ORIGINAL ARTICLE
Comparison of minimally invasive surgical approaches for hysterectomy at a community hospital:robotic-assisted laparoscopic hysterectomy,laparoscopic-assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy
Bang N.Giep •Hoang N.Giep •Helen B.Hubert
Received:27April 2010/Accepted:29June 2010/Published online:10August 2010ÓThe Author(s)2010.This article is published with open access at Springerlink
Abstract The study reported here compares outcomes of three approaches to minimally invasive hysterectomy for benign indications,namely,robotic-assisted laparoscopic (RALH),laparoscopic-assisted vaginal (LAVH)and lapa-roscopic supracervical (LSH)hysterectomy.The total patient cohort comprised the first 237patients undergoing robotic surgeries at our hospital between August 2007and June 2009;the last 100patients undergoing LAVH by the same surgeons between July 2006and February 2008and 165patients undergoing LAVHs performed by nine sur-geons between January 2008and June 2009;87patients undergoing LSH by the same nine surgeons between January 2008and June 2009.Among the RALH patients were cases of greater complexity:(1)higher prevalence of prior a
bdominopelvic surgery than that found among LAVH patients;(2)an increased number of procedures for endometriosis and pelvic reconstruction.Uterine weights also were greater in RALH patients [207.4vs.149.6(LAVH;P \0.001)and 141.1g (LSH;P =0.005)].Despite case complexity,operative time was significantly lower in RALH than in LAVH (89.9vs.124.8min,P \0.001)and similar to that in LSH (89.6min).Esti-mated blood loss was greater in LAVH (167.9ml)than in
RALH (59.0ml,P \0.001)or LSH (65.7ml,P \0.001).Length of hospital stay was shorter for RALH than for LAVH or LSH.Conversion and complication rates were low and similar across procedures.Multivariable regres-sion indicated that LAVH,obesity,uterine weight C 250g and older age predicted significantly longer operative time.The learning curve for RALH demonstrated improved operative time over the case series.Our findings show the benefits of RALH over LAVH.Outcomes in RALH can be as good as or better than those in LSH,suggesting the latter should be the choice primarily for women desiring cervix-sparing surgery.
Keywords Robotics ÁLaparoscopy ÁHysterectomy ÁVaginal hysterectomy ÁSupracervical hysterectomy
Introduction
Although abdominal hysterectomy still accounts for approximately two-thirds of all benign hysterectomies performed in the USA [1,2],minimally invasive tech-niques for this procedure have been slowly gaining acceptance.Recently published national data for 2005indicate that vaginal hysterectomies were performed in about 22%of cases and that 14%of hysterectomies were done laparoscopically [2].Studies have shown that mini-mally invasive techniques for benign hysterectomy are safe for the patient and result in decreased morbidity,shorter hospital stays,and a faster return to normal activity compared to open procedures [3,4].However,with con-ventional laparoscopic surgery,the surgeon generally experiences some decrease in visual acuity,lack of tactile sensory input,and,thus,greater difficulty in mastering the approach.Difficulty with hand–eye coordination with
B.N.Giep ÁH.N.Giep
Department of Obstetrics and Gynecology,Spartanburg Regional Medical Center,Spartanburg,SC,USA H.B.Hubert
Department of Medicine,Stanford University School of Medicine,Stanford,CA,USA
B.N.Giep (&)
Spartanburg and Pelham P.A.,250North Grove Medical Park Drive,Spartanburg,SC 29303,USA e-mail:bgobgyn@yahoo
J Robotic Surg (2010)4:167–175DOI 10.1007/s11701-010-0206-y
laparoscopy and the non-articulated instruments also makes this approach more difficult to master.These factors may explain a large part of the reluctance to adopt mini-mally invasive laparoscopic approaches over abdominal hysterectomy.
