Wen-Chiung Hsu

Transvaginal hysterectomy or laparoscopically assisted vaginal hysterectomy for nonprolapsed uteri.

Background: To define a rational guideline for the use of either laparoscopically assisted vaginal hysterectomy (LAVH) or transvaginal hysterectomy in dealing with a nonprolapsed uterus. Methods: A total of 452 patients receiving LAVH or transvaginal hysterectomy were retrospectively studied between October 2002 and October 2004. The operative time, estimated blood loss, uterine weight, and complications were all recorded for analysis. Results: Significant linear correlations of uterine weight with operative time and estimated blood loss could be seen only in the transvaginal hysterectomy group. Transvaginal hysterectomy required significantly shorter operative time, but longer duration when the uterine weight exceeded 350 g. These 452 patients were stratified into 4 subgroups according to the uterine weight and hysterectomy procedure. Data are expressed as the mean ± standard deviation. For uterine weight less than 350 g, transvaginal hysterectomy had significantly shorter operative time than LAVH (80 ± 27 minutes compared with 118 ± 21 minutes, P < .05) but similar blood loss (70 mL compared with 74 mL). For uterine weight 350 g or less, transvaginal hysterectomy had not only significantly longer operative time (139 ± 30 minutes compared with 118 ± 17 minutes, P < .05) but also more blood loss (242 ± 162 mL compared with 66 ± 51 mL, P < .05) than LAVH. Conclusion: In view of the shorter operative time and less blood loss, LAVH is preferable for uterine weight 350 g or more, whereas transvaginal hysterectomy is better in dealing with uteri weighing less than 350 g. Level of Evidence: II-2

LAVH for large uteri by various strategies.

Background. To study if there are specific problems in laparoscopically assisted vaginal hysterectomy (LAVH) for a certain weight of bulky uteri and the strategies to overcome such problems. Methods. One hundred and eighty‐one women with myoma or adenomyosis, weighing 350‐1,590 g, underwent LAVH between August 2002 and December 2005. Key surgical strategies were special sites for trocar insertion, uterine artery or adnexal collateral pre‐ligation, laparoscopic and transvaginal volume reduction technique. The basic clinical and operative parameters were recorded for analysis. Results. Based on significant differences in the operative time and estimated blood loss, the patients were divided into medium uteri weighing 350–749 g, n = 138 (76%), and large uteri weighing ≥750 g, n = 43 (24%). There was no significant difference in terms of age, body mass index, preoperative diagnoses, complications and duration of hospital stay among groups. The operative time and estimated blood loss increased with larger uterine size (p<0.001). The operative time (196±53, 115–395 min), estimated blood loss (234±200, 50–1,000 ml) and frequency of excessive bleeding (14%) or transfusion (5%) were significantly greater, but in acceptable ranges, for those with large uteri. Conversion to laparotomy was required in a patient (2%) with a large uterus, and the overall conversion rate was 0.6%. There was no re‐operation or surgical mortality. Conclusion. Using various combinations of special strategies, most experienced gynecologic surgeons can conduct LAVH for most large uteri with minimal rates of complications and conversion to laparotomy.

Use of three-dimensional ultrasonography in the evaluation of uterine perfusion and healing after laparoscopic myomectomy

OBJECTIVE To evaluate vascular perfusion and uterine healing after laparoscopic myomectomy using three-dimensional power Doppler ultrasound (3D-PDU). DESIGN Prospective study. SETTING University-affiliated hospital. PATIENT(S) Ninety-seven women with symptomatic myomas warranting laparoscopic myomectomy. INTERVENTION(S) Three-dimensional PDU obtained preoperatively and 1 week and 3 months postoperatively. MAIN OUTCOME MEASURE(S) Resistance index, pulsatility index, and peak systolic velocity of the uterine artery; vascularization index, flow index, and vascularization flow index of the uterine tissue, nonoperative area, and healing myometrial area. RESULT(S) The median age was 39 years. More than half of the patients were nulliparous, and one third desired fertility. The median myoma size was 8 cm, and median weight of the extirpated myomas was 250 g. The median myoma volume was 262 cm(3), and median uterine volume was 380 cm(3). On the 7th postoperative day all laparoscopic myomectomy healing sites appeared as highly echogenic areas with profuse blood flow at the periphery and reduced resistance index and pulsatility index of the uterine artery. Nonoperated areas had significantly more blood flow than healing areas. Two patients had hematomas, which appeared as hypoechoic areas that were almost avascular. By the 3rd postoperative month the blood flow and uterine volume decreased significantly. However, an 11-cm(3) hypoechoic hematoma with poor tissue perfusion was still seen in 1 patient with a 720-cm(3) myoma. CONCLUSION(S) Healing of a laparoscopic myomectomy scar can be evaluated by 3D-PDU. Adequate perfusion demonstrated by 3D-PDU might suggest good wound healing and dissolving of hematomas.

