bs_bs_banner
doi:10.1111/jog.12489
J. Obstet. Gynaecol. Res. Vol. 41, No. 1: 114–119, January 2015
Effects of patient position on lower extremity venous pressure during different types of hysterectomy Xiaoxia Liu1,2, Xiaohong Wang1, Xianhua Meng1, Hongping Wang1 and Zengshun An3 Departments of 1Obstetrics and Gynecology and 3Anesthesiology, Laiwu People’s Hospital, Laiwu, and 2Department of Obstetrics and Gynecology, Clinical Medicine Academy of Taishan Medical University, Taian, China
Abstract Aim: To explore the effects of different types of hysterectomy on lower extremity venous pressure. Methods: Ninety-nine patients with benign uterine diseases who were indicated for hysterectomy were included in the present prospective study. Patients were divided into three groups according to their preferences: (i) total laparoscopic hysterectomy (TLH) group (n = 36); (ii) transvaginal hysterectomy (TVH) group (n = 32); and (iii) transabdominal hysterectomy (TAH) group (n = 31). Lower extremity venous pressure was monitored using a pressure sensor during the surgery. Results: Compared with the supine position (TAH group, lower extremity venous pressure of intraoperative 16.50 cmH2O), lower extremity venous pressure of the improved lithotomy position (TLH group, lower extremity venous pressure of intraoperative 53.27 cmH2O) and conventional lithotomy position (TVH group, lower extremity venous pressure of intraoperative 42.09 cmH2O) were significantly increased (P < 0.01).Venous pressure was reduced when patients lowered their heads by 15° or 5° in modified or conventional lithotomy positions, respectively (P < 0.01). Venous pressure was increased significantly after the establishment of pneumoperitoneum in the TLH group (P < 0.01). Conclusion: Modified lithotomy position (TLH group) and conventional lithotomy position (TVH group) and CO2 pneumoperitoneum may result in increased lower extremity venous pressure during hysterectomy. Furthermore, elevated venous pressure can be altered by changing the intraoperative position. Specifically, intraoperative positioning of the lower extremities represents a modifiable risk factor for deep venous thrombosis. Key words: operation position, pneumoperitoneum, total hysterectomy, venous pressure, venous stasis.
Introduction Hysterectomy is one of the most common clinical operations. According to statistics, there are approximately 4 million cases of hysterectomy performed in Chinese women every year, accounting for more than half of the operations for gynecological benign diseases. The common modes of operation are transvaginal hysterectomy (TVH), total laparoscopic hyster-
ectomy (TLH) and transabdominal hysterectomy (TAH), representing a tripartite confrontation trend. Different types of hysterectomies are performed with different surgical positions, which each have different effects on lower limb venous flow forces. One study found that the reverse Trendelenburg position can induce venous stasis,1 while Kohro et al.2 reported that venous flow was decreased by 38% by moving to the conventional lithotomy position from the supine
Received: November 27 2013. Accepted: April 25 2014. Reprint request to: Dr Xiaohong Wang, Department of Obstetrics and Gynecology, Laiwu People’s Hospital, Laiwu, Shandong 271100, China. Email: [email protected]
114
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Position and lower extremity venous pressure
position. Wang et al.3 confirmed that the velocity and amount of blood flow decreased in the feet-down tilt position. Studies in total hip arthroplasty patients demonstrate that intraoperative manipulation of the lower extremity, including flexion, adduction and internal rotation at the hip, can kink and occlude the femoral vein.4–6 The formation of CO2 pneumoperitoneum during laparoscopic surgery is transmitted to the retroperitoneum, inferior caval vein and iliac veins, leading to slower flow in veins of the lower extremities. Increased chest pressure also has been observed, which could affect cardiac filling, thus in turn impeding venous flow, inducing venous stasis, and activating coagulation and fibrinolysis.7–9 Carbon dioxide pneumoperitoneum or the position itself are an independent risk factors for venous stasis.10 However, in order to provide excellent vision during surgery and a convenient field for operation, use of CO2 pneumoperitoneum and position changes are always required. Lithotomy position is needed in TLH and TVH, but not in TAH. In conventional and improved lithotomy positions, there is hip and knee flexion, with dropping of lower leg and, under anesthesia, the extruding effect of skeletal muscle was reduced. Thus, by the effect of flow gravity, the blood in lower extremity venous had stasis, and venous dilation increased pressure and slow reflux.11,12 Three major factors contributing to the formation of deep vein thrombus (DVT) after operation include stagnant venous blood flow, injuries of the venous walls and a hypercoagulative state.13 Between 75% and 96% of venous thromboembolism (VTE) patients have at least one of these risk factors.14 We hypothesized that intraoperative venous pressure may vary with postural and venous stasis differences. In order to test our hypothesis, patients with benign uterine disease were studied from July 2011 to July 2012 in Laiwu People’s Hospital. The results of the present study will provide evidence for the optimization of intraoperative position, and will improve the degree of lower extremity venous stasis.
