal. One experienced surgeon performed all operations.

RESULTS

LigaSure was used in 67 patients and Enseal was used in 65 patients. Primary outcomes of the study were operative time (time from start of sealing and transection of the round ligament until completion of colpotomy) and total operative time (time from skin incision to skin closure). Secondary outcomes were intraoperative blood loss (blood lost during operative time period) and perioperative complications. Operative time was significantly shorter in LigaSure group (P = 0.001). Total operative time, intraoperative blood loss and perioperative complications were similar. When two groups were further classified according to uterine weight taking 300 g as cut-off value, operative time was significantly shorter in LigaSure group in both subgroups (P = 0.003 and P = 0.007).

CONCLUSION

LigaSure use in total laparoscopic hysterectomy shortens operative time when compared with Enseal; without an apparent increase in intraoperative blood loss and perioperative complications. On the other side, total operative time remains unaffected.

[THREE CASES OF IATROGENIC URETERAL INJURY ASSOCIATED WITH TOTAL LAPAROSCOPIC HYSTERECTOMY]

We report three cases of iatrogenic ureteral injury associated with total laparoscopic hysterectomy. Case 1 was a 50-year-old woman. She underwent total laparoscopic hysterectomy (TLH) for myoma uteri. Postoperatively, a blood test revealed renal dysfunction, and ultrasonography (US) revealed left hydronephrosis. She was referred to our department on the next day of TLH. Computed tomography (CT) revealed left hydronephrosis. Retrograde pyelography (RP) was tried, but the ureteral catheter could not be inserted into the left ureteral orifice. An operation was performed on the second day after THL. The left ureter was ligated near the ureterovesical junction, and so uretero-ureterostomy was conducted. Case 2 was a 38-year-old woman. She underwent TLH for myoma uteri. Postoperatively, she complained of abdominal fullness and diarrhea. A blood test revealed renal dysfunction and US revealed left hydronephrosis on the ninth day after THL. She was referred to our department next day. CT revealed left hydronephrosis and ascitis. RP revealed extravasation of contrast medium from the left ureter. She was diagnosed with left ureteral injury accompanied by extravasation of urine into the intraperitoneal space. Uretero-cystoneostomy was performed. Case 3 was a 45-year-old woman. She underwent TLH for myoma uteri. Postoperatively, a blood test revealed renal dysfunction, and US revealed left hydronephrosis. She was referred to our department on the fifth day after TLH. CT revealed left hdronephrosis and ureteral obstruction of the left lower ureter. An operation was performed under laparoscopy, cystoscopy, and fluoroscopy on that day and the left lower ureter was kinked by threads. Cutting of the threads was performed under laparoscopy. After thread cutting, the kink of the ureter was improved and ureteral stent could be indwelled between the renal pelvis and bladder. After 1 month, the ureteral stent was removed and left hydronephrosis disappeared.

Unidirectional barbed suture for vaginal cuff closure without backward stitch in total laparoscopic hysterectomy

AIM

To evaluate the safety and efficacy of unidirectional barbed suture technique for vaginal cuff closure in total laparoscopic hysterectomy (TLH).

METHODS

In a retrospective chart review, data were analyzed from 165 patients who underwent a TLH with an unidirectional barbed suture technique for vaginal cuff closure from January 2012 to June 2016 at tertiary-care university-based teaching hospital and academic affiliated hospital. Vaginal cuff was closed by single layer 3/0 V-Loc unidirectional 9″, 180 day Absorbable Wound Closure Device (Covidien Healthcare, Mansfield, MA) and the suture was not stitched backward to secure distal end.

RESULTS

A total of 165 patients were included and the median age was 50 years (range, 35-84 years). The median completion time for hysterectomy time was 100 min (range, 40-240 min) and the median vaginal cuff closure time was 7 min (range, 4-15 min). The median estimated blood loss was 87.8 mL (range 30-250 mL) and the median uterine weight was 200 g (range, 40-900 g). Intraoperative complication included bladder perforation (1.2%) and postoperative complications were vaginal cuff dehiscence (1.8%), cuff cellulitis (0.6%), vesicovaginal fistula (0.6%) and unexplained fever (0.6%).

CONCLUSION

According to the results of current study, the use of unidirectional barbed suture without backward stitching appears to be safe for the vaginal cuff closure in TLH.

Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy

BACKGROUND

Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event.

OBJECTIVE

The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial.

STUDY DESIGN

Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy.

RESULTS

After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence.

CONCLUSION

Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention.

Comparison of barbed unidirectional suture with figure-of-eight standard sutures in vaginal cuff closure in total laparoscopic hysterectomy

The aim of the study was to compare postoperative vaginal cuff complications due to the use of barbed sutures (V-Loc™ 180 unidirectional suture; Covidien, Mansfield, MA) and standard braided sutures (Vicryl^®; Ethicon Inc., Somerville, MA) during vaginal cuff closure of patients undergoing a total laparoscopic hysterectomy (TLH) due to benign diseases. Eighty-nine patients were in the standard suture group and 208 patients were included in the barbed suture group. Vaginal cuff dehiscence was identified in only three (3.3%) patients within the standard suture group and none in the barbed suture group. Five (5.6%) patients in the standard suture group and two (0.9%) patients in the barbed suture group developed postoperative cuff infection/cellulitis. Duration of the surgery was significantly shorter in the barbed suture group than in the standard suture group (p < .05). V-Loc™ 180 unidirectional barbed suture, which is used during TLH for vaginal cuff closure, is an applicable, safe and tolerable alternative to a standard suture. IMPACT STATEMENT What is already known on this subject: Barbed sutures are a relatively new type of suture that include sharp barbs inserted on monofilament material in various configurations, and are used for approximating tissues without any need for surgical knotting. They have increasingly been used in obstetrics and gynaecology in recent years, particularly in total laparoscopic hysterectomy and laparoscopic myomectomy. At present, there are a limited number of studies of V-Loc™ suture in the literature. What the results of this study add: We demonstrated that barbed sutures used for enabling vaginal cuff integrity did not cause major morbidity and mortality for the patient. We suggest that V-Loc™ 180 barbed sutures offer a practical, safe and tolerable alternative for surgeons because they are easy to use, do not cause a significant increase in vaginal cuff complications, and shorten the operating time. Our study with V-Loc™ 180 unidirectional barbed suture is the second largest series after the study of Cong et al. What the implications are of these findings for clinical practice and/or further research: We believe that the barbed suture, the surgery results of which are openly discussed in our study, will be more prominent in clinical practice owing to the shortened operating time, and that the use of these sutures does not cause a significant increase in vaginal cuff complications.

Surgical outcomes of total laparoscopic hysterectomy with 2-dimensional versus 3-dimensional laparoscopic surgical systems

Three-dimensional (3D) laparoscopic surgical systems have been developed to account for the lack of depth perception, a known disadvantage of conventional 2-dimensional (2D) laparoscopy. In this study, we retrospectively compared the outcomes of total laparoscopic hysterectomy (TLH) with 3D versus conventional 2D laparoscopy. From November 2014, when we began using a 3D laparoscopic system at our hospital, to December 2015, 47 TLH procedures were performed using a 3D laparoscopic system (3D-TLH). The outcomes of 3D-TLH were compared with the outcomes of TLH using the conventional 2D laparoscopic system (2D-TLH) performed just before the introduction of the 3D system. The 3D-TLH group had a statistically significantly shorter mean operative time than the 2D-TLH group (119±20 vs. 137±20 min), whereas the mean weight of the resected uterus and mean intraoperative blood loss were not statistically different. When we compared the outcomes for 20 cases in each group, using the same energy sealing device in a short period of time, only mean operative time was statistically different between the 3D-TLH and 2D-TLH groups (113±19 vs. 133±21 min). During the observation period, there was one occurrence of postoperative peritonitis in the 2D-TLH group and one occurrence of vaginal cuff dehiscence in each group, which was not statistically different. The surgeon and assistant surgeons did not report any symptoms attributable to the 3D imaging system such as dizziness, eyestrain, nausea, and headache. Therefore, we conclude that the 3D laparoscopic system could be used safely and efficiently for TLH.

Overcoming the learning curve of single-port total laparoscopic hysterectomy with barbed suture: a single surgeon's initial experience

INTRODUCTION

Single-port total laparoscopic hysterectomy (TLH) has not been widely used because of its technical difficulty and steep learning curve, especially the laparoscopic suturing of the vaginal stump. Barbed suturing is a new technology that has the potential to greatly facilitate laparoscopic suturing.

