IJG-08293; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability Amphan Chalermchockcharoenkit ⁎, Korakot Sirimai, Pavit Sutchritpongsa, Rujirek Leelanapapat, Ataporn Panpanit, Harshita Ramamurthy Thai-German Multidisciplinary Endoscopic Training Center, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
a r t i c l e
i n f o
Article history: Received 26 August 2014 Received in revised form 12 January 2015 Accepted 7 April 2015 Keywords: Intellectual disability Laparoscopic hysterectomy Safety Satisfaction Young patients
a b s t r a c t Objective: To evaluate the safety of laparoscopic hysterectomy for young patients with intellectual disability and the postoperative satisfaction levels of their caregivers. Methods: A retrospective analysis was conducted of all patients with intellectual disability who underwent laparoscopic hysterectomy at a center in Thailand between January 5, 2004, and August 31, 2010. Information was retrieved about preoperative, intraoperative, and postoperative characteristics. Caregiver satisfaction levels were assessed 3 months after surgery using a Likert-type scale. Results: The mean age of the 74 included patients was 14.9 ± 4.2 years. The cause of intellectual disability was unknown for 30 patients (41%); 22 (30%) had Down syndrome. Total laparoscopic hysterectomy was performed among 66 (89%) patients. No major operative complications were noted. Overall, 72 (97%) caregivers were extremely satisfied with the surgical outcome; the remaining 2 (3%) reported being very satisfied. Conclusion: Laparoscopic hysterectomy was safe and had good outcomes among patients with intellectual disability. This procedure might be a feasible option to induce therapeutic amenorrhea among young patients with intellectual disability, especially in countries with limited resources. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Intellectual disability presents before the age of 18 years and is characterized by substantial limitations in cognitive functioning and a lack of the behavioral skills required for daily living. Owing to their inability to care for themselves, female patients with intellectual disability are prone to gynecologic and social problems, such as poor menstrual hygiene, inappropriate behavior during menstruation, sexual abuse, unwanted pregnancy, and sexually transmitted infections [1,2]. Furthermore, conducting a gynecologic examination can pose challenges because of limited co-operation, physical issues, and ethical difficulties. The main problem encountered among women with intellectual disability is poor menstrual hygiene. One case–control study found that 67% of affected individuals in Finland sought therapeutic approaches to achieve amenorrhea at some point in their lives [3]. Management of menstrual hygiene in this patient population should start with the least invasive options, such as long-term hormonal medication, before progressing to therapies that require complex forms of consent, such as hysterectomy [4,5]. Inappropriate multidisciplinary health care,
⁎ Corresponding author at: Thai-German Multidisciplinary Endoscopic Training Center, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, No. 2 Prannok Road, Bangkok Noi, Bangkok 10700, Thailand. Tel.: + 66 2419 4744; fax: + 66 2411 4245. E-mail address: [email protected] (A. Chalermchockcharoenkit).
inadequate familial support, and poor economic status are potential obstacles to the use of long-term hormonal medication. In addition, parents or caregivers often find it difficult to care for individuals with poor menstrual hygiene. Surgical intervention should be considered only after other reasonable and less invasive alternatives have been attempted [6–11]. Surgery might be an appropriate alternative option for some young patients with severe intellectual disability, especially in resource-limited settings. Hysterectomy is the most frequent surgical intervention performed among young women with intellectual disability because it not only combats problems associated with menstruation but can also prevent unwanted pregnancy, pelvic inflammatory disease, and other uterine or cervical diseases. Studies with both short-term and long-term postoperative follow-up data [7,8] have indicated that the parents of young patients with intellectual disability are highly satisfied with the postoperative outcome. Furthermore, quality of life for these patients was also improved following surgery [9]. The use of open hysterectomy among women with intellectual disability is controversial, and this approach remains under constant scrutiny given the associated complications of major surgery [1,2,9]. By contrast, laparoscopic hysterectomy for benign gynecologic pathologies has been widely accepted and is considered to be preferred approach [12–14]. The advantages of laparoscopic hysterectomy over open hysterectomy include reduced postoperative pain, fewer complications, shorter length of hospital stay, and rapid recovery [12,13]. In addition, advances in laparoscopic equipment and improvisation of techniques
http://dx.doi.org/10.1016/j.ijgo.2015.01.019 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
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A. Chalermchockcharoenkit et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
have, in our experiences, further reduced complication rates and operation times. The aim of the present study was to evaluate both the safety of performing laparoscopic hysterectomy among young patients with intellectual disability and the postoperative satisfaction levels of their caregivers. 2. Materials and methods A retrospective analysis was conducted of all patients with intellectual disability who underwent laparoscopic hysterectomy in the Department of Obstetrics and Gynecology, Siriraj Hospital, Bangkok, Thailand, between January 5, 2004, and August 31, 2010. The present study was approved by the institutional review board of Siriraj Hospital. Consent for inclusion in the present study was not required because of the retrospective nature of the analysis. Patients had been screened and subsequently diagnosed with intellectual disability by either their pediatricians or psychiatrists specializing in the care of children and adolescents. All hysterectomies were requested by the parents or guardians of the affected individuals; these requests were reviewed and a second opinion obtained before the operation could be approved. All the parents and guardians refused to try other less invasive options for affected individuals. All the procedures were performed either by experienced surgeons or by trainees enrolled in an endoscopic fellowship program who were supervised by experienced members of staff. The type of laparoscopic hysterectomy performed depended on the individual surgeon’s preference. Laparoscopic hysterectomy was defined as subtotal if the cervix was preserved and as total if the entire procedure, including vaginal cuff closure, was conducted via the