The Learning Curve of Total Laparoscopic Hysterectomy: Comparative Analysis of 1647 Cases

doi:10.1016/S1074-3804(05)60414-8

The Journal of the American Association of Gynecologic Laparoscopists

Volume 9, Issue 3, August 2002, Pages 339-345

The Journal of the A...

https://doi.org/10.1016/S1074-3804(05)60414-8 Get rights and content

Abstract

Study Objective

To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them.

Design

Retrospective, comparative study (Canadian Task Force classification II-2).

Setting

University tertiary referral center for endoscopic surgery.

Patients

During 1989–1995 and 1996–1999, 695 and 952 women, respectively, with benign pathology.

Intervention

Total laparoscopic hysterectomy.

Measurements and Main Results

differences in patient characteristics were found between 1989–1995 and 1996–1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22–904 g) and 292.0 g (40–980 g) and operating times 115 minutes (40–270 min) and 90 minutes (40–180 min), respectively, were recorded (p <0.005).

Conclusion

Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.

Section snippets

Materials And Methods

From November 1989 to December 1999, 1647 women underwent total laparoscopic hysterectomy (TLH) due to benign pathology. At the beginning of 1996 we introduced a new uterine manipulator to prevent complications. Therefore, we compared complications rates before and after its introduction. In early (1989–1995) and recent years (1996–1999), 695 and 952 women underwent TLH, respectively. Inclusion criteria were benign uterine disorders and patient consent. Exclusion criteria were anesthetic

Results

No differences were found between time periods for patient age, parity, body mass index (BMI), premenopausal status, and previous abdominal or pelvic surgery (Table 1). There was no difference in indications for surgery between periods. The most common pathologic diagnoses in both periods were myoma, adenomyosis, and endometrial atrophy, with no significant differences between groups.

Significant decreases in major complications (blood transfusion; urinary, bowel and neurologic injuries;

Discussion

The present study, to our knowledge the largest reported to date from a single center, supports the feasibility and overall favorable outcome associated with TLH. Previous reports indicated that even experienced laparoscopists have complication rates of 5.8% to 11.5% and major complication rates of 2.2% to 2.7% after laparoscopic hysterectomy for the management of benign uterine pathology.12, 13 One meta-analysis reported a total complication rate of 15.6%,¹⁴ which was comparable with the