Methods This study was approved by the Ethics Committee of Laiwu People’s Hospital. All patients provided written informed consent. Ninety-nine patients with benign uterine diseases (e.g. hysteromyoma and adenomyosis) were included in this prospective study. According to their wishes, the patients were randomly divided into three groups: (i) TLH group (n = 36); (ii) TVH
group (n = 32); and (iii) TAH group (n = 31). All patients received examinations including blood routine, blood coagulation function, D-dimers, liver function, renal function, blood glucose, urine routine, chest radiograph, electrocardiogram and double lower limb venous ultrasonography. Study inclusion criteria were: females between 45 and 55 years of age with the ability to provide informed consent; a uterus of less than 12 weeks’ gestational size; no fertility requirement; without uterine prolapse or bulge of paries anterior/posterior vaginas; and able to tolerate TAH, TLH or TVH. A patient was excluded if she met one of the following criteria: hypertension, diabetes, coronary heart disease, hypercoagulability, malignancy, edema or motor dysfunction on lower extremities, and conversion to laparotomy. Final diagnoses were based on pathological results and all patients had benign uterine diseases, with no patients needing to be excluded because of malignant disease. All surgeries were conducted by at least two senior doctors and several other doctors. Total laparoscopic hysterectomy was conducted according to the methods provided by Li et al.15 Briefly, for patients in the modified lithotomy position, the angle between thigh and operation table was 10°, the angle between thigh and long axis of the calf was 120°, the angle between thighs was 100°, hips were approximately 2–3 cm above the operation table, with a cushion between the operation table and hips. Pressure of CO2 pneumoperitoneum was 14 mmHg. TVH and TAH were conducted according to the methods provided by Liu et al.16 Conventional lithotomy position was used in TVH in which the position of both of the angles between the thigh and long axis of the body or calf were 100°, the angle between the thighs was 80°, hips were approximately 2–3 cm above the operation table, with a cushion between the operation table and hips. The supine position was used in TAH group. As the positions in TLH, TVH and TAH were different, the time points for lower extremity venous pressure measurement during the operation were chosen based on the changes in position and pneumoperitoneum during TLH. Thus, in the present study, the results of lower extremity venous pressure at different time points during the operation represented the venous pressure after position and pneumoperitoneum change. The positions at different operation time points are shown in Table 1. Changes in the pressure of great saphenous veins on the left lower extremity were determined as follows. Venipuncture was performed in medial malleolus
