Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181 successfully at same sitting.Operative time in 92%was less than 60min.97% women were discharged at 24 hrs of operation. Conclusion: Vaginal hysterectomy using vessel sealers should be a procedure of choice for benign indications. 513 Comparison of Routes of Hysterectomy and Their Surgical Outcomes in Obese Patients Tam T, Gupta M, Alligood-Percoco N, de-los Reyes S, Davies M, Harkins G. Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania Study Objective: To assess surgical outcomes of obese patients who underwent hysterectomy through the abdominal, vaginal or laparoscopic approach. Design: Retrospective cohort study. Setting: University-based teaching hospital. Patients: 1,286 patients who underwent hysterectomy from 12/1/2009 to 12/1/2012, of whom 596 patients met the obese (BMI>30 kg/m2) BMI inclusion criteria. Intervention: Abdominal, vaginal or laparoscopic (conventional or robotic) hysterectomy for benign indications. Measurements and Main Results: Data were abstracted from electronic medical records. Demographics include age, BMI, gravidity and parity. Data on preoperative indication(s), estimated blood loss (EBL), operating time (OT), length of stay (LOS), and postoperative complications were collected. Mean age was 45 years (SD=10), mean BMI=36.5kg/m2 (SD=5.8), and median gravidity and parity were both 2. Most common surgical indications were leiomyoma (31%), abnormal uterine bleeding (29%), and endometriosis (17%) respectively. Descriptive Statistics Variable Standard 25th 75th (N=596) Mean Deviation Minimum %tile Median %tile
Age 44.73 9.78 BMI 36.52 5.80 Gravidity 2.44 1.85 Parity 1.97 1.41 OT 103.13 52.87 LOS 1.18 0.97
83 63 12 8 601 9.95
22 29.5 0 0 24 0.02
38.5 32 1 1 74 0.99
44 35 2 2 94 1.09
50 40 3 3 117 1.17
BMI= body mass index, OT= operating time, LOS= length of stay
The Wilcoxon rank-sum test compared distributions of operating time (OT) and length of stay (LOS) between hysterectomy types. Comparisons to abdominal procedures (n=7) were not considered. The largest differences in OT were between TLH and LAVH (medians: 89,137.5 minutes; P\0.001) and LSC and LAVH (medians: 90,137.5 minutes; P=0.005).
The only statistically significant difference with LOS was between TLH and LAVH (medians: 1.07,1.12 days;P\0.001); however, difference of 0.05 days (1.2 hours) was not considered clinically relevant. Estimated blood loss (EBL) was dichotomized to R200 mL (10%) versus \200 mL (90%) using logistic regression model to assess the association between EBL and hysterectomy type. The odds of EBLR200 mL were higher with VH (n=28, 35.0%) compared to TLH (n=10, 3.4%), [odds ratio (OR)=15.3, 95% CI:(7.0,33.4);P=0.001] or compared to LSH (n=16, 8.4%), [OR=5.9, 95% CI:(3.0,11.7);P\0.001]. No association was seen between high BMI and surgical complications. All p-values were adjusted for multiple testing per outcome using the adaptive Holm adjustment to the stepdown Bonferroni procedure. Conclusion: Laparoscopic hysterectomy offered the shortest operating time with minimal blood loss compared to the vaginal route in the obese patient population. 514 Perioperative Clinical Outcomes with the Use of Barbed Suture in Total Laparoscopic Hysterectomy Tapia JC,1 Lagos I,2 Rodrigo SM,2 Manuel D,2 Eduardo O.1 1ObGyn, Davila Clinic, Santiago, Metropolitan Region, Chile; 2ObGyn, Los Andes University, Santiago, Metropolitan Region, Chile Study Objective: To describe perioperative outcomes with the use of barbed suture to close the vagina in total laparoscopic hysterectomy (TLH) in the first 18 cases of our series. Design: Retrospective review. Setting: This was a series of 18 TLH over a one year period (from May, 2012 to April, 2013) where it was used barbed suture for the vaginal closure. One gynecologist performed all procedures but one and used similar techniques over time. It included 18 women (ages 36 to 77), requiring hysterectomy for symptomatic uterine leiomioma, pelvic pain, endometrial cancer, and ovarian tumors. Intraoperative and early postoperative complications were registered. A continuous suture was performed from one angle of the vagina to the other, going back with two stiches of security in the opposite way. The suture material was cut at the level of the vaginal tissue