James H. Dorsey

Clinical indications for hysterectomy route: Patient characteristics or physician preference?☆☆☆

OBJECTIVES Our purpose was to compare the indications, characteristics, surgical management, and outcomes of patients undergoing total abdominal hysterectomy, total vaginal hysterectomy, and laparoscopically assisted vaginal hysterectomy and to assess whether patients who underwent abdominal hysterectomy might have been candidates for laparoscopically assisted vaginal hysterectomy and whether patients who underwent total abdominal hysterectomy or laparoscopically assisted vaginal hysterectomy might have been candidates for total vaginal hysterectomy. STUDY DESIGN The hospital charts of 502 women who underwent elective inpatient hysterectomy at a single large general hospital between January 1992 and November 1993 were abstracted retrospectively by use of a structured data abstraction instrument. The study included patients operated on by 16 different experienced gynecologists. Data were collected regarding patient demographic characteristics, clinical history and preoperative physical examination, indications for surgery, route of hysterectomy, intraoperative findings, pathologic study results, and outcomes in the immediate postoperative hospitalization period. RESULTS Patient age, race, weight, parity, and previous surgical history were significantly associated with hysterectomy type. Although no nulliparous patients and no patients with a uterine size estimated preoperatively to be > 12 weeks of gestation underwent total vaginal hysterectomy, 16.6% and 30.6% of laparoscopically assisted vaginal hysterectomy patients had these characteristics, respectively. A total of 6.6% of total abdominal hysterectomy cases and 16.7% of laparoscopically assisted vaginal hysterectomy cases lacked an obvious justification for an abdominal procedure. On average, surgical time was 23 minutes longer for laparoscopically assisted vaginal hysterectomy than for total abdominal hysterectomy and 30 minutes longer for total abdominal hysterectomy than for total vaginal hysterectomy. When uterine size or configuration impaired access to uterine vessels, laparoscopically assisted vaginal hysterectomy was difficult to perform. Postoperative morbidity was similar across the three procedures, but average length of hospital stay was 2.8 days, 3.5 days, and 4.4 days for laparoscopically assisted vaginal hysterectomy, total vaginal hysterectomy, and total abdominal hysterectomy, respectively. CONCLUSIONS Although there are some consistent and statistically significant differences in the characteristics of patients undergoing total abdominal hysterectomy versus laparoscopically assisted vaginal hysterectomy versus total vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy is enabling many patients to avoid total abdominal hysterectomy. However, many patients undergoing total abdominal hysterectomy and laparoscopically assisted vaginal hysterectomy could probably undergo total vaginal hysterectomy instead. Clinical outcomes were similar regardless of type of hysterectomy performed. Practice style and personal preference of the surgeon thus may be playing a significant role in selection of hysterectomy type. Laparoscopically assisted vaginal hysterectomy becomes technically difficult and conversion to total abdominal hysterectomy is more frequent when uterine size or configuration impairs access to uterine vessels.

The 4-S Modification of the Roeder Knot: How to Tie It☆

Background The 4-S modification of the Roeder knot may be tied laparoscopically as a single-throw knot. Technique It is tied by adding a fourth wrap around the suture loop and securing the loop in place with a square knot rather than a single half-hitch. Experience We have used this knot in laparoscopic surgeries for more than 2 years and have not observed knot slippage. Conclusion This modification results in a knot comparable in strength to the strongest laparoscopic multiple-throw square knots.

8 Laparoscopic sacral colpopexy and other procedures for prolapse

The repair of pelvic support defects is a demanding task. Irrespective of the route or repair chosen by the surgeon, sound surgical judgement, complete understanding of pelvic anatomy and the mechanisms involved in pelvic organ prolapse, and expertise in pelvic surgery are required if successful outcomes are to be expected. Laparoscopic surgery offers a substitute for conventional open abdominal surgery which, in our hospital, now has a record of low complication rates, speedy discharge and recovery times with outcomes that are equal to those achieved by conventional abdominal surgery. This type of surgery is no more difficult to perform than open abdominal surgery. However, it demands the same rigorous training and a very significant amount of time and dedicated effort to learn. The pelvic surgeon who desires to practise this form of advanced laparoscopic surgery must accept these facts. Obviously, more cases and long-term follow-up are needed for meaningful statistical analysis. Randomized prospective trials are greatly preferred, however, it is difficult for the laparoscopic surgeon to carry out such studies when the majority of patients are referred specifically for the laparoscopic route. Good sound statistical data are now becoming available concerning some essential components of the procedure such as laparoscopic knot and suture strengths. It seems very reasonable to conclude that, based on early experience with laparoscopic pelvic reconstruction, the future of this approach is bright.

A Simple Modification to Add Strength to the Roeder Knot

The Roeder knot is commonly used during laparoscopic suturing because it may be tied extracorporeally and slid down to the target tissue with a single pass of a knot pusher. However, it is significantly weaker than extracorporeally tied knots with several throws. We compared the usual Roeder knot to one that was modified by adding a fourth loop around the standing end of the suture and a second half-hitch to the completed knot. The modified knot (26.6 newtons +/- 15.3) was significantly stronger (p <0.05) than the standard Roeder knot (18.0 newtons +/- 12.1). If a single-pass extracorporeal knot is to be used, we recommend a modified Roeder knot when ligating pedicles at laparoscopy.

