Objective follow-up after transection of uterine round ligament during laparoscopic repair of inguinal hernias in women: assessment of safety and long-term outcomes.

BACKGROUND: Whether to preserve the uterine round ligament during laparoscopic inguinal hernia repair in women is controversial. In this study, we aimed to compare outcomes of uterine round ligament preservation versus transection during such surgery and to explore the impact and long-term outcomes of transecting the round ligament. METHODS: The study cohort comprised 419 women who had undergone laparoscopic inguinal hernia repair in Beijing Chaoyang Hospital and Qilu Hospital from January 2013 to January 2020; 393 (93.8%) of whom were successfully followed up. Patient characteristics and technical details of the operative procedure were collected and analyzed retrospectively. Early and late postoperative follow-up data, complications, especially symptoms related to retroflexed uterus, and fertility outcomes, were collected by a single follow-up nurse who was blinded to the operative procedure. RESULTS: There were 218 women (239 sides) in the uterine round ligament preservation group and 175 (182 sides) in the transection group. The patients in the preservation group were younger (45.9 vs. 53.6 years, p = 0.000), and had lower American Society of Anesthesiologists scores (p = 0.000). The median follow-up times in the preservation and transection groups were 41.8 ± 24.2 and 42.7 ± 24.6 months, respectively (p = 0.692). Compared with the transection group, the preservation group had longer operative times for repair of both primary and recurrent hernias. Intraoperative bleeding, length of hospital stay, development of seromas, recurrence rate, incidence of postoperative pain at the first and third postoperative months, and time of last outpatient visit were similar in the two groups. There were more premenopausal patients in the preservation group; however, we found no evidence that transection of the round ligament affected subsequent pregnancy or childbirth. Moreover, we identified no differences in dyspareunia, dysmenorrhea, chronic pelvic pain, or uterine prolapse. CONCLUSION: Transection of the round ligament during laparoscopic inguinal hernia repair in women does not increase the incidence of dyspareunia, dysmenorrhea, chronic pelvic pain, or uterine prolapse, whereas it has the advantage of reducing the operation time.

Chronic Pelvic Pain Educational Experience Among Minimally Invasive Gynecologic Surgery Fellows and Recent Graduates: A Needs Assessment.

STUDY OBJECTIVE: Learning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP. DESIGN: The AAGL-Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options. SETTING: Electronic survey. PATIENTS: Not applicable. INTERVENTIONS: The survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years. MEASUREMENTS AND MAIN RESULTS: Fifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a "good amount" of experience or "extensive" experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having "no" or "little" experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p =.002; recent graduates OR 1.5, p < .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p = .0021; recent graduates OR 1.5, p <.001), and the desire to incorporate the treatment of CPP into future clinical practice (current fellows OR 1.8, p = .0099; recent graduates OR 1.3, p = .0178). More than 80% (43/53) of current fellows indicated that they believed an expanded pelvic pain curriculum should be part of the FMIGS fellowship. CONCLUSION: This needs assessment of FMIGS fellows and recent graduates suggests that there are gaps between FMIGS curriculum objectives and current educational experiences, and that fellows desire increased CPP exposure. Expansion and standardization of the CPP educational experience is needed and could lead to increased focus on this disease process among subspecialty benign gynecologic surgeons.

Negative Sliding Sign during Dynamic Ultrasonography Predicts Low Endometriosis Fertility Index at Laparoscopy.

STUDY OBJECTIVE: Endometriosis fertility index (EFI) is a robust tool to predict the pregnancy rate in patients with endometriosis who are attempting non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Newly established imaging techniques such as sliding sign, which is used to diagnose pouch of Douglas obliteration, could provide a promising alternative. The objective of this study was to investigate the practicality of using ultrasound data to predict a low EFI (score ≤6). DESIGN: Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort, clinicaltrials.gov #NCT02911090). Analyzed data were captured from December 2013 to June 2017. SETTING: Tertiary referral center at British Columbia Women's Hospital. PATIENTS: We analyzed data for 2583 participants from the Endometriosis Pelvic Pain Interdisciplinary Cohort. In this cross-sectional study, we included 86 women aged <40 years. INTERVENTIONS: Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Logistic regression was used to obtain receiver operating characteristic area under the curve (AUC) for the prediction models. Significance was p <.05. Patients with a negative sliding sign were older and had severe endometriosis and longer duration of infertility. Patients with a negative sliding sign had significantly lower total EFI scores and lower surgical factors scores than patients with a positive sliding sign. Logistic regression showed that a negative sliding sign and EFI historic factors score can predict an EFI score ≤6 (sensitivity = 87.9%, specificity = 81.1%, AUC = 0.93 [95% confidence interval, 0.88-0.98]). Adding the diagnosis of endometrioma to the previous prediction model resulted in AUC = 0.95 (95% confidence interval, 0.90-0.995), sensitivity = 84.8%, and specificity = 92.5%. CONCLUSION: The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historic factors and the diagnosis of endometrioma to predict an EFI score ≤6 for patients who are not scheduled for immediate surgery.

