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Gynecologists May Underestimate the Amount of Blood Loss during Total Laparoscopic Hysterectomy.

ABSTRACT: Background:We considered the possibility of underestimation of the amount of bleeding during laparoscopic surgery, and we investigated comparing the amount of bleeding between laparoscopic surgery and open surgery by considering the concentration of hemoglobin before and after surgery as indicators. Methods:The following procedures were included: A, surgery for ovarian tumor; B, myomectomy; and C, hysterectomy either by laparoscopic surgery or open surgery. Patients who underwent the above procedures in between January 1, 2010, and December 31, 2017, were enrolled. We identified 1749 cases (A: 90, B: 105, and C: 325 of open surgery and A: 667, B: 437, and C: 125 of laparoscopic surgery). We considered the sum as an estimation of blood loss during surgery and the change in the value of hemoglobin in laboratory testing one day before and after surgery. Results:During laparoscopic surgery, the measurements of blood loss included the following: A: 59.8?ml; B: 168.6?ml; and C: 206.8?ml. During open surgery, measurements of blood loss included the following: A: 130.7?ml; B: 236.7?ml; and C; 280.9?ml. The reduction of hemoglobin after surgery compared with that before surgery was less in laparoscopic surgery than that in open surgery in A and B; however, this reduction was not significantly different in C. Conclusion:Our results suggest that the estimation of the bleeding in A and B was appropriate; however, the estimation might be underestimated in C during laparoscopic surgery.

SUBMITTER: Sato M

PROVIDER: S-EPMC6311784 | biostudies-other | 2018

REPOSITORIES: biostudies-other

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Gynecologists May Underestimate the Amount of Blood Loss during Total Laparoscopic Hysterectomy.

Sato Masakazu M Koizumi Minako M Inaba Kei K Takahashi Yu Y Nagashima Natsuki N Ki Hiroshi H Itaoka Nao N Ueshima Chiharu C Nakata Maki M Hasumi Yoko Y

Obstetrics and gynecology international 20181216

<h4>Background</h4>We considered the possibility of underestimation of the amount of bleeding during laparoscopic surgery, and we investigated comparing the amount of bleeding between laparoscopic surgery and open surgery by considering the concentration of hemoglobin before and after surgery as indicators.<h4>Methods</h4>The following procedures were included: A, surgery for ovarian tumor; B, myomectomy; and C, hysterectomy either by laparoscopic surgery or open surgery. Patients who underwent ...[more]

PMID: 30647741

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Project description:BackgroundAdvanced surgical techniques, such as total laparoscopic hysterectomy, are often challenging to acquire beyond fellowship training programs for practicing obstetrician-gynecologists. A lack of formative data currently exist for continuing medical education programs, limiting our understanding of how improvement in surgical skills and training programs occur.ObjectiveThis study aimed to investigate how practicing obstetrician-gynecologists acting as trainees experience a program that aims to teach them total laparoscopic hysterectomy, and to assess whether their surgical skills improve according to data from formative assessment tools and qualitative data from open-ended survey questions and in-depth interviews.Study designWe report a process analysis of formative data collected during a pilot implementation trial of a surgical training program targeting practicing obstetrician-gynecologists. Eleven consultant obstetrician-gynecologists and 4 experienced surgical mentors participated in 4 hospitals in Queensland, Australia. Total laparoscopic hysterectomy was performed in 700 patients over the course of the study. A total laparoscopic hysterectomy surgical mentorship training program of 10 training days with up to 3 total laparoscopic hysterectomy procedures per day was performed. Both the obstetrician-gynecologists and the surgical mentor completed a formative assessment questionnaire analyzing the trainee's performance after each surgical procedure. Mentors were formatively assessed by the Structured Training Trainer Assessment Report (STTAR) and at the completion of the study by the mini-STTAR, a summative assessment of quality of mentorship. Obstetrician-gynecologists, mentors, hospital leaders, and surgical administrative staff participated in qualitative interviews about the training program.ResultsOver time, there was a demonstrated improvement in trainee performance reported by both mentors and trainees in all competency assessment tool domains as the case number increased, with mentors consistently rating trainees' performance higher than the trainees themselves. Most trainees were satisfied with their mentor in all 31 areas during formative assessment, and at the end of the training, structure, attributes, and role modeling were all rated high (average score >4.5; range, 3.79-5.00), whereas training behavior was rated slightly lower at 4.1 (range, 3.79-4.45). Qualitative interviews demonstrated that the trainees found the training to be a beneficial, hands-on experience.ConclusionFormative assessment clearly documented improvement in surgical skills during a total laparoscopic hysterectomy training program for consultant obstetrician-gynecologists.

