In Laparoscopic Myomectomy, Does a Caseload of 100 Patients During the Learning Curve Produce a Significant Improvement in Performance Measures?

PURPOSE: Laparoscopic myomectomy (LM) offers considerable advantages over open myomectomy; however, LM is technically complex and associated with a steep learning curve. Few studies have evaluated the effect of the learning curve, and the limitations of most of these studies were the number of women included and the multiplicity of surgeons undertaking the procedure. The aim of this study is to evaluate the effect of a caseload of 100 patients during the learning curve of a single experienced surgeon performing LM. METHODS: A prospective comparative analysis of 200 consecutive cases of LM was conducted between December 2004 and March 2013. Outcomes of the first 100 procedures (Group A) were compared with the later 100 (Group B). RESULTS: The mean age of the cohort was 39 years (24-54 years), with a mean BMI of 27 kg/m(2) (16-46). Both the groups were very similar with regard to the number, size and weight of myomas removed, the duration of surgery, and blood loss. More women were sent home within 24 h in the second group (27 vs 10.2 %, p = 0.002). Group A suffered significantly higher complication rates compared to Group B (11 vs 7, p < 0.05). The laparotomy conversion rate was 1.5 % (3 in Group A, none in Group B). CONCLUSIONS: After a caseload of 100 patients during the learning curve, there was no difference in outcomes apart from increased confidence to discharge patients after 24 h and reduced complication rates. Thus, mere numbers do not influence the number/size of fibroids removed, operating time, or blood loss but do influence complication rates and post-operative discharge times.

Implications of perihepatic adhesions in women undergoing laparoscopic surgery for ectopic pregnancy.

OBJECTIVE: To establish whether the finding of perihepatic adhesions (PHAs) at laparoscopy for ectopic pregnancy (EP) is associated with poor perioperative and reproductive outcomes. METHODS: A retrospective cohort study was undertaken of all cases of EP managed surgically at a teaching hospital in northeast London in 2003-2013. Data for symptoms, reproductive history, ultrasonography findings, blood parameters, and findings at surgery were compared between patients with and without perihepatic adhesions (PHAs) identified at laparoscopy. RESULTS: Among 802 women with EP, PHAs were identified during surgery for 60 (7.5%). Compared with women without PHAs, patients with PHAs were significantly more likely to have had previous pelvic inflammatory disease, previous EP, previous tubal surgery, and the finding of abnormal contralateral adnexa or other adhesions during laparoscopy (P≤0.024 for all). They also had higher preoperative hemoglobin concentrations and smaller hemoperitoneum volumes (P≤0.04 for both). CONCLUSION: Women with PHAs at laparoscopy for EP had lower blood loss than did those without PHAs. The finding of PHAs was associated with an increased rate of recurrent EP, irrespective of a previous history of PID or EP.

Should we abandon all conservative treatments for uterine fibroids? The problem with leiomyosarcomas.

Fibroids are the most common tumor in women and many medical and surgical options exist for their management. The incidence of uterine sarcoma in women undergoing treatment for fibroids has previously been thought to be extremely rare, however there has been recent controversy as to whether this risk has been underestimated. This article reviews the literature investigating the incidence of leiomyosarcoma and explores how different treatment modalities may affect risk from occult malignancy. We aim to provide a tool for counseling women who are considering options for the management of their fibroids.

Beyond Guidelines: Effectiveness of a Programme in Achieving Operative Laparoscopy for all Women Requiring Surgical Management of Ectopic Pregnancy.

BACKGROUND/AIMS: Operative laparoscopy (OL) is considered the gold standard surgical treatment of ectopic pregnancy (EP). We questioned whether a training programme to foster OL treatment is able to ensure that all women needing surgical management are treated by OL irrespective of the site of EP, haemodynamic status and clinical complexity. METHODS: A 13-year cohort study of 963 women who underwent surgical management was conducted. We instituted a 'universal OL' programme in 2003 for the management of all the types of EP irrespective of the haemodynamic status. RESULTS: There were 802 women in the prospective (2003-2013) and 161 in the retrospective arm (2000-2002). The rate of OL before 2003 was 34%. During the year of programme implementation, the OL rate rose from 89% in 2003 to 96% in 2004. It took 4 years to achieve a 100% OL rate in haemodynamically stable patients. In 2013, we were able to achieve OL treatment for all patients irrespective of haemodynamic status, the complexity of surgery or the location of EP. CONCLUSION: Our study demonstrates that a dedicated team with special training in minimal invasive surgery can improve surgical management of all categories of EPs, and this goal should be achievable across most units.

Evaluation of the selective use of abdomino-pelvic drains at laparoscopic myomectomy: in enhanced recovery, do drains delay discharge home?