Improvements in minimally invasive techniques were introduced with2005Federal Drug Administration(FDA) approval of the da Vinci Surgical System(Intuitive Sur-gical,Sunnyvale,CA)for use in gynecologic procedures. Since that time,the use of the robotic system for hyster-ectomy has been shown to shorten the learning curve for laparoscopically naı¨ve surgeons with improved three-dimensional(3D)visual acuity,articulated wrist-like movement of instruments without tremor and ergonomic seating[5–7].
Few studies have compared clinical outcomes of the robot system with other minimally invasive techniques for hysterectomy.Payne and Dauterive demonstrated that patients who had undergone robotic-assisted compared to total laparoscopic hysterectomy had similar complication rates,but sign
ificantly less blood loss,fewer conversions to laparotomy and shorter hospital stays[7].A recent inves-tigation comparing robotic-assisted to traditional laparo-scopic hysterectomy confirmed thesefindings[8].A similar comparative study showed shorter hospital stays but longer operative times for patients who underwent a robotic procedure[9].A number of studies have compared laparoscopic supracervical hysterectomy(LSH)to laparo-scopic-assisted vaginal hysterectomy(LAVH)or to total laparoscopic hysterectomy.Results have repeatedly shown better outcomes with LSH than ,shorter oper-ative time,less blood loss and lower complication rates [10–12].To date,however,there have been no comparative studies of robotic-assisted laparoscopic hysterectomy (RALH)to LAVH alone or to LSH.The goal of the study reported here was to provide such comparative data on clinical outcomes and learning curves for minimally invasive procedures in a community-practice setting. Materials and methods
Patients and cases
The Spartanburg Regional Healthcare System is an inte-grated healthcare system delivering services,including ambulatory and inpatient surgery,to several counties in North and South Carolina.This study compares hysterec-tomies performed by multiple community surgeons at the Spartanburg Regional Medical Center,a facility within that system.Only two surgeons performed RAL
H during the time period of this study(BG,HG),so the robotic cohort (n=237)includes their entire consecutive RALH experience beginning with thefirst patient in August2007 through to June2009.Between July2006and February 2008,these same surgeons performed their last100 LAVHs,transitioning almost exclusively to RALH in the latter half of2007.Thus,the LAVH cohort for this study includes their last consecutive patients(n=100)along with those of nine other gynecologists who performed LAVH at the same institution between January2008and June2009(n=165),for a total of265LAVH cases.In addition,consecutive LSH patients of the nine other gynecologists(n=87)were identified during a similar time period,January2008to June2009.Patients were selected for LSH,rather than LAVH,if they preferred a procedure that spared the cervix or if the surgeon believed it to be a better choice.There were too few total laparo-scopic hysterectomies performed at the hospital during this time to form another comparison group.Every patient included in this study presented with a benign gynecologic condition.
Surgical procedures
All procedures were performed under general endotracheal anesthesia with preoperative antibiotics given.A steep Trendelenburg position was used with a gel pad underneath the patient for stabilization.A Foley catheter and uterine manipulator were placed for all surgeries.温州交警大队
Robotic-assisted laparoscopic hysterectomy
A8.5-mm trocar was placed at the umbilicus and8-mm trocars were placed in the right and left lower quadrants. A11-mm bladeless trocar was placed in the right upper quadrant.Docking of the robotic arms to the trocars fol-lowed by insertion of the3-D camera was completed.
A Gyrus PK Dissector(Gyrus ACMI,Maple Grove,MN) and monopolar scissors were inserted,at which time the console portion of the procedure began.Dissection of the bilateral round ligaments,adnexa and broad ligaments was performed in the standard manner.The bladderflap was created with a combination of sharp and blunt dis-section.A colpotomy was performed with the monopolar scissors and carried circumferentially until the specimen was amputated from the vagina.The specimen was either removed vaginally or endoscopically,and the vaginal cuff was closed laparoscopically with interruptedfigure-of-eight stitches of0Vicryl.
