Hysterectomy for benign conditions: Complications relative to surgical approach and other variables that lead to post-operative readmission within 90 days of surgery.

OBJECTIVE: To examine variables associated with hysterectomy-related complications, relative to surgical approach and other variables, that lead to readmission within 90 days of surgery. METHODS: We conducted an observational cohort study for which data were extracted from electronic health records. Data were extracted of all patients (n = 3106) who underwent hysterectomies at 10 Kaiser Permanente Southern California medical centers between June 2010 and September 2011. Patients who were pregnant or had a cancer diagnosis were excluded from the study. To identify univariate associations between examined variables and procedure type, chi-square tests for categorical variables and t-tests or analysis of variance for continuous variables were used. Generalized estimating equations methods were used to test associations between independent variables and primary outcomes of interest. Statistical significance was determined using a p-value <.05. RESULTS: Of 3106 patients, 109 experienced 168 post-operative complications. The most common post-operative complications were related to pelvic abscesses, bowel obstruction, or severe ileus, and the vaginal cuff. Pelvic abscesses were most frequent among total laparoscopic hysterectomy and total abdominal hysterectomy cases (p = .002), and vaginal cuff complications were most frequent among total laparoscopic hysterectomy cases (p = .015). Patients who underwent total vaginal hysterectomy (odds ratio = 2.13, confidence interval = 1.15-3.92), laparoscopic supracervical hysterectomy (odds ratio = 3.11, confidence interval = 1.13-8.57), and total laparoscopic hysterectomy (odds ratio = 5.60, confidence interval = 2.90-10.79) experienced increased occurrence of post-operative complications resulting in readmission. Other variables associated with an increased risk for readmission included high estimated blood loss (201-300 mL and 301+ mL, relative to 0-50 mL; odds ratio = 2.28, confidence interval = 1.24-4.18 and odds ratio = 2.63, confidence interval = 1.67-4.14) and long length of stay of 3 days or more (relative to 0 days; odds ratio = 2.93, confidence interval = 1.28-6.69). Pelvic specimen weight in the 151-300 g and 501+ g ranges appeared protective (odds ratio = 0.40, confidence interval = 0.25-0.64 and odds ratio = 0.54, confidence interval = 0.33-0.90). In a sub-analysis of 1294 patients, 74 hospital operative complications directly related to hysterectomy were identified among 59 patients. The most common hospital operative complications were excessive bleeding associated with surgery or injury to nearby structures. Among the sub-sample of 1294 patients, those with hospital operative complications were more likely to experience post-operative complications that lead to readmission (odds ratio = 3.82, confidence interval = 1.55-9.43, p = .004). CONCLUSION: The observed increased risk of complications among patients of Black race, who underwent laparoscopic supracervical hysterectomy or total laparoscopic hysterectomy, who experienced more than 300 mL surgical blood loss, who suffered hospital operative complications, and those whose hospitalization was 3 days or greater, offers an opportunity for higher scrutiny and preventive measures during usual hysterectomy care to prevent later readmission.

A randomized trial of prophylactic uterosacral ligament suspension at the time of hysterectomy for Prevention of Vaginal Vault Prolapse (PULS): design and methods.

The primary aim of this randomized trial is to evaluate whether a standardized uterosacral ligament suspension colpopexy (USLSC), added to a planned hysterectomy for an indication other than pelvic organ prolapse (POP), decreases the rate of subsequent vaginal vault prolapse in women without preoperative symptomatic POP. Secondary aims include comparison of perioperative complications, urinary, bowel and sexual functions between subjects with and without concomitant USLSC. If shown to be beneficial, the cost-effectiveness of prophylactic USLSC at the time of hysterectomy will be evaluated. This trial will be performed at 4 centers across the United States. The data will be analyzed by the data-coordinating center of the Southern California Kaiser Permanente. Standardized questionnaires and objective measurements will be obtained. The patients and providers performing assessments are masked to treatment assignment. The primary outcome, defined as absence of POP at/distal to the hymen on Pelvic Organ Prolapse Quantitative examination, will be determined 12 months post-operatively. Secondary outcomes include: no prolapse symptoms by questionnaires, and no treatment for POP besides the prophylactic study intervention. Additional follow-up occurs annually for a total of 5 years. Accrual is projected to take 3 years. Given cost and morbidity of surgical repair of post-hysterectomy prolapse, preventive strategies are of outmost importance. The risks and benefits of prophylactic USLSC have never been studied prospectively. This trial is designed to determine if USLSC is an appropriate clinical adjunct at the time of hysterectomy, with subsequent reduction of symptomatic POP.

