Exploring Adverse Events and Utilization of Topical Hemostatic Agents in Surgery.

Background and Objectives: This retrospective study provides preliminary qualitative assessment of the adverse events (AEs), focusing on pelvic and abdominal AEs and patient outcomes reported for three hemostatic agents used in gynecologic surgery. Methods: Utilization rates for oxidized regenerated cellulose powder (ORC), polysaccharide powder (PSP), and fibrin sealant solution (FSS) were obtained from hospitals via the Premier Healthcare databases for all surgical procedures from January 1, 2018 to September 30, 2020. All reported cases were extracted from the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for ORC and PSP and from the FDA Adverse Event Reporting System (FAERS) database for FSS. Distributions of AEs by anatomical site (MAUDE/FAERS) and surgical procedures by specialty (Premier) were evaluated for each product. Number of cases and number and types of AEs were compared to the total utilization for each product. Results: PSP was the most used product during the period analyzed (n = 126,509 uses), followed by FSS (n = 80,628 uses), and ORC (n = 41,583 uses). Distribution of surgical procedures by anatomical site varied significantly between hemostatic agents (p < 0.001). ORC was associated with more patient cases with AEs and numbers of reported AEs compared with PSP and FSS (p < 0.001). ORC was associated with higher number of infections than PSP (p < 0.001) and FSS (p < 0.001). Conclusion: These findings suggest that ORC use in abdominal and pelvic surgery may result in more postoperative complications compared with non-ORC hemostatic agents. Further prospective randomized studies are needed to compare efficacy and safety of these products.

Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients.

OBJECTIVE: To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients. METHODS: This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH. RESULTS: Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients. CONCLUSION: TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.

Biological origins of sexual orientation and gender identity: Impact on health.

Gynecologic Oncologists are sometimes consulted to care for patients who present with diverse gender identities or sexual orientations. Clinicians can create more helpful relationships with their patients if they understand the etiologies of these diverse expressions of sexual humanity. Multidisciplinary evidence reveals that a sexually dimorphic spectrum of somatic and neurologic anatomy, traits and abilities, including sexual orientation and gender identity, are conferred together during the first half of pregnancy due to genetics, epigenetics and the diversity of timing and function of sex chromosomes, sex-determining protein secretion, gonadal hormone secretion, receptor levels, adrenal function, maternally ingested dietary hormones, fetal health, and many other factors. Multiple layers of evidence confirm that sexual orientation and gender identity are as biological, innate and immutable as the other traits conferred during that critical time in gestation. Negative social responses to diverse orientations or gender identities have caused marginalization of these individuals with resultant alienation from medical care, reduced self-care and reduced access to medical care. The increased risks for many diseases, including gynecologic cancers are reviewed. Gynecologic Oncologists can potentially create more effective healthcare relationships with their patients if they have this information.

Comprehensive laparoscopic lymphadenectomy from the deep circumflex iliac vein to the renal veins: Impact on quality of life.

OBJECTIVE: Compare quality of life metrics for consecutive patients having total laparoscopic hysterectomy, bilateral salpingo-oophorectomy (TLHBSO) with and without comprehensive pelvic/aortic lymphadenectomy (CPALND) from proximal to the distal circumflex iliac nodes and vessels to the renal vessels. METHODS: Analysis of mailed survey responses with 25 validated questions regarding musculoskeletal/lower extremity, gastro-intestinal, abdominal, urological, and energetic/activities of daily living. Data analyzed with Chi-Square tests of Association, Mann-Whitney U tests and follow up regression analysis. RESULTS: Of 533 surveys mailed, 197 (37%) responded; 57 (28.9%) received CPALND. Age and parity were not different between groups, but the TLHBSO group had a higher BMI (31.4 v. 25.8, p<0.001), and were less likely to receive chemotherapy (CT), radiotherapy (RT), or both (CT+RT). In the CPALND cohort, a mean of 47 nodes were removed, of which 26% were positive: 21% pelvic, 11% inframesenteric, 11% infrarenal. Both groups had similar total quality of life total scores of 86/92. Those having CPALND did not report more swelling but they did report more tingling/numbness (2.8 v. 3.5, p<0.001). A series of hierarchical regressions confirmed that CPALND, per se, did not significantly reduce lower extremity scores apart from CT (p=0.402) and CT+RT (p=0.108). However, CPALND did predict for lower extremity swelling after receipt of CT, RT, or CT+RT. Node count, in total, or from each basin, did not correlate with any QOL decrement. CONCLUSIONS: CPALND did not cause lymphedema or a reduction in overall quality of life. Only after controlling for BMI, and receipt of radiation and/or chemotherapy were QOL scores mildly reduced. Routine omission of the distal circumflex nodes from the dissection may account for the low risk of lymphedema from the dissection. Larger prospective studies are needed to determine the optimal staging protocols that address all the likely sites of metastasis and recurrence, and optimize survival, while maintaining our patients' quality of life.

