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Outpatient Laparoscopic Subtotal Hysterectomies Considered Safe


 

SAN DIEGO — Laparoscopic supracervical hysterectomies can be done safely on an outpatient basis, a review of 190 cases suggests, Stefanos Chandakas, M.D., reported.

The surgeries were performed over a 14-month period by a two-surgeon team at Princess Royal University Hospital, London, where subtotal hysterectomies have been the norm since 2001. Patients underwent the hysterectomies to treat endometriosis (22%), menorrhagia (66%), and endometrial pathology (12%). All had failed medical therapy.

Patients lost an estimated 200 mL of blood on average, ranging from 50 to 2,000 mL. Less than 100 mL of blood was lost in 74% of cases, estimated Dr. Chandakas of the hospital, and his associates.

There were no significant intraoperative complications, vascular injuries, or nerve or ureter injuries. The average length of stay was 8 hours, and 94% of patients were discharged in less than 24 hours.

Postoperative complications included bladder infection or dysfunction in 2%, deep vein thrombosis in less than 1%, and paralytic ileus in one patient. Minimal cyclic bleeding occurred in 1% of patients. That's better than complication rates of 1%–10% reported in the literature, perhaps “because we spend 3–5 minutes coagulating the cervical canal” during the surgery, he said. One patient required reoperation for an intraabdominal abscess.

Compared with total abdominal hysterectomy or total vaginal hysterectomy, laparoscopic supracervical hysterectomy is “a much safer and easier operation to do,” Dr. Chandakas said.

Patients ranged in age from 33 to 53 years, with uterine sizes of 8–41 weeks and uterine weights of 36–325 g. The procedure took 125 minutes when first adopted by Dr. Chandakas' institution, but in recent years 80% of laparoscopic supracervical hysterectomies have averaged 40–45 minutes. The main reason for the longer surgical times was difficulty with the morcellator. Operating times decreased when the surgeons switched to disposable morcellators, he noted.

The team performed laparoscopic supracervical hysterectomy using PlasmaKinetic energy for tissue dissection and coagulation and a 12-mm morcellator to remove dissected organs. U.S. physicians in the audience said that surgeons in this country are just starting to use this approach.

“In the last 3–4 years, we can see a trend of supracervical hysterectomies coming back and becoming more and more widespread both in the U.K. and in the U.S.,” Dr. Chandakas said. The laparoscopic approach to supracervical hysterectomies is newer and easier, he added.

Concerns have been expressed in the literature that subtotal hysterectomies to treat malignancies may leave patients with higher risk compared with total hysterectomies, because the cervix remains intact. There is no evidence, however, that total hysterectomies decrease mortality from cervical cancer. It's the Pap screening that reduces mortality, he noted.

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