Project description:This study directly compares total intrafascial laparoscopic (TAIL) hysterectomy with vaginal (VH) and abdominal (AH) hysterectomy with regard to safety, operating time and time of convalescence. The study is a prospective cohort study (Canadian Task Force classification II-2), including data from patients of a single university-affiliated teaching institution, admitted between 1997 and 2008 for hysterectomy due to benign uterus pathology. Patient data were collected pre-, intra- and postoperatively and complications documented using a standardised data sheet of a Swiss obstetric and gynaecological study group (Arbeitsgemeinschaft Schweizerische Frauenkliniken, Amlikon/Switzerland). Classification of complications (major complications and minor complications) for all three operation techniques, evaluation of surgeons and comparison of operation times and days of hospitalisation were analysed. 3066 patients were included in this study. 993 patients underwent AH, 642 VH and 1,431 total intrafascial hysterectomy. No statistically significant difference for the operation times comparing the three groups can be demonstrated. The mean hospital stay in the TAIL hysterectomy, VH and AH groups is 5.8 +/- 2.4, 8.8 +/- 4.0 and 10.4 +/- 3.9 days, respectively. The postoperative minor complications including infection rates are low in the TAIL hysterectomy group (3.8%) when compared with either the AH group (15.3%) or the VH group (11.2%), respectively. The total of minor complications is statistically significant lower for TAIL hysterectomy as for AH (O.R. 4.52, CI 3.25-6.31) or VH (O.R. 3.16, CI 2.16-4.62). Major haemorrhage with consecutive reoperation is observed statistically significantly more frequent in the AH group when compared to the TAIL hysterectomy group, with an O.R. of 6.13 (CI 3.05-12.62). Overall, major intra- and postoperative complications occur significant more frequently in the AH group (8.6%) when compared to the VH group (3%) and the TAIL hysterectomy group (1.8%). The incidence of major complications applying the standardised TAIL hysterectomy technique is not related to the experience of the surgeons. We conclude that a standardised intrafascial technique of total laparoscopic (TAIL) hysterectomy using an anatomically developed special uterine device is associated with a very low incidence of minor and major intra- and postoperative complications. The direct comparison of complication rates with either vaginal or abdominal hysterectomy favours the total laparoscopic technique, and therefore, this technique can be recommended as a relatively atraumatic procedure. The operation times are comparable for all three techniques without any statistically significant differences. This technique for laparoscopic hysterectomy is shown to be equally safe when applied by experienced gynaecologic surgeons or by residents in training. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s10397-010-0569-0) contains supplementary material, which is available to authorized users.