Analysis of a Standardized Technique for Laparoscopic Cuff Closure following 1924 Total Laparoscopic Hysterectomies.

Objective. To review the vaginal cuff complications from a large series of total laparoscopic hysterectomies in which the laparoscopic culdotomy closure was highly standardized. Methods. Retrospective cohort study (Canadian Task Force Classification II-3) of consecutive total and radical laparoscopic hysterectomy patients with all culdotomy closures performed laparoscopically was conducted using three guidelines: placement of all sutures 5 mm deep from the vaginal edge with a 5 mm interval, incorporation of the uterosacral ligaments with the pubocervical fascia at each angle, and, whenever possible, suturing the bladder peritoneum over the vaginal cuff edge utilizing two suture types of comparable tensile strength. Four outcomes are reviewed: dehiscence, bleeding, infection, and adhesions. Results. Of 1924 patients undergoing total laparoscopic hysterectomy, 44 patients (2.29%) experienced a vaginal cuff complication, with 19 (0.99%) requiring reoperation. Five patients (0.26%) had dehiscence after sexual penetration on days 30-83, with 3 requiring reoperation. Thirteen patients (0.68%) developed bleeding, with 9 (0.47%) requiring reoperation. Twenty-three (1.20%) patients developed infections, with 4 (0.21%) requiring reoperation. Three patients (0.16%) developed obstructive small bowel adhesions to the cuff requiring laparoscopic lysis. Conclusion. A running 5 mm deep × 5 mm apart culdotomy closure that incorporates the uterosacral ligaments with the pubocervical fascia, with reperitonealization when possible, appears to be associated with few postoperative vaginal cuff complications.

Infrarenal lymphadenectomy for gynecological malignancies: two laparoscopic approaches.

OBJECTIVE: Compare two approaches for laparoscopic infrarenal lymphadenectomy. METHODS: Retrospective chart review. Statistical analyses with SPSS. PATIENTS: 4 stage II/III cervical carcinoma, 75 clinical stage I/II endometrial carcinoma, 36 clinically stage I/II tubal/ovarian cancer. 36 transperitoneal approaches; 79 extraperitoneal approaches. Both groups had similar age, 58years (range 29-80), BMI of 25 (range 18-41), blood loss, 150cm(3) (range 25-1500), and hospital stay, 1day (range 1-6). The extraperitoneal surgery took longer (240 v 202min; p=.001); yielded more nodes (50 v 41; p=.004). Extraperitoneal approach yielded more inframesenteric (14 v 10; p=.036), and infrarenal nodes (14 v 9; p=.001). 25% of cervical, 19% of endometrial and 14% of ovarian cancer patients had metastases in radiographically negative infrarenal nodes. 50% of cervical, 33% of endometrial and 17% of ovarian cancer patients had therapy altered by aortic lymphadenectomy. When the inframesenteric nodes were positive, 63% of endometrial and 80% of ovarian cancer patients had infrarenal metastases. More metastases were identified with increasing aortic node count. Extraperitoneal lymphadenectomy had no learning curve (p=0.320), while transperitoneal lymphadenectomy did (p=0.016). Higher BMI patients had lower aortic node yields by transperitoneal (p=.057) but not extraperitoneal approach (p=.578). Among the 14 patients whose BMI was 35-41, mean extraperitoneal total aortic nodal yield was 30; transperitoneal yield was 6. CONCLUSIONS: Infrarenal aortic lymphadenectomy may offer higher aortic nodal yields, even in patients with BMI's of 45. Larger prospective studies are needed to confirm whether this dissection in high-risk patients ensures more accurate therapy, and possibly improves cure rates.