AIM

To compare surgical outcomes and vaginal vault healing between barbed sutures and traditional sutures in the repair of the vaginal vault during single-port TLH.

MATERIAL AND METHODS

Between August 2013 and June 2015, we performed single-port TLH in 85 consecutive patients for benign or premalignant gynecological conditions. The first 48 patients underwent single-port TLH with traditional interrupted sutures, and the next 37 patients underwent single-port TLH with absorbable unidirectional knotless barbed sutures for repair of the vaginal vault.

RESULTS

The patient characteristics (age, body mass index), procedures performed, uterine weight, and uterine disease were similar between the groups. There were no differences in blood loss, hemoglobin change, length of hospital stay, or perioperative complications. Operative time and the time required for vaginal cuff suturing were significantly shorter in the barbed suture group than in the traditional suture group (57.8 ±13.5 vs. 80.1 ±18.7 min, p < 0.001; 5.5 ±1.7 vs. 12.9 ±3.5 min, p < 0.001). Moreover, the use of barbed sutures significantly reduced the incidence of vaginal granulation tissue formation (2.7% vs. 35.4%, p < 0.001).

CONCLUSIONS

Use of barbed sutures in single-port TLH reduced the operative time, suturing time of the vaginal vault, and formation of vaginal granulation tissue. Barbed suturing may help overcome surgical difficulties and vaginal cuff complications.

Total laparoscopic hysterectomy for large uterine cervical myoma

Ureterolysis is a surgical method with a high level of difficulty, which may be necessary when performing total laparoscopic hysterectomy (TLH) for large cervical myoma, despite the benign nature of this tumor. The aim of the present study was to introduce techniques that are commonly applied in malignant tumor surgery in order to safely perform TLH for large cervical myoma. Between 2014 and 2016, TLH was performed at the Shimane University Hospital (Izumo, Japan) in 153 patients with benign tumors, including 25 cases with a large uterus (uterine weight ≥500 g). The surgical methods applied in 3 of these large uterine cervical myoma cases were investigated in detail, including techniques devised by our department. TLH was performed without enucleating myomectomy in all 3 cases; however, all 3 cases required ureterolysis, transection of the anterior layer of the vesicouterine ligament and isolation of the ureter. In conclusion, although radical laparoscopic hysterectomy is commonly performed for cervical cancer at our department, techniques used for malignant tumor surgery may prove useful for benign cases with a high level of difficulty.

[Total laparoscopic hysterectomy with the coagulation of the uterine arteries at their origin]

INTRODUCTION

Hysterectomy is one of the most frequently performed gynecological operations worldwide. Due to patient perceived advantages of technical development laparoscopic hysterectomy has become a widely used method. The attitude of patients, surgeons and service providers to laparoscopic procedures is not uniform, but total laparoscopic hysterectomy has prevailed due to its advantages from other types of laparoscopic hysterectomies. Coagulation of the uterine arteries at their origin during the standardized method of total laparoscopic hysterectomy provides further benefits for this procedure.

AIM

Our aim was the presentation of our experience together with a review of the relevant literature.

METHOD

Operations were performed with the coagulation of the uterine arteries at their origin right at the beginning of the procedure. Inclusion criteria were the use of the standardized method, video documentation of the surgery, and pre- and postoperative haemostatus results.

RESULTS

Our results confirm that the procedure involves an acceptable operating time that is comparable to that of open abdominal and vaginal hysterectomies, minimal blood loss that is far less than that in open procedures, a much shorter duration of hospitalization and a low complication rate.

CONCLUSION

In skilled hands with proper knowledge of the anatomy the standardized method of total laparoscopic hysterectomy with the coagulation of the uterine arteries at their origin is a safe and reproducible technique which suitably utilizes the advantages of minimally invasive surgery. Orv. Hetil., 2017, 158(8), 298-303.

Risk of spilling cancer cells during total laparoscopic hysterectomy in low-risk endometrial cancer

Objective

To evaluate the risk of spilling cancer cells during total laparoscopic hysterectomy (TLH) using a uterine manipulator in early-stage endometrial cancer patients.

