Does Laparoscopy Safely Improve Technicity for Complex Hysterectomy Cases?

Transcription

1 GYNAECOLOGY Does Laparoscopy Safely Improve Technicity for Complex Hysterectomy Cases? Amanda Grant-Orser, BSc, 1 Ramadan El Sugy, MD, 1,2 Sukhbir S. Singh, MD, FRCSC 1,2,3 1 Department of Obstetrics and Gynaecology, The Ottawa Hospital, Ottawa ON 2 Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa ON 3 Ottawa Hospital Research Institute, Ottawa ON Abstract Objective: The minimally invasive surgical (MIS) approach to hysterectomy (vaginal or laparoscopic), when compared with laparotomy, results in shorter length of stay, fewer minor and major complications, and quicker return to normal activity. The complexity of the hysterectomy procedure or pathology may affect the success of an MIS approach. This study examined the indications, complications, and outcomes of all hysterectomies performed, irrespective of the severity of pathology or patient habitus, in a Canadian tertiary level gynaecologic surgical referral service. Methods: We performed a retrospective chart review of all hysterectomies performed by a single surgeon between September 2007 and June 2011, noting indications, complications, and outcomes. One-way analysis of variance was used to calculate the influence of various factors across surgery types. Significance was set at P < 0.05 for all tests. Results: A total of 305 cases were included; 291 of these (95.4%) were managed through an MIS approach, providing a technicity rate of 95.4%. Mean patient age was 45.5 years, and mean BMI was The main indicators for surgery were fibroids (42.0%), pain (38.4%), and heavy menstrual bleeding (37.4%). Eighty-one percent of cases were tertiary referrals. Of the laparoscopic cohort, endometriosis was moderate-severe in 61.2% of patients. Mean length of stay was 1.14 days, mean uterine weight was g, and mean estimated blood loss was 179 ml. Conclusion: This retrospective study of a tertiary level referral gynaecologic service suggests that complex hysterectomy may be effectively and efficiently managed through an MIS approach. Key Words: Laparoscopy, hysterectomy, technicity, complications Competing Interests: None declared Received on September 7, 2013 Accepted on November 4, 2013 Résumé Objectif : Le recours à une approche chirurgicale à effraction minimale (CEM) aux fins de la tenue d une hystérectomie (par voie vaginale ou laparoscopique), par comparaison avec le recours à une laparotomie, entraîne une diminution de la durée de l hospitalisation et du nombre de complications mineures et majeures, ainsi qu une accélération du retour aux activités normales. La complexité de l hystérectomie ou de la pathologie pourrait affecter la réussite du recours à une approche CEM. Cette étude s est penchée sur les indications, les complications et les issues de toutes les hystérectomies menées, sans égard à la gravité de la pathologie ou à l habitus de la patiente, au sein d un service canadien d orientation en chirurgie gynécologique de niveau tertiaire. Méthodes : Nous avons mené une analyse rétrospective des dossiers portant sur toutes les hystérectomies menées par un même chirurgien entre septembre 2007 et juin 2011, en prenant note des indications, des complications et des issues. Une analyse de variance à un critère de classification a été utilisée pour calculer l influence de divers facteurs sur tous les types de chirurgie. Le niveau de signification a été établi à P < 0,05 pour tous les tests. Résultats : Au total, 305 cas ont été inclus; 291 de ces cas (95,4 %) ont été pris en charge au moyen d une approche CEM, offrant ainsi un taux de technicité de 95,4 %. L âge moyen des patientes était de 45,5 ans et l IMC moyen était de 28,9. Les fibromes (42,0 %), la douleur (38,4 %) et la présence de règles abondantes (37,4 %) constituaient les principaux indicateurs du recours à la chirurgie. Les orientations tertiaires représentaient 81 % des cas. Au sein de la cohorte «laparoscopie», l endométriose allait de modérée à grave chez 61,2 % des patientes. La durée moyenne de l hospitalisation était de 1,14 jour, le poids utérin moyen était de 277,6 g et la perte sanguine estimée moyenne était de 179 ml. Conclusion : Cette étude rétrospective ayant porté sur un service d orientation en chirurgie gynécologique de niveau tertiaire semble indiquer que les cas complexes d hystérectomie pourraient être pris en charge de façon efficace au moyen d une approche CEM. J Obstet Gynaecol Can 2014;36(3): MARCH JOGC MARS 2014