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
115
X. Liu et al.
Table 1 Positions corresponding to the operation time
TLH TVH TAH
5 min BA
5 min AA
TSS
IP 5 min
IP 10 min
IP 45 min
TETS
PS 5 min
SPt SPt SPt
SPt SPt SPt
MLP CLP SPt
MLP + C P CLPLTH5° SPt
MLPLTH15° + C P CLPLTH5° SPt
MLPLTH15° + C P CLPLTH5° SPt
MLPLTH15° CLPLTH5° SPt
SPt SPt SPt
5 min AA, 5 min after anesthesia; 5 min BA, 5 min before anesthesia; C P, CO2 pneumoperitoneum; CLP, conventional lithotomy position; CLPLTH5°, conventional lithotomy position lowered their heads by 5°; IP 10 min, intraoperative 10 min ; IP 45 min, intraoperative 45 min; IP 5 min, intraoperative 5 min; MLP, modified lithotomy position; MLPLTH15°, modified lithotomy position lowered their heads by 15°; PS 5 min, postoperative supine 5 min; SPt, supine position; TETS, the end of the surgery; TSS, the start of surgery.
Table 2 Clinical data of 99 cases patients (±SD) TLH (n = 36) TVH (n = 32) TAH (n = 31) F, between groups P, between groups
Age
BMI
OT
SP
DP
48.50 ± 3.02 48.78 ± 3.30 48.23 ± 2.78 0.263 0.77
23.47 ± 2.40 23.53 ± 2.20 23.61 ± 2.21 0.031 0.970
89.14 ± 11.68 87.88 ± 10.92 94.00 ± 8.52 2.98 0.056
116.21 ± 5.65 112.98 ± 5.09 115.02 ± 6.13 2.82 0.0645
79.19 ± 7.59 82.88 ± 7.92 83.06 ± 8.52 2.56 0.0824
BMI, body mass index; DP, diastolic pressure; OT, operating time SP, systolic pressure.
veins using a 20-G i.v. needle with the cannula remaining in the vein. A pressure sensor with a resistance chip planted at the internal malleolus at the same horizontal position with the venipuncture site was connected to an electrocardiogram (ECG) monitor and adjusted to zero. The patient was then administrated general anesthetic and data on vein pressure was directly read from the ECG monitor and recorded at different time point to provide a real-time monitoring of vein pressure until the operation was completed. All statistical analysis was performed using SPSS version 13.0 software package. Quantitative data were expressed as mean ± standard deviation. One-way anova was performed between the groups at the same time point, and a Student’s paired-sample t-test was performed in each group. From the beginning to 45 min of the operation, two-way repeated-measures anova was performed in the three groups. P < 0.05 was considered statistically significant.
Results The study included 99 patients who met the inclusion criteria. The mean age of the patients was 48.49 ± 3.02 years. Statistical analysis showed no significant difference in age, body mass index, operation time or blood pressure among the three groups (Table 2). None of the patients had symptoms of DVT, lower extremity varicosis, valve insufficiency of lower extremity veins, or edema.
116
Lower extremity venous pressure differed between the groups as the positions during the operations were different. Statistical analysis showed that the relative group venous pressure was as follows: TLH (modified lithotomy position) > TVH (conventional lithotomy position) > TAH (supine position) (P < 0.01). Two-way repeated-measures anova were used to compare the venous pressures between the groups at four time points (at the start of the operation and intraoperative 5, 10 and 45 min), and the results showed that at all four time points the TLH group had the highest venous pressure, while the TAH group had the lowest venous pressure (P < 0.01). For patients in the TLH or TVH groups, moving to the conventional or modified lithotomy position from the supine position resulted in an increase in lower extremity venous pressure. Ten minutes after TLH, when the patients in the modified lithotomy position lowered their heads by 15°, their venous pressure decreased significantly as compared with 5 min after the surgery (P < 0.01). Similar results were also found in the TVH group where venous pressure decreased from 46.15 ± 3.26 cmH2O before the position change to 40.56 ± 3.92 cmH2O when the patients lowered their heads by 5° (P < 0.01). Furthermore, the venous pressure in the TLH or TVH group were lower at the end of the surgery, as compared with the pressure at 10 and 45 min intraoperatively, and the differences were statistically significant between the results of each time point (P < 0.05). However, the venous pressures at the
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
47.33 ± 4.83 38.03 ± 353# 14.16 ± 3.79 562.812
doi:10.1111/jog.12489
J. Obstet. Gynaecol. Res. Vol. 41, No. 1: 114–119, January 2015
Effects of patient position on lower extremity venous pressure during different types of hysterectomy Xiaoxia Liu1,2, Xiaohong Wang1, Xianhua Meng1, Hongping Wang1 and Zengshun An3 Departments of 1Obstetrics and Gynecology and 3Anesthesiology, Laiwu People’s Hospital, Laiwu, and 2Department of Obstetrics and Gynecology, Clinical Medicine Academy of Taishan Medical University, Taian, China
