Previous Abdominal Surgery and Obesity Do Not Affect Outcomes of Total Laparoscopic Hysterectomy Adversely

Abstract

Objective:

The aim of this research was to assess the effects of previous abdominal surgery and obesity on the outcomes of total laparoscopic hysterectomy (TLH).

Materials and Methods:

In this retrospective cohort study, 234 women who underwent TLH for benign conditions between January 2011 and December 2016 in a university hospital were included. The study group consisted of patients who had at least 1 previous abdominal surgery and the control group had previous abdominal surgeries. In a further analysis, obese patients who underwent TLH were compared to obese patients who underwent total abdominal hysterectomy (TAH) during the same timeperiod. The main outcome parameters were duration of hospital stays and major complication rates.

Results:

The mean durations of hospital stays and major complication rates were similar between the patients with and without previous surgery (p = 0.372 and p = 0.099, respectively). The outcomes of 93 TLH and 146 TAH patients whose BMIs were ≥30 kg/m² were also compared. The mean BMIs of the TLH and TAH groups were 32.8 ± 2.3 kg/m² and 33.0 ± 2.7 kg/m2, respectively. The durations of hospital stays were significantly lower in the TLH group than in the TAH group (3.1 ± 2.0 days versus 4.2 ± 3.5 days; p = 0.006). There was a tendency for increased major complication rates in the TAH group, but this was not statistically significant.

Conclusions:

Having previous abdominal surgery does not seem to affect outcomes of TLH unfavorably. Laparoscopic surgery, rather than open surgery, shortens hospital stays of obese hysterectomy patients without unfavorable effects. Moreover, TLH is likely to be associated with lower major complication rates. ClinicalTrials.gov ID: NCT03738085. (J GYNECOL SURG 37:512)

Introduction

Although hysterectomy is one of the most performed gynecologic operations, the ideal surgical approach has been an important and controversial issue in gynecologic practice. Hysterectomy can be performed via abdominal, vaginal, laparoscopic, and robotic routes. Although there are many factors affecting the type of surgery—such as the surgeon's education and expertise or hospital facilities and charges—the rate of laparoscopic hysterectomy significantly increased worldwide during the last decade and the rates of abdominal and vaginal hysterectomies have decreased.^1–3

The vaginal approach was described as the most preferable way according to many remarkable studies because of its rapid recovery time, shortest operation time, and lowest complication rate.^4,5 When it is hard to perform a hysterectomy vaginally because of a large uterus, insufficient accessibility to the uterus, and/or suspected adhesions, laparoscopic hysterectomy is considered as an alternative to vaginal hysterectomy.⁶ Despite the advantages of total laparoscopic hysterectomy (TLH) over laparotomy, several studies have reported increased risk of urologic complications and longer operation time.^5,7,8 Furthermore, some studies have reported that previous abdominal surgery was a risk factor for increased complication rates and conversion to laparotomy during TLH.^9,10

In addition to previous surgery, obesity has also been cited as an unfavorable factor during TLH. It is known that complication rates increase as body mass index (BMI) increases, regardless of surgical route.¹¹ However, compared to abdominal hysterectomy, TLH has advantages, such as lower postoperative complication rates, lower wound-infection risks, and shorter durations of hospitalizations.^11–13 However, increased rates of conversion to laparotomy and longer operation times have been proposed as disadvantages of TLH in obese patients, whereas the complication risks did not change.^14–18

The aim of this study was to assess the effects of previous abdominal surgery and obesity on intraoperative and postoperative outcomes of TLH.

Materials and Methods

For this single-center, retrospective-cohort study, the data of all women who underwent TLH for benign conditions in a tertiary academic center from January 2011 to December 2016 were reviewed. The study was approved by the institutional review board and the university ethical committee. Ethical approval was given by the Ethical Committee of Ankara University's School of Medicine, Ankara, Turkey (Approval no:12-562-16; approval date: June 272016).

Variables, including age, BMI (in kg/m²), indication for surgery, presence of systemic conditions (e.g., diabetes mellitus, hypertension, coronary heart disease, thyroid disease, hyperlipidemia, asthma), additional bilateral salpingo-oophorectomy (BSO), operation time (in minutes), duration of the hospital stay (in days), postoperative hemoglobin drop (g/dL), estimated blood loss (EBL; in mL), intraoperative or postoperative major complications, and need for blood transfusion, were recorded from the patients' files.

