Laparoscopic hysterectomy. Supracervical vs. assisted vaginal.

Twenty cases of laparoscopic supracervical hysterectomy performed by operative laparoscopy without vaginal assistance were retrospectively compared to 232 cases of laparoscopically assisted vaginal hysterectomy reported in the literature. The specimens were morcellated intraabdominally and removed through the umbilicus. This is the first reported series of this technique with intraabdominal morcellation, which emphasizes cosmetic considerations and remains within the confines of the umbilicus. The postoperative hospitalization time ranged from 3.75 to 22.2 hours. On the second postoperative day, 10% of the patients returned to work, and 15% were able to drive. Patients resumed normal activity in an average of 5.6 days after surgery. As compared to laparoscopically assisted vaginal hysterectomy, there was a decrease in morbidity, blood loss and recovery time. Prolonged anesthesia from the longer operating time was clinically insignificant in terms of the patients' recovery. By decreasing the disability from hysterectomy from six weeks to one, the procedure provided financial savings through work time gained.

PIP: A physician compared data on 20 women, 25-60 years old, who underwent laparoscopic supracervical hysterectomy (LSH) without vaginal assistance at HCA West Paces Medical Center in Atlanta, Georgia, between December 1991 and June 1992 with 232 cases reported in the literature of laparoscopically assisted vaginal hysterectomy (LAVH) with both vaginal and laparoscopic components. For the LSH, the uterus was morcellated intraabdominally and the pieces removed through the navel. Among LSH patients, the mean postoperative hospitalization time was almost 14 hours (range, 3.75-22.2 hours). It took an average of only 5.6 days after LSH to return to work or resume normal activity. Two women (10%) returned to work 2 days after the operation. Three women (15%) were able to drive 2 days after. Compared to LAVH patients, LSH patients experienced lower hospitalization (0.58 vs. 1.18-4.4 days), less blood loss (40 vs. 115.85 ml), less recovery time (5.6 vs. 7-35 days), and quicker return to normal sexual activity (10.2 vs 21 days) than did LAVH patients. The prolonged anesthesia associated with the longer operating time with LSH was not clinically significant in terms of patients' recovery. Even though hospital costs are higher with LSH than with total abdominal hysterectomy, LSH reduces the disability from hysterectomy from 6 weeks to 1 week, therefore providing financial savings through work time gained.

Complications of laparoscopic hysterectomy.

OBJECTIVE: To evaluate complications of laparoscopic hysterectomy. METHODS: A retrospective analysis of complications was tabulated from hospital and office records. Forty-five consecutive patients had laparoscopic hysterectomies from November 1991 to November 1992. Complications were divided into operative, anesthetic, postoperative, nursing, and equipment. Each complication was subjectively graded from mild to severe. RESULTS: Complication rates by group were: operative 11%, anesthetic 7%, postoperative 16%, nursing 4%, and equipment 56%. Operative complications included one bladder perforation, two superficial epigastric artery perforations, and two subcutaneous emphysema cases. There were three anesthetic complications from fluid overload. Postoperative complications included four patients with periumbilical cellulitis. Three patients, who had laparoscopic supracervical hysterectomies, continued to menstruate. Nursing complications included two transient nerve injuries, one femoral and one peroneal. Equipment complications had the highest incidence; the most common type was bipolar cautery dysfunction (22 of 45). There were two video difficulties and one lost laser tip. There were no cases of death, postoperative ileus, fever, thrombophlebitis, transfusions, urinary tract infections, urinary atony, pneumonia, bowel injuries, ureteral injuries, or atelectasis. All patients were treated as outpatients, and no one was admitted or readmitted. Ninety-eight percent of the complications were mild to moderate, with only 2% (one of 45) severe. CONCLUSION: Overall complication rates are high after laparoscopic hysterectomy, even though the complications are predominantly mild to moderate in severity.

Laparoscopic salpingectomy for ectopic pregnancy.

In selective cases operative laparoscopic salpingectomy is an alternative to laparotomy in the surgical treatment of ectopic pregnancy. The obvious advantages of this procedure are decreased morbidity and surgical pain, lower cost, shorter hospitalization and convalescence, and less disability, as well as a cosmetic surgical scar. Because the procedure is so cost-effective, and since the tools are familiar to most gynecologists, we hope it will gain wider utilization. Laparoscopic salpingectomy is not a difficult procedure when the basic principles of surgery are followed. Depending on the fertility desires of the patient and the condition of the opposite tube, this procedure may be preferable to laparotomy. If a complication such as bleeding does occur and fails to respond to cauterization, laparotomy can be done as usual for an ectopic pregnancy.

beta-hCG as a diagnostic aid for suspected ectopic pregnancy.

During 13 months from November 1, 1977, through November 30, 1978, 283 patients underwent radioimmunoassay (RIA) for determination of serum beta-subunit of human chorionic gonadotropin (beta-hCG) to rule out ectopic pregnancy. The records of 234 patients were available for statistical analysis and of these, 188 (80%) had negative results, defined as less than 1 ng/ml. The ectopic group comprised 22 patients, all of whom had elevated beta-hCG levels. There were no false-negative results in either group. Patients with suspected ectopic pregnancy had symptoms similar to patients previously reported in the literature with proved ectopic pregnancies. The most common presenting symptoms of those with suspected ectopic pregnancy were abdominal pain (91%), amenorrhea (76%), irregular bleeding (68%), and andexal mass (55%). Seventy-three patients presented with the classic triad of pain, uterine bleeding, and adnexal mass. Only 10 (14%) had ectopic pregnancies. Urine pregnancy tests were found to be of no benefit in diagnosing ectopic pregnancy and confused the clinicians in some instances. In patients with suspected ectopic pregnancy, a negative beta-hCG, by the RIA technique ruled out ectopic pregnancy in 100% of the cases.