Patrice M. Holtz

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.

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.

Profiling Assisted Reproductive Technology: Outcomes and Quality of Infertility Management

OBJECTIVE To critically appraise the content of the American Society for Reproductive Medicine (ASRM)/Society for Reproductive Technology (SART) Registry. DESIGN English-language literature review. PATIENT(S) Women undergoing treatment with assisted reproductive technology (ART). INTERVENTION(S) Current ART treatments, including IVF, GIFT, zygote intrafollopian transfer (ZIFT), oocyte micromanipulation, and cryopreserved embryo transfers. MAIN OUTCOME MEASURE(S) Compliance with clinical practice guidelines, and casemix-adjusted rates of live delivery, clinical pregnancy, ectopic pregnancy, miscarriage, birth defects, implantation, fertilization, and retrieval. RESULT(S) Outcomes should be adjusted for variation in patient characteristics known to affect prognosis, including maternal age, the duration of infertility, the presumed cause(s) of infertility, the patients prior history of treatment for infertility, and diethylstilbestrol exposure. Outcome rates should be reported using the patient as the denominator, as well as cycle, retrieval, and transfer. The statistical significance of observed differences in events rates should be indicated. Because widely accepted clinical practice guidelines related to performance of ART procedures are not available, compliance with practice guidelines cannot currently be assessed. CONCLUSION(S) Reports based on ASRM/SART Registry data can be enhanced by refined casemix adjustment, assessing outcome rates per patient, as well as per component of ART procedure, and by providing an indication of the statistical significance of observed differences in event rates. In addition, a critical appraisal of available evidence related to particular aspects of infertility management would help clarify the areas in which there is an evidentiary basis for formulation of practice guidelines, as well as topics requiring additional clinical research.

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 (

COSTS AND CHARGES ASSOCIATED WITH THREE ALTERNATIVE TECHNIQUES OF HYSTERECTOMY

133.28 ± 82.90), C (

The Effect of Knot Geometry on the Strength of Laparoscopic Slip Knots

131.09 ± 59.06), FR (

A simple technique to add knot strength to Roeder's loop

125.00 ± 72.98), and ML (