Effect of Umbilical Port and Endoscope Size on Discharge Times and Postoperative Recovery After Total Laparoscopic Hysterectomy: A Retrospective Review

Abstract

Background: Laparoscopy is increasingly replacing open surgery as the preferred treatment option in most patients across disciplines. In addition, as technological improvements have occurred, minilaparoscopic instruments have been designed to reduce surgical trauma further and minimize invasiveness. Several studies in the literature have shown that using minilaparoscopic instruments does not increase complication rates and may improve patient recovery. There are no data examining the use of smaller incisions for the endoscope. Objective: This review was conducted to determine differences in discharge times and postoperative recovery when using a 5-mm trocar, compared to a 10-mm trocar, when making umbilical incisions. Materials and Methods: This retrospective review of a single surgeon series of 328 consecutive cases examined the implications (discharge times and postoperative recovery) of using a 5-mm umbilical incision and endoscope, compared with the conventional 10-mm incision and endoscope. Results: The 5-mm incision and endoscope decreased length of stay and was a safe alternative to the 10-mm incision and endoscope. Conclusions: The 5-mm incision and trocar should be used rather than the 10-mm incision and trocar when performing a total laparoscopic hysterectomy. (J GYNECOL SURG 30:273)

Introduction

Minimizing the invasiveness of procedures drives surgeons ever forward in the search for surgical perfection. Minisite laparoscopy is becoming more commonplace in articles in peer-reviewed journals, and has been described as as the future of minimally invasive surgery. While minilaparoscopy has been discussed in the literature since the 1990s, the technique has only been used in complex surgical procedures (requiring considerable dissection), such as cholecystectomy and hysterectomy, since 2009.¹ To remain on the forefront of surgical advancement, gynecologic surgeons who perform laparoscopic procedures must adopt the use of smaller port sites and thus smaller laparoscopes.

The use of 10-mm transumbilical laparoscopes for laparoscopic hysterectomy is the standard practice for gynecologic surgeons in Western Australia. Although there is a move toward smaller incisions and instruments, the literature focuses on the use of minilaparoscopic instruments through the ancillary ports and not through the primary port.

The difference in patient outcomes for laparoscopic hysterectomy using 5-mm versus 10-mm umbilical ports has not been examined in the literature to date. Currently, there is not a clear standard for using a smaller laparoscope size routinely for hysterectomy at the King Edward Memorial Hospital because of the inequalities in image definition and quality between the 10-mm and 5-mm scope.

This review was designed to investigate the differences in performing total laparoscopic hysterectomy as well as the postoperative recovery and length of stay when using either a 5-mm or 10-mm umbilical incision and endoscope.

Materials and Methods

This review covered 328 consecutive cases in a single-surgeon series of total laparoscopic hysterectomies. The results were acquired by accessing both the hospital theater records and the surgeon's patient files. All patients in this study had benign disease, or early stage endometrial cancer that did not require further staging, or borderline tumors that required additional appendectomy and omentectomy, both of which were also performed laparoscopically.

Laparoscopic hysterectomy was performed with the use of 3 ports: an umbilical port for the laparoscopic camera (either 5-mm or 10-mm) and two ports (5-mm) in the bilateral lower quadrants. The hysterectomies were performed in a standard fashion, entirely laparoscopically, which included electrocoagulation of the uterine arteries and cardinal ligaments, incision of the vagina, and suturing of the vaginal cuff. Omentectomy and pelvic lymph-node dissection was performed through these same ports. Appendectomy was performed by placing the stapler through the vaginal cuff prior to closure. Electrocoagulation for vascular pedicles during the laparoscopic hysterectomies was performed using either the Ligasure (Covidien Corporation, Boulder, CO) or Gyrus PK (Gyrus ACMI, Southborough, MA) devices. There were no changes in practice over the review time period of performance of the surgeries. The data for the patients were divided into 2 groups—one in which the standard 10-mm, incisions and instruments were used and one in which 5-mm incisions and instruments were used.

Data collected included age, body mass index, reason for operation, rate of conversion to laparotomy, estimated blood loss (EBL), length of hospital stay, complication rates, and return to normal daily activities.

Results

There were 328 cases examined from January 2008 to May 2012; these cases were operations performed by a single surgeon. The patients' demographics, baseline characteristics, and indications for surgery were comparable between the 2 groups (Table 1). The procedures performed included total laparoscopic hysterectomy±bilateral salpingo-oopherectomy±pelvic lymph node dissection±omentectomy±appendectomy.

Table 1.

Patients' Demographics, Baseline Characteristics, and Indications for Surgery

Characteristics	10-mm (n=164)	5-mm (n=164)	p-Value
Age	59.8 (range: 29–92)	61.2 (range: 20–90)	0.4746
BMI	35.1 (range: 20–65)	36.4 (range: 20–75)	0.1579
ASA score	1.571429	1.532967	0.5117
Indication for surgery
Dysfunctional uterine bleeding	25%	28%
Endometrial carcinoma	38%	41%
Atypical endometrial hyperplasia	14%	10%
Ovarian mass	14%	11%
Borderline tumour staging	9%	10%

BMI, body mass index, ASA, American Society of Anesthosiologists.