Laparoscopic-assisted vaginal hysterectomy
To begin,the laparoscope was placed through a5-mm umbilical trocar.Three additional5-mm ports were placed in the right and left lower quadrants and suprapubically.
A Maryland bipolar dissector was used.Dissection of the bilateral round ligaments,adnexa,and broad ligaments was performed in the standard manner.The bladderflap was created with a combination of sharp and blunt dissection.A small anterior colpotomy was performed with monopolar scissors.The remainder of the procedure was completed vaginally.A posterior colpotomy was performed sharply, and then cardino-uterosacral ligaments and uterine vessels were divided and sutured.After the specimen was removed vaginally,the vaginal cuff was closed with0Vicryl in a running locked fashion.
A5-mm trocar was placed at the umbilicus and two additional5-mm trocars were placed in the right and left lower quadrants.Dissection of the bilateral round liga-ments,adnexa and broad ligaments was performed in the standard manner using either Harmonic ACE curved shears (Ethicon,Cincinnati,OH)or a LigaSure(Covidien, Mansfield,MA)device.The bladder was dissected free from the lower uterine segment,and the uterine vessels were coagulated and transected.The uterus was amputated from the cervix using either monopolar scissors or the Harmonic ACE curved shears and the endocervical canal fulgurated with the monopolar scissors.The specimen was then extracted with a Gynecare Morcellex Tissue Morcel-lator(Ethicon).
Patient characteristics and clinical procedures
The Institutional Review Board of Spartanburg Regional Hospital approved this study.A standardized retrospective chart review was completed by the research nursing staff, and quality control procedures included verification of data inconsistencies and outliers using the medical records.The following characteristics were obtained for all patients: age,body mass index(BMI),the presence or absence of previous abdominopelvic surgery,gravidity,parity,and the primary indication for surgery.Perioperative characteris-tics included concomitant procedures performed with the hysterectomy reflecting the complexity of the surgery, skin-to-skin operative time(defined as Foley catheter insertion to skin closure),uterine weight,conversion to laparotomy,estimated blood loss(EBL),length of hospital stay and intraoperative and postoperative complications up to30days post-discharge.Estimated blood loss was determined initially by canister collection as the differen-tial between aspirated and irrigatedfluids and necessitated agreement between the surgeon and anesthesiologist. Blood collection was later done with the Stryker Neptune system that also enabled quantification of very small amounts of blood loss that went undetectable using the original system.Thus,if no blood was detected by the canister collection method,EBL was recorded as25ml. Minor complications following discharge(such as urinary tract infection)were captured on the patient follow-up visit for robotic surgery.However,these were not available on all LAVH and LSH patients.Therefore,with regard to postoperative complications,only those patients requiring a visit to the emergency room or a readmission to the hos-pital were reported in this study.
Statistical analyses
Data analyses included all pair-wise comparisons of min-imally invasive surgical methods,namely,RALH to each of the two other approaches(LAVH and LSH)as well as LAVH to LSH,using SAS software ver.9.2.1(SAS Institute,Cary,NC).Continuous variables were compared using two-sample t tests.Discrete variables were analyzed using chi-squared tests or Fisher’s exact test with conti-nuity correction.In addition,multivariable regression analyses were used to identify patient and procedure characteristics that had a significant impact on operative time.To identify changes in operative time,blood loss and uterine weight that could be associated with surgical experience,these parameters were compared over the consecutive patient series for the RALH and LAVH pro-cedures performed by the same surgeons(BG,HG).In all instances a P value\0.05was considered to be statisti-cally significant.