Materials and methods

We conducted a prospective study among women undergoing TLH for Clinical Stage IA endometrial cancer between March 2015 and November 2015. Peritoneal washings before the insertion of the uterine manipulator and after TLH were obtained. The two sets of washings were reviewed by a cytopathologist to determine the presence or absence of malignant cells in a blinded manner.

Results

Thirteen endometrial cancer patients (age 39-79 years, median: 62.2 years) were enrolled. The postoperative tumor grades were: G1: 11 (84.6%) and G2: 2 (15.4%). All patients underwent TLH and bilateral salpingo-oophorectomy. Pelvic/para-aortic lymph node dissection was not performed in all cases. Only one patient showed positive peritoneal cytology in the pre-TLH sample. There was high agreement (92.3%) between the two sets of washings in all patients. No patients received postoperative treatment.

Conclusion

We conclude that fallopian tubal cauterization is sufficient to provide protection from the dissemination of cancer cells into the peritoneal cavity at the time of TLH for endometrial cancers in early stages.

Barbed versus conventional 2-layer continuous running sutures for laparoscopic vaginal cuff closure

We compared results using unidirectional barbed sutures and conventional sutures for vaginal cuff closure during total laparoscopic hysterectomy (TLH).The electronic medical records and surgical videos of 170 patients who underwent TLH between January 2013 and March 2015 at Uijeong-bu St. Mary's Hospital of Catholic University of Korea were reviewed. Vaginal cuffs were closed using the 2-layer continuous running technique with unidirectional barbed sutures (V-Loc; Covidien, Mansfield, MA) in 64 patients and with polycolic acid Vicryl; Ethicon, Somerville, NJ sutures in 106 patients. Procedure time, clinical characteristics, and postoperative complications were compared between the 2 study groups. There were no differences in clinical characteristics (age, body mass index, and demographic data) between groups. The mean suturing time was significantly reduced in the barbed group (7.2 vs 12.2 minutes; P < 0.001), although the mean number of stitches was greater than in the Vicryl group (14.1 vs 12.3, P < 0.001). Perioperative complications, including episodes of vaginal bleeding, vaginal cuff cellulitis, and postoperative fever, did not differ between groups. There were no instances of vaginal cuff dehiscence in either group. Unidirectional barbed sutures can be used safely to reduce procedure time and surgical difficulty relative to conventional sutures in laparoscopic vaginal cuff closure.

Single-port access total laparoscopic hysterectomy with Korean-made OCTO Port: Turkish surgeons' initial experience

We present our initial experience with single-port access total laparoscopic hysterectomy (TLH) surgery using a Korean-made laparoscopic port (OCTO™ Port). In a retrospective study, single-port access TLH (SPA-TLH) with the OCTO Port was performed on 34 patients with benign gynaecological indications from July 2013 to May 2014 by two surgeons (Ahmet Kale and Hasan Terzi). All patients were divided into two groups. The first 15 patients who underwent SPA-TLH were classified as Group 1, and the second 19 patients who underwent SPA-TLH were classified as Group 2. Patient data were analyzed for age, body mass index (BMI, kg/m(2)), weight of uterus, vaginal cuff suturation time, estimated blood loss, operation time, hysterectomy indications and operative outcomes. The median time needed for the surgery was 75 min in both groups. The duration of suturing of the vaginal cuff was shorter in Group 2 compared with that in Group 1. The estimated blood loss was less in Group 2 compared with Group 1: Four patients in Group 1 required blood transfusion while none of the patients in Group 2 required blood transfusion. The OCTO Port has soft and flexible instrumental movements, which can reduce crowding of instruments during surgery, and the cap rotates 360 degrees. The OCTO Port might facilitate the learning curve of single-port laparoscopic hysterectomy surgery.

Laparoscopic sentinel lymph node mapping after cervical injection of indocyanine green for endometrial cancer - preliminary report

Introduction

Endometrial cancer (EC) has an increasing incidence worldwide, with lymph node metastases as the main prognostic factor. Systemic lymphadenectomy is connected with elevated morbidity. Sentinel lymph node (SLN) biopsy is intended to avoid extensive lymphadenectomy and provide significant oncologic information.

Aim

To evaluate the accuracy of laparoscopic SLN biopsy guided by indocyanine green (ICG) injection into the cervix in EC patients and to develop ideas to improve this method. The optimal time from dye injection to lymph node visualization was assessed.