Subjective social status and depression symptoms: a prospective study of women with noncancerous pelvic problems.

OBJECTIVE: Subjective social status (SSS) may be a stronger determinant of health than objective measures of socioeconomic status. We sought to examine the effect of community and national SSS on symptoms of depression in a racially/ethnically diverse sample of adult women with noncancerous uterine conditions. METHODS: We conducted a secondary analysis of data obtained from 634 women who enrolled in the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) in 2003 and 2004. SOPHIA was a longitudinal study of women aged 31 to 54 who were experiencing abnormal uterine bleeding, symptomatic fibroids, or pelvic pain. The primary outcome for this analysis consisted of symptoms suggesting major or other depressive disorder, as measured by the Patient Health Questionnaire-9, 2 years after study enrollment. We hypothesized that women who had low community and national SSS at baseline, as measured by the MacArthur SSS ladder, would be at higher risk of experiencing symptoms of depression at follow-up. RESULTS: Women with low community SSS had an increased odds of experiencing depression symptoms 2 years later compared with women with high SSS, after adjusting for age, pelvic problem impact and baseline depression (odds ratio, 2.93; 95% CI, 1.11-7.77). Odds remained elevated after further adjusting for income and education. Results for the national ladder were not significant. CONCLUSION: Low perceived community social status is predictive of symptoms suggestive of major or other depressive disorder among women with noncancerous uterine conditions. Asking about perceived community social status can help clinicians to identify patients who may be at increased risk for depressive disorders. Asking about perceived national social status does not seem to add value beyond that provided by income and education.

A descriptive cost analysis study of cases of right iliac fossa pain.

Patients with suspected appendicitis comprise a large proportion of general surgical workload. The resulting healthcare burden is significant when one considers that investigations, observation and surgical procedures are often needed. As no previous study has examined the cost of managing patients with suspected appendicitis, we performed a cost analysis study of management of cases of right iliac fossa (RIF) pain in University Hospital Limerick. Patients who were admitted with right iliac fossa pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients' medical records were reviewed. Costing data collected comprised details on length of stay, number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed. Costs for radiological investigations were obtained from casemix data. Blood investigation costs were obtained from relevant laboratories. Medication costs were obtained from the pharmacy department. Operation costs were based on the cost of equipment combined with cost relating to operating theatre time and recovery unit time. Due to unavailability of data on Irish public hospital bed-day cost, a private hospital provided cost details on this aspect. 94 patients (M = 33, F = 61) were admitted with RIF pain during this time period. 62 underwent surgery. There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis. Blood test, radiology, pharmacy, operative and bed-day costs were €1857, €6252, €3517, €184,191 and €152,706 respectively. The total estimated cost was €348,525 (€3708 average per patient). There is a high cost associated with managing suspected appendicitis in Ireland. Strategies to reduce cost include reducing unnecessary admissions and unnecessary operations. Reducing LOS may be another potentially valuable cost saving method. It is imperative that resources are channelled into the provision of accurate costing structures.

Long-term follow-up after meshectomy with acellular human dermis repair for postherniorrhaphy inguinodynia.