laparoscopic route. In all other cases, the procedure was classified generally as laparoscopic hysterectomy [14]. All the procedures were conducted with the patient in the lithotomy position and under general anesthesia. Bladder drainage was achieved using a 12-French Foley catheter; the uterus was maneuvered with a sound–tenaculum combined manipulator. Laparoscopic ports were placed using a 10-mm intraumbilical port and two or three 5-mm ancillary ports. All plane dissection and coagulation of vascular pedicles were performed by bipolar coagulation. A monopolar hook was used to open the vaginal vault, aided by a vaginal tube that had been modified by the Thai-German Multidisciplinary Endoscopic Training Center at Siriraj Hospital. This customized vaginal tube helped to demarcate the level of the cervix, as well as outline the vault for ease of cutting. Four sizes of tube were available (Fig. 1); the two smallest (22.5 mm and 30.0 mm) were used in most procedures. The uterine specimen was removed predominantly through the vagina. When the specimen was large, it was first subjected to mechanical morcellation before retrieval through the vagina. The 12-French Foley catheter was removed immediately after surgery. Postoperative care was conducted as per the routine departmental protocols. Hemograms were performed only if the estimated blood loss exceeded 1000 mL. Information was retrieved about preoperative, intraoperative, and postoperative characteristics of the patients. These measures included age, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), results of intelligence quotient (IQ) testing, diagnosis, type of laparoscopic hysterectomy performed, operation time (from first incision until complete skin closure), intraoperative blood loss, requirement for blood transfusion, conversion to laparotomy, length of hospital stay, pathology report, and contact telephone number for the parents or caregivers. Major complications of surgery were also recorded. These complications included internal organ injury, hemorrhage requiring transfusion, blood loss in excess of 1000 mL, postoperative fever, and wound infections. Estimated intraoperative blood loss was defined as the difference between the volume of fluid in the suction equipment and the volume of saline solution used during irrigation. Postoperative fever was defined as a temperature of at least 38 °C, measured on two separate
Fig. 1. The vaginal tube used at the Thai-German Multidisciplinary Endoscopic Training Center. A handle (top) is attached to a tube of the chosen size. Four sizes of tube are available: SS (22.5 mm), S (30.0 mm), M (35.0 mm), and L (40.0 mm). The base of the handle is covered with a red silicon cap (5 or 10 mm) that includes a valve to prevent gas leakage and allow the insertion of a 5- or 10-mm instrument through it for specimen retrieval. The vaginal tube is made of a heat-resistant polyplastic material (polyoxymethylene copolymer).
occasions at least 12 hours apart, after the first day of the postoperative period. The presence of a purulent or foul-smelling discharge was considered symptomatic of wound infection. Laparo-conversion was defined as the need to use laparotomy to complete the procedure. Late postoperative complications were determined after 6 weeks, 3 months, and 6 months. A Likert-type scale [15] was used to assess the satisfaction levels of caregivers 3 months after surgery through a telephone interview and feedback. The present sample size was based on pre-existing institutional data. The total major complication rate of laparoscopic hysterectomy at Siriraj Hospital between January 4, 2006 and December 26, 2008 was 3.8% (22 of 582 cases). Because of a limitation in the number of patients, a 95% confidence interval and a precision of 5%, instead of 1.9%, were used for the calculations [16]. Using a simple formula appropriate for a prevalence study, it was determined that at least 56 patients were required to provide a representative sample size. The data were analyzed using SPSS version 13.0 (SPSS Inc, Chicago, IL, USA). Data were presented as number (percentage), mean ± standard deviation, median, mean difference (range), or odds ratio (95% confidence interval), as appropriate. The Pearson χ2 or Fisher exact tests were used to compare proportions. P b 0.05 was considered statistically significant.
3. Results During the present study period, laparoscopic gynecologic surgery was conducted among 97 patients with intellectual disability, of whom 22 (23%) underwent laparoscopic tubal sterilizations and 1 (1%) a laparoscopic ovarian cystectomy. These 23 patients were excluded from the analysis; therefore, the final sample included 74 patients. No appreciable difference was detected in the results of IQ testing between patients who underwent tubal sterilization and those who underwent laparoscopic hysterectomy (data not shown). The median follow-up for the 74 patients was 3 months (range 3–6). The mean age at time of surgery was 14.9 years (median 14; range 9–32); most of the patients were aged 9–19 years (Table 1). The mean IQ testing result was 45.7 (median 44; range 14–79). Poor menstrual hygiene was the main issue behind the decision to perform surgery for 72 (97%) patients; dysmenorrhea and inappropriate behavior due to fear of menstrual blood were the main reasons for the other 2 patients. The underlying cause of intellectual disability was Down
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
A. Chalermchockcharoenkit et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx Table 1 Baseline characteristics (n = 74). Characteristics
Valuesa
Age, y 9–19 N19 Previous pregnancy Weight, kg Height, cm Body mass index b IQ c Level of intellectual impairment Mild (IQ ≥50) Severe (IQ b50) Unspecified Cause of intellectual disability Down syndrome Autism Cerebral palsy Unknown Underlying condition Congenital heart disease Epilepsy Deafness Thyroid disease Pan-hypopituitarism Thoracic kyphosis Diabetes mellitus None
14.9 ± 4.2 65 (88) 9 (12) 0 51.2 ± 16.9 149.2 ± 10.3 23.1 ± 7.1 45.7 ± 17.1 13 (18) 38 (51) 23 (31) 22 (30) 18 (24) 4 (5) 30 (41) 11 (15) 6 (8) 2 (3) 2 (3) 1 (1) 1 (1) 1 (1) 50 (68)
Abbreviation: IQ, intelligence quotient. a Values are given as mean ± standard deviation or number (percentage). b Calculated as weight in kilograms divided by the square of height in meters. c Data available for 51 patients.
Table 2 Operative outcomes (n = 74). Outcomes
Valuesa
Surgical time, min Estimated blood loss, mL Blood transfusion received Length of hospital stay, d Postoperative fever Major organ injury Type of procedure Total laparoscopic hysterectomy Laparoscopic hysterectomy Subtotal laparoscopic hysterectomy Satisfaction level of caregiver Not at all satisfied Slightly satisfied Moderately satisfied Very satisfied Extremely satisfied
132.9 ± 49.5 38.8 ± 44.2 0 1.5 ± 2.0 0 0
a
66 (89) 4 (5) 4 (5) 0 0 0 2 (3) 72 (97)
Values are given as mean ± standard deviation or number (percentage).