Comprehensive, therapeutic retroperitoneal pelvic and infrarenal aortic lymphadenectomy for advanced cervical carcinoma.

This 49-year-old female with stage III cervical carcinoma presented with a PET/CT scan showing bilateral pelvic and common ileac adenopathy. A retroperitoneal approach to resect the nodes well above the highest documented PET positive region was employed in July 2011. The bilateral infrarenal, bulky inframesenteric and pelvic nodes were comprehensively removed, revealing bilaterally positive nodes in 5/36 pelvic nodes, 13/25 inframesenteric nodes, and 3/20 infrarenal nodes (these latter not detected on PET). Image-modulated radiation to 10 cm above the renal vein, with concurrent cisplatin chemotherapy was undertaken, resulting in a disease-free status thus far.

Quality improvement: single-field sterile scrub, prep, and dwell for laparoscopic hysterectomy.

The vulva and vaginal interior are considered a contaminated surgical area, and current OR guidelines require surgeons who are gloved and gowned at the abdominal field to avoid contact with the urethral catheter, the uterine manipulator, and the introitus or to change their gloves and even regown if contact occurs. It is our belief that the perception of the vaginal field as contaminated reflects a lack of specific standards for the preoperative cleansing of the deeper vagina and a lack of preoperative prep instructions for the combined fields. We developed a comprehensive single-field prep technique designed to improve surgical efficiency and prevent contamination of the sterile field. Combining a methodical scrub, prep, and dwell, this technique allows the entire abdomino-perineovaginal field to be treated as a single sterile field for laparoscopic procedures. Our surgical site infection rate of 1.8% when using this single-field prep technique and the subsequent surgical treatment of the abdominal, vaginal, and perineal fields as a single sterile field is well within reported norms.

Total laparoscopic hysterectomy: evaluation of an evidence-based educational strategy using a novel simulated suture and knot-tying challenge, the "holiotomy".

Objective. The purpose of this study was to evaluate perceptions of skills and practice patterns of gynecologists attending a course on total laparoscopic hysterectomy (TLH). This course employed extensive use of pelvic trainer boxes to accomplish the Holiotomy Challenge. The "Holiotomy Challenge" entailed suturing two plastic pieces with six figure-of-N sutures tied with four square knots each. Methods. A survey was administered before the course and 3 months later. Data were analyzed by paired t-tests, McNemar's Chi Squares, and ANCOVAs with significance set P < .05. Results. At baseline, 216 surgeons and at 3 months 102 surgeons returned the survey. Surgeons' self-perceptions of their skills significantly increased from 6.24 to 7.28. Their reports of their surgical practice at home revealed significantly increased rates of minimally invasive procedures, from 42% to 54%. Significantly more surgeons reported having the ability to close the vagina, or a small cystotomy or enterotomy. Participation in the cadaver lab and presence of their practice partner did not impact these rates. Conclusions. A comprehensive course employing laparoscopic surgical simulation focused on basic surgical skills essential to TLH has a positive impact on attendees' self-rated skill level and rate of laparoscopic approaches. Many had begun performing TLH after the course.

Single-field sterile-scrub, preparation, and dwell for laparoscopic hysterectomy.

Type VII laparoscopic hysterectomy is classified as a "clean-contaminated" procedure because the surgery involves contact with both the abdominal and vaginal fields. Because the vulva has traditionally been perceived as a separate but contaminated field, operating room guidelines have evolved to require that surgeons gloved and gowned at the abdominal field either avoid contact with the urethral catheter, the uterine manipulator, and the introitus or change their gloves and even re-gown after any contact with those fields. In the belief that the perception of the vaginal field as contaminated stems from inadequate preoperative preparation instructions, we have developed a rigorous abdomino-perineo-vaginal field preparation technique to improve surgical efficiency and prevent surgical site infections. This thorough scrub, preparation, and dwell technique enables the entire abdomino-perineo-vaginal field to be safely treated as a single sterile field while maintaining a low rate of surgical site infection, and should be further investigated in randomized studies.