All TLH and total abdominal hysterectomy (TAH) procedures were performed by senior gynecologists with more than 10 years of laparoscopic surgery experience and with more than 15 years of abdominal gynecologic surgery experience. Although the preferred approach was laparoscopic surgery, patients could choose TAH because of the additional charge for laparoscopy. The decision to perform BSO were made by the surgeons, according to menopausal status of the patients and also based on inspection of both ovaries in each patient. Operation time was described as the duration from the first skin incision to closure of the wounds. Patients were admitted to the hospital on the day of surgery, and all patients who passed flatus, were able to eat solid food comfortably, and self-urinate were discharged. Complete blood count was examined routinely 12 hours after the surgery and postoperative hemoglobin drop was defined as the difference between preoperative and postoperative hemoglobin counts. EBL was calculated regarding to the aspiration and irrigation fluids. Surgeons decided on blood transfusions depending on each patient's vital signs, postoperative hemoglobin count, and clinical examination results.

Routine follow-up examination was performed 1 month after each operation, and all patients were encouraged to attend the clinic for any complaints during this timeperiod.

Patients were grouped based on whether or not they had experienced previous abdominal surgeries. The study group consisted of patients who had at least 1 previous abdominal surgery and the control group consisted of patients with no previous abdominal surgeries. In a further analysis, a subgroup of obese patients with BMIs ≥30 kg/m² was evaluated. For this analysis, the obese patients who underwent TLH were grouped and their results were compared to the results of obese patients who underwent TAH during the same timeperiod. The main outcomes of this study were duration of hospitals stays and major complication rates.

Each TLH procedure was performed according to the same basic steps. With the patient under general anesthesia, uterine manipulator (V-care,^® CONMED, Largo, FL, USA) was inserted through the cervix after placing a Foley catheter into the bladder with the patient in a Trandelenburg position. Then, a pneumoperitoneum was created with CO₂. TLH was performed mainly with an advanced bipolar device (Ligasure,™ Valleylab, Boulder, CO, USA). After coagulating and cutting infundibulopelvic or ovarian ligaments and round ligaments, the retroperitoneum was entered and the ureters were visualized. Then, bilateral uterine arteries were sealed and cut, and the bladder peritoneum was dissected from the cervix. The cardinal and sacrouterine ligaments were coagulated and transected. Finally, circumferential colpotomy was performed via hook monopolar cautery and the vaginal cuff was closed by interrupted no. 1 Vicryl sutures. All the patients' uteri were extracted vaginally without abdominal morcellation.

Statistical analyses

Data analyses were performed with SPSS Version 21.0 (IBM Corporation, Armonk, NY, USA). A Shapiro–Wilk test was used to test distribution of normality. Differences between the groups for categorical variables were analyzed by a χ² test, and comparisons of continuous variables between the 2 groups were analyzed by a Student's t-test, according to results of their normality tests. A p-value <0.05 was considered to be statistically significant.

Results

A total of 234 TLH patients were included in the first analysis, according to whether or not the patients had previous surgeries. The study (n = 74) and control (n = 160) groups were comparable regarding their demographic parameters. The mean duration of hospital stays and major complication rates were similar between the patients with and without previous surgery (p = 0.372 and p = 0.099, respectively; Table 1).

Table 1.