OBJECTIVE: To assess whether the use of abdominal drains at laparoscopic myomectomy (LM) influences length of hospital stay. The primary outcome was to determine whether the use of intra-abdominal drains after LM was associated with prolonged hospital stay after surgery. Secondary outcomes were to identify factors that influence the use of abdomino-pelvic drains during LM. STUDY DESIGN: Retrospective cohort study of 217 consecutive single surgeon LMs in a London university teaching hospital. Abdominal drains were used selectively after LM. Of the 217 patients, 123 (57%) had a drain left in situ at the end of the operation. RESULTS: The two cohorts of patients were not significantly different in their demographics. The use of a drain was significantly associated with an increased number of fibroids (4.6±3.8 vs. 2.8±2.1, p<0.0001), increased weight of fibroids (277±211 g vs. 133±153 g, p<0.0001), increased surgical time (133±40 min vs. 90±35 min, p<0.0001) and increased estimated blood loss (406±265 ml vs. 199±98 ml, p<0.0001). There was no statistically significant difference in length of hospital stay (mean duration of admission 2.1 days±0.98 with drain, vs. 2.1 days±0.97 without a drain, p=0.98). CONCLUSION: We conclude that although the use of a drain may be associated with a more complex operation, this does not delay the patient's discharge.

Laparoscopic treatment of uterine fibroids: a comparison of peri-operative outcomes in laparoscopic hysterectomy and myomectomy.

PURPOSE: To compare peri-operative outcomes between laparoscopic myomectomy (LM) and laparoscopic hysterectomy (LH) for the treatment of uterine fibroids. METHODS: Retrospective cohort study including 400 women who underwent LH or LM for the management of uterine fibroids. RESULTS: LH patients were older, with higher BMI and larger uterine size but LH was associated with shorter operative duration (80.2 vs. 115.7 min, p < 0.0001), lower blood loss (215 vs. 316 ml, p < 0.0001), and shorter hospital stay (1.81 vs. 2.12 days, p = 0.0003). Seven LM patients (3.2%) had blood loss >1000 ml compared with no LH patients and five LM patients (2.3%) required blood transfusion compared to 1 (0.5%) LH patient. Three LM patients (1.9%) and no LH patients required conversion to laparotomy. Bladder injury occurred in three LH cases (1.6%) and no LM cases. When the data was restricted only to women aged 44 years or over, LH was again associated with significantly lower operative duration and estimated blood loss. CONCLUSIONS: Particularly in perimenopausal women, the decision to perform myomectomy can be controversial. These data suggest that there are potential advantages to LH over LM, including reduced operation length, blood loss and hospital stay but increased risk of urinary tract injury.

Co-existence of uterine myomas and endometriosis in women undergoing laparoscopic myomectomy: risk factors and surgical implications.

STUDY OBJECTIVE: To investigate the prevalence of and explore risk factors for the coexistence of uterine myomas and endometriosis and to assess operative outcomes during laparoscopic myomectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary referral center in London, England. PATIENTS: Two hundred twelve women undergoing laparoscopic myomectomy to treat symptomatic uterine myomas. INTERVENTION: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Coexisting myomas and endometriosis were identified in 21.2% of patients. Endometriosis was more common in those with subfertility (44% vs 25.7%; p = .02) and less common in those with bleeding disorders (20% vs 45%; p = .003). Parity, location of myoma, and race/ethnicity affected risk of endometriosis, whereas size and number of myomas did not. Of patients with endometriosis, 42% underwent surgical treatment of endometriosis during myomectomy. Significantly more patients with endometriosis also underwent ovarian cystectomy than did those without endometriosis (15.6% vs 3%; p = .004). Operative time was similar in both groups (109.6 minutes vs 116.4 minutes; p = .83), as was estimated blood loss (271 mL vs 327 mL; p = .16). CONCLUSIONS: A diagnosis of concomitant endometriosis should be considered, in particular in patients with subfertility and pain. This enables optimal preoperative counseling and consent for potential additional procedures such as treatment of endometriosis or ovarian cystectomy.

Interstinal obstruction due to obturator hernia {a rarest presentation}.

An obturator hernia is a rare variety of abdominal hernia that presents with a confusing clinical picture. We present a case of 74-year-old woman who admitted to our hospital because of abdominal distention, abdominal pain, and vomiting for 3 days. Incarcerated intestinal obstruction due to the right-sided obturator hernia was found preoperatively. Perforation of the small bowel due to incarceration was noted during laparotomy. Bowel resection and anastomosis were done. She was recovered after 15 days of postoperative care. In this case report, we emphasize that preoperative high index of suspicion is required for diagnosis and treatment.

Plasma cell myeloma diagnosed in pregnancy.

Plasma cell myeloma (PCM) is an essentially incurable neoplastic disorder of terminally differentiated B cells. The neoplastic clone usually secretes a monoclonal protein in the serum or urine (the 'M band'). About 20% of PCM secrete light chains only, which are detectable in the urine as Bence Jones protein. The clinical picture is one of bone marrow failure, due to infiltration of the marrow by malignant plasma cells; renal failure due to damage to renal tubules by the excess light chains and pain due to lytic lesions of the bones. The outcome remains poor with median survival of 5 years.