Outpatient laparoscopic hysterectomy for large uteri.

OBJECTIVE: To determine the incidence of perioperative complications associated with laparoscopic hysterectomies performed for very large uteri on an outpatient basis. METHODS: A retrospective chart review of consecutive women who underwent total laparoscopic (TLH) or supracervical laparoscopic (LSH) hysterectomy with uterine weight ≥ 500 grams. Clinical, demographic, and surgical characteristics were ascertained. Deviation from a normal intraoperative/perioperative course and readmission rate were assessed. Complications were graded by Dindo morbidity scale. Surgical characteristics and complications were compared between TLH and LSH groups using Chi2 tests for categorical and unpaired t tests for continuous variables. Logistic regressions were performed to identify specific risk factors. RESULTS: TLH and LSH were performed in 113 (25.3%) and 333 (74.7%) cases, respectively, with no differences in baseline characteristics between the groups. Median uterine weight was 786 gm (range: 500-4500). Mean operative time was 27 minutes longer in the TLH group: 186.5 ± 58.6 vs. 159.6 ± 53.8 minutes for LSH (P < 0.0001). Life threatening complications (Dindo's grade IV morbidity) occurred in 0.7%. Surgical intervention requiring general anesthesia (IIIB) occurred in 0.45% of cases. Visceral injury was limited to 6 (1.3%) cases of cystotomy. The rate of vascular injury was 0.22%. Conversion to laparotomy occurred in 3.4% of cases. 92.8% of patients were discharged on post-operative day zero, with 1.1% readmission rate. There was no association between perioperative morbidity and patient/surgical characteristics. CONCLUSION: Laparoscopic hysterectomy is a viable option for women with very large uteri. Same day discharge of clinically stable patients can be safely implemented.

Pregnancy in a hermaphrodite with a male-predominant mosaic karyotype.

OBJECTIVE: To report a pregnancy in a hermaphrodite and review of the literature. DESIGN: Case report and literature review. SETTING: Clinical. PATIENT(S): A patient with male-predominant mosaic karyotype 96% 46XY. INTERVENTION(S): Removal of left ovotestis in combination with a supracervical hysterectomy and bilateral salpingo-oophorectomy. MAIN OUTCOME MEASURE(S): Identification of published cases of pregnancy and hermaphroditism. RESULT(S): The current patient had previous pregnancy and a wedge biopsy of her left gonad, which demonstrated an ovotestis and an area suspicious for a gonadoblastoma. After delivery of her second pregnancy, the patient underwent a hysterectomy and bilateral salpingo-oophorectomy. The histopathologic evaluation following bilateral oophorectomy demonstrated a residual ovotestis without further evidence of a gonadoblastoma. Review of the literature identified 10 other cases of pregnancy in a hermaphrodite patient. CONCLUSION(S): This is the 11th reported case of fertility in a true hermaphrodite and only the second report of a mosaic true hermaphrodite to demonstrate fertility. This is the only case of a pregnancy involving a male-predominant mosaic 96% 46XY and the only case to confirm the genetics of the offspring.

Aortic puncture with a laparoscopic fascial closure device.

BACKGROUND: Vascular injury during laparoscopic surgery typically occurs with the blind insertion of either the Veress needle or the trocar. We report an aortic puncture from the use of a laparoscopic fascial closure device. CASE: After a laparoscopic-assisted vaginal hysterectomy and during closure of the 10-mm umbilical port with a fascial closure device, attempted passage of the needle encountered unusual resistance in the abdominal wall. Application of increased force resulted in uncontrolled entry of the needle into the abdominal cavity and a 1-mm puncture of the aorta. After emergency laparotomy the puncture was successfully repaired by a vascular surgeon. CONCLUSION: A previously unreported complication of this laparoscopic fascial closure device is aortic injury. Unusual resistance to passage of the needle should engender extra caution. The use of assistive closure devices should be reserved for patients with difficult anatomy.