Laparoscopic hysterectomy: impact of uterine size.

OBJECTIVE: To analyze surgical results of women having Type VII laparoscopic hysterectomy to determine whether differences in outcomes exist on the basis of uterine size. METHODS: This is an analysis of data from 983 cases of type VII laparoscopic hysterectomy performed from September 1996 through August 2010. Demographic and surgical data were stratified by uterine weight (range 14-3,131 g) less than 250 g (n = 720) and 250 g or more (n = 263). Analyses were done by Pearson's χ(2), Wilcoxon rank-sum, and Kruskal-Wallis tests with significance set at 2-sided (p <.05). Outcomes examined include estimated blood loss, skin-to-skin operative time, complications (non-reoperative and reoperative), and duration of hospital stay. Estimated blood loss, skin-to-skin operative time, and length of hospital stay were further analyzed using backwards, stepwise, multivariable, linear regression to control for and identify independent predictors affecting these outcomes. Baseline demographic data were included in the multivariable model. Only covariates that were significant in both multivariable and univariable analyses are presented as statistically significant. DESIGN: A case-controlled, retrospective study (Canadian Task Force Classification II-2). RESULTS: Median operating time varied by uterine weight, with a shorter duration of surgery in patients with uteri less than 250 g at 97 minutes (range 29-330), and patients with uteri greater than 250 g at 135 minutes (range 45-345) (p <.001). Median estimated blood loss was also less in patients with uteri less than 250 g at 50 mL, (range 0-1400), than in patients with uteri weighing 250 g or more, at 150 mL, (range 0-2100) (p <.001). There was no significant difference by uterine weight in median duration of hospital stay of 1 day (range 0-13), total complication rate (7.0%), reoperative complications (3.7%), or non-reoperative complications (3.4%). Duration of surgery, volume of blood lost, and length of hospital stay all decreased with the surgeon's increasing experience. CONCLUSIONS: Laparoscopic hysterectomy is feasible and safe, resulting in a short hospital stay, minimal blood loss, minimal operating time, and few complications for patients regardless of uterine weight.

Cystosufflation to prevent bladder injury.

STUDY OBJECTIVE: This brief report will share information about the use and safety of inflating the bladder with carbon dioxide to delineate the margins during laparoscopic dissections near the bladder in patients who have scarring, adhesions, or challenging anatomy. DESIGN: A retrospective chart review of patients undergoing total or radical laparoscopic hysterectomy, or support procedures from September 5, 1996, through October 30, 2008, was conducted. Canadian Task Force level III. SETTING: Community hospital. PATIENTS: Of 1004 patients having simple or radical laparoscopic hysterectomy or laparoscopic support procedures, cystosufflation was used in 173 patients. Indications included finding of adhesions from earlier cesarean section or massive myomas obscuring bladder margins, or planned anterior colpopexy or vaginal sacrocolpopexy. INTERVENTIONS: Cystosufflation uniformly entailed the following: clamping of the bladder catheter with a Kelly clamp; connection of the laparoscopic carbon-dioxide insufflation tubing to the catheter; then under direct laparoscopic observation, release of the Kelly clamp with immediate bladder inflation revealing the cystic margins. MEASUREMENTS AND MAIN RESULTS: Cystosufflation safely facilitated the dissection of the bladder off the anterior cervix and vagina, or off the anterior abdominal wall. Distention of the bladder elevated and rounded up the bladder margins so that the muscularis could be clearly identified, preventing bladder injury in all patients. No urologic complications occurred in these cases. CONCLUSION: These retrospective data suggest that cystosufflation is well tolerated by patients and can reliably prevent cystotomy.

Total laparoscopic hysterectomy for female-to-male transsexuals.