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Laparoscopic hysterectomy for benign pathology in a tertiary university hospital: Analysis and evolution in a period of 8 years
2024, Clinica e Investigacion en Ginecologia y Obstetricia
Reflexionar desde el análisis de los datos del número de histerectomías laparoscópicas que puede realizar cada miembro de un servicio de ginecología de un hospital terciario sobre la conveniencia de limitar este procedimiento a un número limitado de profesionales.
Estudio retrospectivo, descriptivo, sobre las histerectomías realizadas por cualquier indicación en nuestro hospital en el periodo comprendido entre el 1 de mayo del año 2014 y el 30 de abril del año 2022.
En este periodo hemos realizado 1548 histerectomías, de las que 760 se efectuaron por vía laparoscópica; y de ellas, 289 fueron indicadas por patología benigna. Considerando el total de profesionales que conforman el pool de cirujanos que realizan cirugía por patología benigna, la media de histerectomías laparoscópicas por cirujano y año sería de 1,4 casos.
Para garantizar la adecuada calidad de la cirugía, el número de profesionales que realizan histerectomías laparoscópicas en un hospital terciario debe ser limitado.
To reflect from the analysis of the data of the number of laparoscopic hysterectomies that each member of a gynaecology service of a tertiary hospital can perform on the convenience of limiting this procedure to a limited number of professionals.
Retrospective, descriptive study on hysterectomies performed for any indication in our hospital in the period between May 1, 2014 and April 30, 2022.
In this period, we have performed 1548 hysterectomies of which 760 were performed laparoscopically and of these, 289 were indicated for benign pathology. Considering the total number of professionals that make up the pool of surgeons who perform surgery for benign pathology, the average number of laparoscopic hysterectomies per surgeon per year would be 1.4 cases.
To ensure adequate quality of surgery, the number of professionals performing laparoscopic hysterectomies in a tertiary hospital should be limited.
Total laparoscopic hysterectomy without uterine manipulator. A retrospective study of 1023 cases
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
The aim of this study was to evaluate the feasibility and safety of a total laparoscopic hysterectomy (TLH) without the use of a uterine manipulator in women with benign indications for hysterectomy.
Between January 2011 and January 2020, 1023 patients underwent a TLH without the use of any type of uterine manipulator. The indications for hysterectomy were all benign conditions. The patients’ details were obtained from the hospital medical records and the indications for hysterectomy, the surgical data and the intra and postoperative complications were evaluated. All operations were performed by the same surgical team.
The median age was 48.2 years, while the BMI ranged from between 26.2 kg/m² and 47.8 kg/m². A small percentage of the women were menopausal (278, 27 %) and, following a detailed consultation with 563 (55 %) of the patients, we performed a TLH with adnexectomy. The mean operative time was 78 min (43–168 min), while the estimated blood loss was 59 mL (20–260 ml) and the mean uterine weight was 255 g (40–1510 g). There was no case of conversion to laparotomy. A blood transfusion was required for 14 patients (1.4 %), while there was one case of ureteral injury and three cases where the bladder was opened and fixed laparoscopically. The average hospital stay was 1.1 days, with only 38 patients staying for two or more days. In the long term, we had five cases (0.5 %) of vaginal vault dehiscence and one case of vaginal vault hematoma.
A TLH without the use of a uterine manipulator is a feasible and safe procedure. While it is perhaps a more demanding procedure for young doctors, when performed by well-trained and experienced laparoscopic surgeons, the procedure entails a short operative time and a low complications rate. As such, it should be the first step in the training of young doctors for performing laparoscopic radical hysterectomies.
The outcomes of laparoscopic hysterectomies in a Spanish district hospital
2020, Clinica e Investigacion en Ginecologia y Obstetricia
Calcular la tasa de conversión y describir las indicaciones, tipos de cirugía y complicaciones de las histerectomías laparoscópicas en un hospital comarcal. Analizar los tiempos quirúrgicos y el peso uterino.
Estudio retrospectivo y descriptivo de la base de datos quirúrgica de las mujeres atendidas en el Servicio de Ginecología y Obstetricia del Hospital Comarcal de Valdeorras (Orense). Programamos a 78 mujeres para histerectomía laparoscópica desde mayo del 2011 hasta febrero de 2018. Describimos las características demográficas, clínica, tipo de cirugía y tratamientos previos. Realizamos 62 histerectomías totales, 15 subtotales y una operación de Manchester. Calculamos la tasa de conversión, porcentaje de morcelación, tiempo quirúrgico, complicaciones (clasificadas según la escala de Clavien-Dindo y el Comprehensive Complication Index) y los resultados de anatomía patológica.
Nuestra tasa de conversión fue del 5,13%. El porcentaje de morcelación fue 35,90%. En las histerectomías totales calculamos un peso uterino teórico (190 g o más) a partir del cual la morcelación sería más probable. No hubo transfusiones. Encontramos mayor tiempo quirúrgico entre los cirujanos junior, pero no más complicaciones. Las complicaciones según Clavien-Dindo fueron: 10 pacientes grado I, 10 grado II, uno grado IIIa y 4 grado IIIb. Según el Comprehensive Complication Index, 20 pacientes obtuvieron una puntuación baja (<30 puntos) y 4 pacientes entre 31 y 40 puntos. La cesárea previa estaba asociada a mayor riesgo de lesión vesical. La estancia media fue de 2,48 días. No hubo resultados de malignidad entre los úteros morcelados.
La histerectomía laparoscópica es una técnica quirúrgica fácilmente reproducible en hospitales comarcales, con baja tasa de conversión y escasas complicaciones.
To calculate the conversion rate and describe indications, type of surgery, and complications of laparoscopic hysterectomies in a district hospital, as well as to analyse surgical time and uterine weight.
A descriptive and retrospective study was carried using the database of the Surgical Record of Gynaecology (Canadian Task Force classification III). It was conducted in the Gynaecology and Obstetrics Department of Valdeorras District Hospital (Orense, Spain).
