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Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Laparoscopic hysterectomy in large uteri: Experience from a tertiary care hospital in Bangladesh Samsad Jahan,1 Akter Jahan,2 Mahjabin Joarder,3 Samira Humaira Habib,4 Farzana Sharmin5 & Reefat Nayer1 1 Department of Gynecology and Obstetrics, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh 2 Government Homeopathic College, Dhaka, Bangladesh 3 Research Training Management International, Cox’s Bazar, Bangladesh 4 Health Economics Unit, Bangladesh Diabetic Somiti (BADAS), Dhaka, Bangladesh 5 Department of Obstetrics and Gynecology, Bangladesh Institute of Health Sciences (BIHS) & Hospital, Dhaka, Bangladesh
Keywords Bangladesh; laparoscopic hysterectomy; large uterus Correspondence Samsad Jahan, Department of Gynecology and Obstetrics, BIRDEM, Dhaka, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. Tel: +880 2 8616641 50/ext-2270 (off) Fax: +880 2 9677772 Email: [email protected]; [email protected]; [email protected] Received 3 June 2014; revised 15 December 2014; accepted 7 February 2015 DOI:10.1111/ases.12184
Abstract Introduction: The purpose of this study was to examine the safety and feasibility of laparoscopically assisted vaginal hysterectomy for uteri weighing more than 500 g as compared to uteri weighing less than 500 g in benign gynecological diseases. Methods: This was a retrospective study. Patients were admitted through the outpatient department. They were divided into two groups: uterine weight ≥500 g (group 1) and uterine weight >500 g (group 2). There were no exclusion criteria based on the size, number, or location of leiomyomas. The patient characteristics for the two groups were compared in terms of demographic and socioeconomic details, operating time, amount of blood loss, requirement of blood transfusion, need for analgesia, and length of hospital stay. Results: The characteristics age and BMI were well balanced between the two groups. Uterine weight was 267.2 ± 97.6 g in group 1 and 740.0 ± 371.4 g in group 2 (P < 0.001). Length of operation and amount of blood loss were greater in group 2 than in group 1 (operation: 89.1 ± 26.7 vs 73.3 ± 24.6 min, P < 0.01; blood loss: 570.5 ± 503.6 vs 262.5 ± 270.0 mL, P < 0.001). However, there was no significant difference in hospital stay or incidence of operative complications between the two groups. No patients were switched from laparoscopy to laparotomy during operation. The rate of blood transfusion was lower in group1 than in group 2 (4.9% vs 32.6%; P < 0.001). Conclusion: This study demonstrated that despite the increased operating time and blood loss, laparoscopy should be considered instead of laparotomy in cases of large uteri. Laparoscopically assisted vaginal hysterectomy can be performed safely for a large uterus.
Introduction Since Harry Reich first described laparoscopic hysterectomy technique in 1989, laparoscopically assisted vaginal hysterectomy (LAVH) has become a popular alternative to abdominal hysterectomy in cases that are difficult to manage via the vaginal route alone (1). Today, LAVH is a safe and feasible technique to manage benign uterine pathology as it offers minimal postoperative discomfort,
shorter hospital stay, rapid convalescence, and early return to activities of daily living (2–8). The rationale for LAVH is to convert abdominal hysterectomy into a laparoscopic procedure and thereby reduce trauma and morbidity (9). Electrosurgery, stapling devices, and/or intracorporeal or extracorporeal sutures are used for cutting and ligating the stumps (10,11), and , and numerous articles have discussed the use of different methods to improve this
Asian J Endosc Surg •• (2015) ••–•• © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
1
Laparoscopic hysterectomy
S Jahan et al.
surgical technique (11–17). The relatively limited operating field, poor opportunity angle of laparoscopic instruments, and the removal of surgical specimens increase the difficulties of LAVH involving a large uterus and thus may contribute to increases in surgical morbidity. Under such circumstances, the safety and feasibility of the laparoscopic approach may be of concern. To shed light on this issue, we retrospectively investigated the outcome of LAVH in large uterus cases. In this study, uterine size at 16 weeks’ gestation was used as the cut-off value to define a large uterus. According to our clinical observations, a uterine size at 16 weeks’ gestation is approximately equal to 500 g. Most studies set an upper limit for uterine size, and a uterus at 15–16 weeks’ gestation or that is heavier than 500 g is considered large (18). It has been suggested that very enlarged uteri should be treated by laparotomy. An enlarged uterus can cause difficulties including limited access to uterine vascular pedicles depending on the size and location of myomas and a high risk of complications such as hemorrhage. Other concerns regarding laparoscopic management of large uteri include the risk of bowel and urinary tract injury due to poor exposure, difficulty extracting the uterus, and extended duration of the procedure. To overcome these limitations, LAVH in cases of enlarged uteri should be modified to make it feasible in all cases. We have adopted technical modifications for this procedure to make it applicable in cases of large uteri.