Use of the automatic surgical stapler for intestinal anastomosis associated with gynecologic malignancy: Review of 283 procedures

Abstract Between the years 1974 and 1980, 283 intestinal stapling procedures involving the large and small bowel have been performed on the Gynecologic Oncology service. The automatic surgical staplers used in this series were: the gastrointestinal anastomosis (GIA), the thoracoabdominal (TA-55/30), and the end-to-end anastomosis (EEA) stapler (United States Surgical Corp., Stamford, Conn.). The 283 stapling operations were performed on 162 patients. Fifty-three of the patients had received pelvic irradiation prior to the intestinal operations. The complication rate was low, and compared very favorably with other techniques of gastrointestinal anastomosis which were performed by the same authors. There was one disruption of a small-bowel anastomosis, temporary stricture in three anastomoses of rectum to colon, a leak in a low colonie-rectal anastomosis which resulted in a pelvic abscess, and a rectovaginal fistula. Fifty-two patients underwent urinary diversion by bowel conduit. In all of these cases the conduit was fashioned with the aid of the automatic stapler. The low complication rate in gastrointestinal anastomoses performed with the automatic surgical staplers supports the conclusion that this is a technically superior method which provides better utilization of operating time on radical pelvic procedures.

Electrocoagulation versus the Endo GIA in LAVH

We compared the operating room time using bipolar electrocoagulation and Endo GIA staples in 11 women undergoing laparoscopic-assisted vaginal hysterectomy (LAVH). Electrocoagulation was used on one side of the uterine pedicles and the Endo GIA stapling device on the contralateral pedicles. Each patient was randomized to the method used on each side and which method was used first. All procedures were symmetric, with or without bilateral salpingo-oophorectomy. Data were compared using the paired t test. Normal distribution was assessed by the Shapiro-Wilks test and the K-S (Lilliefors) test. The mean (± SD) procedure times for electrocoagulation and Endo GIA were 13.03 ± 1.34 minutes and 4.4 ± 0.33 minutes, respectively. This resulted in a mean difference of 8.66 ± 3.62 minutes (p <0.001). Patients requiring longer electrocoagulation times also required longer Endo GIA stapling times (p = 0.034). The Endo GIA stapling device required significantly less time to perform LAVH compared with electrocoagulation. The difference of 8.66 minutes, if multiplied by 2 (to account for a bilateral procedure), may or may not be clinically or economically significant, depending on hospital costs and charges for instruments, operating room time, and anesthesia.

The Effect of Knot Geometry on the Strength of Laparoscopic Slipknots

We evaluated and compared the strength of six extracorporeal slipknots used in laparoscopic surgery as measured with a tensiometer. Two multiple-throw laparoscopic square knots (intracorporeal two-turn flat square knot and extracorporeal sliding square knot) were used as controls. Each knot type was tied five times, and each type tied in random order by the same primary and assisting surgeons using a laparoscopic pelvic surgery training model. A one-way analysis of variance was performed to detect significant differences in knot strengths. The variability in strength for each knot type was determined using Tukeys multiple comparison test. A significant main effect for knot geometry was discovered (p <0.001). The mean knot strengths, measured in Newtons from strongest to weakest, were 4S knot 28.01 ± 11.45, fishermans knot 22.45 ± 6.89, modified Roeder knot 19.86 ± 9.30, Roeder knot 15.77 ± 7.02, Weston knot 7.28 ± 7.96, and Duncan knot 6.55 ± 0.95. The mean knot strengths for the multiple-throw control square knots were intracorporeal two-turn flat square knot 41.21 ± 2.69 and extracorporeal sliding square knot 27.81 ± 16.27. The intracorporeal two-turn flat square knot (control) was significantly stronger (p <0.05) than all slipknots except the 4S and fishermans knot. These are the strongest laparoscopic slipknots and are the only slipknots that compare in strength with multiple-throw square knots.

Five Methods of Tubal Sterilization

We prospectively compared five methods of interval tubal sterilization: minilaparotomy Pomeroy (ML), laparoscopic coagulation (C), laparoscopic Falope ring (FR), laparoscopic Pomeroy with endoloops (E), and laparoscopic Hulka clip (H). The 114 women undergoing interval sterilization were interviewed by nurses using a structured data-abstraction instrument immediately postoperatively, and 24 hours and 2 weeks postoperatively to compare pain, vomiting episodes, overall satisfaction with the surgical experience, and time to resuming activities. Operating time, time in the recovery room, and cost of medical supplies also were compared. The measured variables were evaluated for significance by analysis of variance and Bonferronis correction for multiple comparisons. Significant differences were found for postoperative pain (p = 0.01) between FR (6.96 ± 2.91) and C (4.36 ± 3.51); time in the recovery room (p <0.001) between ML (271.87 ± 57.95) and H (162.78 ± 48.79), FR (161.80 ± 47.78), and C (138.06 ± 41.77); and cost of surgical supplies (p <0.001) between E (

Costs and Charges Associated with Three Alternative Techniques of Hysterectomy

352.73 ± 42.76) and H (

Microsurgical conization of the cervix by carbon dioxide laser

133.28 ± 82.90), C (