OBJECTIVE: To compare the results of laparoscopic hysterectomy, salpingo-oophorectomy, and incidental appendectomy for female-to-male transsexuals with those of female patients. METHODS: Retrospective chart abstraction of all patients undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy since September 1996. Significance from analysis of covariance or chi2 was set at .05. RESULTS: Five hundred ninety-three patients underwent total laparoscopic hysterectomy, oophorectomy, and appendectomy. Forty-one were identified as transsexual, 552 as females. The transsexuals were significantly younger (mean 32 years compared with 51 years, median 32 years compared with 49 years, P<.001), with lower parity (mean 0.05 pregnancies compared with 1.34 pregnancies, median 0 pregnancies compared with 1 pregnancy, P<.001), yet had similar body mass index and height. Transsexuals' surgeries had shorter operating times (mean 74 minutes compared with 120 minutes, median 57.5 minutes compared with 116 minutes, P<.001), with less blood loss (mean 27 mL compared with 107 mL, median 20 mL compared with 50 mL, P<.001) and lower uterine weight (mean 118 g compared with 167 g, median 89 g compared with 140.5 g, P<.001). The total complication rates (12.2% compared with 8.3%), as well as the reoperative complication rates (4.9% compared with 4.3%) were not significantly different. CONCLUSION: Total laparoscopic hysterectomy offers appropriate surgical outcomes for those patients identifying themselves as transsexual.

Total laparoscopic hysterectomy: technique and complications of 830 cases.

OBJECTIVE: This study analyses the technique and complications from total laparoscopic hysterectomy. METHODS: Retrospective chart abstraction was performed on 830 consecutive patients operated on between 1996 and 2006. Demographic and surgical data were analyzed by ANOVA, chi-square, and Spearman and Pearson correlation techniques were used with significance set at P<0.05. RESULTS: Of 830 consecutive patients, 5 (0.6%) were converted to laparotomy. Patients had a mean age of 50 (+/-11) years, a mean of 1.3 (+/-1.3) pregnancies, and a mean BMI of 27.6 (+/-6.8) kg/m(2). The mean surgical duration was 132 (+/-55) minutes, with mean blood loss of 130 (+/-189) mL and average hospital stay of 1.4 (+/-0.9) days. Duration of surgery, blood loss, and hospital stay all decreased with the surgeon's increasing experience. Reoperative complications occurred in 38 patients (4.7%). Urologic injuries were observed in 23 patients (2.6%), with 9 (1.1%) requiring reoperation. CONCLUSIONS: This technique for TLH offers the benefits of minimally invasive surgery for patients needing hysterectomy, even those without vaginal capacity and uterine prolapse.

Total laparoscopic hysterectomy with and without lymph node dissection for uterine neoplasia.

STUDY OBJECTIVE: To compare surgical outcomes of patients with uterine neoplasia undergoing total laparoscopic hysterectomy only (TLH) with those having TLH and lymph node dissection (TLHND) from September 5, 1996 through January 13, 2007. DESIGN: Retrospective chart analysis (Canadian Task Force classification II-2). SETTING: Three tertiary surgical centers in California. PATIENTS: 112 patients with uterine neoplasia operated on from 1996 through 2006. INTERVENTIONS: All patients underwent total laparoscopic hysterectomy and bilateral salpingoophorectomy; however, 30 patients with FIGO stage IC or higher, lymph channel involvement, or grade 3 disease also underwent pelvic and aortic node dissection. MEASUREMENTS AND MAIN RESULTS: Of 807 patients having TLH, 112 had a uterine neoplasia: twenty-one hyperplasia, 86 carcinoma, 2 ovarian and endometrial carcinoma, and 3 low-grade endometrial stromal sarcoma; 82 had TLH and adnexectomy; and 30 had TLHND. For both groups, the mean age was 60 (NS), Quatlet index was 31.2 (NS), parity was 1.6 (NS), and the mean blood loss was 148 mL (NS). The node dissection added 56 minutes to TLH (132 vs 188 minutes, p <.001) and yielded a mean of 25 nodes. Patients in both groups spent a median of 1 day in the hospital (NS). There were 7 complications (6.3%) in the series: among the patients in the TLH group, 1 conversion to laparotomy for bleeding from an ovarian artery, 1 vaginal rupture during coitus at 6 weeks, and 1 nonsurgical episode of diverticulitis. There were 4 patients in the TLHLND group with complications: 1 ureteral injury, 1 trocar-site hernia, 1 vaginal laceration, and 1 pelvic abscess. CONCLUSIONS: Node dissection added 56 minutes and entailed no additional blood loss, transfusion, or length of hospital stay, as well as minimal risk of complication. Total laparoscopic hysterectomy with indicated lymph node dissections for endometrial disease is reasonably well tolerated and warrants prospective randomized study to document its role in the therapy of endometrial carcinoma.