Project description:Study objectiveThe findings of previous studies have been inconsistent as to whether benign hysterectomy via minimally invasive laparoscopic surgery increases the risk of vesicoureteral injury when compared with laparotomy. The objectives of our study were to (1) examine the rate of vesicoureteral injury on benign hysterectomy by the surgical approach and (2) compare the risk of vesicoureteral injury specifically between minimally invasive laparoscopic and abdominal hysterectomy on a populational level.DesignRetrospective population-based observational study.SettingThe National Inpatient Sample.PatientsA total of 501 110 women who had undergone hysterectomy for benign gynecologic disease between January 2012 and September 2015 were included as follows: total abdominal hysterectomy (TAH, n = 284 365 [56.7%]), total laparoscopic hysterectomy (TLH, n = 60 410 [12.1%]), abdominal supracervical hysterectomy (Abd-SCH, n = 55 655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n = 45 620 [9.1%]), total vaginal hysterectomy (TVH, n = 34 865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH, n = 20 195 [4.0%]).InterventionsA comprehensive risk assessment for vesicoureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing was used to compare (1) TLH versus TAH and (2) LSC-SCH versus Abd-SCH with generalized estimating equations. In a sensitivity analysis, gynecologic disease-specific injury risk and vaginal route-specific injury risk (LAVH vs TVH) were assessed.Measurements and main resultsVesicoureteral injury was reported in 1045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas LSC-SCH had the lowest (0.10%) (p <.001). TLH (0.13%) had the highest ureteral injury rate, whereas TAH had the lowest (0.04%) (p <.001). In propensity score inverse probability of treatment weighing models, compared with TAH, TLH was associated with an increased risk of ureteral injury (odds ratio [OR] 3.95, 95% confidence interval [CI] 2.03-7.67, p <.001) but not bladder injury (OR 1.04, 95% CI 0.57-1.90, p = .897). Risk of ureteral injury was particularly high when TLH was performed for endometriosis (OR 6.15, 95% CI 1.18-31.9, p = .031) or for uterine myoma (OR 4.15, 95% CI 2.13-8.11, p <.001). In contrast, for supracervical or vaginal hysterectomy, minimally invasive laparoscopic approaches were not associated with an increased risk of vesicoureteral injury (LSC-SCH vs Abd-SCH: OR 0.62, 95% CI 0.19-1.98, p = .419; LAVH vs TVH: OR 1.21, 95% CI 0.63-2.33, p = .564).ConclusionThe risk of vesicoureteral injury on benign hysterectomy is low overall regardless of hysterotomy modalities but varies widely with the surgical approach. Compared with TAH, TLH may be associated with an increased risk of ureteral injury.

Project description:IntroductionHysterectomy is the most common major gynaecological procedure in women and minimally invasive approaches should be used wherever possible; total laparoscopic hysterectomy (TLH) is one such surgical approach which allows removal of the uterus entirely laparoscopically. However, lack of surgical training opportunities is impeding its increased adoption. This study will formally test a surgical outreach training model to equip surgeons with the skills to provide TLH as an alternative to total abdominal hysterectomy (TAH).Methods and analysisStepped wedge implementation trial of a surgical training programme for practising obstetrician gynaecologist specialists in four hospitals.Primary outcomesChange in the proportion of hysterectomies performed by TAH, measured between preintervention and postintervention; we aim to reduce TAH by at least 30% in 75% of the trainees.Secondary outcomes(1) Number of hospitals screened, eligible, agree to training and complete the training; (2) number of surgeons screened for eligibility, eligible, agree to training, who complete training and achieve proficiency; (3) proportion of trainees achieving proficiency in correct theatre setup, vascular exposure, mobilisation and surgery closure; change in proportion proficient over time; (4) adverse events (conversion from TLH to TAH, anaesthetic incident, intraoperative visceral injury, red cell transfusions, hospital stay >7 days, incidental finding of malignancy, unplanned readmission, admission to intensive care, return to theatre, postoperative pulmonary embolism or deep vein thrombosis, development of a fistula, vault haematoma, vaginal vault dehiscence or pelvic infection); (5) hospital length-of-stay; (6) cost-effectiveness and (7) trainee surgeon proficiency with TLH.Ethics and disseminationThe study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee and has received site-specific approval from all participating hospitals. Results will be submitted for publication in a peer-reviewed journal.Trial registration numberNCT03617354; Pre-results.

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Gynecologists May Underestimate the Amount of Blood Loss during Total Laparoscopic Hysterectomy.

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Gynecologists May Underestimate the Amount of Blood Loss during Total Laparoscopic Hysterectomy.

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