Pain and pulmonary function following laparoscopic and abdominal hysterectomy: a randomized study.

BACKGROUND: The aim of this study was to evaluate pain and pulmonary function the first two days after abdominal and laparoscopic hysterectomy. METHODS: Women scheduled for abdominal hysterectomy were prospectively randomized to either laparoscopic (n=20) or abdominal (n=20) hysterectomy. Analgesics were self-administered by the patients by means of a programable infusion pump containing morphine. Postoperative pain was evaluated using a visual analog scale. Oxygen saturation was measured with an oxymeter. Pulmonary function was assessed using a peak flow meter measuring peak expiratory flow and a vitalograph measuring forced vital capacity and forced expiratory volume in one second. RESULTS: Pain scores were lower after laparoscopic hysterectomy at the first (p<0.05) and second postoperative day (p<0.01). Lung function was impaired on days 1 and 2 postoperatively, measured as peak expiratory flow, forced vital capacity and forced expiratory volume in one second, in both groups compared to the preoperative values. The patients undergoing laparoscopic hysterectomy had less impairment of lung function measured by peak expiratory flow (p<0.01), forced vital capacity (p<0.05) and forced expiratory volume in one second (p<0.05) the first postoperative day compared to the patients undergoing abdominal hysterectomy. The second postoperative day differences between the groups remained for peak expiratory flow (p<0.05) and forced expiratory volume in one second (p<0.05). CONCLUSIONS: Laparoscopic hysterectomy results in less pain and less impairment of respiratory function compared to abdominal hysterectomy.

A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy.

OBJECTIVE: To perform a cost-consequence analysis after total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH). METHODS: Women scheduled for TAH were randomized prospectively to undergo the procedure by laparoscopic (n = 71) or abdominal (n = 72) surgery. Postoperative health status was assessed using The Medical Outcome Trust 36-Item Short-Form Health Survey questionnaire. The financial accounting system at the hospital and information from the local national health insurance office were used for the economic analysis. We evaluated changes in direct costs (hospital costs) and indirect costs (loss of production value) when performing a laparoscopic hysterectomy instead of an abdominal hysterectomy. RESULTS: Postoperative health status improved significantly faster after TLH than after TAH. The direct costs were 1.7% higher and the indirect costs 50.3% lower for patients undergoing laparoscopic surgery. The total costs were 23.1% lower after laparoscopic hysterectomy. CONCLUSION: A change in surgical technique from abdominal to laparoscopic hysterectomy was possible without compromising the health status of the patients, and it provided substantial financial benefits to society.

Tissue Trauma after Laparoscopic and Abdominal Hysterectomy Measuring Inflammatory Response

It is suggested that laparoscopic surgery reduces postoperative pain and shortens hospital stay and convalescence because of the small amount of tissue trauma. We evaluated the inflammatory response during abdominal hysterectomy (AH, 12 women) and laparoscopic hysterectomy (LH, 12 women) by measuring interleukin (IL)-6, neopterin and terminal C5b9 complement complex (TCC). Blood samples were drawn preoperatively, perioperatively, 1 minute, 24 hours, and 7 days postoperatively. Levels of IL-6 were determined to evaluate cytokine release, neopterin was determined as a marker for macrophage-monocyte activation, and TCC was determined to assess complement activation. The IL-6 concentrations, as a percentage of preoperative level, were significantly elevated postoperatively in both groups, and also perioperatively in the LH group. Neopterin concentrations, as a percentage of perioperative level, were significantly increased in the LH group preoperatively and postoperatively. No elevation was seen in the AH group. There was no sign of complement activation in either group. Our results indicate significant tissue trauma during both LH and AH. The extent of trauma might be greater in laparoscopic surgery. Despite this, the LH group had a shorter hospital stay and convalescence than the AH group. The proposed advantages to the patient of laparsocopic surgery thus seem to be attributable to other factors than the amount of tissue trauma.

Cost Effectiveness and Health Status after Laparoscopic and Abdominal Hysterectomy

Laparoscopic hysterectomy has rapidly become a routine procedure without a preceding evaluation of its cost effectiveness in comparison with abdominal hysterectomy. Economic analysis must include an assessment of patients' health status. Direct costs (hospital costs) and indirect costs (value of production loss) were calculated for 20 women randomized to total laparoscopic hysterectomy (TLH) and 20 to total abdominal hysterectomy (TAH). Health status was evaluated by scoring responses to standardized questions 1, 3, and 12 weeks after the operation. Direct costs were 7% lower for TLH than for TAH. The shorter hospital stay after TLH more than compensated for the increased costs due to longer operating time. Indirect costs were 52% lower for TLH than for TAH. One and 3 weeks after the operation, limitations in physical and social activity were less pronounced, general mental health was better, and pain less pronounced after TLH compared with TAH. Fewer women considered their hospital stay and sick leave as too short after TLH compared with TAH. We conclude that, compared with TAH, TLH offers economic advantages to the patient, hospital, and society.