Abstract Aim: To explore the effects of different types of hysterectomy on lower extremity venous pressure. Methods: Ninety-nine patients with benign uterine diseases who were indicated for hysterectomy were included in the present prospective study. Patients were divided into three groups according to their preferences: (i) total laparoscopic hysterectomy (TLH) group (n = 36); (ii) transvaginal hysterectomy (TVH) group (n = 32); and (iii) transabdominal hysterectomy (TAH) group (n = 31). Lower extremity venous pressure was monitored using a pressure sensor during the surgery. Results: Compared with the supine position (TAH group, lower extremity venous pressure of intraoperative 16.50 cmH2O), lower extremity venous pressure of the improved lithotomy position (TLH group, lower extremity venous pressure of intraoperative 53.27 cmH2O) and conventional lithotomy position (TVH group, lower extremity venous pressure of intraoperative 42.09 cmH2O) were significantly increased (P < 0.01).Venous pressure was reduced when patients lowered their heads by 15° or 5° in modified or conventional lithotomy positions, respectively (P < 0.01). Venous pressure was increased significantly after the establishment of pneumoperitoneum in the TLH group (P < 0.01). Conclusion: Modified lithotomy position (TLH group) and conventional lithotomy position (TVH group) and CO2 pneumoperitoneum may result in increased lower extremity venous pressure during hysterectomy. Furthermore, elevated venous pressure can be altered by changing the intraoperative position. Specifically, intraoperative positioning of the lower extremities represents a modifiable risk factor for deep venous thrombosis. Key words: operation position, pneumoperitoneum, total hysterectomy, venous pressure, venous stasis.
Introduction Hysterectomy is one of the most common clinical operations. According to statistics, there are approximately 4 million cases of hysterectomy performed in Chinese women every year, accounting for more than half of the operations for gynecological benign diseases. The common modes of operation are transvaginal hysterectomy (TVH), total laparoscopic hyster-
ectomy (TLH) and transabdominal hysterectomy (TAH), representing a tripartite confrontation trend. Different types of hysterectomies are performed with different surgical positions, which each have different effects on lower limb venous flow forces. One study found that the reverse Trendelenburg position can induce venous stasis,1 while Kohro et al.2 reported that venous flow was decreased by 38% by moving to the conventional lithotomy position from the supine
Received: November 27 2013. Accepted: April 25 2014. Reprint request to: Dr Xiaohong Wang, Department of Obstetrics and Gynecology, Laiwu People’s Hospital, Laiwu, Shandong 271100, China. Email: [email protected]
114
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Position and lower extremity venous pressure
position. Wang et al.3 confirmed that the velocity and amount of blood flow decreased in the feet-down tilt position. Studies in total hip arthroplasty patients demonstrate that intraoperative manipulation of the lower extremity, including flexion, adduction and internal rotation at the hip, can kink and occlude the femoral vein.4–6 The formation of CO2 pneumoperitoneum during laparoscopic surgery is transmitted to the retroperitoneum, inferior caval vein and iliac veins, leading to slower flow in veins of the lower extremities. Increased chest pressure also has been observed, which could affect cardiac filling, thus in turn impeding venous flow, inducing venous stasis, and activating coagulation and fibrinolysis.7–9 Carbon dioxide pneumoperitoneum or the position itself are an independent risk factors for venous stasis.10 However, in order to provide excellent vision during surgery and a convenient field for operation, use of CO2 pneumoperitoneum and position changes are always required. Lithotomy position is needed in TLH and TVH, but not in TAH. In conventional and improved lithotomy positions, there is hip and knee flexion, with dropping of lower leg and, under anesthesia, the extruding effect of skeletal muscle was reduced. Thus, by the effect of flow gravity, the blood in lower extremity venous had stasis, and venous dilation increased pressure and slow reflux.11,12 Three major factors contributing to the formation of deep vein thrombus (DVT) after operation include stagnant venous blood flow, injuries of the venous walls and a hypercoagulative state.13 Between 75% and 96% of venous thromboembolism (VTE) patients have at least one of these risk factors.14 We hypothesized that intraoperative venous pressure may vary with postural and venous stasis differences. In order to test our hypothesis, patients with benign uterine disease were studied from July 2011 to July 2012 in Laiwu People’s Hospital. The results of the present study will provide evidence for the optimization of intraoperative position, and will improve the degree of lower extremity venous stasis.