Cystoscopy with a 5-mm laparoscope and suction irrigator.

To investigate the hypothesis that cystoscopy using a 5-mm suction irrigator and video laparoscope is safe and useful during total laparoscopic hysterectomy (TLH), a retrospective analysis of patients undergoing total or radical laparoscopic hysterectomy over a 10-year period was conducted. Of 744 patients having simple or radical laparoscopic hysterectomy for either benign or malignant indications, 344 had cystoscopy using a 5-mm laparoscope after inflating the bladder with a 5-mm saline suction irrigator. Procedures in which cystoscopy was used took 13 minutes longer (mean: 141 vs 128, p = .0012) and patients lost 30 dL more blood (mean 145 vs 115, p = .0300), but patients did not have a longer hospital stay or more complications. Cystoscopy accurately confirmed cystotomy closure in 12 patients and identified 3 patients with ureteral injury; it did not identify 3 patients who developed a ureteral fistula 7 to 9 days after surgery. One complication was attributable to the cystoscopy. The data from this retrospective series suggest that cystoscopy during TLH is well-tolerated and can accurately reassure surgeons of immediate urologic tract integrity; but it is not useful to identify patients who may later fistulize.

257 incidental appendectomies during total laparoscopic hysterectomy.

OBJECTIVE: This retrospective observational report analyzes the demographics, blood loss, length of surgical duration, number of days in the hospital, and complications for 821 consecutive patients undergoing total laparoscopic hysterectomy over a 11-year period stratified by incidental appendectomy. METHODS: A retrospective chart abstraction was performed. ANOVA and chi-square tests were performed with significance preset at P<0.05. RESULTS: Of 821 consecutive patients undergoing total laparoscopic hysterectomy, 257 underwent elective appendectomy with the ultrasonic scalpel, either as part of their staging, treatment for pelvic pain, or prophylaxis against appendicitis. Comparing the 2 groups, no difference existed in mean age of 50+/-10 years or mean BMI of 27.6+/-6.7. Both groups had a similar mean blood loss of 130 mL. Surgery took less time (137 vs 118 minutes, P<0.0012) and the hospital stay was shorter in the appendectomy group (1.5 vs 1.2, P<0.0001) possibly because it was performed incidentally in most cases. No complications were attributable to the appendectomy, and complication types and rates in both groups were similar. Though all appendicies appeared normal, pathology was documented in 9%, including 3 carcinoid tumors. CONCLUSIONS: Incidental appendectomy during total laparoscopic hysterectomy is not associated with significant risk and can be routinely offered to patients planning elective gynecologic laparoscopic procedures, as is standard for open procedures.

Total laparoscopic hysterectomy for uterine pathology: impact of body mass index on outcomes.