HYPOTHESIS: Direct inguinal hernia repair with acellular human dermis (AHD) may offer greater symptom improvement and lower risk of hernia recurrence than anatomical repair without mesh (AWM) after mesh removal (with or without neurectomy) for postherniorrhaphy inguinodynia. DESIGN: Retrospective cohort study with long-term follow-up. SETTING: Tertiary referral center for mesh inguinodynia. PATIENTS: Patients undergoing meshectomy (with or without neurectomy) for postherniorrhaphy inguinodynia were identified. Medical records were reviewed, and patients were contacted to evaluate outcomes. Patients whose postmeshectomy hernias were repaired using AHD vs AWM were compared. MAIN OUTCOME MEASURES: Patient satisfaction and recurrence. RESULTS: Sixty-seven patients (35 in the AHD group and 32 in the AWM group) completed the follow-up. Patient demographics, duration and severity of symptoms, and time to meshectomy were similar between groups. The mean length of follow-up was 31.9 months for the AHD group and 80.2 months for the AWM group (P < .001). Fewer neurectomies were performed in the AHD group than in the AWM group (43% [15 of 35] vs 72% [23 of 32], P = .03). Eighty-three percent (29 of 35) of patients in the AHD group reported good or excellent groin pain improvement compared with 72% (23 of 32) of patients in the AWM group (P = .38). Eighty-three percent (29 of 35) of patients in the AHD group were satisfied with results compared with 81% (26 of 32) of patients in the AWM group (P = >.99). The AHD vs AWM procedures were associated with similar recovery, time to hernia recurrence, complication rates (11% [4 of 35] vs 3% [1 of 32], P = .36), and hernia recurrence rates (9% [3 of 35] vs 12% [4 of 32], P = .80). Predictors of patient dissatisfaction with meshectomy included patient smoking (odds ratio, 9.1; P = .01) and filing of workers' compensation claims (odds ratio, 12.8; P = .02). CONCLUSIONS: Meshectomy (with or without neurectomy) for postherniorrhaphy inguinodynia leads to significant symptom improvement and patient satisfaction, with acceptable morbidity and recurrence rates. The use of AHD vs AWM does not improve iatrogenic hernia recurrence.

Predictors of hysterectomy use and satisfaction.

OBJECTIVE: To identify static and time-varying sociodemographic, clinical, health-related quality-of-life and attitudinal predictors of use and satisfaction with hysterectomy for noncancerous conditions. METHODS: The Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) was conducted from 1998 to 2008. English-, Spanish-, or Chinese-speaking premenopausal women (n=1,420) with intact uteri who had sought care for pelvic pressure, bleeding, or pain from an academic medical center, county hospital, closed-panel health maintenance organization, or one of several community-based practices in the San Francisco Bay area were interviewed annually for up to 8 years. Primary outcomes were use of and satisfaction with hysterectomy. RESULTS: A total of 207 women (14.6%) underwent hysterectomy. In addition to well-established clinical predictors (entering menopause, symptomatic leiomyomas, prior treatment with gonadotropin-releasing hormone agonist, and less symptom resolution), greater symptom impact on sex (P=.001), higher 12-Item Short Form Health Survey mental component summary scores (P=.010), and higher scores on an attitude measure describing "benefits of not having a uterus" and lower "hysterectomy concerns" scores (P<.001 for each) were predictive of hysterectomy use. Most participants who underwent hysterectomy were very (63.9%) or somewhat (21.4%) satisfied in the year after the procedure, and we observed significant variations in posthysterectomy satisfaction across the clinical sites (omnibus P=.036). Other determinants of postsurgical satisfaction included higher pelvic problem impact (P=.035) and "benefits of not having a uterus" scores (P=.008) before surgery and greater posthysterectomy symptom resolution (P=.001). CONCLUSION: Numerous factors beyond clinical symptoms predict hysterectomy use and satisfaction. Providers should discuss health-related quality of life, sexual function, and attitudes with patients to help identify those who are most likely to benefit from this procedure.

Laparoscopic uterine nerve ablation versus vaginal uterosacral ligament resection in postmenopausal women with intractable midline chronic pelvic pain: a randomized study.

OBJECTIVE: To assess and compare the laparoscopic uterine nerve ablation (LUNA) and the vaginal uterosacral ligament resection (VUSR) in postmenopausal women with chronic pelvic pain (CPP). STUDY DESIGN: Eighty postmenopausal women with intractable and severe midline CPP were randomized to undergo LUNA or VUSR. Costs of two surgical procedures were assesses. Cure rate, severity of CPP, and deep dyspareunia were also evaluated after 6 and 12 months from surgery. RESULTS: The mean cost of LUNA resulted significantly higher in comparison with VURS (2078+/-637 versus 1497+/-297, P<0.001). The cure rate was not significantly different between the two groups at 6 (33/40, 82.5% versus 35/40, 87.5% for groups A and B, respectively; P=0.530; RR 0.94, 95% CI 0.78-1.13), and 12 months (27/36, 75.0% versus 28/38, 73.7%, for groups A and B, respectively; P=0.901; RR 0.90, 95% CI 0.78-1.33) of follow-up. At same times, a significant (P<0.01) decrease in severity of CPP and deep dyspareunia was observed in both groups with no difference between them. CONCLUSIONS: Both LUNA and VUSR are equally effective surgical treatments in postmenopausal women with central CPP but VUNR is significantly cheaper than LUNA.