The study included 78 women scheduled for laparoscopic hysterectomy from May 2011 to February 2018. A description is presented of the demographic characteristics, symptoms, type of surgery, and previous medical treatments. A total of 62 total and 15 subtotal hysterectomies, were performed, as well as one Manchester surgery. A calculation was made of the rate of conversion, morcellation percentage, operating time, complications (classified according to the Clavien-Dindo scale and the Comprehensive Complication Index), and pathology results.
The conversion rate was 5.13%, and the morcellation percentage was 35.90%. A theoretical cut-off was calculated of a uterus weight of 190 grammes or more for being morcellated among total hysterectomies. There were no transfusions. There were longer operating times with junior surgeons, but no difference in surgical complications compared to senior surgeons. Complications according to the Clavien-Dindo scale: 10 patients grade I, 10 grade II, one grade IIIa, and 4 grade IIIb. Using the CCI, 20 patients attained a low score (<30 points), and 4 patients scored 31-40 points. A history of caesarean section was associated with a higher risk of bladder injury. Mean days to discharge was 2.48 days.
There were no malignant samples among the morcellated uteruses.
Laparoscopic hysterectomy is a technique that can be performed in a district hospital and in most cases with a minimum conversion rate and few complications.
Laparoscopic Radiofrequency Ablation of Uterine Leiomyomas: Clinical Outcomes during Early Adoption into Surgical Practice
2020, Journal of Minimally Invasive Gynecology
To assess surgical outcomes, clinical effectiveness, and gynecologist experience of introducing laparoscopic radiofrequency ablation (RFA) of leiomyomas into surgical practice.
Uncontrolled clinical trial.
Five academic medical centers across California.
Premenopausal women with symptomatic uterine leiomyomas, uterus size ≤16 weeks size, and all leiomyomas ≤10 cm with no more than 6 total leiomyomas.
Laparoscopic RFA of leiomyomas.
We assessed intraoperative complications, blood loss, operative time, and adverse events. Gynecologists reported the operative difficulty and need for further training after each case. Participants reported leiomyoma symptoms preoperatively and at 6 and 12 weeks after surgery. We analyzed all outcome data from the first case performed by gynecologists with no previous RFA experience. Patient demand for RFA was high, but poor insurance authorization prevented 74% of eligible women from trial participation; 26 women underwent surgery and were enrolled. The mean age of the participants was 41.5 ± 4.9 years. The mean operating time was 153 ± 51 minutes, and mean estimated blood loss was 24 ± 40 cc. There were no intraoperative complications and no major adverse events. Menstrual bleeding, sexual function, and quality of life symptoms improved significantly from baseline to 12 weeks, with a 25 ± 18-point, or 47%, decrease in the Leiomyoma Symptom Severity Score. After the first procedure, the mean difficulty score was 6 (95% confidence interval [CI], 4–7.5) on a 10-point scale, and 89% of surgeons felt “very or somewhat” confident in performing laparoscopic RFA. The difficulty score decreased to 4.25 (95% CI, 1.2–6) after the fourth procedure, with all gynecologists reporting surgical confidence.
Laparoscopic RFA of leiomyomas can be introduced into surgical practice with good clinical outcomes for patients. Gynecologists with no previous experience are able to gain confidence and skill with the procedure in fewer than 5 cases.
Minilaparoscopic Total Hysterectomy in Current Practice Feasibility and Benefits: A Unicentric, Randomized Controlled Trial
2020, Journal of Minimally Invasive Gynecology
To investigate whether mini-instrumentation may be used for hysterectomy (HT) by all surgeons (assistants and seniors) without increasing the operative time or altering surgeon working conditions.
A unicenter, randomized controlled, single blind, parallel, noninferiority trial comparing 2 surgical techniques.
A tertiary referral center.
Thirty-two patients undergoing HT for a benign gynecologic disease were enrolled in this study in our center between April 2, 2015, and June 1, 2018. Sixteen patients were randomized in group A and 16 patients in group B.
HT with bilateral annexectomy or ovarian conservation using 3-mm instruments (group A) or conventional 5-mm instruments (group B).
Concerning the primary outcome, the operative time for the HT 3-mm group was 128 minutes (range, 122–150 minutes) versus 111 minutes (range, 92–143 minutes) for the HT 5-mm group (i.e., δ = 17 [90% confidence interval, −6 to 39]), with rejection of the noninferiority threshold at 35 minutes. Thirty-one percent of HTs initially performed using 3-mm instruments were completed with conventional instruments. HTs performed with mini-instruments required more concentration (p = .02) with surgeons reporting higher levels of frustration (p = .009) and sense of failure (p = .006). Patients tend to experience greater satisfaction regarding scars with a significant difference noted during the postoperative visit both for scar pain (1 vs 4 patients with moderate pain [30–50 mm on the Patient Scar Assessment Scale) in the HT 3-mm group and the HT 5-mm group, respectively) and scar firmness (p = .021; 3 vs 7 patients with moderate firmness [30–50 mm on the Patient Scar Assessment Scale] in the HT 3-mm group and the HT 5-mm group, respectively).
Total minilaparoscopic HT appears inferior to standard laparoscopy in terms of operative time and surgeon working conditions; only the short-term cosmetic appearance was in favor of the 3-mm approach.
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Original ArticlesThe Learning Curve of Total Laparoscopic Hysterectomy: Comparative Analysis of 1647 Cases

Abstract

Study Objective

Design

Setting

Patients

Intervention

Measurements and Main Results

Conclusion

Section snippets

Materials And Methods

Results

Discussion

Am J Obstet Gynecol

Am J Obstet Gynecol

J Am Assoc Gynecol Laparosc

Am J Obstet Gynecol

Am J Surg

Am J Obstet Gynecol

Am J Obstet Gynecol

J Am Assoc Gynecol Laparosc

Comparison of laparoscopic assisted vaginal hysterectomy and abdominal hysterectomy

J Gynecol Surg

A critical analysis of laparoscopic assisted vaginal hysterectomies compared with vaginal hysterectomies unassisted by laparoscopy and abdominal hysterectomies

J Gynecol Surg

Original Articles
The Learning Curve of Total Laparoscopic Hysterectomy: Comparative Analysis of 1647 Cases