Prediction of operation time for laparoscopic myomectomy by ultrasound measurements

BackgroundThis study aimed to develop a regression-based prediction equation for operation time for laparoscopic myomectomy (LM) using ultrasound measurement.MethodsPatients who were to undergo laparoscopic myomectomy from March 2003 to December 2005 were enrolled prospectively in a tertiary institution. Ultrasound was performed before operation. The myoma weights were calculated and converted into mass units (g) by an assumed smooth muscle density of 1.04 g/cm3. Myomas were weighed immediately after operation, and the correlation between these two weights was assessed by linear regression and limits of agreement. A multivariate linear regression model was fitted to the ultrasound parameters and clinical variables to predict operation time.ResultsOf 109 patients, 203 myomas were removed laparoscopically with a mean ultrasound-measured myoma weight of 137.9 (100.7) g, a diameter of the dominant myoma of 6.30 (1.92) cm, and an operation time of 125 (41) min. Strong correlations were observed between the ultrasound-measured and operated myoma weights. A predictive model, in which operation time = 0.14 × ultrasound-measured myoma weight + 1.68 × BMI + 5.21 × operated myoma number + 0.06 × (ultrasound-measured myoma weight × operated myoma number) + 43.97, was developed.ConclusionsOperation time was significantly related to the myoma weight measured by ultrasound. The ultrasound-derived prediction equation is valid and reliable in predicting operation time for LM.

Laparoscopic-Assisted Vaginal Hysterectomy with In Situ Morcellation for Large Uteri

STUDY OBJECTIVE To estimate whether laparoscopic in situ morcellation (LISM) can facilitate laparoscopic-assisted vaginal hysterectomy (LAVH) for large uteri. DESIGN Prospective study (Canadian Task Force classification II-1). SETTING University-affiliated hospital. PATIENTS In all, 147 women with myoma or adenomyosis weighing more than 500 g from January 2004 through December 2007 were enrolled. The patients were divided into 4 subgroups: patients with uteri weighing 500 to 749 g who had traditional LAVH without LISM (group 1A, n=69) or with LISM (group 1B, n=16); and patients with uteri weighing 750 g or more who were treated by traditional LAVH without LISM (group 2A, n=38) or with LISM (group 2B, n=24). INTERVENTIONS Laparoscopic-assisted vaginal hysterectomy with or without LISM. MEASUREMENT AND MAIN RESULTS No significant differences existed in age, body mass index, preoperative diagnoses, complications, or duration of hospital stay among groups. The mean uterine weights were 608+/-75, 597+/-66, 989+/-179, and 935+/-226 g for groups 1A, 1B, 2A, and 2B, respectively. The operative time (120+/-16 vs 157+/-36 minutes, p<.001; 140+/-19 vs 224+/-57 minutes, p<.001) were significantly shorter in patients with LISM than without in both groups 1 and 2. The estimated blood loss was highest in group 2A. Six (16%) patients lost more than 500 mL of blood and 3 (8%) of them needed blood transfusions. Conversion to laparotomy occurred in 1 (2.6%) of 38 patients in group 2A. No repeated surgery or surgical mortality occurred. CONCLUSION Laparoscopic-assisted vaginal hysterectomy with LISM was an efficient and safe procedure for removal of large uteri during LAVH.

Visceral Sliding Technique Is Useful for Detecting Abdominal Adhesion and Preventing Laparoscopic Surgical Complications

Study Objective: Introduce a non-invasive method preoperatively to prevent bowel injury by the Veres needle and trocar during laparoscopy. Design: Case-controlled study. Setting: A hospital-based study. Patients: Five hundred and twelve patients who underwent laparoscopic surgery were prospectively enrolled. Intervention: A simple and non-invasive method to detect bowel adhesions preoperatively. Results: A total of 512 patients who underwent operative laparoscopy were prospectively enrolled for ultrasonographic visceral sliding evaluation. They were subdivided into two groups as follows: group I, 332 patients without previous abdominal surgery; group II, 180 patients with previous abdominal surgery. No bowel adhesion to the umbilicus was present in group I. In group II, only two cases with bowel adhered to the periumbilical area were found by visceral sliding technique. No patients suffered any bowel injury. Conclusion: The proposed technique is useful and highly effective in guiding the insertion of the Veres needle and trocar to prevent bowel injury in laparoscopy.

