Chung-Chang Shen

Major complications associated with laparoscopic-assisted vaginal hysterectomy: ten-year experience.

STUDY OBJECTIVE To describe our experience with major complications associated with laparoscopic-assisted vaginal hysterectomy (LAVH) and compare our results with those of the American Association of Gynecologic Laparoscopists (AAGL) membership survey and another similar study. DESIGN Retrospective study (Canadian Task Force classification II-3). SETTING University-affiliated hospital. PATIENTS Two thousand seven hundred two women. Intervention. LAVH. MEASUREMENTS AND MAIN RESULTS Demographic data and medical histories (age, parity, surgical indications, pathologic findings, major complications) were analyzed. Major complications were 11 bladder injuries, 4 ureter injuries, 11 bowel injuries, 2 vascular injuries, 2 cases of massive bleeding from the vaginal cuff or colpotomy wound with associated impending shock, 2 cases of postoperative ileus, and 2 pelvic abscesses. Our overall major complication rate was 1.3% compared with 2.7% in the AAGL 1995 membership survey (p <0.001). Similar rates of febrile morbidity (2.2% and 2.0%), bleeding requiring transfusion (0.05% and 0.06%), and bowel, ureteral, or bladder injury (1.0% and 1.0%) were noted between our study and the other 1995 study (all p >0.05). Of 34 major complications in our study, 24 occurred during hysterectomy performed by inexperienced general gynecologists and 10 by an experienced endoscopist (p = 0.005). CONCLUSION The rate of major complications associated with LAVH can be reduced when the procedure is performed by a well-trained laparoscopic surgeon compared with a less-experienced general gynecologist.

Laparoscopic-Assisted Vaginal Hysterectomy in Women of all Weights and the Effects of Weight on Complications

STUDY OBJECTIVE To compare intraoperative and postoperative complication rates for laparoscopic-assisted vaginal hysterectomy (LAVH) between women classified as obese, normal weight, or very thin based on body mass index (BMI). DESIGN Retrospective cohort study (Canadian Task Force classification II-3). SETTING University hospital. PATIENTS Six hundred seventy women (162 with BMI >25, 34 with BMI <18.5, 474 with BMI 18.5-25 kg/m(2)). INTERVENTION LAVH. MEASUREMENTS AND MAIN RESULTS For women with high BMIs, 34 procedures (21.0%) were converted to laparotomy, compared with 48 (10.1%) for women of normal body weight and 3 (8.8%) for those with low BMI (p = 0.001). Average blood loss was 299.3 +/- 87.8, 219.1 +/- 57.5, and 231.8 +/- 65.9 ml, respectively (p <0.001). Very thin women had similar intraoperative and postoperative complication rates (8.8 %) as women of normal body weight (8.6%) and obese women (11.1%). CONCLUSION Obese women had increased likelihood of conversion to laparotomy and greater blood loss after LAVH than nonobese women. Very thin women had similar intraoperative and postoperative complication rates as women of normal body weight and obese women.

Comparison of one- and two-layer vaginal cuff closure and open vaginal cuff during laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE To evaluate clinical outcomes of three surgical techniques during laparoscopic-assisted vaginal hysterectomy. DESIGN Prospective, randomized study (Canadian Task Force classification I). SETTING Medical school-affiliated hospital. PATIENTS Four-hundred twenty-seven women. INTERVENTION By means of a computer-generated randomization code, patients were assigned immediately before operation to one of three groups according to type of surgical procedure: group 1, 147 women having one-layer closure of the vaginal cuff; group 2, 138 having two-layer closure of the vaginal cuff; and group 3, 142 having open vaginal cuff. MEASUREMENTS AND MAIN RESULTS Patients were observed for morbidity during hospitalization, and 1 and 6 weeks and 6 months postoperatively. No significant differences were found among the groups for length of surgery, operative blood loss, postoperative hematocrit, length of hospital stay, postoperative febrile morbidity, frequency of pelvic and urinary tract infection, dyspareunia, postcoital spotting, vaginal discharge, and morbidity of the cuff (cellulitis, abscess formation, bleeding, hematoma, dehiscence). Operating time was greatest for two-layer closure. The frequency of postoperative granulation of cuff tissue and vaginal discharge was greater for group 1 than for the other two groups. CONCLUSION Two-layer closure of the vaginal cuff during laparoscopic-assisted vaginal hysterectomy is associated with fewer instances of vaginal vault granulation and vaginal discharge than either one-layer closure or open vaginal cuff.