SOGC clinical guidelines. Hysterectomy.

OBJECTIVE: To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully. OPTIONS: The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners. OUTCOMES: Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits. EVIDENCE: Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery. RECOMMENDATIONS: Benign Disease 1. Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus. (I-A) 2. Abnormal uterine bleeding: Endometrial lesions must be excluded and medical alternatives should be considered as a first line of therapy. (III-B) 3. Endometriosis: Hysterectomy is often indicated in the presence of severe symptoms with failure of other treatments and when fertility is no longer desired. (1-B) 4. Pelvic relaxation: A surgical solution usually includes vaginal hysterectomy, but must include pelvic supporting procedures. (II-B) 5. Pelvic pain: A multidisciplinary approach is recommended, as there is little evidence that hysterectomy will cure chronic pelvic pain. When the pain is confined to dysmenorrhea or associated with significant pelvic disease, hysterectomy may offer relief. (II-C) Preinvasive Disease 1. Hysterectomy is usually indicated for endometrial hyperplasia with atypia. (I-A) 2. Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy. (I-B) 3. Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when invasive disease has been excluded. (I-B) Invasive Disease 1. Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma. (I-A) Acute Conditions 1. Hysterectomy is indicated for intractable postpartum hemorrhage when conservative therapy has failed to control bleeding. (II-B) 2. Tubo-ovarian abscesses that are ruptured or do not respond to antibiotics may be treated with hysterectomy and bilateral salpingo-oophorectomy in selected cases. (I-C) 3. Hysterectomy may be required for cases of acute menorrhagia refractory to medical or conservative surgical treatment. (II-C) Other Indications 1. Consultation with an oncologist or geneticist is recommended when considering hysterectomy and prophylactic oophorectomy for a familial history of ovarian cancer. (III-C) Surgical Approach 1. The vaginal route shoe should be considered as a first choice for all benign indications. The laparoscopic approach should be considered when it reduces the need for a laparotomy. (III-B) VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.

A comparison of laparoscopic supracervical hysterectomy vs laparoscopically assisted vaginal hysterectomy.

BACKGROUND: We set out to compare the length of stay, costs, and morbidity associated with laparoscopic supracervical hysterectomy (LSH) with laparoscopically assisted vaginal hysterectomy (LAVH). METHODS: We performed a cohort analysis of consecutive patients at a university-based medical center from April 1997 through October 1999. RESULTS: A total of 145 patients were identified initially; however, 13 cases were excluded because of concomitant procedures (retropubic urethropexy, lymphadenectomy, paravaginal repair). Of the 132 patients included in the study, 27 underwent LSH and 105 underwent LAVH. The two groups were similar with respect to gravidity, parity, uterine weight, and preoperative diagnosis. Patients undergoing LSH had significantly shorter operating times (median, 181 vs 220 min, p = 0.007), briefer hospital stays (median, 1.0 vs 2.0 days, p = 0.0001), and less blood loss (median, 125 vs 400 ml, p = 0.0001). None of the patients submitted to LSH experienced morbidity, as compared with a 13% morbidity rate for LAVH (bladder injury, n = 3; blood loss >1000 ml, n = 7; vaginal cuff hematoma, n = 4; 0% vs 13%; p = 0.04). CONCLUSIONS: Patients undergoing laparoscopic supracervical hysterectomy had shorter operating times, shorter hospital stays, and less morbidity than those who underwent laparoscopically assisted vaginal hysterectomy. The practice of routine cervicectomy at laparoscopic hysterectomy should be reconsidered.

Transvaginal hydrolaparoscopy, a new technique for pelvic assessment.

Transvaginal hydrolaparoscopy is based on classic culdoscopy. With alterations in equipment and method, the procedure holds promise for evaluation of pelvic pathology. We performed transvaginal hydrolaparoscopy in the operating room just before operative laparoscopy in 15 patients, to evaluate the feasibility of this procedure. Excellent images of the cul-de-sac, fimbriae, and caudal surface of the uterus, ovaries, and pelvic sidewall were obtained. We believe this is a practical and convenient office diagnostic procedure.