3
syndrome for almost one-third of patients, but was unknown for twofifths (Table 1). No major intraoperative or postoperative complications were noted (Table 2). No patients required a blood transfusion either during or after surgery. No instances of laparo-conversion were recorded. The mean hospital stay after laparoscopic hysterectomy was 1.5 days. Two (3%) patients were discharged on the day of the surgery; however, 1 (1%) patient remained in hospital for 18 days for surgical care of a lipoma wound on her left thigh after concurrent excision. Total laparoscopic hysterectomy was the most frequently performed procedure (Table 2). The proportion of patients who underwent total laparoscopic hysterectomy between September 2008 and August 2010 was greater than that observed between January 2004 and August 2008 (37/37 [100%] vs 29/37 [78%]; P = 0.003). The uterine specimen was removed via the vagina without the need for morcellation among 56 (76%) patients. Most of the histopathologic reports that were scrutinized postoperatively showed that the uterus was healthy; however, 2 (3%) indicated evidence of endometrial polyps. Notably, a retained condom was found in the vagina of one patient during insertion of a uterine manipulator. After surgery, almost all caregivers reported being extremely satisfied with the outcome (Table 2). Table 3 presents the patient characteristics by age group. Patients aged 19 years or younger had a lower mean IQ than did those older than 19 years (P = 0.022). A similar trend was observed for mean uterine specimen weight (P = 0.023). 4. Discussion Minimal blood loss, absence of major complications, mild degree of postoperative pain, and short length of hospital stay were all noted among young women with intellectual disability who had undergone laparoscopic hysterectomy during the present study period. Furthermore, their caregivers expressed a high level of satisfaction with the outcome of this procedure. The overall rate of major complications of laparoscopic hysterectomies recorded at Siriraj Hospital between January 2006 and December 2008 was 3.8% (95% confidence interval 2.5%–5.6%). However, the rate dropped to 2.4% (95% confidence interval, 1.7%–3.2%; 38 of 1613 patients) between January 5, 2009, and December 29, 2013. The decrease in complication rates probably reflects increased surgical experience. Therefore, expect even better outcomes are expected for young patients with intellectual disability who undergo surgery in the future. In line with the findings of another study [3], poor menstrual hygiene was the main issue underpinning approval of surgical intervention among most of the patients in the present study. The severity of intellectual disability was the leading cause of hysterectomy in the present study. None of the patients included in the present analysis had an IQ test result of 80 or higher; furthermore, patients aged 19 years or younger had a lower score than did patients aged older than 19 years.
Table 3 Characteristics and outcomes by age group.a Characteristics
≤19 y (n = 65)
N19 y (n = 9)
Mean difference (range)
P value
Weight, kg Height, cm Body mass indexb Intelligence quotient Uterine specimen removal through vaginal route Operative time, min Estimated blood loss, mL Uterine specimen weight, g Length of hospital stay, d
51.2 ± 17.8 148.8 ± 10.7 23.0 ± 7.2 41.4 ± 14.3 48 (74) 135.1 ± 48.5 36.5 ± 44.6 44.0 ± 27.1 1.5 ± 2.1
50.8 ± 11.1 150.9 ± 7.5 23.3 ± 7.2 56.8 ± 7.0 8 (89) 117.8 ± 56.5 55.6 ± 39.1 68.8 ± 36.0 1.3 ± 0.9
0.48 (−12.73 to 13.69) −2.11 (−10.12 to 5.89) −0.29 (−5.85 to 5.27) 15.41 (−28.47 to −2.35) 0.83 (0.63–1.09)c 17.27 (−17.78 to 52.31) −19.09 (−50.33 to 12.14) −24.78 (−46.05 to −3.52) 0.12 (−1.31 to 1.56)
0.942 0.518 0.962 0.022 0.300 0.404 0.204 0.023 0.864
a b c
Values are given as mean ± standard deviation or number (percentage), unless indicated otherwise. Calculated as weight in kilograms divided by the square of height in meters. Value given as odds ratio (95% confidence interval).
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
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A. Chalermchockcharoenkit et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Although the use of hysterectomy or tubal sterilization among women with intellectual disability is controversial and raises ethical concerns in many high-income countries [2–6,9,11], this approach might still be considered an appropriate method to induce therapeutic amenorrhea among selected young patients with severe intellectual disability. Hysterectomy could, therefore, be particularly relevant in low-income countries with limited resources, where poor socioeconomic status might be an obstacle for long-term hormonal medication. At Siriraj Hospital, laparoscopic hysterectomy is currently the primary route for surgical intervention that aims to treat young patients with intellectual disability and poor menstrual hygiene. Nevertheless, informed parental consent and departmental approval (including a second opinion) are both required before the procedure can go ahead. Procedures performed in other large studies have either been abdominal hysterectomies or vaginal hysterectomies [1,7,11]. However, laparoscopic hysterectomy is associated with markedly less morbidity than is abdominal hysterectomy [17–21]. A large proportion of hysterectomies can also be carried out vaginally, with considerable benefits to the patient [22]; however, myomas, adnexal pathologies, pelvic adhesions, and a narrow vagina can present obstacles to the use of this route. Consequently, vaginal hysterectomy is not routinely performed at Siriraj Hospital for the treatment of young patients with intellectual disability. Total laparoscopic hysterectomy can be performed in the same manner for pediatric patients and adult patients. Nonetheless, there are some minor differences in the anatomy of juvenile pelvic organs versus adult pelvic organs that should be considered when operating on a young patient. For example, it is important for the surgeon to exercise caution when introducing a Veress (spring-loaded) needle or primary trocar into the abdominal cavity because the wall surrounding the umbilicus is thin, with the aorta lying directly beneath [23]. Siriraj Hospital has recorded a steady rise in the number of minimally invasive surgeries performed over time. With regards to regular gynecologic cases, the number of total laparoscopic hysterectomies increased from 1 (1.2%) of 80 patients undergoing hysterectomy in 2004 to 28 (23.9%) of 117 patients in 