with no material protruding. There was no peritoneal coverage performed. Patients: 18 patient underwent to Total laparocopic histerectomy. Intervention: Closure of the vagina with barbed suture. Measurements and Main Results: The average age of patients was 48 years. The most common diagnosis was uterine leiomioma (60%), followed by adenomyosis (21.6%), endometrial cancer (10%) and ovarian tumors (10%). All operations were completed successfully by laparoscopy. There was no complication at the moment of the suture. There was one patient who presented a dehiscence of the vaginal suture at the 16th post op day and required resuturing. Conclusion: Barbed suture seems to be a safe way for suturing the vaginal cuff. In our series, there was one complication related to the suture, all the
Comparisons of Operating Time and Length of Stay Between Hysterectomy Types Outcome
Hysterectomy Route (Type 1 vs Type Hysterectomy Type 1 Median (25th 2) %tile, 75th %tile)
Operating Time (minutes) TLH vs LSC TLH vs VH TLH vs LAVH LSC vs VH LSC vs LAVH VH vs LAVH Length of Stay (days) TLH vs LSC TLH vs VH TLH vs LAVH LSC vs VH LSC vs LAVH VH vs LAVH
89 89 80 90 90.0 106.5 1.07 1.07 1.07 108 108 1.12
(74.0, 109.0) (74.0, 109.0) (74.0, 109.0) (68.0, 116.0) (68.0,116.0) (85.0, 132.0) (0.96, 1.16) (0.96, 1.16) (0.96, 1.16) (0.99, 1.16) (0.99, 1.16) (1.05, 1.21)
Hysterectomy Type 2 Median (25th %tile, 75th %tile)
90 106.5 137.5 106.5 137.5 137.5 1.08 1.12 1.13 1.12 1.13 1.13
1.00 \0.001 \0.001 0.005 \0.001 0.04 1.00 0.005 1.00 0.05 1.00 1.00
(68.0, 116.0) (85.0, 132.0) (110.5, 160.5) (85.0,132.0) (110.5, 160.5) (110.5, 160.5) (0.99, 1.16) (1.05, 1.21) (1.01, 1.17) (1.05, 1.21) (1.01, 1.17) (1.01, 1.17)
*Wilcoxon rank-sum test. P-values are adjusted for multiple testing using adaptive Holm adjustment to the stepdown Bonferroni procedure.
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
rest had no adverse outcomes. More research comparing traditional suture with barbed suture is needed, and also longer follow up to determine later complications.
515 Laparoendoscopic Single-Site Hysterectomy after Gonadotropin Releasing Hormone Agonist Treatment of Huge Myoma Uteri or Adenomyosis Torng P-L, Tai YH. Obstetric and Gynecology, National Taiwan University Hospital, Taipei, Taiwan Study Objective: Patients with huge myomatous uteri or adenomyosis are usually technically challenged to laparoscopic surgery. We study the feasibility of treating these patients with gonadotropin releasing hormone agonist (GnRHa) follow by laparoendoscopic single-site total hysterectomy (LESS-LTH). Design: Prospective cohort study from May, 2011 to May, 2013. Setting: A university hospital. Patients: Fifteen patients who requested for hysterectomy due to mass compression or anemia caused by huge uterus with either multiple or large myomas or adenomyosis were included. Intervention: These patients received GnRHa followed by LESS LTH. Measurements and Main Results: Laboratory tests for anemia and pelvic sonographies for location and estimation of myoma and uteri sizes were performed before and after GnRHa treatments. Eight patients were anemia before treatment, and one patient did not show improvement of anemia and required blood transfusion before surgery. The mean age of these patients were 47.1 4.3 years, and the mean doses of GnRHa used was 3.5 1.6. Uteri masses decreased by 40 to 50% in size. But, in a case of intraligamentous myoma, the operated uteri size was larger than sonographic estimation. The mean operated uteri weight was 455.8 200 (rang: 150 - 844) g, operative time was 167.3 71.9 (range: 100 – 360) min, estimated blood loss was 183.3 173.9 (range: 50 – 600) mL. The patient with huge intraligamentous myoma required an additional trocar for morcellation and was complicated with ureter injury. Another patient with multiple large myoma was complicated with bladder perforation. Operative time became lesser despite of uteri mass during subsequent surgeries. Conclusion: Treatment of GnRHa in myoma uteri could be ineffective in cases with intraligamentous, submucosa, or peduculated myoma. However, with effective shrinkage of uteri size, treatment of GnRHa followed by LESS LTH is feasible in women with adenomyosis, large or multiple myoma that cause mass compression or anemia.
