Background and Objectives:The purpose of this study is to estimate the cumulative incidence, patient characteristics, and potential risk factors for secondary hemorrhage after total laparoscopic hysterectomy.Methods:All women who underwent total laparoscopic hysterectomy at Paul's Hospital between January 2004 and April 2012 were included in the study. Patients who had bleeding per vaginam between 24 hours and 6 weeks after primary surgery were included in the analysis.Results:A total of 1613 patients underwent total laparoscopic hysterectomy during the study period, and 21 patients had secondary hemorrhage after hysterectomy. The overall cumulative incidence of secondary hemorrhage after total laparoscopic hysterectomy was 1.3%. The mean size of the uterus was 541.4 g in the secondary hemorrhage group and 318.9 g in patients without hemorrhage, which was statistically significant. The median time interval between hysterectomy and secondary hemorrhage was 13 days. Packing was sufficient to control the bleeding in 13 patients, and 6 patients required vault suturing. Laparoscopic coagulation of the uterine artery was performed in 1 patient. Uterine artery embolization was performed twice in 1 patient to control the bleeding.Conclusions:Our data suggest that secondary hemorrhage is rare but may occur more often after total laparoscopic hysterectomy than after other hysterectomy approaches. Whether it is related to the application of thermal energy to tissues, which causes more tissue necrosis and devascularization than sharp culdotomy in abdominal and vaginal hysterectomies, is not clear. A large uterus size, excessive use of an energy source for the uterine artery, and culdotomy may play a role.

Secondary hemorrhage after hysterectomy is rare but a life-threatening complication. The aim of this study is to estimate the cumulative incidence, patient characteristics, and potential risk factors of secondary hemorrhage after abdominal, vaginal, and laparoscopic hysterectomies. We did a retrospective observational study in which 1,623 cases of total laparoscopic hysterectomy (TLH), 963 cases of total abdominal hysterectomy (TAH), and 1,171 cases of vaginal hysterectomy (VH) were analyzed. Of the total 37 hemorrhages following hysterectomies, 23 were after TLH, 8 following VH, and 6 were after TAH. The cumulative incidence of secondary hemorrhage after any type of total hysterectomies was 0.98 %. TLH was associated with the highest risk of secondary hemorrhage (1.51 %) followed by VH (0.68 %) and TAH group (0.62 %). The relative risk of secondary hemorrhage following TLH compared to TAH and VH were 2.3 and 2.1, respectively. Both were statistically significant. The average size of the uterus in the TLH group was 516.7 g, and in the TAH and VH group, it was 140 and 142.5 g, respectively, which was statistically significant. The median time interval between hysterectomy and secondary hemorrhage was 11 days in TAH and VH group and 13 days in TLH group. Our data suggest that secondary hemorrhage is rare but may occur more often after TLH than after other hysterectomy approaches. Whether it is related to the application of thermal energy to tissues which cause more tissue necrosis and devascularization than sharp colpotomies in the TAH and VH groups is unclear. Large size of uteri, excessive use of energy source for uterine artery, and colpotomy may play a role.

Hysterectomy in frozen pelvis is a challenging surgical condition whether done by laparotomy or laparoscopy. We describe an alternative technique of total laparoscopic hysterectomy with retrograde adhesiolysis in patients with frozen pelvis. Total laparoscopic hysterectomy with retrograde adhesiolysis was done in 25 patients with frozen pelvis between October 2003 and May 2012. The mean (standard deviation; 95 % confidence interval) age of patients was 42.6 (6.00; 40.1-45.07). Body mass index was 27.48 (5.06; 25.3-29.57). Twenty (80 %) patients had previous abdominal surgery, and three (15 %) patients had previous failed surgeries for attempted hysterectomy. Twenty-three patients had frozen pelvis due to severe endometriosis, and two patients had severe abdominopelvic adhesions due to multiple previous surgeries. One patient had intraoperative injury to the sigmoid colon and bladder during adhesiolysis, and laparotomy conversion was performed. The median (range) operating time was 210 (120-300) min, and estimated blood loss was 400 (300-600) ml. Length of post-operative stay was 1 (1-6) days, and the post-operative period was uneventful except in two patients who had paralytic ileus. The median (range) followup at 1 month and 6 months was 100 and 68 % (17 of 25), respectively. Our technique of laparoscopic hysterectomy with retrograde adhesiolysis and subsequent removal of adnexa is an alternative technique for hysterectomy in frozen pelvis and limits the potential hazards of injury to vital organs; it is associated with fewer complications. We emphasize that adequate surgical experience and expertise still remain the prerequisites for performing hysterectomy in frozen pelvis.

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trimester. The most common presenting complaint was vaginal bleeding (37,4%) and the commonest complication was hyperthyroidism (16,6%). Twenty-six (11,2%) patients required blood transfusion. Seventeen patients (7,2%) required a second evacuation due to ongoing bleeding with 4 patients (1,7%) requiring a hysterectomy due to excessive haemorrhage. Patients with GTD normalized their HCG at a median time of 12 weeks post evacuation. There were 40 cases of persistent trophoblastic disease (PTD), all of whom had HCG levels above 6000 mIU/mL and 4000 mIU/mL at 4 weeks and 8 weeks respectively. Almost 45% of patients never completed follow-up. Conclusions The incidence of GTD within our centre is declining but remains an important cause of morbidity as it mainly affects the reproductive age. We strongly recommend a revised follow up protocol to accommodate patients with complex socio-economic backgrounds as the current protocol seems to be associated with an increase rate of loss to follow up.