Results
Comparisons of preoperative patient characteristics are shown in Table1.The most frequent primary indication for benign hysterectomy among these patients was abnormal uterine bleeding in RALH(50%)and LAVH(36%)and fibroids in LSH(39%).Endometriosis was the third most frequent indi
cation,ranging from8%in RALH patients to almost21%in LSH cases.The age range of all patients was 23–78years.Those who underwent LSH were younger on average than either RALH(P=0.067)or LAVH (P=0.006)patients by1.5and2.5years,respectively,not surprising given the desire for a cervix-preserving proce-dure.Differences in gravidity and parity followed similar trends,with RALH patients having had significantly fewer pregnancies and live births than either LAVH or LSH patients,with no differences between those in the LAVH and LSH groups.Means for BMI indicate that many patients were obese(BMI C30)or bordering on obesity. Differences in BMI by approach were small,and compar-isons were not statistically significant.A large proportion of patients had undergone prior abdominopelvic surgery,
with RALH patients exhibiting the highest percentage (83.1%),which was significantly greater than that in patients who underwent LAVH(73.2%;P=0.01). Patients who underwent LSH did not differ from the other groups with respect to prior surgery.Comparisons of pre-operative characteristics between LAVH patients of Drs. Giep versus the other nine surgeons show very similar baseline profiles,with almost identical mean ages(42.6vs.冲绿灯
42.4years,respectively)and very similar mean BMI(29.9 vs.29.5kg/m2,respectively)and proportion with prior abdominopelvic surgeries(75.2vs.70.0%).Thesefindings provide reassurance that patients f
rom the two groups of surgeons combined as one LAVH cohort were very similar.
Examination of intraoperative characteristics by approach indicates that concomitant procedures were more often performed with RALH(in50.6%of surgeries)than with either LAVH(in26%)or LSH(in20.6%;Table2). Specifically,the proportion of patients who had surgical procedures for endometriosis or lysis of adhesions was significantly greater in the RALH group than in the LAVH (P\0.001)or LSH(P\0.001)groups.Similarfindings were evident for pelvic reconstruction(RALH vs.LAVH P=0.012,RALH vs.LSH P\0.001).Most pelvic reconstruction involved robotically assisted uterosacral fixation,anterior and posterior repair and pubovaginal sling with cystoscopy.These procedures would be expected to
Table1Preoperative characteristics by minimally invasive approach to hysterectomy
Preoperative characteristics RALH(n=237)LAVH(n=265)LSH(n=87)P value
Primary indication for surgery,n(%)
Benign pelvic mass1(0.4)––
Abnormal uterine bleeding119(50.2)96(36.2)28(32.2)
Fibroids68(28.7)89(33.6)34(39.1)
Endometriosis19(8.0)27(10.2)18(20.7)
Pelvic pain11(4.6)14(5.3)–
Abnormal PAP–1(0.4)–
Pelvic relaxation16(6.8)7(2.6)–
Ovarian cyst–2(0.8)3(3.4)
Prolapse(uterine/vaginal)3(1.3)17(6.4)–
Other–12(4.5)4(4.6)
Age(years)
Mean(SD)41.5(8.4)42.5(10.6)39.9(6.3)0.240a 95%CI40.4–42.541.2–43.838.6–41.30.067b
0.006c Gravidity,n(%)