517 First 2 Cases of Hand Morcellattion When the Morcellator Failed Virk KS. Womencare of Williamsburg, Williamsburg, Virginia Study Objective: Mortcellators have become an important part of minimally invasive hysterectomies. There is a wide variety of morcellators available at this time. Hand morcellation with a scalpel, either vaginally or by extending one of the port sites is still an important technique to learn. Design: We are presenting the first 2 cases in which we had to do hand morcellation because the morcellator failed to cut into calcified fibroids. First patient was a 46 year old female with 625 gram uterus and the second patient was a 43 year old female with 2792 gram uterus. In both cases the blade of the morcellator became blunt twice. The umbilical incision was extended to about 2 inches and the smallest size self retaining, disposable self retractor was placed and the specimen was morcellated with a scalpel under direct visualization. Both patients stayed overnight and were back to work in 2 weeks. There was no additional need for pain medication. Conclusion: Hand morcellation is an important technique when the morcellator malfunctions or the specimen is too calcified for the morcellator to work and can save a patient from laparotomy for removal of specimen. There is no difference in infection rate, post operative pain, hospital stay and return to work compared to patients in whom the uterus was removed after morcellation or vaginally.
516 A 2800 gram Uterus Removed Laparoscopically. The Edge of MIGS Fellowship Virk KS. Womencare of Williamsburg, Williamsburg, Virginia Study Objective: Despite all the advantages of minimally invasive surgery >65% hysterectomies are done via laparotomy in United States. Patients are still excluded from laparoscopic hysterectomy due to prior history of abdominal surgery, obesity and large fibroid uterus. Hysterectomy done using minimally invasive techniques results in less blood loss, quicker recovery and fewer complications. Design: We performed a laparoscopic hysterectomy on a 43 year old nulliparous female with a 2792 gram uterus. Total blood loss was 200ml. The patient stayed overnight in the hospital and returned to work in 2 weeks. Conclusion: Before doing a MIGS fellowship I would have done a vertical midline incision hysterectomy for this patient. Every patient deserves an attempt at laparoscopic hysterectomy. In the hands of MIGS fellowship trained surgeons, laparotomy can be avoided in almost all cases of hysterectomy for benign disease.
518 Impact of a Robotic Surgical System on Hysterectomy Trends Wasson MN, Hoffman MK. Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware Study Objective: To determine the changes in hysterectomy trends following the addition of a robotic surgical system. Design: Retrospective cohort study. Setting: A large community-based academic medical center. Patients: 4,781 women who underwent hysterectomy from January, 2007 to December, 2012. Intervention: Hysterectomy performed with robotic assistance, laparoscopy, laparotomy, vaginal, or laparoscopically assisted vaginal approach. Measurements and Main Results: The primary outcome was the surgical approach to hysterectomy. For the purposes of analysis, surgical approaches were categorized as robotically assisted, laparoscopic, laparotomy, vaginal, or laparoscopically assisted vaginal. The exposure of interest was quarter