Methods This study was approved by the Ethics Committee of Laiwu People’s Hospital. All patients provided written informed consent. Ninety-nine patients with benign uterine diseases (e.g. hysteromyoma and adenomyosis) were included in this prospective study. According to their wishes, the patients were randomly divided into three groups: (i) TLH group (n = 36); (ii) TVH
group (n = 32); and (iii) TAH group (n = 31). All patients received examinations including blood routine, blood coagulation function, D-dimers, liver function, renal function, blood glucose, urine routine, chest radiograph, electrocardiogram and double lower limb venous ultrasonography. Study inclusion criteria were: females between 45 and 55 years of age with the ability to provide informed consent; a uterus of less than 12 weeks’ gestational size; no fertility requirement; without uterine prolapse or bulge of paries anterior/posterior vaginas; and able to tolerate TAH, TLH or TVH. A patient was excluded if she met one of the following criteria: hypertension, diabetes, coronary heart disease, hypercoagulability, malignancy, edema or motor dysfunction on lower extremities, and conversion to laparotomy. Final diagnoses were based on pathological results and all patients had benign uterine diseases, with no patients needing to be excluded because of malignant disease. All surgeries were conducted by at least two senior doctors and several other doctors. Total laparoscopic hysterectomy was conducted according to the methods provided by Li et al.15 Briefly, for patients in the modified lithotomy position, the angle between thigh and operation table was 10°, the angle between thigh and long axis of the calf was 120°, the angle between thighs was 100°, hips were approximately 2–3 cm above the operation table, with a cushion between the operation table and hips. Pressure of CO2 pneumoperitoneum was 14 mmHg. TVH and TAH were conducted according to the methods provided by Liu et al.16 Conventional lithotomy position was used in TVH in which the position of both of the angles between the thigh and long axis of the body or calf were 100°, the angle between the thighs was 80°, hips were approximately 2–3 cm above the operation table, with a cushion between the operation table and hips. The supine position was used in TAH group. As the positions in TLH, TVH and TAH were different, the time points for lower extremity venous pressure measurement during the operation were chosen based on the changes in position and pneumoperitoneum during TLH. Thus, in the present study, the results of lower extremity venous pressure at different time points during the operation represented the venous pressure after position and pneumoperitoneum change. The positions at different operation time points are shown in Table 1. Changes in the pressure of great saphenous veins on the left lower extremity were determined as follows. Venipuncture was performed in medial malleolus