2006 [24]. Moreover, this procedure constituted 704 of 845 (83.3%) hysterectomies performed at Siriraj Hospital between 2009 and 2010. Consequently, all young patients with intellectual disability could undergo total laparoscopic hysterectomy at this center between September 2008 and August 2010. The customized vaginal tube used in the present study was advantageous for colpotomy in young patients with intellectual disability because the tube could be selected on the basis of the size of each individual patient’s vagina and introitus. Use of this system prevented iatrogenic tears, which can be a problem when using commercially available tubes that are larger in size than the customized version. Most of the patients included in the present study were aged 9–19 years. Although poor menstrual hygiene was the main issue behind the decision to perform laparoscopic hysterectomy, a non-intact hymen was noted in many patients as an incidental finding. Threequarters of the uterine specimens were easily retrieved through the vagina, without the need for mechanical morcellation. Although it is difficult to speculate on sexual abuse and exploitation solely on the basis of the finding of a non-intact hymen, such abuse might potentially be a large and unexposed problem among young patients with intellectual disability that should not be overlooked. Parents or caregivers of the patients included in the present study were highly satisfied with the postoperative outcome of laparoscopic hysterectomy and provided excellent feedback. This endorsement eventually led to an overall increase in the number of patients seeking treatment at Siriraj Hospital. A number of limitations of the present study should be acknowledged, including the retrospective nature of the design and the small sample size. In addition, long-term follow-up was not conducted, and the participants’ postoperative quality of life was not assessed. In conclusion, the findings of the present study suggested that the use of laparoscopic hysterectomy among young patients with
intellectual disability is both feasible and safe. It is suitable for these patients, who tend to be easily agitated. Such minimally invasive surgery allows for a short recovery period and complete mobilization on the day of surgery with minimal discomfort to the patient. Consequently, this procedure could be considered an appropriate method to induce therapeutic amenorrhea among selected young patients with severe intellectual disability, especially in countries with limited resources. Furthermore, laparoscopic hysterectomy might be recommended as the primary surgical route for affected individuals who lack the ability to care for themselves.
Conflict of interest The authors have no conflicts of interest.
References [1] Wingfield M, Healy DL, Nicholson A. Gynaecological care for women with intellectual disability. Med J Aust 1994;160(9):536–8. [2] Prevatt B. Gynecological care for women with mental retardation. J Obstet Gynecol Neonatal Nurs 1998;27(3):251–6. [3] Huovinen KJ. Gynecological problems of mentally retarded women. A case–control study from southern Finland. Acta Obstet Gynecol Scand 1993;72(6):475–80. [4] Wilkinson JE, Cerreto MC. Primary care for women with intellectual disabilities. J Am Board Fam Med 2008;21(3):215–22. [5] Atkinson E, Bennett MJ, Dudley J, Grover S, Matthews K, Moore P, et al. Consensus statement: Menstrual and contraceptive management in women with an intellectual disability. Aust N Z J Obstet Gynaecol 2003;43(2):109–10. [6] ACOG. Sterilization of women, including those with mental disabilities. Number 371. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committeeon-Ethics/Sterilization-of-Women-Including-Those-With-Mental-Disabilities. Published July 2007. Updated 2009. Accessed November 20, 2014. [7] Wheeless CR. Abdominal hysterectomy for surgical sterilization in the mentally retarded: a review of parental opinion. Am J Obstet Gynecol 1975;122(7):872–5. [8] Van der Merwe JV, Roux JP. Sterilization of mentally retarded persons. Obstet Gynecol Surv 1987;42(8):489–93. [9] Kaunitz AM, Thompson RJ, Kaunitz KK. Mental retardation: a controversial indication for hysterectomy. Obstet Gynecol 1986;68(3):436–8. [10] Passer A, Rauh J, Chamberlain A, McGrath M, Burket R. Issues in fertility control for mentally retarded female adolescents: II. Parental attitudes toward sterilization. Pediatrics 1984;73(4):451–4. [11] Sheth S, Malpani A. Vaginal hysterectomy for the management of menstruation in mentally retarded women. Int J Gynecol Obstet 1991;35(4):319–21. [12] Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano GF. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol 1999;180(2 Pt 1):270–5. [13] Olsson JH, Ellstrom M, Hahlin M. A randomised prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol 1996;103(4):345–50. [14] Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005; 330(7506):1478. [15] Vagias WM. Likert-type scale response anchors. https://www.clemson.edu/centersinstitutes/tourism/documents/sample-scales.pdf. Published 2006. Accessed November 20, 2014. [16] Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci 2006;1:9–14. [17] Frumovitz M, dos Reis R, Sun CC, Milam MR, Bevers MW, Brown J, et al. Comparison of total laparoscopic and abdominal radical hysterectomy for patients with earlystage cervical cancer. Obstet Gynecol 2007;110(1):96–102. [18] Reich H, Roberts L. Laparoscopic hysterectomy in current gynaecological practice. Rev Gynaecol Pract 2003;3:32–40. [19] Sarmini OR, Lefholz K, Froeschke HP. A comparison of laparoscopic supracervical hysterectomy and total abdominal hysterectomy outcomes. J Minim Invasive Gynecol 2005;12(2):121–4. [20] Schindlbeck C, Klauser K, Dian D, Janni W, Friese K. Comparison of total laparoscopic, vaginal and abdominal hysterectomy. Arch Gynecol Obstet 2008;277(4):331–7. [21] Chalermchockchareonkit A, Tekasakul P, Chaisilwattana P, Sirimai K, Wahab N. Laparoscopic hysterectomy versus abdominal hysterectomy for severe pelvic endometriosis. Int J Gynecol Obstet 2012;116(2):109–11. [22] American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Number 311, April 2005. Appropriate use of laparoscopically assisted vaginal hysterectomy. Obstet Gynecol 2005;105(4):929–30. [23] Takeda A, Manabe S, Hosono S, Nakamura H. Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger. J Minim Invasive Gynecol 2005;12(3):234–40. [24] Chalermchockcharoenkit A, Tanmahasamut P. The trend shift in hysterectomy technique in Siriraj Hospital. Siriraj Med J 2007;59:325–7.