024(10.1)8(3.0)3(3.4)0.003a 138(16.0)40(15.1)8(9.2)0.009b C2175(73.9)217(81.9)76(87.4)0.387c Parity,n(%)
028(11.8)13(4.9)4(4.6)0.007a 146(19.4)48(18.1)9(10.3)0.004b C2163(68.8)204(77.0)74(85.1)0.207c BMI
Mean(SD)30.3(7.5)29.9(6.7)31.2(7.7)0.530a 95%CI29.4–31.229.0–30.729.6–32.80.343b
人保车险怎么样0.132c Prior abdominal or pelvic surgery,n(%)197(83.1)194(73.2)69(79.3)0.010a
0.529b
0.320c RALH Robotic-assisted laparoscopic hysterectomy,LAVH laparoscopic-assisted vaginal hysterectomy,LSH laparoscopic supracervical hyster-ectomy,SD standard deviation,CI confidence interval
a Comparison of RALH to LAVH
b Comparison of RALH to LSH
c Comparison of LAVH to LSH
contribute to an increase in operative time.Although the rates of pelvic reconstruction were low in both LAVH and LSH,they were statistically higher in LAVH(4.9%)than LSH(3.4%;P=0.04).Uterine weights ranged from24to 1,233g.The mean uterine weight was similar in LAVH and LSH patients but differed significantly from that of RALH cases who had the largest uteri(207.4±194.5 (RALH)vs.149.6±118.7(LAVH)g,P\.001;vs. 141.1±172.5(LSH)g,P=0.005].The percentage of patients with uteri of at least250g was23.2%in RALH compared to9.1and8.0%in LAVH(P\0.001)and LSH (P=0.004),respectively.However,mean skin-to-skin operative time was35min longer for LAVH patients compared to both RALH and LSH patients for whom procedures took approximately 1.5h on average(both comparisons,P\0.001).Similarly,estimated blood loss was highest in LAVH,being over100ml greater than in RALH and LSH(both comparisons,P\0.001).Length of
Table2Intraoperative and perioperative characteristics by minimally invasive approach to hysterectomy
Intraoperative and perioperative characteristics RALH(n=237)LAVH(n=265)LSH(n=87)P value
Concomitant procedures,n(%)
Endometriosis/lysis of adhesions93(39.2)56(21.1)15(17.2)\0.001a
\0.001b
0.520c Pelvic reconstruction27(11.4)13(4.9)3(3.4)0.012a
\0.001b
0.044c Uterine weight(g)
Mean(SD)207.4(194.5)149.6(118.7)141.1(172.5)\0.001a 95%CI182.5–232.6134.9–164.3105.2–177.10.005b
0.670c Stratified uterine weight
\250g182(76.8)241(90.9)80(92.0)\0.001a C250g55(23.2)24(9.1)7(8.0)0.004b
0.867c Skin to skin operative time(min)
Mean(SD)89.9(37.5)124.8(48.7)89.6(38.0)\0.001a 95%CI84.9–94.5118.9–130.780.9–98.50.949b
\0.001c Estimated blood loss(ml)
Mean(SD)59.0(75.7)167.9(146.0)65.7(60.7)\0.001a 95%CI49.2–68.6150.2–185.652.7–78.60.412b
\0.001c Length of hospital stay(days)
Mean(SD) 1.0(0.1) 1.2(0.7) 1.2(0.8)\0.001a 95%CI 1.0–1.03 1.1–1.2 1.0–1.40.022b
1.00c Conversion,n(%)4(1.7)1(0.4)None0.194a
0.577b
1.00c Intraoperative complications,n(%)1(0.4)1(0.4)None NA Postoperative complications,n(%)8(3.4)4(1.5)2(
2.3)0.243a
1.00b
0.640c RALH Robotic-assisted laparoscopic hysterectomy,LAVH laparoscopic-assisted vaginal hysterectomy,LSH laparoscopic supracervical hyster-ectomy,SD standard deviation,CI confidence interval,NA Not available
a Comparison of RALH to LAVH
雪铁龙富康2005款b Comparison of RALH to LSHsinna
c Comparison of LAVH to LSH
hospital stay was short for all approaches,but significantly shorter for RALH patients than either LAVH(P\0.001) or LSH(P=0.022)patients.