Material and methods

This retrospective study was conducted between July 2014 and March 2015 in a group of 9 women with EC, at low and intermediate risk of recurrence, scheduled for total laparoscopic hysterectomy and pelvic lymphadenectomy. All patients underwent cervical ICG injection and SLN biopsy, followed by surgery. Pelvic lymph nodes were located using an ICG endoscopic camera.

Results

The following data were collected: There were 9 patients with endometrial cancer at low and intermediate risk of recurrence. Median patient age was 59 years, median body mass index (BMI) 28 kg/m², endometrioid adenocarcinoma in 9 cases, grading: G1 – 1 patient, G2 – 8 patients. No intraoperative or postoperative complications were noted. Median time from ICG injection and SLN detection during surgery was 25 min. There were no lymph nodes metastasis, all identified by the SLN protocol using ICG injection.

Conclusions

Sentinel lymph node mapping can play a significant role in lymph node assessment and staging in early-stage EC patients with low risk of recurrence according to the ESMO classification. The use of SLN mapping in EC is much needed and the therapeutic benefit is high.

Safe vaginal uterine morcellation following total laparoscopic hysterectomy

The minimally invasive approach for hysterectomy with proven benefits and lower morbidity has become the gold standard, even in women with large uterine masses. Most women with a malignant condition present with abnormal vaginal bleeding and/or suspicious imaging such that few are diagnosed by final histopathology after surgery. However, if a malignancy is not diagnosed preoperatively, intraabdominal morcellation for uterus extraction has an increased risk for potential tumor spread and peritoneal metastases, especially in cases of unexpected leiomyosarcoma. We describe a simple method to wrap the uterus in a contained environment with a plastic bag through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in total laparoscopic hysterectomy. We further describe our experience with a risk stratification and treatment algorithm to implement this procedure in daily routine. A video and an illustrating sketch demonstrate the simplicity and safety of the procedure.

Ligation of uterine vessels in total laparoscopic hysterectomy using Hem-o-lok clips

OBJECTIVE

The Hem-o-lok clip ligation has become the preferred method for vessel ligation. We evaluated the feasibility and safety of uterine vessel ligation using the Hem-o-lok clip during total laparoscopic hysterectomy.

MATERIALS AND METHODS

The clinical outcomes of 58 hysterectomies were compared between the following two groups: Hem-o-lok clip group (n = 29) and bipolar coagulation group (n = 29).

RESULTS

Of the 29 patients in the Hem-o-lok clip group, bilateral application of Hem-o-lok clips was completed in 25 patients (86%); unilateral use of the bipolar coagulator was needed in four patients for rapid control of bleeding from lacerated uterine vessels during dissection and/or because of anatomical difficulty. No complications, such as dislodgement, slippage, or bleeding, were identified in the Hem-o-lok clip group. No difference was identified in surgical outcomes, such as blood loss or operative time, between the two groups. Postoperative pelvic infections occurred in one patient from each group with unilateral and bilateral use of the Hem-o-lok clip; the ligated uterine vessels using the Hem-o-lok clip were intact, but the coagulated uterine vessels were weakened by the pelvic infections, which caused active uterine bleeding requiring emergent reoperation.

CONCLUSION

The Hem-o-lok clip could be used for ligation of uterine vessels and might be resistant to pelvic infections compared with bipolar coagulation. Prospective randomized trials are needed to confirm the real clinical benefit of this surgical approach.

Uterine artery ligation at the beginning of total laparoscopic hysterectomy reduces total blood loss and operation duration

The purpose of this study was to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom uterine arteries were not ligated at the beginning of TLH. In our prospective study, a total of 60 women underwent TLH. Uterine artery ligation (UAL) was done at the beginning of the procedure. Women were divided into TLH + UAL (n = 30) and TLH (n = 30) groups. In TLH group, TLH was done without ligating the uterine arteries at the beginning of the procedure. In TLH + UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. The mean operating time was longer for the TLH group (99.16 ± 7.01) than TLH + UAL group (63.27 ± 7.16). The median total blood loss was higher in TLH group (109.38 ± 33.03 mL) than TLH + UAL group (47.50 ± 8.12 mL). UAL at the beginning of TLH is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure and length of hospital stay.