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability Amphan Chalermchockcharoenkit ⁎, Korakot Sirimai, Pavit Sutchritpongsa, Rujirek Leelanapapat, Ataporn Panpanit, Harshita Ramamurthy Thai-German Multidisciplinary Endoscopic Training Center, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
a r t i c l e
i n f o
Article history: Received 26 August 2014 Received in revised form 12 January 2015 Accepted 7 April 2015 Keywords: Intellectual disability Laparoscopic hysterectomy Safety Satisfaction Young patients
a b s t r a c t Objective: To evaluate the safety of laparoscopic hysterectomy for young patients with intellectual disability and the postoperative satisfaction levels of their caregivers. Methods: A retrospective analysis was conducted of all patients with intellectual disability who underwent laparoscopic hysterectomy at a center in Thailand between January 5, 2004, and August 31, 2010. Information was retrieved about preoperative, intraoperative, and postoperative characteristics. Caregiver satisfaction levels were assessed 3 months after surgery using a Likert-type scale. Results: The mean age of the 74 included patients was 14.9 ± 4.2 years. The cause of intellectual disability was unknown for 30 patients (41%); 22 (30%) had Down syndrome. Total laparoscopic hysterectomy was performed among 66 (89%) patients. No major operative complications were noted. Overall, 72 (97%) caregivers were extremely satisfied with the surgical outcome; the remaining 2 (3%) reported being very satisfied. Conclusion: Laparoscopic hysterectomy was safe and had good outcomes among patients with intellectual disability. This procedure might be a feasible option to induce therapeutic amenorrhea among young patients with intellectual disability, especially in countries with limited resources. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Intellectual disability presents before the age of 18 years and is characterized by substantial limitations in cognitive functioning and a lack of the behavioral skills required for daily living. Owing to their inability to care for themselves, female patients with intellectual disability are prone to gynecologic and social problems, such as poor menstrual hygiene, inappropriate behavior during menstruation, sexual abuse, unwanted pregnancy, and sexually transmitted infections [1,2]. Furthermore, conducting a gynecologic examination can pose challenges because of limited co-operation, physical issues, and ethical difficulties. The main problem encountered among women with intellectual disability is poor menstrual hygiene. One case–control study found that 67% of affected individuals in Finland sought therapeutic approaches to achieve amenorrhea at some point in their lives [3]. Management of menstrual hygiene in this patient population should start with the least invasive options, such as long-term hormonal medication, before progressing to therapies that require complex forms of consent, such as hysterectomy [4,5]. Inappropriate multidisciplinary health care,
⁎ Corresponding author at: Thai-German Multidisciplinary Endoscopic Training Center, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, No. 2 Prannok Road, Bangkok Noi, Bangkok 10700, Thailand. Tel.: + 66 2419 4744; fax: + 66 2411 4245. E-mail address: [email protected] (A. Chalermchockcharoenkit).
inadequate familial support, and poor economic status are potential obstacles to the use of long-term hormonal medication. In addition, parents or caregivers often find it difficult to care for individuals with poor menstrual hygiene. Surgical intervention should be considered only after other reasonable and less invasive alternatives have been attempted [6–11]. Surgery might be an appropriate alternative option for some young patients with severe intellectual disability, especially in resource-limited settings. Hysterectomy is the most frequent surgical intervention performed among young women with intellectual disability because it not only combats problems associated with menstruation but can also prevent unwanted pregnancy, pelvic inflammatory disease, and other uterine or cervical diseases. Studies with both short-term and long-term postoperative follow-up data [7,8] have indicated that the parents of young patients with intellectual disability are highly satisfied with the postoperative outcome. Furthermore, quality of life for these patients was also improved following surgery [9]. The use of open hysterectomy among women with intellectual disability is controversial, and this approach remains under constant scrutiny given the associated complications of major surgery [1,2,9]. By contrast, laparoscopic hysterectomy for benign gynecologic pathologies has been widely accepted and is considered to be preferred approach [12–14]. The advantages of laparoscopic hysterectomy over open hysterectomy include reduced postoperative pain, fewer complications, shorter length of hospital stay, and rapid recovery [12,13]. In addition, advances in laparoscopic equipment and improvisation of techniques
http://dx.doi.org/10.1016/j.ijgo.2015.01.019 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
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A. Chalermchockcharoenkit et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
have, in our experiences, further reduced complication rates and operation times. The aim of the present study was to evaluate both the safety of performing laparoscopic hysterectomy among young patients with intellectual disability and the postoperative satisfaction levels of their caregivers. 2. Materials and methods A retrospective analysis was conducted of all patients with intellectual disability who underwent laparoscopic hysterectomy in the Department of Obstetrics and Gynecology, Siriraj Hospital, Bangkok, Thailand, between January 5, 2004, and August 31, 2010. The present study was approved by the institutional review board of Siriraj Hospital. Consent for inclusion in the present study was not required because of the retrospective nature of the analysis. Patients had been screened and subsequently diagnosed with intellectual disability by either their pediatricians or psychiatrists specializing in the care of children and adolescents. All hysterectomies were requested by the parents or guardians of the affected individuals; these requests were reviewed and a second opinion obtained before the operation could be approved. All the parents and guardians refused to try other less invasive options for affected individuals. All the procedures were performed either by experienced surgeons or by trainees enrolled in an endoscopic fellowship program who were supervised by experienced members of staff. The type of laparoscopic hysterectomy performed depended on the individual surgeon’s preference. Laparoscopic hysterectomy was defined as subtotal if the cervix was preserved and as total if the entire procedure, including vaginal cuff closure, was conducted via the