The rates of conversion to an open procedure were low, ranging from zero to1.7%,and did not differ by surgical approach(Table2).The conversions in the RALH group occurred early in the learning curve.Two conversions were within thefirst25cases and another two within thefirst150 cases.These occurred in patients with large uteri where there was difficulty in accessing the blood vessels.Simi-larly,one conversion in the LAVH group occurred in a patient with a16-week uterus where it was difficult to maintain hemostasis while proceeding laparoscopically. This patient was subsequently converted to an abdominal hysterectomy.Rates of intraoperative and postoperative complications within30days of surgery were low across the three surgical approaches:the overall rates totaled3.8% for RALH,1.9%for LAVH and2.3%for LSH,with the majority being minor in severity.No statistically significant differences were noted by surgical method.In both the RALH and LAVH cohorts,there was one intraoperative cystotomy repair with no further sequelae.There were also two patients with incisi
onal infections and one with a bacterial infection in the RALH cohort;these were treated with antibiotics during their hospital stay.One patient in the robotic cohort and one in the LAVH cohort experienced a pelvic abscess that was subsequently drained and treated. There were no instances of cuff dehiscence requiring repair in any of the cohorts.There was one patient in the robotic group who was treated for cuff cellulitis,and two patients reported bleeding from the vaginal cuff in the RALH and LAVH cohorts.Both of these latter complications were resolved without the need for reintervention.During the perioperative period,one patient in the robotic group suf-fered a pulmonary embolism that was treated by antico-agulation with heparin and then enoxaparin(Lovenox). Atelectasis was noted in three patients,one from the LAVH cohort and two in the LSH cohort.
Comparisons of perioperative characteristics for the LAVH procedures performed by Drs.Giep versus the other surgeons show similar patient uterine weights(153.4±124.5vs.147.0±114.4g,respectively),EBL(157.3±111.4vs.173.6±163.3ml,respectively)and length of hospital stay(1.1vs. 1.2days,respectively).However, operative time was significantly shorter for procedures performed by Drs.Giep given their extensive experience with laparoscopic procedures(101.5±39.7vs.138.9±48.4;P\.001).
Multivariable linear regression was used to identify those characteristics of the patients and the appr
oach that were significant predictors of skin-to-skin operative time.The characteristics considered included patient age(dichoto-mized above or below the median age=41years),obesity (BMI\30,C30),previous abdominal or pelvic surgery, uterine weight(\250g,C250g),any concomitant proce-dure beyond hysterectomy with salpingo-oophorectomy and approach to surgery(RALH,LAVH,LSH).Younger age (P\0.001),BMI\30(P=0.02),uterine weight\250g (P\0.001)and surgery other than LAVH(P\0.001)were all independently associated with shorter operative times (data not shown).On average,the operative times were longer for older patients versus younger ones(21min),for obese patients versus non-obese patients(8min),for greater uterine weight patients versus those with a smaller uterus (24min)and for those undergoing LAVH surgeries vs.those undergoing LSH and RALH(35min).
Data points,representing the means of25sequential patients,were generated for skin-to-skin times,uterine weights and EBL over the entire case series for the RALH patients and for the comparable100LAVH patients whose procedures were performed by the same surgeons(HG, BG).Comparisons of thefirst25cases to the last showed no statistically significant differences for any of the LAVH parameters,although uterine weights generally increased with longer surgical experience(data not shown).Similar findings were evident in RALH for uterine weight and EBL (comp
arison offirst and last data points,P=0.189and P=0.875,respectively).However,operative skin-to-skin time significantly decreased with surgical experience (comparison offirst25to last37patients,P=0.003, Fig.1).Thefirst25RALH patients had a mean operative time of106.4min,which is comparable to that of the LAVH procedures(101.5min)and significantly different from the last patients’operative time of76.5
min. Fig.1Learning curve for robotic-assisted laparoscopic hysterectomy (RALH).Solid black line connects the mean skin-to-skin operative times at25-case intervals for RALH(P=0.003for mean offirs
t25 vs.last37patients).Dashed black line Mean skin-to-skin time for100 comparable laparoscopic-assisted vaginal hysterectomy(LAVH) patients(HG,BG only).There were no significant differences in operative time for thefirst25LAVH cases vs.the last25cases, P=0.59.Gray bars Mean uterine weights corresponding to the each of the RALH25-case intervals(P=0.189comparingfirst25vs.last 37cases)
发布评论