Short- and Long-Term Clinical Results of Laparoscopic-Assisted Vaginal Hysterectomy and Total Abdominal Hysterectomy

STUDY OBJECTIVE To compare short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH). DESIGN Retrospective cohort study (Canadian Task Force classification II-1). SETTING University-affiliated hospital. PATIENTS One hundred fifty women who underwent LAVH and 146 who underwent TAH. INTERVENTION Hysterectomy. MEASUREMENTS AND MAIN RESULTS Blood loss during surgery, narcotic analgesic consumption, duration of hospital stay, and convalescence time were significantly higher for women who underwent TAH than for those who underwent LAVH (p <0.05). Operating time was significantly longer for LAVH than for TAH (152.2 +/- 32.4 vs 96.5 +/- 29.6 min, p = 0.014). Eight-year follow-up showed no statistically significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital spotting, and cuff granulation between procedures (p >0.05). CONCLUSIONS Although short-term clinical results revealed some statistically significant differences between LAVH and TAH, long-term follow-up recorded similar frequencies of surgical sequelae.

Characteristics and Management of Large Bowel Injury in Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE To review laparoscopic-assisted vaginal hysterectomies (LAVH) for large bowel injuries. DESIGN Retrospective review (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Two thousand eighty-four women. INTERVENTION LAVH. MEASUREMENTS AND MAIN RESULTS Indications for hysterectomy were myomata uteri, adenomyosis, intractable menorrhagia, endometriosis, severe pelvic adhesions, cervical intraepithelial neoplasia, endometrial polyps, and hyperplasia. Large bowel injuries occurred in six women (2.9/1000), only one of which was recognized postoperatively. Colostomy was performed in four patients, simple repair in one, and laparoscopic repair in one. All these patients were discharged without sequelae. CONCLUSION In our experience, bowel injury during LAVH was not a common event.

A Prospective, Randomized Study of Closed-Suction Drainage after Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE To estimate whether closed-suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy reduces the risk of postoperative morbidity. DESIGN Prospective, randomized study (Canadian Task Force classification 1). SETTING Teaching medical center. PATIENTS Three hundred twenty-four women. INTERVENTION Laparoscopic-assisted vaginal hysterectomy. MEASUREMENTS AND MAIN RESULTS The 160 women in group 1 had closed-suction (Jackson-Pratt) drains inserted into the peritoneal cavity and cul-de-sac, whereas the 164 in group 2 had no drains. Postoperative time to flatulence, hemoglobin, analgesic requirements, duration of hospital stay, rehospitalization, complications, febrile morbidity, and infection were studied. No statistically significant differences were seen between groups in demographics, outcome measures, postoperative infectious morbidity, or complications. The small power value may mean that no true differences existed for most tests. A statistically significant difference in analgesic requirement was found, with more oral analgesics taken by women in group 2. CONCLUSION Prophylactic surgical drainage may not be necessary to prevent postoperative morbidity after laparoscopic-assisted vaginal hysterectomy when prophylactic and postoperative antibiotics are given. A drain still has its role in gynecologic laparoscopy in selected women, such as in those with persistent ooze from raw surfaces, bowel injury, or frank pus in the abdomen.

Small Intestine Injury in Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE To review laparoscopic-assisted vaginal hysterectomy (LAVH) cases for instances of small intestine injury. DESIGN Retrospective review (Canadian Task Force Classification II-2). SETTING Tertiary care university hospital. PATIENTS Two thousand six hundred eighty-two women. INTERVENTION LAVH. MEASUREMENTS AND MAIN RESULTS Indications for hysterectomy were myomata uteri, adenomyosis, intractable menorrhagia, endometriosis, severe pelvic adhesions, cervical intraepithelial neoplasia, endometrial polyps, and hyperplasia. Small bowel injuries occurred in five women (1.9/1000), one (20%) of which was recognized postoperatively. Thermal injuries occurred in two patients, trocar injuries in two, and a dissection wound in one. Two-layer closure was performed for three patients, and partial resection with reanastomosis for two. All patients were discharged without sequelae. CONCLUSION Small bowel injury during LAVH is not common. It may have unusual characteristics and devastating consequences if not recognized and treated promptly.

