Adelaide Laparoscopic Hysterectomy Audit

After anecdotal reports of significant complications with laparoscopic hysterectomy, the Royal Australian College of Obstetricians and Gynaecologists, South Australian branch, instituted the Adelaide laparoscopic hysterectomy audit. All 760 cases performed in the city of Adelaide (population 1 million) from commencement in 1991 to 1994 were analyzed with specific attention to major complications such as hemorrhage, hematoma, laparotomy rates, and urinary tract injuries. Potential bias was carefully avoided by auditing independent of the surgeons involved. Eighty-nine percent of cases were performed with disposable endoscopic surgical staples. Surgical technique was a combined laparoscopic and vaginal approach. Mean operating time was 129 minutes, mean estimated blood loss was 263 ml, and average hospital stay was 4.9 days. Significant hemorrhagic complications occurred in 3% of women. Hematoma formation requiring reintervention was reported at 3.3%, with an overall laparotomy rate of 5.3%. Urinary tract injury overall totaled 2.4%, consisting of bladder laceration 0.9%, ureteric laceration 0.5%, and late diagnosis 1.1%. Hemorrhage, hematoma, and laparotomy rates were higher than published data suggest but compared favorably with appropriate abdominal and vaginal hysterectomy complication series. However, urinary tract injuries were significantly elevated in comparison with published data, raising the questions of learning curve and experience as factors.

Laparoscopic Burch Colposuspension for Urinary Stress Incontinence

To date we have performed 58 laparoscopic Burch colposuspensions, 28 by the extraperitoneal route and 30 with the transperitoneal approach. The 58 women (mean age 48.9 yrs, mean weight 71.1 kg) all underwent urodynamic studies. Sixteen had mixed findings of stress and urge incontinence. The operative technique involved dissection into the space of Retzius. Laparoscopic suturing techniques were employed using either 0 Dacron or polyester between the paravaginal fascia and the iliopectineal ligaments. Satisfactory elevation of the bladder neck was obtained. Associated procedures were predominantly laparoscopic hysterectomy. Comparison of the two approaches showed equivalent blood loss, return to normal activity, operating times, and duration of postoperative catheterization. Hospitalization was significantly longer in the extraperitoneal group. Significant complications were cystotomy in four women and conversion to laparotomy in four. Duration of follow-up was equivalent in both groups, ranging from 6 to 33 months. Success rates were also equivalent, with only one failure in total, occurring in the transperitoneal group. Laparoscopic Burch colposuspension is a safe, effective procedure and should replace the conventional approach by laparotomy.

Laparoscopic Burch Colposuspension-New Approaches

Endoscopic surgical developments have produced considerable benefits in reduction of postoperative morbidity and healthcare costs for the community. The Burch colposuspension via a transverse lower abdominal incision has achieved widespread acceptance in the management of stress incontinence. However, the potential benefits of laparoscopic Burch colposuspension include decreased perioperative and postoperative morbidity, shortened hospitalization, reduction of blood loss, and early return to normal activity. We present our initial 10 cases, 7 via the transperitoneal approach, and 3 using balloon distension of the retropubic space via an extraperitoneal approach. In all cases, the bladder neck and iliopectineal ligaments were clearly visualized laparoscopically. Sutures were placed between the paravaginal fascia and iliopectineal ligaments bilaterally, producing good bladder neck elevation. A suprapubic catheter was subsequently inserted. This initial group (N = 10), mean age 41 years (range 35-54 years) all had preoperative urodynamic studies confirming stress incontinence. A mean operating time of 3 hours 7 minutes (range 2-5 hrs) was achieved using the transperitoneal approach. However, switching to the balloon extraperitoneal method (N = 3), mean surgical time diminished to 65 minutes. All patients were managed with postoperative suprapubic catheterization with hospital discharge after 5.5 days (range 4-7 days) and minimal postoperative blood loss. All patients returned to normal activity within 18 days. Initial follow-up confirmed the absence of stress incontinence. Laparoscopic colposuspension would now appear to be the surgery of choice for stress incontinence.