2 Does Laparoscopy Safely Improve Technicity for Complex Hysterectomy Cases? INTRODUCTION Nieober et al. 1 (2009) and the AAGL 2 (2011) assert that the optimal route of hysterectomy for benign gynaecologic disease is a minimally invasive surgical approach that may include a vaginal or laparoscopically assisted technique. The MIS approach, when compared with laparotomy, results in shorter length of stay, fewer minor and major complications, and a quicker return to normal activity. 3 5 The complexity of the hysterectomy procedure or the associated pathology are factors that may affect the success of an MIS approach. In addition, surgical outcomes and approaches are known to be influenced by the surgeon s experience. 3,6 8 While much has been published on outcomes of hysterectomy performed using an MIS technique, there is a need to determine how the approach in complex tertiary level gynaecology cases is affected by the severity of pathology and by patient factors such as high BMI. Many series in the literature exclude complex cases, such as those involving deep endometriosis or large fibroid uteri, which limits the extrapolation of outcomes. 1,4,5,6,8 Furthermore, there may be significant differences in outcome depending on the surgeon s experience. 3,9,10 We conducted this retrospective chart review to examine the indications for and complications and outcomes of all hysterectomies performed by a single surgeon, irrespective of the severity of pathology or patient habitus. The study cohort was derived from a Canadian tertiary level gynaecologic surgical referral service. METHODS We performed a chart audit of all hysterectomies performed by a single surgeon between September 2007 and June The study cohort was drawn from an academic tertiary referral practice (> 80% of referrals coming from specialists) providing management of women with complex gynaecologic pathology. A total of 305 cases requiring hysterectomy for benign disease were included in the sample. We excluded cases associated with malignancy, abortion, or pregnancy. Currently practised surgical approaches to hysterectomy include abdominal hysterectomy via a laparotomy or a mini-laparotomy, vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopically assisted vaginal hysterectomy, ABBREVIATIONS EBL LOS MIS estimated blood loss length of stay minimally invasive surgical and laparoscopically assisted subtotal hysterectomy. In this study, mini-laparotomy was defined as laparotomy using a 4 to 6 cm suprapubic transverse incision. Standardized analgesia, administration of antibiotics, anaesthetic care, and advice for postoperative care were provided. Conversions from laparoscopy to mini-laparotomy or laparotomy were documented. All surgical procedures were performed by the same surgeon (S.S.), assisted by a clinical fellow in minimally invasive gynaecology, a resident, a staff gynaecologist, or a general surgeon. Data were obtained through office and online health records, and were coded by a clinical fellow and research assistant. Variables included patient characteristics, surgical history, preoperative diagnosis, postoperative diagnosis, length of stay, operating room time, complications, estimated blood loss, pathology, and uterine weight. The technicity rate was defined as the number of hysterectomies performed by an MIS approach (laparoscopic and vaginal hysterectomy) divided by the total number of hysterectomies performed. 