Comparison of Patients With and Without Previous Abdominal Surgery

Demographic parameters	Previous surgery (n = 74)	No previous surgery (n = 160)	p
Age (yrs; mean ± SD)	49.8 ± 6.3	50.7 ± 8.5	0.435
BMI (kg/m²; mean ± SD)	28.1 ± 4.3	28.6 ± 3.7	0.342
Indications for surgery, n (%)			0.120
Adenomyosis	3 (4.1)	2 (1.3)
Adnexal mass	9 (12.2)	25 (15.6)
Endometrial pathology	22 (29.7)	51 (31.9)
Cervical pathology	2 (2.7)	11 (6.9)
Uterine prolapse	10 (13.5)	8 (5.0)
Fibroid	28 (37.8)	63 (39.4)
Systemic disease, n (%)	31 (41.9)	83 (51.9)	0.155
BSO, n (%)	64 (86.5)	139 (86.9)	0.935
Operative time (min; mean ± SD)	91.8 ± 31.6	92.7 ± 29.9	0.841
EBL (mL; mean ± SD)	190.3 ± 123.3	193.3 ± 99.2	0.843
Hemoglobin drop (g/dL; mean ± SD)	1.7 ± 0.8	1.5 ± 0.8	0.190
Blood transfusion, n (%)	2 (2.7)	11 (6.9)	0.195
Hospital stay (d; mean ± SD)	2.7 ± 1.3	3.0 ± 1.9	0.372
Major complications, n (%)	2 (2.7)^a	1 (0.6)^b	0.235
Conversion to laparotomy, n (%)	3 (3.8)	4 (2.4)	0.683

Bladder injury (n = 1) and intestinal injury (n = 1).

Vaginal cuff dehiscence (n = 1).

yrs, years; SD, standard deviation; BMI, body mass index; BSO, bilateral salpingo-oophorectomy; min, minutes; EBL, estimated blood loss; d, days.

There were 9 major complications among the TAH patients, including 7 bladder injuries, 1 intestinal injury, and 1 iliac-vessel injury, and there were 3 major complications, including 1 serosal bladder injury, 1 intestinal injury, and 1 vaginal cuff dehiscence in the TLH group. Bladder injuries were repaired by double- or one-layer interrupted sutures, according to the injury characteristics. All intestinal injuries were serosal, and they were also sutured with interrupted sutures. The minor iliac-vessel injury in the TAH group was sutured with a 4.0 polydioxanone suture. The late vaginal cuff dehiscence complication was sutured vaginally.

The serosal bladder injury and intestinal injury in the TLH previous-surgery group were repaired laparoscopically with interrupted sutures and managed without conversion to laparotomy. The vaginal-cuff dehiscence in the no-previous-surgery TLH group was sutured vaginally.

Of all the TLH patients, 93 had BMIs ≥30 kg/m², and their results were compared with 146 TAH patients who had BMIs ≥30 kg/m². The mean BMIs of the TLH and TAH groups were 32.8 ± 2.3 kg/m² and 33.0 ± 2.7 kg/m², respectively. The obese TLH and obese TAH groups were comparable regarding their demographic parameters. The duration of hospital stays was significantly lower in the TLH group than in the TAH group (3.1 ± 2.0 days versus 4.2 ± 3.5 days; p = 0.006). Although not reaching statistical significance, a tendency for increased major complication rates was noted in the TAH group (Table 2).

Table 2.

Comparison of Obese Total Laparoscopic Hysterectomy and Total Abdominal Hysterectomy Patients

Demographic parameters	TLH group	TAH group	p
Demographic parameters	(n = 93)	(n = 146)	p
Age (yrs; mean ± SD)	50.9 ± 6.1	49.6 ± 6.8	0.118
BMI (kg/m²; mean ± SD)	32.8 ± 2.3	33.0 ± 2.7	0.511
Indications for surgery, n (%)			0.074
Adenomyosis	0 (0)	3 (2.1)
Adnexal mass	11 (11.8)	11 (7.5)
Endometrial pathology	32 (34.4)	69 (47.3)
Cervical pathology	2 (2.2)	3 (2.1)
Uterine prolapse	6 (6.5)	2 (1.4)
Fibroid	42 (38.9)	58 (39.7)
Systemic disease, n (%)	53 (57.0)	82 (56.2)	0.900
Previous abdominal surgery, n (%)	28 (30.1)	47 (32.2)	0.735
BSO, n (%)	35 (37.6)	60 (41.1)	0.594
Operative time (min; mean ± SD)	92.0 ± 29.7	84.6 ± 31.1	0.071
EBL (mL; mean ± SD)	191.9 ± 88.8	193.3 ± 88.2	0.906
Hemoglobin drop (g/dL; mean ± SD)	1.5 ± 0.8	1.4 ± 1.0	0.392
Blood transfusion, n (%)	5 (5.4)	2 (1.4)	0.073
Hospital stay (d; mean ± SD)	3.1 ± 2.0	4.2 ± 3.5	0.006
Major complications, n (%)	3 (3.2%)^a	9 (6.1%)^b	0.376

Bladder injury (n = 1), intestinal injury (n = 1), and vaginal cuff dehiscence (n = 1) in theTLH group.