laparoscopic route. In all other cases, the procedure was classified generally as laparoscopic hysterectomy [14]. All the procedures were conducted with the patient in the lithotomy position and under general anesthesia. Bladder drainage was achieved using a 12-French Foley catheter; the uterus was maneuvered with a sound–tenaculum combined manipulator. Laparoscopic ports were placed using a 10-mm intraumbilical port and two or three 5-mm ancillary ports. All plane dissection and coagulation of vascular pedicles were performed by bipolar coagulation. A monopolar hook was used to open the vaginal vault, aided by a vaginal tube that had been modified by the Thai-German Multidisciplinary Endoscopic Training Center at Siriraj Hospital. This customized vaginal tube helped to demarcate the level of the cervix, as well as outline the vault for ease of cutting. Four sizes of tube were available (Fig. 1); the two smallest (22.5 mm and 30.0 mm) were used in most procedures. The uterine specimen was removed predominantly through the vagina. When the specimen was large, it was first subjected to mechanical morcellation before retrieval through the vagina. The 12-French Foley catheter was removed immediately after surgery. Postoperative care was conducted as per the routine departmental protocols. Hemograms were performed only if the estimated blood loss exceeded 1000 mL. Information was retrieved about preoperative, intraoperative, and postoperative characteristics of the patients. These measures included age, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), results of intelligence quotient (IQ) testing, diagnosis, type of laparoscopic hysterectomy performed, operation time (from first incision until complete skin closure), intraoperative blood loss, requirement for blood transfusion, conversion to laparotomy, length of hospital stay, pathology report, and contact telephone number for the parents or caregivers. Major complications of surgery were also recorded. These complications included internal organ injury, hemorrhage requiring transfusion, blood loss in excess of 1000 mL, postoperative fever, and wound infections. Estimated intraoperative blood loss was defined as the difference between the volume of fluid in the suction equipment and the volume of saline solution used during irrigation. Postoperative fever was defined as a temperature of at least 38 °C, measured on two separate
Fig. 1. The vaginal tube used at the Thai-German Multidisciplinary Endoscopic Training Center. A handle (top) is attached to a tube of the chosen size. Four sizes of tube are available: SS (22.5 mm), S (30.0 mm), M (35.0 mm), and L (40.0 mm). The base of the handle is covered with a red silicon cap (5 or 10 mm) that includes a valve to prevent gas leakage and allow the insertion of a 5- or 10-mm instrument through it for specimen retrieval. The vaginal tube is made of a heat-resistant polyplastic material (polyoxymethylene copolymer).
occasions at least 12 hours apart, after the first day of the postoperative period. The presence of a purulent or foul-smelling discharge was considered symptomatic of wound infection. Laparo-conversion was defined as the need to use laparotomy to complete the procedure. Late postoperative complications were determined after 6 weeks, 3 months, and 6 months. A Likert-type scale [15] was used to assess the satisfaction levels of caregivers 3 months after surgery through a telephone interview and feedback. The present sample size was based on pre-existing institutional data. The total major complication rate of laparoscopic hysterectomy at Siriraj Hospital between January 4, 2006 and December 26, 2008 was 3.8% (22 of 582 cases). Because of a limitation in the number of patients, a 95% confidence interval and a precision of 5%, instead of 1.9%, were used for the calculations [16]. Using a simple formula appropriate for a prevalence study, it was determined that at least 56 patients were required to provide a representative sample size. The data were analyzed using SPSS version 13.0 (SPSS Inc, Chicago, IL, USA). Data were presented as number (percentage), mean ± standard deviation, median, mean difference (range), or odds ratio (95% confidence interval), as appropriate. The Pearson χ2 or Fisher exact tests were used to compare proportions. P b 0.05 was considered statistically significant.
3. Results During the present study period, laparoscopic gynecologic surgery was conducted among 97 patients with intellectual disability, of whom 22 (23%) underwent laparoscopic tubal sterilizations and 1 (1%) a laparoscopic ovarian cystectomy. These 23 patients were excluded from the analysis; therefore, the final sample included 74 patients. No appreciable difference was detected in the results of IQ testing between patients who underwent tubal sterilization and those who underwent laparoscopic hysterectomy (data not shown). The median follow-up for the 74 patients was 3 months (range 3–6). The mean age at time of surgery was 14.9 years (median 14; range 9–32); most of the patients were aged 9–19 years (Table 1). The mean IQ testing result was 45.7 (median 44; range 14–79). Poor menstrual hygiene was the main issue behind the decision to perform surgery for 72 (97%) patients; dysmenorrhea and inappropriate behavior due to fear of menstrual blood were the main reasons for the other 2 patients. The underlying cause of intellectual disability was Down
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
A. Chalermchockcharoenkit et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx Table 1 Baseline characteristics (n = 74). Characteristics
Valuesa
Age, y 9–19 N19 Previous pregnancy Weight, kg Height, cm Body mass index b IQ c Level of intellectual impairment Mild (IQ ≥50) Severe (IQ b50) Unspecified Cause of intellectual disability Down syndrome Autism Cerebral palsy Unknown Underlying condition Congenital heart disease Epilepsy Deafness Thyroid disease Pan-hypopituitarism Thoracic kyphosis Diabetes mellitus None
14.9 ± 4.2 65 (88) 9 (12) 0 51.2 ± 16.9 149.2 ± 10.3 23.1 ± 7.1 45.7 ± 17.1 13 (18) 38 (51) 23 (31) 22 (30) 18 (24) 4 (5) 30 (41) 11 (15) 6 (8) 2 (3) 2 (3) 1 (1) 1 (1) 1 (1) 50 (68)
Abbreviation: IQ, intelligence quotient. a Values are given as mean ± standard deviation or number (percentage). b Calculated as weight in kilograms divided by the square of height in meters. c Data available for 51 patients.
Table 2 Operative outcomes (n = 74). Outcomes
Valuesa
Surgical time, min Estimated blood loss, mL Blood transfusion received Length of hospital stay, d Postoperative fever Major organ injury Type of procedure Total laparoscopic hysterectomy Laparoscopic hysterectomy Subtotal laparoscopic hysterectomy Satisfaction level of caregiver Not at all satisfied Slightly satisfied Moderately satisfied Very satisfied Extremely satisfied
132.9 ± 49.5 38.8 ± 44.2 0 1.5 ± 2.0 0 0
a
66 (89) 4 (5) 4 (5) 0 0 0 2 (3) 72 (97)
Values are given as mean ± standard deviation or number (percentage).