3 Patient characteristics included age, BMI, and the number of previous abdominal and/or pelvic surgical procedures. Previous abdominal and/or pelvic surgery was recorded whether related to the present surgical indication or not. Concurrent procedures included excision of endometriosis, lysis of adhesions, bilateral salpingo-oophorectomy, unilateral salpingooophorectomy, cystectomy, salpingectomy, appendectomy, pelvic floor repair, ureterolysis, morcellation (performed vaginally, at minilaparotomy, or by mechanical morcellator), and internal iliac artery ligation. Surgical outcomes included LOS, uterine weight, operative time (defined as the time from first operative incision to closure), and EBL. Complications during surgery, immediately postoperatively, and during subsequent follow-up visits were recorded, as were all re-admissions. Major and minor complications were classified as in previous reports. 7,11 One-way analysis of variance was used to calculate the significance of various factors across surgery types. All data were analyzed using SPSS software (IBM Corp., Armonk NY). Significance was set at P < 0.05 for all tests. Ethics approval for the study was obtained from The Ottawa Hospital Research and Ethics Board. RESULTS Of the 305 cases reviewed, 291 were managed through an MIS approach. This provided a technicity rate of 95.4%, with 219 total laparoscopic hysterectomies, 13 laparoscopically assisted vaginal hysterectomies, 33 laparoscopically assisted MARCH JOGC MARS

3 Gynaecology Table 1. Patient characteristics by surgery type: preoperative diagnoses TLH LAVH LASH VH AH Total Surgery, total (%) 219 (71.8) 13 (4.3) 33 (10.8) 26 (8.5) 14 (4.6) 305 Mean age, years Mean BMI Mean no. of prior abdomino-pelvic procedures Preoperative diagnosis* Fibroids 76 (34.7) 5 (38.5) 27 (81.8) 7 (26.9) 13 (92.9) 128 (42.0) Heavy menstrual bleeding 79 (36.1) 5 (38.5) 12 (36.4) 12 (46.2) 6 (42.9) 114 (37.4) Pain 93 (42.5) 4 (30.8) 11 (33.3) 8 (30.8) 1 (7.1) 117 (38.4) Endometriosis 41 (18.7) 2 (15.4) 0 (0) 0 (0) 1 (7.1) 44 (14.4) Ovarian mass 42 (19.2) 0 (0) 1 (3.0) 0 (0) 0 (0) 43 (14.1) Cancer adjuvant 25 (11.4) 0 (0) 0 (0) 1 (3.8) 0 (0) 26 (8.5) Pelvic floor dysfunction 13 (5.9) 4 (30.8) 4 (12.1) 7 (26.9) 1 (7.1) 29 (9.5) Other 48 (21.9) 0 (0) 2 (6.1) 8 (30.8) 4 (28.6) 62 (20.3) TLH: total laparoscopic hysterectomy; LAVH: laparoscopically assisted vaginal hysterectomy; LASH: laparoscopically assisted subtotal hysterectomy; VH: vaginal hysterectomy; AH: abdominal hysterectomy. Preoperative diagnoses are listed as n (% within surgery type), total values are listed as n (% within total). *Patients may present with more than one indicator. Includes dysmenorrhea, dyspareunia, and chronic pelvic pain. Patients with BRCA or hormonally sensitive breast cancer. Table 2. Surgical outcomes by surgery type Surgery type Laparoscopic cases (265) VH (26) AH (14) Total (305) P LOS, days 1.14 (1) 0.96 (1) 3.38 (2) 1.22 (1) < 0.01 Uterus weight, g (149) (125) 1759 (1065) (149) < 0.01 Operative time, min. 189* (172) 97 (176) 166 (157) 187 (172) 0.38 EBL, ml 179 (150) 200 (150) 629 (325) 202 (150) < 0.01 Postoperative diagnosis, n (% of surgery type) Fibroid 131 (49.4) 6 (27.3) 13 (92.9) 150 Adhesions 127 (47.9) 0 (0) 3 (21.4) 130 Endometriosis 98 (37.0) 0 (0) 3 (21.4) 101 Ovarian/adnexal cyst 76 (28.7) 5 (22.7) 2 (14.3) 83 Cancer adjuvant 24 (9.1) 2 (9.1) 1 (7.1) 27 Abnormal anatomy 24 (9.1) 2 (9.1) 0 (0) 26 Prolapse 15 (5.7) 10 (45.5) 0 (0) 25 Abscess/infection 7 (2.6) 0 (0) 0 (0) 7 Polyp 6 (2.3) 0 (0.0) 0 (0) 6 VH: vaginal hysterectomy; AH: abdominal hysterectomy. LOS, uterus weight, operative time and EBL values are listed as mean (median) with a one-way analysis of variance across surgery type. *Outlier of 638 min excluded because of unusual case of severe bowel adhesions, endometriomas, adenomyosis, and appendicitis (completed laparoscopically). Patients may present with more than one postoperative diagnosis. 250 MARCH JOGC MARS 2014