OBJECTIVE: We sought to analyze surgical results of women with uterine cancers having TLH+/-staging, stratifying data by body mass index (BMI). METHODS: This is a retrospective analysis of data from 9 years, using Pearson and Spearman correlations, ANOVA and Fisher's Exact Test with significance at P<0.05, stratifying by BMI (kg/m2): underweight (<18.5 kg/m2), ideal (18.5-24.9 kg/m2), overweight (25 to 29.9 kg/m2), obese (30 to 39.9 kg/m2) and morbidly obese (40 kg/m2 or more). RESULTS: Of 702 patients having TLH over 9 years, 90 patients had uterine pathology. Two (2%) procedures were converted to laparotomy due to unsuspected widespread metastasis and excluded from analysis. BMI ranged from 18 to 60 kg/m2, with 31 patients having ideal, 19 having overweight and 38 having obese BMI. Of these, 19 patients had hyperplasia, while 63 had endometrial carcinoma, 1 had both ovarian and endometrial carcinoma and 5 had sarcoma. Of these 88 patients, 61 had TLH while 27 patients had indicated pelvic and aortic node dissection. The mean age was 60 years, and mean parity was 1.5 for all BMI groups. There were no significant differences in mean duration of surgery (150 min), blood loss (129 cm3) and days in hospital (1.7 days) for all BMI groups. There was no significant difference in uterine weight (140 gm) or number of nodes dissected (21 nodes). Complications occurred in 4 patients (4.5%): 1 diverticulitis, 1 ureteral injury, 1 laparotomy for bleeding and 1 incisional hernia. CONCLUSIONS: Total laparoscopic hysterectomy is feasible and safe for women with uterine neoplasia for every BMI category and extends the benefits of minimally invasive hysterectomy to more women, regardless of BMI.

Health policy considerations for our sexual minority patients.

Homosexuality and transsexuality are still widely viewed by lay individuals as morally negative and deserving of legal proscription. Peer-reviewed data confirm that experiences of legal discrimination are associated with stress-related health problems, reduced utilization of health care, and financial and legal challenges for individuals and families, especially those with children. In the last 3 years, the American Psychiatric Association, American Psychological Association, and American Psychoanalytic Association have each reviewed the research on sexual orientation and identity, and each has confirmed that sexual orientation and gender identity do not correlate with mental illness or immorality. They have each endorsed laws that confer equality to sexual minorities, including nondiscrimination in employment, medical insurance coverage, adoption, and access to civil marriage. The American College of Obstetricians and Gynecologists (ACOG), by virtue of its history of advocacy for women's health, is in a position to promote policy and make similar recommendations, recognizing that sexual minority women's health and their family issues are an integral component of taking care of all women. The College should review the policies of America's premier mental health associations and consider including sexual orientation and gender identity in its own nondiscrimination policy, and ACOG should issue a policy statement in support of laws to provide safety from violence and discrimination, equal employment opportunities, equal health insurance coverage, and equal access to civil marriage.

Total laparoscopic hysterectomy versus total abdominal hysterectomy: cohort review of patients with uterine neoplasia.

OBJECTIVE: Retrospective analysis of surgico-pathologic data comparing total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH) patients with uterine neoplasia. METHODS: We conducted a chart abstraction of all patients undergoing hysterectomy for uterine neoplasia from September 1996 to November 2004. Patients were assigned to undergo the abdominal or laparoscopic approach based on established clinical safety criteria. RESULTS: The study included 105 patients, 29 with TAH and 76 with TLH. TAH patients were older (68 vs. 61, P=0.021); however, both groups had similar body mass indexes (31) and parities (1.6). Controlling for age, surgical duration was similar (152 minutes). Average blood loss was higher for TAH, (504 vs. 138 mL, P<0.001). Hospital stays were significantly longer for patients with TAH than for those with TLH (5.4 vs. 1.8 days, P<0.0001). Uterine weight was greater (197 vs. 135 g, P=0.008) and myometrial invasion deeper in the TAH group (48% outer half vs. 17%, P=0.001). More patients had Stage II or higher disease in the TAH group (35% vs. 17%, P=0.038). More TAH patients needed node dissection (79% vs. 28%, P<.001). Node yields from dissections of 23 TAH cases and 21 laparoscopic cases were similar (17 nodes). Total and reoperative complications from TAH versus TLH were not statistically different in our small sample (14.3 vs. 5.2% total, NS; 10.3 vs. 2.6% reoperative). One conversion was necessary from laparoscopy to laparotomy for unsuspected bulky metastatic disease. CONCLUSION: Based on clinical selection criteria, TLH performed for endometrial pathology has few complications and is well tolerated by select patients. The advantages are less blood loss and a shorter length of hospital stay for qualified patients.