Evaluation of tissue trauma after laparoscopic and abdominal hysterectomy: measurements of neutrophil activation and release of interleukin-6, cortisol, and C-reactive protein.

BACKGROUND: Trauma and major surgery stimulate a cascade of events that mediate the inflammatory response. The aim of our study was to determine whether or not hysterectomy leads to release of cytokines, cortisol, and C-reactive protein (CRP), activation of neutrophils, and activation of the complement cascade. A further aim was to compare laparoscopic and abdominal hysterectomy with regard to the same parameters. STUDY DESIGN: Twenty-four consecutive patients were randomized to either abdominal (n = 12) or laparoscopic hysterectomy (n = 12). Blood samples were drawn preoperatively, intraoperatively, and then at one minute, 24 hours, and seven days postoperatively. Interleukin-6 (IL-6) levels were used to evaluate cytokine release, cortisol and CRP to evaluate the inflammatory response, and polymorphonuclear (PMN) elastase to detect neutrophil activation. To evaluate complement activation, the terminal C5b-9 complement complex (TCC) was determined. RESULTS: Interleukin-6 concentrations were significantly elevated one minute and 24 hours postoperatively in both groups. Independent of the surgical technique or operative time, the highest IL-6 concentration was reached four hours after beginning the operation. Cortisol levels were significantly elevated during and after the operation in both groups. C-reactive peptide levels were significantly elevated in both groups 24 hours and seven days after the operation. Polymorphonuclear elastase was elevated 24 hours postoperatively in both groups. There were no signs of complement activation during the operative period or postoperatively in either patient group. CONCLUSIONS: Our results indicate serious tissue trauma during both laparoscopic and abdominal hysterectomy. The extent of surgical trauma did not differ between the two operative methods.

A randomised prospective trial comparing laparoscopic and abdominal hysterectomy.

OBJECTIVE: To compare short term clinical results in a prospective randomised trial of laparoscopic hysterectomy compared with abdominal hysterectomy. METHODS: One hundred and forty-three women scheduled for total abdominal hysterectomy, with or without salpingo-oophorectomy and with a maximum uterine width of less than ll cm, were prospectively randomised to undergo the procedure by laparoscopic hysterectomy (n = 71) or abdominal hysterectomy (n = 72). During laparoscopic hysterectomy, the uterine arteries as well as the upper portion of the cardinal ligaments were transected laparoscopically. The perioperative and post-operative courses of the groups were compared. RESULTS: The number of women with a complication did not differ significantly between laparoscopic hysterectomy (27%) and abdominal hysterectomy (33%) groups. The post-operative fall in erythrocyte volume fraction was significantly greater following abdominal hysterectomy (5.6% compared with 4.1% median value, P < 0.001). Post operative pain, assessed by the patients two days after surgery on a visual analogue scale, was significantly higher following abdominal hysterectomy (4.2 compared with 3.6 units median value, P < 0.05). Although laparoscopic hysterectomy took longer (148 min compared with 85 min median value, P < 0.001), the women undergoing this procedure had a shorter post-operative time in hospital (two compared with four days median value, P < 0.001) and a shorter convalescence (16 compared with 35 days median value, P < 0.001). CONCLUSIONS: Laparoscopic hysterectomy is a safe procedure for selected patients scheduled for abdominal hysterectomy, and offers benefits to the patients in the form of less operative bleeding, less post-operative pain, shorter time in hospital and shorter convalescence time.

Gynaecological and sexual function related to anatomical changes in the female pelvis after restorative proctocolectomy.

Restorative proctocolectomy with an ileal pouch-anal anastomosis preserves anal sphincters, the normal route of defaecation and the normal body image and it has been suggested that the procedure might be associated with less gynaecological and sexual problems than conventional proctocolectomy. To shed further light on this subject 60 female patients were invited to participate in a study comprising a detailed interview, examination by a gynaecologist and investigation with hysterosalpingography and vaginography. Twenty-one women with a mean follow-up of 38 months after surgery agreed to participate. Their gynaecological state was considered normal although one woman complained of vaginal discharge. Five women experienced occasional dyspareunia and 2 patients had to take special precautions to avoid bowel leaks at intercourse. While the position of the vagina and uterus in the pelvis appeared normal, hysterosalpingography disclosed bilateral occlusion of the fallopian tubes in 2 and unilateral occlusion in another 9 patients with tubes adhering to the bottom of the lesser pelvis in 10 of the patients. Only one out of 14 patients succeeded in trying to conceive during the follow-up period. Among the remaining 39 women not specially studied 5 out of 14 had conceived after the operation.