Modeling of medical and surgical treatment costs of chronic pelvic pain: new paradigms for making clinical decisions.

Additional complexity has been added to the healthcare decision-making process by the socioeconomic constraints of the industry and a population that is increasingly educated about healthcare. As a result, decisions balanced on the basis of outcomes and economic realities are needed. This modeling of surgical versus medical treatment costs for chronic pelvic pain and endometriosis factors in the large number of women with chronic pelvic pain, direct and indirect costs of the condition, and clinical benefits, projected costs, and savings of the therapies. This process of calculation becomes an aid for decision making in the current healthcare system.

Office microlaparoscopy under local anesthesia.

Office laparoscopy under local anesthesia is especially suited to meet the current pressures of quality versus cost in an era of managed care. It is likely that this technique will soon become a major part of the practicing gynecologist's diagnostic operative armamentarium. Advantages of office microlaparoscopy under local anesthesia are realized by the practitioner, the patient, and the managed care provider. Office microlaparoscopy under local anesthesia is a safe, effective, and less costly tool for the evaluation of patients with many different indications. To date, the procedure has been primarily used for patients with infertility, chronic pelvic pain, and tubal ligation. The ease of scheduling, reduced costs, and rapid recovery suggest that it may be the preferred initial procedure for these patients.

Comparative study of laparoscopic oophorectomy.

STUDY OBJECTIVE: To determine the differences between laparoscopic oophorectomies and oophorectomies performed by laparotomy with respect to total hospital cost, length of hospital stay, and operative time. DESIGN: A prospective analysis of all women who underwent one of these procedures from January 1, 1992, to December 31, 1992. SETTING: A university-affiliated hospital. PATIENTS: Fifty-seven women requiring surgery for the management of pelvic pain, adnexal masses, or endometriosis. INTERVENTIONS: Twenty-six women underwent laparoscopic surgery and 31 had laparotomy. MEASUREMENTS AND MAIN RESULTS: The results for laparoscopy and laparotomy, respectively, were as follows: mean hospital cost $6139 versus $7053 (p = 0.02); hospital stay 1.07 versus 3.87 days (p = 0. 00); and mean operative time 175.23 versus 136.94 minutes (p = 0. 003). No woman had a serious complication, and none in the laparoscopy group required a laparotomy. CONCLUSION: Laparoscopic oophorectomy is a safe, highly successful, and cost-effective procedure, although it is associated with a longer operative time than laparotomy.

Cost-benefit analysis of laparoscopic versus laparotomy salpingo-oophorectomy for benign tubo-ovarian disease.

STUDY OBJECTIVE: To compare laparoscopy and laparotomy adnexectomy with respect to operating time, complications, length of hospitalization, convalescence, effectiveness, and surgical and equipment cost. DESIGN: A comparison of 30 consecutive patients undergoing laparoscopic adnexectomy from January 1990 to July 1991, and 27 consecutive patients who underwent adnexectomy by laparotomy from January 1985 to December 1990. SETTING: Private practice of one surgeon (GAV), and Department of Obstetrics and Gynecology, Lawson Research Institute, St. Joseph's Health Care Center, London, Ontario, Canada. PATIENTS: All patients had had a hysterectomy with preservation of at least one adnexa. The indications for adnexectomy were chronic pelvic pain or adnexal mass less than 6 cm diameter, with benign characteristics defined by sonography and tumor markers. INTERVENTIONS: Laparoscopic adnexectomy was performed by three-puncture technique with bipolar coagulation and endoloop ligation of the pedicle. Dissection and resection were performed with the carbon dioxide laser or scissors. RESULTS: Differences were noted between laparoscopy and laparotomy (mean +/- SD) in operating time (90 +/- 40 vs 65 + 20 min, p < 0.01), complications (11% vs 18.5%, p < 0.05), effectiveness (72% vs 72%), length of hospitalization (1.7 +/- 1.0 vs 7.1 +/- 1.2 days, p < 0.05), convalescence (2.2 +/- 1.7 vs 9.5 +/- 5.2 wks, p < 0.05), surgical cost ($1603 vs $5158), and equipment cost ($198,048 vs $17,345). CONCLUSIONS: Operating time, complications, safety, efficiency, and effectiveness were comparable for the two procedures. Markedly reduced hospitalization in the laparoscopy group resulted in a mean saving per patient of $3555. These women also had shorter convalescence and earlier return to normal activities and employment. The cost of laparoscopic equipment appears prohibitive, but it pays for itself after 50 surgical procedures.

