Urological complications of laparoscopic hysterectomy: a four-year review at KK Women's and Children's Hospital, Singapore.

INTRODUCTION: This review assessed the incidence, predisposing conditions, and key surgical steps, where urological injuries occurred during laparoscopic hysterectomies at the Minimally Invasive Surgery Unit, KK Women's and Children's Hospital over a four-year period. METHODS: A retrospective review of 495 cases of laparoscopic assisted vaginal hysterectomies (LAVH) and total laparoscopic hysterectomy (TLH) from January 2001 to December 2004 was conducted. RESULTS: A total of eight urological injuries occurred, all within the initial two years of review. There were seven unintentional bladder injuries occurring at LAVH during dissection of the bladder off the uterovaginal attachment. The associated factors included previous caesarean section and fibroids. All bladder injuries were diagnosed and repaired intraoperatively with no long-term complications. A single case of ureteric injury occurred with TLH. The patient presented on the ninth postoperative day with fever and continuous vaginal discharge. The most likely aetiology was thermal damage from electrocautery used to secure haemostasis of the uterine artery pedicle. Ureteric re-implantation was eventually required in the patient. CONCLUSION: Urological injuries occurred in 1.6 percent of laparoscopic hysterectomies in our hospital. The predisposing factors include previous caesarean surgery, multiple fibroids and severe endometriosis. A definite learning curve exists with laparoscopic hysterectomy with a thorough knowledge of pelvic anatomy being an essential prerequisite for advanced pelvic surgery. Similarly, good exposure of the surgical field, vigilant dissection and judicious use of electro-surgery are important practices to adopt to prevent injuries.

Internal iliac artery ligation for arresting postpartum haemorrhage.

OBJECTIVE: To study the role of internal iliac artery ligation (IIAL) in arresting and preventing postpartum haemorrhage (PPH). DESIGN: Retrospective chart review of women undergoing therapeutic IIAL for PPH or prophylactic IIAL for risk of PPH. SETTING: Tertiary care hospital in Pune, India. SAMPLE: Women admitted to King Edward Memorial (KEM) Hospital, Pune, India, who underwent IIAL to control or prevent PPH. METHODS: Bilateral IIAL was performed in all women. MAIN OUTCOME MEASURES: Need for re-laparotomy or hysterectomy to control haemorrhage, complications of the procedure. RESULTS: Out of 110 women who underwent IIAL, 88 had therapeutic IIAL for PPH from atony (36), genital tract injury (23), placenta praevia (21), placental abruption (4), uterine inversion (3) or coagulopathy (1). Hysterectomy was performed after IIAL failed to arrest haemorrhage in 33 (39.3%) of 84 women (excluding 4 with vaginal lacerations). Hysterectomy was more likely with uterine rupture (79%) than with nontraumatic PPH (up to 27%). Failure to control haemorrhage by IIAL was evident immediately, and bleeding arrested by IIAL did not recur to require later laparotomy in any woman. Out of 22 women at high risk for PPH undergoing prophylactic IIAL at caesarean section, none had subsequent haemorrhage. One woman had an iliac vein injury that was repaired with no further morbidity. There were no ischaemic complications either during inpatient stay or up to 6 weeks. CONCLUSIONS: IIAL is useful in the treatment and prevention of PPH from any cause. Early resort to IIAL effectively prevents hysterectomy in women with atonic PPH. In traumatic PPH, IIAL facilitates hysterectomy or repair as indicated and prevents reactionary haemorrhage.