3
syndrome for almost one-third of patients, but was unknown for twofifths (Table 1). No major intraoperative or postoperative complications were noted (Table 2). No patients required a blood transfusion either during or after surgery. No instances of laparo-conversion were recorded. The mean hospital stay after laparoscopic hysterectomy was 1.5 days. Two (3%) patients were discharged on the day of the surgery; however, 1 (1%) patient remained in hospital for 18 days for surgical care of a lipoma wound on her left thigh after concurrent excision. Total laparoscopic hysterectomy was the most frequently performed procedure (Table 2). The proportion of patients who underwent total laparoscopic hysterectomy between September 2008 and August 2010 was greater than that observed between January 2004 and August 2008 (37/37 [100%] vs 29/37 [78%]; P = 0.003). The uterine specimen was removed via the vagina without the need for morcellation among 56 (76%) patients. Most of the histopathologic reports that were scrutinized postoperatively showed that the uterus was healthy; however, 2 (3%) indicated evidence of endometrial polyps. Notably, a retained condom was found in the vagina of one patient during insertion of a uterine manipulator. After surgery, almost all caregivers reported being extremely satisfied with the outcome (Table 2). Table 3 presents the patient characteristics by age group. Patients aged 19 years or younger had a lower mean IQ than did those older than 19 years (P = 0.022). A similar trend was observed for mean uterine specimen weight (P = 0.023). 4. Discussion Minimal blood loss, absence of major complications, mild degree of postoperative pain, and short length of hospital stay were all noted among young women with intellectual disability who had undergone laparoscopic hysterectomy during the present study period. Furthermore, their caregivers expressed a high level of satisfaction with the outcome of this procedure. The overall rate of major complications of laparoscopic hysterectomies recorded at Siriraj Hospital between January 2006 and December 2008 was 3.8% (95% confidence interval 2.5%–5.6%). However, the rate dropped to 2.4% (95% confidence interval, 1.7%–3.2%; 38 of 1613 patients) between January 5, 2009, and December 29, 2013. The decrease in complication rates probably reflects increased surgical experience. Therefore, expect even better outcomes are expected for young patients with intellectual disability who undergo surgery in the future. In line with the findings of another study [3], poor menstrual hygiene was the main issue underpinning approval of surgical intervention among most of the patients in the present study. The severity of intellectual disability was the leading cause of hysterectomy in the present study. None of the patients included in the present analysis had an IQ test result of 80 or higher; furthermore, patients aged 19 years or younger had a lower score than did patients aged older than 19 years.
Table 3 Characteristics and outcomes by age group.a Characteristics
≤19 y (n = 65)
N19 y (n = 9)
Mean difference (range)
P value
Weight, kg Height, cm Body mass indexb Intelligence quotient Uterine specimen removal through vaginal route Operative time, min Estimated blood loss, mL Uterine specimen weight, g Length of hospital stay, d
51.2 ± 17.8 148.8 ± 10.7 23.0 ± 7.2 41.4 ± 14.3 48 (74) 135.1 ± 48.5 36.5 ± 44.6 44.0 ± 27.1 1.5 ± 2.1
50.8 ± 11.1 150.9 ± 7.5 23.3 ± 7.2 56.8 ± 7.0 8 (89) 117.8 ± 56.5 55.6 ± 39.1 68.8 ± 36.0 1.3 ± 0.9
0.48 (−12.73 to 13.69) −2.11 (−10.12 to 5.89) −0.29 (−5.85 to 5.27) 15.41 (−28.47 to −2.35) 0.83 (0.63–1.09)c 17.27 (−17.78 to 52.31) −19.09 (−50.33 to 12.14) −24.78 (−46.05 to −3.52) 0.12 (−1.31 to 1.56)
0.942 0.518 0.962 0.022 0.300 0.404 0.204 0.023 0.864
a b c
Values are given as mean ± standard deviation or number (percentage), unless indicated otherwise. Calculated as weight in kilograms divided by the square of height in meters. Value given as odds ratio (95% confidence interval).
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
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A. Chalermchockcharoenkit et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Although the use of hysterectomy or tubal sterilization among women with intellectual disability is controversial and raises ethical concerns in many high-income countries [2–6,9,11], this approach might still be considered an appropriate method to induce therapeutic amenorrhea among selected young patients with severe intellectual disability. Hysterectomy could, therefore, be particularly relevant in low-income countries with limited resources, where poor socioeconomic status might be an obstacle for long-term hormonal medication. At Siriraj Hospital, laparoscopic hysterectomy is currently the primary route for surgical intervention that aims to treat young patients with intellectual disability and poor menstrual hygiene. Nevertheless, informed parental consent and departmental approval (including a second opinion) are both required before the procedure can go ahead. Procedures performed in other large studies have either been abdominal hysterectomies or vaginal hysterectomies [1,7,11]. However, laparoscopic hysterectomy is associated with markedly less morbidity than is abdominal hysterectomy [17–21]. A large proportion of hysterectomies can also be carried out vaginally, with considerable benefits to the patient [22]; however, myomas, adnexal pathologies, pelvic adhesions, and a narrow vagina can present obstacles to the use of this route. Consequently, vaginal hysterectomy is not routinely performed at Siriraj Hospital for the treatment of young patients with intellectual disability. Total laparoscopic hysterectomy can be performed in the same manner for pediatric patients and adult patients. Nonetheless, there are some minor differences in the anatomy of juvenile pelvic organs versus adult pelvic organs that should be considered when operating on a young patient. For example, it is important for the surgeon to exercise caution when introducing a Veress (spring-loaded) needle or primary trocar into the abdominal cavity because the wall surrounding the umbilicus is thin, with the aorta lying directly beneath [23]. Siriraj Hospital has recorded a steady rise in the number of minimally invasive surgeries performed over time. With regards to regular gynecologic cases, the number of total laparoscopic hysterectomies increased from 1 (1.2%) of 80 patients undergoing hysterectomy in 2004 to 28 (23.9%) of 117 patients in 2006 [24]. Moreover, this procedure constituted 704 of 845 (83.3%) hysterectomies performed at Siriraj Hospital between 2009 and 2010. Consequently, all young patients with intellectual disability could undergo total laparoscopic hysterectomy at this center between September 2008 and August 2010. The customized vaginal tube used in the present study was advantageous for colpotomy in young patients with intellectual disability because the tube could be selected on the basis of the size of each individual patient’s vagina and introitus. Use of this system prevented iatrogenic tears, which can be a problem when using commercially available tubes that are larger in size than the customized version. Most of the patients included in the present study were aged 9–19 years. Although poor menstrual hygiene was the main issue behind the decision to perform laparoscopic hysterectomy, a non-intact hymen was noted in many patients as an incidental finding. Threequarters of the uterine specimens were easily retrieved through the vagina, without the need for mechanical morcellation. Although it is difficult to speculate on sexual abuse and exploitation solely on the basis of the finding of a non-intact hymen, such abuse might potentially be a large and unexposed problem among young patients with intellectual disability that should not be overlooked. Parents or caregivers of the patients included in the present study were highly satisfied with the postoperative outcome of laparoscopic hysterectomy and provided excellent feedback. This endorsement eventually led to an overall increase in the number of patients seeking treatment at Siriraj Hospital. A number of limitations of the present study should be acknowledged, including the retrospective nature of the design and the small sample size. In addition, long-term follow-up was not conducted, and the participants’ postoperative quality of life was not assessed. In conclusion, the findings of the present study suggested that the use of laparoscopic hysterectomy among young patients with
intellectual disability is both feasible and safe. It is suitable for these patients, who tend to be easily agitated. Such minimally invasive surgery allows for a short recovery period and complete mobilization on the day of surgery with minimal discomfort to the patient. Consequently, this procedure could be considered an appropriate method to induce therapeutic amenorrhea among selected young patients with severe intellectual disability, especially in countries with limited resources. Furthermore, laparoscopic hysterectomy might be recommended as the primary surgical route for affected individuals who lack the ability to care for themselves.