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
115
X. Liu et al.
Table 1 Positions corresponding to the operation time
TLH TVH TAH
5 min BA
5 min AA
TSS
IP 5 min
IP 10 min
IP 45 min
TETS
PS 5 min
SPt SPt SPt
SPt SPt SPt
MLP CLP SPt
MLP + C P CLPLTH5° SPt
MLPLTH15° + C P CLPLTH5° SPt
MLPLTH15° + C P CLPLTH5° SPt
MLPLTH15° CLPLTH5° SPt
SPt SPt SPt
5 min AA, 5 min after anesthesia; 5 min BA, 5 min before anesthesia; C P, CO2 pneumoperitoneum; CLP, conventional lithotomy position; CLPLTH5°, conventional lithotomy position lowered their heads by 5°; IP 10 min, intraoperative 10 min ; IP 45 min, intraoperative 45 min; IP 5 min, intraoperative 5 min; MLP, modified lithotomy position; MLPLTH15°, modified lithotomy position lowered their heads by 15°; PS 5 min, postoperative supine 5 min; SPt, supine position; TETS, the end of the surgery; TSS, the start of surgery.
Table 2 Clinical data of 99 cases patients (±SD) TLH (n = 36) TVH (n = 32) TAH (n = 31) F, between groups P, between groups
Age
BMI
OT
SP
DP
48.50 ± 3.02 48.78 ± 3.30 48.23 ± 2.78 0.263 0.77
23.47 ± 2.40 23.53 ± 2.20 23.61 ± 2.21 0.031 0.970
89.14 ± 11.68 87.88 ± 10.92 94.00 ± 8.52 2.98 0.056
116.21 ± 5.65 112.98 ± 5.09 115.02 ± 6.13 2.82 0.0645
79.19 ± 7.59 82.88 ± 7.92 83.06 ± 8.52 2.56 0.0824
BMI, body mass index; DP, diastolic pressure; OT, operating time SP, systolic pressure.
veins using a 20-G i.v. needle with the cannula remaining in the vein. A pressure sensor with a resistance chip planted at the internal malleolus at the same horizontal position with the venipuncture site was connected to an electrocardiogram (ECG) monitor and adjusted to zero. The patient was then administrated general anesthetic and data on vein pressure was directly read from the ECG monitor and recorded at different time point to provide a real-time monitoring of vein pressure until the operation was completed. All statistical analysis was performed using SPSS version 13.0 software package. Quantitative data were expressed as mean ± standard deviation. One-way anova was performed between the groups at the same time point, and a Student’s paired-sample t-test was performed in each group. From the beginning to 45 min of the operation, two-way repeated-measures anova was performed in the three groups. P < 0.05 was considered statistically significant.
Results The study included 99 patients who met the inclusion criteria. The mean age of the patients was 48.49 ± 3.02 years. Statistical analysis showed no significant difference in age, body mass index, operation time or blood pressure among the three groups (Table 2). None of the patients had symptoms of DVT, lower extremity varicosis, valve insufficiency of lower extremity veins, or edema.
116
Lower extremity venous pressure differed between the groups as the positions during the operations were different. Statistical analysis showed that the relative group venous pressure was as follows: TLH (modified lithotomy position) > TVH (conventional lithotomy position) > TAH (supine position) (P < 0.01). Two-way repeated-measures anova were used to compare the venous pressures between the groups at four time points (at the start of the operation and intraoperative 5, 10 and 45 min), and the results showed that at all four time points the TLH group had the highest venous pressure, while the TAH group had the lowest venous pressure (P < 0.01). For patients in the TLH or TVH groups, moving to the conventional or modified lithotomy position from the supine position resulted in an increase in lower extremity venous pressure. Ten minutes after TLH, when the patients in the modified lithotomy position lowered their heads by 15°, their venous pressure decreased significantly as compared with 5 min after the surgery (P < 0.01). Similar results were also found in the TVH group where venous pressure decreased from 46.15 ± 3.26 cmH2O before the position change to 40.56 ± 3.92 cmH2O when the patients lowered their heads by 5° (P < 0.01). Furthermore, the venous pressure in the TLH or TVH group were lower at the end of the surgery, as compared with the pressure at 10 and 45 min intraoperatively, and the differences were statistically significant between the results of each time point (P < 0.05). However, the venous pressures at the
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
47.33 ± 4.83 38.03 ± 353# 14.16 ± 3.79 562.812