The 2 groups were comparable for operative time and EBL. The operating time was 37 minutes for total laparoscopic hysterectomy (range: 20–74 minutes), 72 minutes (range: 50–96 minutes) for total laparoscopic hysterectomy+pelvic lymph-node dissection, and 80 minutes (range: 50–115 minutes) for total laparoscopic hysterectomy+omentectomy and appendectomy. No patients required blood transfusion and the EBLs for the patients were all <200 mL. There were no intraoperative complications or conversions to open surgery in either group. No patient in the 5-mm group required that the umbilical port be converted to 10-mm to allow completion of the procedure. No patient had development of postoperative complications during the study period.

Hospital stays were markedly reduced in the 5-mm endoscope patients. Table 2 shows the percentage of patients discharged by day in 6-month time blocks. The surgeon began using a 5-mm umbilical incision and 5-mm endoscope in January 2011.

Table 2.

% of Patients Discharged by Day

Time period	Day 1	Day 2	Day 3	Day 4	Day 5
January–June, 2008	7	43	43	7	0
July–December, 2008	0	25	50	17	8
January–June, 2009	0	42	42	13	4
July–December, 2009	5	46	36	8	5
January–June, 2010	0	58	34	8	0
July–December, 2010	0	68	32	0	0
January–June, 2011	29	49	12	8	2
July–December, 2011	28	67	4	0	0
January–June, 2012	51	34	7	7	0

During this period, hospital data also showed that the laparoscopic hysterectomy patients, both those who had 5 mm and 10-mm umbilical incisions, had a much shorter length of stay than patients who had undergone vaginal or abdominal hysterectomy (Table 3).

Table 3.

LOS per Hysterectomy Procedure

Procedure	Mean LOS	Median LOS
Laparoscopic—5-mm	1.9	2
Laparoscopic—10-mm	3.05	3
Vaginal	4.47	4
Abdominal	6.38	5

LOS, length of stay.

Patients were asked at their 6-week postoperative follow-up when they felt that they had returned to their normal activities. For patients who had 10-mm umbilical incisiona, the average return was 17 days, and, for the 5-mm incision patients, the average return was 8 days.

Discussion

There are many articles in the literature showing that recovery time is faster in a woman undergoing minimally invasive surgery, such as a total laparoscopic hysterectomy, compared with a laparotomy approach.^2,3 In September 2012, the Cochrane Gynecological Cancer Group published a systematic review of eight randomized controlled trials (RCTs) comparing laparotomy or laparoscopic surgical approach for total hysterectomy in women with early stages of endometrial cancer. The trials included 3644 women with Stage I–IIA endometrial cancers who were treated primarily with surgery. Primary outcomes measured were overall survival and recurrence-free survival, and secondary outcomes included adverse effects, intraoperative blood loss, operative time, local recurrence of disease, distant recurrence of disease, length of hospital stay, and quality of life. This systematic review showed that the overall survival and disease-free survival were similar in both the laparotomy and laparoscopic groups, but the laparoscopic group reported shorter length of stays and decreased perioperative morbidity.⁴ These data can be safety applied to considering benign hysterectomy for patients, given the similarity of the procedure used for early stage endometrial cancer.

One randomized controlled trial compared minilaparoscopic total hysterectomies and conventional total laparoscopic hysterectomies performed by Ghezzi et al. in Italy, 2011.⁵ Seventy-six women were randomized to 2 groups, minilaparoscopy and standard laparoscopy, for treatment for benign conditions requiring hysterectomy at a single tertiary hospital. The primary outcome measured was postoperative pain—measured at 1, 3, 8, and 24 hours—and this outcome did not differ significantly between the groups. Secondary outcomes measured included length of stay, EBL, and haemoglobin drop, all of which were not significantly different between the groups. There were no conversions from minilaparoscopy or conventional laparoscopy to abdominal hysterectomy. There were no complications recorded for any of the women from either group. Both study arms discussed in that article, however, used a standardized 10-mm endoscope. Other similar studies have shown that the port size can be reduced without having a negative impact on the surgeon but yielded nonsignificant improvements in discharge times or recovery times for patients.⁶ However, the smaller diameter of minilaparoscopes has several advantages—reducing postoperative complications, such as subcutaneous or subfascial extravasation of blood and hematoma formation.⁵

Conclusions

To date there has been no RCTs assessing the impact of umbilical port size and endoscope size on total laparoscopic hysterectomy. The data collected in this review showed that there may be significant improvement for patients and for health care systems, with improved length of stays and postoperative recoveries. However, as this review was a retrospective audit and involved a sequence of operations by single surgeon, there may be other contributing factors to explain the reductions in length of stay, such as an improved surgical technique, patient counseling, and expectations for discharge. Therefore further studies investigating the effect on discharge times and patient recovery when using a 5-mm incision and endoscope for total laparoscopic hysterectomy are required.

Footnotes

Disclosure Statement

No financial conflicts exist.

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