Effects of Closed Suction Drainage in Reducing Pain after Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE To estimate whether closed suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy (LAVH) reduces the frequency and intensity of shoulder-tip, abdominal, and back pain. DESIGN Prospective, randomized study (Canadian Task Force classification 1). SETTING Teaching medical center. PATIENTS One hundred sixty-four women. INTERVENTION LAVH. MEASUREMENTS AND MAIN RESULTS For group 1 (80 women), closed suction (Jackson-Pratt) drains were inserted into the peritoneal cavity and cul-de-sac, whereas for group 2 (84), no drains were placed. Shoulder-tip, abdominal, and back pain were evaluated by visual analog scores (VAS) 3, 24, and 48 hours after surgery. The frequency of shoulder-tip pain was significantly lower in group 1 at 24 hours (23% vs 40%, p = 0.013) and 48 hours (9% vs 21%, p = 0.024; VAS scores at 24 hrs 2.2 +/- 1.1 vs 3.8 +/- 1.3, p = 0.010; VAS scores at 48 hours 1.5 +/- 1.0 vs 2.5 +/- 1.2, p = 0.018). At 48 hours fewer women in group 1 experienced abdominal pain (31% vs 50%, p = 0.039; VAS scores 2.0 +/- 1.1 vs 4.0 +/- 1.3, p = 0.007). No statistically significant differences in frequency and VAS scores for back pain were found at any time. The quantity of oral analgesics was greater for group 2 than for group 1 (12.4 +/- 1.6 vs 9.0 +/- 1.4, p <0.001). Economic evaluation of analgesic requirements and material costs for the two groups showed that simple analgesics were more cost-effective than closed suction drainage in the treatment of pain. CONCLUSION Closed suction drains may reduce the frequency and intensity of shoulder-tip and abdominal pain and postoperative analgesia requirements after LAVH, but simple oral analgesics are more cost effective.

Pelvic Castleman's disease presenting as an adnexal tumor

Castleman’s disease, first described in 1954 (1), is a rare benign disorder of unknown etiology characterized by a proliferation of lymphoid tissues. It is also known as angiofollicular lymph node hyperplasia, angiomatous lymphoid hamartoma, lymphoid hamartoma, and giant lymph node hyperplasia. Flendrig et al. (2) distinguished two basic histopathologic types and one mixed variant, which Keller et al. (3) designated the hyaline-vascular, plasma-cell, and hyaline-vascular plasma-cell types. Two clinical entities also have been described: a unicentric presentation with disease confined to a single anatomic lymph node-bearing region and a multicentric presentation characterized by generalized lymphadenopathy, systemic symptoms, hepatosplenomegaly, and a more aggressive clinical course with the potential for malignant transformation (4–6). In 70% of cases, this tumor occurs in the mediastinum (3), and the neck (7), pancreas (8), pelvis (9–13), and axillary and inguinal lymph nodes (14) are uncommon sites of involvement. In gynecologic practice, the condition appears to be extremely rare. We report a patient with unicentric Castleman’s disease of the hyaline-vascular type in the pelvic retroperitoneum, which initially presented as an adnexal tumor.

Peripartum Heart Failure due to Primary Pulmonary Hypertension: Two Case Reports

Summary Objective Primary pulmonary hypertension (PPH) with pregnancy can result in peripartum heart failure and a high mortality rate. We report two cases of fatal PPH in pregnant women. Case Reports From July 1992 to July 2002, two pregnant women with PPH were treated in our hospital. Case 1 was a 24-year-old primigravida, referred to our institution at 33 weeks of gestation because of signs of heart failure. She delivered a male baby by emergency cesarean section under general anesthesia. Five hours later, she developed severe systemic hypotension and died of cardiovascular collapse despite aggressive treatment and intensive care. Case 2 was a 29-year-old para 0 gravida 1 woman. She had been transferred to our hospital at 34 weeks of gestation, when fatigue, increasing dyspnea, orthopnea, tachycardia, chest pain, and peripheral cyanosis were found in our emergency department. She delivered a male baby by cesarean section under general anesthesia. Four hours later, she suddenly developed cyanosis and tachycardia, followed by electromechanical dissociation. All attempts at resuscitation were unsuccessful, and cardiac arrest ensued. Conclusion We suggest that cesarean section be carried out with the help of the intensive care unit since transportation of the patient from the operating theatre to the intensive care unit is time-consuming and may result in deterioration of the patients condition. A multidisciplinary team approach to management in the second trimester may reduce the high mortality rate.