Conflict of interest The authors have no conflicts of interest.
References [1] Wingfield M, Healy DL, Nicholson A. Gynaecological care for women with intellectual disability. Med J Aust 1994;160(9):536–8. [2] Prevatt B. Gynecological care for women with mental retardation. J Obstet Gynecol Neonatal Nurs 1998;27(3):251–6. [3] Huovinen KJ. Gynecological problems of mentally retarded women. A case–control study from southern Finland. Acta Obstet Gynecol Scand 1993;72(6):475–80. [4] Wilkinson JE, Cerreto MC. Primary care for women with intellectual disabilities. J Am Board Fam Med 2008;21(3):215–22. [5] Atkinson E, Bennett MJ, Dudley J, Grover S, Matthews K, Moore P, et al. Consensus statement: Menstrual and contraceptive management in women with an intellectual disability. Aust N Z J Obstet Gynaecol 2003;43(2):109–10. [6] ACOG. Sterilization of women, including those with mental disabilities. Number 371. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committeeon-Ethics/Sterilization-of-Women-Including-Those-With-Mental-Disabilities. Published July 2007. Updated 2009. Accessed November 20, 2014. [7] Wheeless CR. Abdominal hysterectomy for surgical sterilization in the mentally retarded: a review of parental opinion. Am J Obstet Gynecol 1975;122(7):872–5. [8] Van der Merwe JV, Roux JP. Sterilization of mentally retarded persons. Obstet Gynecol Surv 1987;42(8):489–93. [9] Kaunitz AM, Thompson RJ, Kaunitz KK. Mental retardation: a controversial indication for hysterectomy. Obstet Gynecol 1986;68(3):436–8. [10] Passer A, Rauh J, Chamberlain A, McGrath M, Burket R. Issues in fertility control for mentally retarded female adolescents: II. Parental attitudes toward sterilization. Pediatrics 1984;73(4):451–4. [11] Sheth S, Malpani A. Vaginal hysterectomy for the management of menstruation in mentally retarded women. Int J Gynecol Obstet 1991;35(4):319–21. [12] Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano GF. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol 1999;180(2 Pt 1):270–5. [13] Olsson JH, Ellstrom M, Hahlin M. A randomised prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol 1996;103(4):345–50. [14] Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005; 330(7506):1478. [15] Vagias WM. Likert-type scale response anchors. https://www.clemson.edu/centersinstitutes/tourism/documents/sample-scales.pdf. Published 2006. Accessed November 20, 2014. [16] Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci 2006;1:9–14. [17] Frumovitz M, dos Reis R, Sun CC, Milam MR, Bevers MW, Brown J, et al. Comparison of total laparoscopic and abdominal radical hysterectomy for patients with earlystage cervical cancer. Obstet Gynecol 2007;110(1):96–102. [18] Reich H, Roberts L. Laparoscopic hysterectomy in current gynaecological practice. Rev Gynaecol Pract 2003;3:32–40. [19] Sarmini OR, Lefholz K, Froeschke HP. A comparison of laparoscopic supracervical hysterectomy and total abdominal hysterectomy outcomes. J Minim Invasive Gynecol 2005;12(2):121–4. [20] Schindlbeck C, Klauser K, Dian D, Janni W, Friese K. Comparison of total laparoscopic, vaginal and abdominal hysterectomy. Arch Gynecol Obstet 2008;277(4):331–7. [21] Chalermchockchareonkit A, Tekasakul P, Chaisilwattana P, Sirimai K, Wahab N. Laparoscopic hysterectomy versus abdominal hysterectomy for severe pelvic endometriosis. Int J Gynecol Obstet 2012;116(2):109–11. [22] American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Number 311, April 2005. Appropriate use of laparoscopically assisted vaginal hysterectomy. Obstet Gynecol 2005;105(4):929–30. [23] Takeda A, Manabe S, Hosono S, Nakamura H. Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger. J Minim Invasive Gynecol 2005;12(3):234–40. [24] Chalermchockcharoenkit A, Tanmahasamut P. The trend shift in hysterectomy technique in Siriraj Hospital. Siriraj Med J 2007;59:325–7.
Please cite this article as: Chalermchockcharoenkit A, et al, Safety and caregiver satisfaction associated with laparoscopic hysterectomy among young patients with intellectual disability, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.01.019