Methods and Materials Between November 2008 and October 2012, 100 women with different benign gynecological diseases underwent LAVH at Japan Bangladesh Friendship Hospital (JBFH) (Dhaka, Bangladesh). In this retrospective comparative study, we divided the patients into two groups: one with uterine weight
Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Laparoscopic hysterectomy in large uteri: Experience from a tertiary care hospital in Bangladesh Samsad Jahan,1 Akter Jahan,2 Mahjabin Joarder,3 Samira Humaira Habib,4 Farzana Sharmin5 & Reefat Nayer1 1 Department of Gynecology and Obstetrics, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh 2 Government Homeopathic College, Dhaka, Bangladesh 3 Research Training Management International, Cox’s Bazar, Bangladesh 4 Health Economics Unit, Bangladesh Diabetic Somiti (BADAS), Dhaka, Bangladesh 5 Department of Obstetrics and Gynecology, Bangladesh Institute of Health Sciences (BIHS) & Hospital, Dhaka, Bangladesh
Keywords Bangladesh; laparoscopic hysterectomy; large uterus Correspondence Samsad Jahan, Department of Gynecology and Obstetrics, BIRDEM, Dhaka, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. Tel: +880 2 8616641 50/ext-2270 (off) Fax: +880 2 9677772 Email: [email protected]; [email protected]; [email protected] Received 3 June 2014; revised 15 December 2014; accepted 7 February 2015 DOI:10.1111/ases.12184
Abstract Introduction: The purpose of this study was to examine the safety and feasibility of laparoscopically assisted vaginal hysterectomy for uteri weighing more than 500 g as compared to uteri weighing less than 500 g in benign gynecological diseases. Methods: This was a retrospective study. Patients were admitted through the outpatient department. They were divided into two groups: uterine weight ≥500 g (group 1) and uterine weight >500 g (group 2). There were no exclusion criteria based on the size, number, or location of leiomyomas. The patient characteristics for the two groups were compared in terms of demographic and socioeconomic details, operating time, amount of blood loss, requirement of blood transfusion, need for analgesia, and length of hospital stay. Results: The characteristics age and BMI were well balanced between the two groups. Uterine weight was 267.2 ± 97.6 g in group 1 and 740.0 ± 371.4 g in group 2 (P < 0.001). Length of operation and amount of blood loss were greater in group 2 than in group 1 (operation: 89.1 ± 26.7 vs 73.3 ± 24.6 min, P < 0.01; blood loss: 570.5 ± 503.6 vs 262.5 ± 270.0 mL, P < 0.001). However, there was no significant difference in hospital stay or incidence of operative complications between the two groups. No patients were switched from laparoscopy to laparotomy during operation. The rate of blood transfusion was lower in group1 than in group 2 (4.9% vs 32.6%; P < 0.001). Conclusion: This study demonstrated that despite the increased operating time and blood loss, laparoscopy should be considered instead of laparotomy in cases of large uteri. Laparoscopically assisted vaginal hysterectomy can be performed safely for a large uterus.
Introduction Since Harry Reich first described laparoscopic hysterectomy technique in 1989, laparoscopically assisted vaginal hysterectomy (LAVH) has become a popular alternative to abdominal hysterectomy in cases that are difficult to manage via the vaginal route alone (1). Today, LAVH is a safe and feasible technique to manage benign uterine pathology as it offers minimal postoperative discomfort,
shorter hospital stay, rapid convalescence, and early return to activities of daily living (2–8). The rationale for LAVH is to convert abdominal hysterectomy into a laparoscopic procedure and thereby reduce trauma and morbidity (9). Electrosurgery, stapling devices, and/or intracorporeal or extracorporeal sutures are used for cutting and ligating the stumps (10,11), and , and numerous articles have discussed the use of different methods to improve this
Asian J Endosc Surg •• (2015) ••–•• © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
1
Laparoscopic hysterectomy
S Jahan et al.
surgical technique (11–17). The relatively limited operating field, poor opportunity angle of laparoscopic instruments, and the removal of surgical specimens increase the difficulties of LAVH involving a large uterus and thus may contribute to increases in surgical morbidity. Under such circumstances, the safety and feasibility of the laparoscopic approach may be of concern. To shed light on this issue, we retrospectively investigated the outcome of LAVH in large uterus cases. In this study, uterine size at 16 weeks’ gestation was used as the cut-off value to define a large uterus. According to our clinical observations, a uterine size at 16 weeks’ gestation is approximately equal to 500 g. Most studies set an upper limit for uterine size, and a uterus at 15–16 weeks’ gestation or that is heavier than 500 g is considered large (18). It has been suggested that very enlarged uteri should be treated by laparotomy. An enlarged uterus can cause difficulties including limited access to uterine vascular pedicles depending on the size and location of myomas and a high risk of complications such as hemorrhage. Other concerns regarding laparoscopic management of large uteri include the risk of bowel and urinary tract injury due to poor exposure, difficulty extracting the uterus, and extended duration of the procedure. To overcome these limitations, LAVH in cases of enlarged uteri should be modified to make it feasible in all cases. We have adopted technical modifications for this procedure to make it applicable in cases of large uteri.
Methods and Materials Between November 2008 and October 2012, 100 women with different benign gynecological diseases underwent LAVH at Japan Bangladesh Friendship Hospital (JBFH) (Dhaka, Bangladesh). In this retrospective comparative study, we divided the patients into two groups: one with uterine weight