4 Does Laparoscopy Safely Improve Technicity for Complex Hysterectomy Cases? subtotal hysterectomies, and 26 vaginal hysterectomies. Of the 14 abdominal hysterectomies, seven were performed by mini-laparotomy. The mean patient age was 45.5 years, and mean BMI was Neither patient age nor BMI varied significantly across type of surgery. Of the total, 38.0% of patients were obese or morbidly obese. Patients had had an average of 1.4 previous abdominal and/or pelvic surgical procedures. The main preoperative diagnoses were uterine fibroids (42.0%), pain (38.4%), and heavy menstrual bleeding (37.4%). Patient characteristics are listed in Table 1. Two hundred forty-seven of the 305 cases (81.0%) were tertiary referrals from a specialist physician, including gynaecologists, general surgeons, gynaecologic oncologists, and urogynaecologists. All cases were accepted and had surgery performed with no further referrals to other specialists. Because of the extensive pathology in most patients, concurrent procedures were often performed at the time of hysterectomy. The mean rates of concurrent procedures were 2.71 procedures per laparoscopic hysterectomy, 0.81 per vaginal hysterectomy, and 1.50 per abdominal hysterectomy. These rates were significantly different from each other, according to a one-way analysis of variance (P < 0.01). Laparoscopic Outcomes Many patients presented with multiple diagnoses. The most frequent postoperative diagnosis was uterine fibroids (n = 131, 49.4% of cases), followed by adhesions (n = 127, 47.9%) and endometriosis (n = 98, 37.0%). Patients had an average of 1.92 postoperative diagnoses. Endometriosis was classified as moderate-severe (American Society for Reproductive Medicine stage III to IV) in 60 patients (61.2%). Of these, 42 (70%) were cases of deep endometriosis that involved the bowel. Mean LOS was 1.14 days, with 91.5% of patients discharged within 24 hours. Mean uterine weight, operative time, and EBL are shown in Table 2. Laparoscopic complication rates are shown in Table 3. Intraoperative complications occurred in 2.64% of cases (n = 6 with hemorrhage > 1000 ml and 1 ureteric injury). Major postoperative complications occurred at a rate of 3.77% of cases, and minor postoperative complications occurred at a rate of 4.91% of all cases. Patients who developed complications had a mean BMI of 29.8, a mean LOS of 1.46 days, and mean operative time of 222 min. The rate of conversion to laparotomy was 2.6%. Abdominal Hysterectomies Fourteen of the 305 cases were abdominal hysterectomies; seven (50%) of these were performed by mini-laparotomy. As Table 3. Laparoscopic complication rates (n = 265) Complication Complication type Rate, n (%) Intraoperative Hemorrhage 6 (2.30) shown in Table 2, mean LOS was 3.38 days (range 1 to 14 days), significantly higher than the mean LOS for MIS procedures (P < 0.01). Mean uterine weight (1759 grams) and mean EBL (629 ml) were both significantly higher than those associated with laparoscopic approaches (P < 0.01). The most common postoperative diagnosis was fibroids, occurring in 13 of the 14 patients (92.9%). Four of the cases (28.6%) were emergency cases admitted through the emergency room and referred to the on-call gynaecology service. Major complications occurred in five patients (35.7%), most of which were related to bleeding > 1000 ml. DISCUSSION Ureteric injury 1 (0.38) Postoperative Major 10 (3.77) Vault* 9 (3.40) Surgical site infection 1 (0.38) Minor 13 (4.91) Surgical site infection 5 (1.89) Nausea/vomiting 1 (0.38) Urinary tract infection 4 (1.51) Fever 3 (1.13) *Includes vault abscesses, dehiscence, cellulitis, and bleeding. Surgical skills vary considerably among surgeons. 7 This study therefore controlled for surgical experience by having all cases performed by a single gynaecologist with formal MIS training. There is currently no standardized definition of gynaecologic case complexity. For this study, case complexity was defined on the basis of referral profile, patient characteristics, and severity of pathology. Of the 305 cases, 81% were tertiary referrals, indicating case complexity and a need for subspecialty management. Of the patients who underwent laparoscopic management, more than one third (38.4%) were obese or morbidly obese. Mean uterine weight was g, with a maximum of 2637 g. Pathology was severe; moderate-severe endometriosis was present in 61.2% of patients, with 70% of these cases involving the bowel. The findings suggest that among those cases performed using a minimally invasive approach, the complexity of the case did not affect surgical outcomes. In laparoscopic cases, mean LOS remained low at 1.14 days, with 91.5% of patients discharged within one day. Mean EBL was 179 ml, with MARCH JOGC MARS