Laparoscopic-assisted vaginal hysterectomy using the laparosonic coagulating shears.

The use of the Laparosonic Coagulating Shears (LCS) for laparoscopic-assisted vaginal hysterectomy (LAVH) was evaluated in three women. The indications for surgery included chronic pelvic pain, adhesions, endometriosis, symptomatic uterine fibroids, and abnormal bleeding. The entire laparoscopic portion of the LAVH was performed with the LCS. All three patients had an uneventful postoperative course, and continue to do well one year postoperatively. The harmonic scalpel produces surgical incisions with concomitant hemostasis. With the introduction of the LCS, larger vessels can be managed safely. The LCS produces less charring and less thermal tissue injury, reduces postoperative adhesions, and promotes faster healing. The cavitational effect facilitates dissection, and the minimal heat production and absence of current through the patient contribute to safety. Ultrasonic activated technology is easy to use, cost effective, and affords the surgeon a greater margin of safety. This is only a preliminary report, and further study is needed, but the benefits of ultrasonically activated technology and the LCS are readily apparent.

The initial worcester experience with laparoscopic hysterectomy.

STUDY OBJECTIVE: To examine three community hospital's experience with the first 108 attempted laparoscopic hysterectomies. DESIGN: Retrospective analysis of hospital and office charts using a standardized data-collection sheet. SETTING: All procedures were performed at the Medical Center of Central Massachusetts, St. Vincent's Hospital, or the University of Massachusetts Medical School, Worcester, Massachusetts. PATIENTS: The first 108 patients to have a laparoscopic hysterectomy attempted. Ninety procedures were completed successfully. MEASUREMENTS AND MAIN RESULTS: Areas that were analyzed were indications for surgery, type of laparoscopic hysterectomy, surgeons' instrument preference, failure to complete the operation, complications, and relative cost. Surgical indications, patient demographics, and complication rates were comparable with those unpublished papers. However, our data showed no improvement in estimated blood loss or operating room time with increased operator experience. Review of pathology reports indicated no cases in which an unsuspected malignancy was encountered. CONCLUSIONS: Laparoscopic hysterectomy can be performed safely and successfully by generalists in obstetrics and gynecology. Additional study is required to know whether variables such as operating room time and expense will improve as this procedure is increasingly performed by generalists rather than specialists.

Long-term risk of hysterectomy among 80,007 sterilized and comparison women at Kaiser Permanente, 1971-1987.

To study the long-term risk of hysterectomy after tubal sterilization, the authors analyzed historical hospital discharge data on 39,502 parous women sterilized during 1971-1984 and 40,505 comparison women matched on age, race, parity, and interval since last birth. Sterilized women were significantly more likely than were comparison women to undergo hysterectomy (relative risk (RR) = 1.35, 95% confidence interval (CI) 1.26-1.44), especially for diagnoses of menstrual dysfunction and pelvic pain (RR = 1.88, 95% CI 1.65-2.13). Higher relative risks were not associated with greater tissue-destructive methods of tubal occlusion. Relative risks were highest for women who were young on the reference date (RR = 2.45, 95% CI 1.79-3.36 for women aged 20-24 years), but declined steadily as age increased (RR = 0.96, 95% CI 0.72-1.28 for women aged 40-49 years). In all age groups, relative risks were significantly above 1.00 after 7 years of follow-up. Reasons for elevated risks may be related to a greater willingness of sterilized women to forgo their uteruses. The emergence of greater risk in all age groups, however, prevents the authors from ruling out a possible latent biologic effect of tubal sterilization.

PIP: To study the longterm risk of hysterectomy after tubal sterilization, the authors analyzed historical hospital discharge data on 39.502 parous women sterilized between 1971 and 1984, and 40,535 comparison women matched on age, race, parity, and interval since last birth. Sterilized women were significantly more likely than were comparison women to undergo hysterectomy (relative risk [RR] = 1.35, 95% confidence interval [CI] 1.26-1.44), especially for diagnoses of menstrual dysfunction and pelvic pain (RR = 1.88, 95% CI, 1.65-2.13). Higher relative risks were not associated with greater tissue-destructive methods of tubal occlusion. Relative risks were highest for women who were young on the reference data (RR = 2.45, 95% CI 1.79-3.36 for women aged 20-24 years), but declined steadily as age increased (RR = 0.96, 95% CI 0.72-1.28 for women aged 40-49 years).