Simultaneous Enucleation and In Situ Morcellation of Myomas in Laparoscopic Myomectomy

OBJECTIVE To evaluate the outcome of myoma enucleation by morcellation while it is attached to the uterus (in situ morcellation) in laparoscopic myomectomy. MATERIALS AND METHODS A total of 82 patients diagnosed with myoma or adenomyosis in 2007 were enrolled. The patients were divided into three groups according to the myoma weight. The operative time, myoma weight, blood loss, duration of hospital stay, and complication experienced were recorded for analysis. RESULTS The mean myoma weight was 265 ± 240 g and the mean operative time was 93 ± 30 minutes. The patients were divided into three groups: group A with myomas less than 150 g; group B with myomas 150-349 g; and group C with myomas greater than 350 g. The mean myoma weights were 73 ± 34 g, 214 ± 52 g, and 571 ± 218 g for groups A, B, and C, respectively; the mean operative times were 79 ± 17 minutes, 84 ± 22 minutes, and 121 ± 32 minutes, respectively. The operative time increased with myoma weight. Two patients (8%) in group C had excessive intraoperative hemorrhage and one (4%) required a blood transfusion. There was no conversion to laparotomy. CONCLUSION In situ morcellation was an efficient and safe procedure for removal of large uterine myoma during laparoscopic myomectomy.

Effect of simultaneous morcellation in situ on operative time during laparoscopic myomectomy

BACKGROUND Laparoscopic myomectomy (LM) is technically difficult and time consuming procedure that requires surgical skill and modifications. The aim of this study was to assess factors which affect operative times in LM. METHODS From March 2003 to June 2007, 174 women, who underwent LM for symptomatic myomas, were enrolled. Standard LM was performed in the first 4 years and simultaneous morcellation in situ (SMI) method was applied in the fifth year. RESULTS The mean myoma weight was 213.5 +/- 190.4 g and the mean operative time was 117.0 +/- 39.6 min. No laparoconversions occurred and there was a 2.3% rate of complications. Total myoma weight increased and operative time declined significantly over time. The surgeons learning curve and the effect of SMI on operative time were identified by establishing a nonlinear multiple regression model. Model assumptions showed little violation by residual plots. Slopes of the average myoma weight (total myoma weight/number of myoma operated) for describing the operative time declined along with the study year, suggesting that operative experience is a major factor influencing operative time. SMI showed a further 19 min reduction in the predicted operative time. CONCLUSIONS Operative time in LM is dependent on a multitude of factors including surgical experience. Applying SMI during LM is an efficient way to further reduce operative time.

Comparison between transumbilical and transabdominal ports for the laparoscopic retrieval of benign adnexal masses: a randomized trial

OBJECTIVE To compare the feasibility, operative time, specimen retrieval time, and effect on postoperative pain of laparoscopic retrieval of benign adnexal masses between a 10-mm transumbilical and a 10-mm transabdominal port. STUDY DESIGN Fifty women with adnexal masses who were scheduled for a laparoscopic procedure between July 2008 and April 2009 were enrolled. The patients were randomized into two groups; these were patients where a transumbilical port was used for specimen retrieval (transumbilical group, n=25) and patients where a transabdominal port was used for specimen retrieval (transabdominal group, n=25). Preoperative suspicion of malignancy and indications suggesting a need for hysterectomy or myomectomy were considered to be exclusion criteria. Randomization was centralized and computer-based. Patients recorded the severity of incisional pain on a visual analog scale (VAS) with 0 meaning no pain and 10 meaning unbearable pain. RESULTS There were no significant differences in age, body mass index, umbilical thickness, abdominal thickness, cyst size, cyst amount, cyst weight, histology, complications and duration of hospital stay when the two groups were compared. Patients in the transumbilical group had a significantly shorter specimen retrieval time (0.7 ± 1.8 min vs. 4.9 ± 12.6 min, p=0.006) and a significantly lower postoperative day (POD) 0 VAS pain score (5.2 ± 2.1 vs. 6.6 ± 2.2, p=0.015). Significantly fewer patients in the transumbilical group had a specimen retrieval time of ≥10 min (0% vs. 20%, p=0.025) and a POD 0 VAS pain score of >5 (36% vs. 84%, p<0.001). However, the average POD 1 VAS pain score (3.2 ± 1.8, vs. 3.6 ± 1.6) and the proportion with a POD 1 VAS pain score >5 (12% vs. 12%) were similar for the two groups. CONCLUSION When laparoscopic surgery on benign adnexal masses is carried out using a 10-mm incision wound, removal of the specimen via the umbilical port has a shorter retrieval time and produces less postoperative pain than retrieval via a lateral abdominal port.

Changes in uterine blood flow following laparoscopic myomectomy with or without uterine artery ligation on two‐ and three‐dimensional power Doppler ultrasound

To evaluate differences in uterine perfusion following laparoscopic myomectomy with or without uterine artery ligation (UAL).