5 Gynaecology significantly higher EBL in the LAVH cases. These results are consistent with the findings of Twijnstra and colleagues, even though their large cohort of over 1500 cases included all laparoscopic cases regardless of complexity. 7 Limitations of this study include the fact that the source of data was a single surgeon in his first five years of practice and that the study was retrospective. Wallenstein et al. have shown that high volume surgeons in high volume institutions have lower morbidity rates and lower associated costs than low volume surgeons. 9 Therefore, this audit will be extended over several years to determine whether surgical outcomes improve and costs reduce with increasing surgical volume. Another important limitation of this study was the lack of consistent reporting of postoperative complications. Our objective was to include all major complications requiring hospital admission or further surgical management and all minor complications including those managed on an outpatient basis. We hope these standards will act as a guideline for further reports. Most hysterectomies in the United States are currently performed using an abdominal approach. 12 In 2005, 66% of all hysterectomies performed at The Ottawa Hospital were through the abdominal approach (from internal hospital audit). In the following five years, there was a significant increase in the number of laparoscopic hysterectomies performed, from 3% in 2005 to 21% in Overall, abdominal hysterectomy rates subsequently declined to 35% in This significant increase in use of a laparoscopic approach was the outcome of a strategic initiative by the hospital to increase minimally invasive surgery rates. This was achieved by the recruitment of staff trained in MIS fellowships, the establishment of an MIS fellowship, and the creation of a tertiary referral service for surgical gynaecology. CONCLUSION Performing minimally invasive surgery is an effective and efficient use of hospital resources with good surgical outcomes. We found that an MIS approach allows effective management of complex cases, such as patients with a large uterus, obesity, and complex pathology (for example, severe endometriosis). Laparoscopic hysterectomy for complex cases was associated with good outcomes in expert hands, with low complication rates and short LOS. REFERENCES 1. Nieober TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al. Surgical approach to hysterectomy for benign gynecologic disease. Cochrane Database Syst Rev 2009, Issue 3. Art. No.:CD DOI: / CD pub4. 2. Advancing Minimally Invasive Gynecology Worldwide. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol 2011;18(1): Laberge PY, Singh SS. Surgical approach to hysterectomy: introducing the concept of technicity. J Obstet Gynaecol Can 2009;31(11): Cheung V, Rosenthal DM, Morton M, Kadanka H. Total laparoscopic hysterectomy: a five year experience. J Obstet Gynaecol Can 2007;29(4): Pather A, Loadsman J, Mansfield C, Roa A, Arora V, Philp A, Carter J. Perioperative outcomes after total laparoscopic hysterectomy compared with fast-track open hysterectomy a retrospective case-control study. Aust N Z J Obstet Gynaecol 2011;51: Donnez, O, Donnez J. A series of 400 laparoscopic hysterectomies for benign disease: a single centre, single surgeon prospective study of complications confirming a previous retrospective study. BJOG 2010;117: Twijnstra AR, Blikkendaal MD, van Zwet EW, Kesteren PJ, de Kroon CR, Willem Jansen F. Predictors of successful surgical outcome in laparoscopic hysterectomy. Obstet Gynaecol 2012;119: Garry R, Fountain J, Mason S, Napp V, Brown J, Hawe J, et al. The evaluate Study: two parallel randomized trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004;328: Wallenstein MR, Ananth CV, Kim JH, Burke WM, Hershman DL, Lewin SN, et al. Effect of surgical volume on outcomes for laparoscopic hysterectomy for benign indications. Obstet Gynecol 2012;119(4): Levy B. Experience counts. Obstet Gynecol 119(4): Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2009;116(4): Jacoby VL, Autry A, Jacobson G, Domush R, Nakagawa S, Jacoby A. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol 2009;114: MARCH JOGC MARS 2014