Bladder injury (n = 7), intestinal injury (n = 1), and iliac-vessel injury (n = 1) in the TAH group.

TLH, total laparoscopic hysterectomy; TAH, total abdominal hysterectomy; yrs, years; SD, standard deviation; BMI, body mass index; BSO, bilateral salpingo-oophorectomy; min, minutes; EBL, estimated blood loss; d, days.

Discussion

The present study assessed the effects of previous abdominal surgery and obesity on the intraoperative and postoperative outcomes of TLH. Having previous abdominal surgery did not affect outcomes of TLH adversely. In addition, laparoscopic surgery, rather than open surgery, shortened hospital stay in obese hysterectomy patients without unfavorable effects. Moreover, TLH was likely to be associated with fewer major complication rates than TAH in obese patients.

Previously, obesity and prior abdominal surgery were reported as risk factors for poor surgical outcomes of TLH.¹⁹ In a 2016 review, previous abdominal surgery was determined to be a predictor for increased complication rates and longer operation times for TLH.²⁰ It is already known that previous abdominal surgery increases adhesion formation.²¹ A poor surgical outcome is generally associated with adhesions. In the present study, 2 (2.7%) patients had major complications in the previous-abdominal-surgery group, and this result was significantly higher, compared to the control group, consistent with the literature.^22,23 Yet, previous abdominal surgery did not prolong the duration of surgery.

The incidence of conversion to laparotomy had been reported in a wide range between 0% and 19%.^24,25 Unlike obesity, previous abdominal surgery was not associated with an increased risk for conversion.¹⁴ In the current study, there was no effect of previous abdominal surgery on rates of conversion to laparotomy. There were 3 (3.8%) conversions in the previous-surgery group and 4 (2.4%) conversions in the control group. Detailed preoperative examinations and an experienced surgical team might be the main factors for comparable conversion rates.

Vaisbuch et al. reported longer operating times and shorter hospitalization stays for TLH, compared to TAH, and similar complication rates for these 2 routes in obese patients.²⁶ Open surgery in obese patients is difficult because of longer preparation times for the surgical areas and confined spaces for working because of the presence of fatty tissues. Hence, TAH is longer in obese patients and, as a result, there was no significant difference in operation times between TLH and TAH groups in the present study. Although, increased rates of urinary-tract injuries were reported in TLH patients, there was no statistically significant difference between bladder and urinary-tract injuries between the TLH and TAH groups in obese patients.^27,28 It is obvious that, regardless of the route of surgery, higher BMI is associated with increased blood loss, longer operation times, and higher complication rates. However, there were no significant differences for these variables between the 2 groups in the current study cohort. In addition, without statistical significance, the blood-transfusion rate was higher in the TLH group. This was a result of lower preoperative hemoglobin levels, given that hemoglobin drop and EBL were also similar between the 2 groups.

The main strength of this study was the detailed exploration of possible variables that could have affected the outcomes. In addition, all surgeries were performed in a single center and all were performed by the same experienced surgeons with the same technical instruments and same surgical steps. The main limitations of this study were its retrospective design and relatively small sample size. However, it was not possible to include more patients into such a single-center study with strict inclusion and exclusion criteria.

Conclusions

Although previous abdominal surgery and obesity are 2 common challenging factors during hysterectomy, they are not associated with poor surgical outcomes in TLH. Moreover, the duration of hospital stay shortens with a laparoscopic approach in obese patients. The route of hysterectomy should be decided for each patient separately by taking into consideration several factors, including patient's clinical condition and the skills of the surgeon. However, previous abdominal surgery and/or obesity should not indicate open surgery instead of TLH.

Footnotes

Author Disclosure Statement

No financial conflicts of interest exist.

Funding Information

No funding was received for this research.

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