Total laparoscopic hysterectomy with previous cesarean section using a standardized technique: experience of Pontificia Universidad Catolica de Chile

Abstract

Total laparoscopic hysterectomy (TLH) in the presence of patients with previous cesarean section (CS) is becoming increasingly common. When performing TLH in these patients, bladder adhesions to the uterus may make dissection much more difficult with higher complication rates. The aim of this study was to assess the safety of TLH in patients with previous CS in an OBGYN residence program. Retrospective study of all TLH performed at our center for either benign or malignant conditions. Of our study cohort, 40 % had undergone one or more previous CS. Average surgical time was 128 min for patients without previous CS and 136 min for patients with previous CS (p = NS). Conversion to laparotomy was required in 1 % of cases showing no variation between the CS and non-CS groups. The overall complication rate among patients undergoing TLH was 3.5 %. Major complication rate was of 3 % (n=14), 5 cases with previous CS and 9 cases with no previous CS (p = NS). Urologic lesion was the most common major complication, accounting for 1.5 % (n=7) of all cases, 3 cases with previous CS and 4 with no previous CS (p = NS). Of urologic complications, three were cystotomies, 1 with no previous CS and 2 with previous CS (p = NS). TLH in patients with 1 or more previous CS is technically feasible. In the hands of thoroughly trained laparoscopic surgeons using a standardized technique, it is a safe procedure with minimal complication rates and may be even performed by OBGYN residents ensuring the same success rates.

<p>Perioperative Complications of Hysterectomy After a Previous Cesarean Section: A Systematic Review and Meta-Analysis</p>

“…The odds of the following surgical complications after hysterectomy were significantly increased in women with a previous history of CS compared with those without CS: urinary tract injury (pooled unadjusted OR=3. 15 Of included studies with a reported unadjusted OR, previous CS significantly increased risk of bladder injury (OR=3.43, 95% CI=2.00-5.90, 10 studies) and was marginally significantly associated with the risk of ureteric injury (OR=2.85, 95% CI=1.00-8.15, 6 studies). For those included studies with a reported adjusted OR (aOR), previous CS was significantly associated with an increased risk of bladder injury (aOR=2.58, 95% CI=1.63-4.10, 3 studies), but was also marginally significant for the risk of ureteric injury (aOR=1.44; 95% CI=0.96-2.15, 1 study).…”

“…14,17,29,32,33 Ten of the remaining included studies assessed the odds of surgical complications following minimally invasive hysterectomy (laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and roboticassisted hysterectomy) 16,[20][21][22][23]27,28,31,34,35 and 11 included studies assessed the odds of various types of hysterectomy including total abdominal hysterectomy and vaginal hysterectomy. 4,6,15,18,19,[24][25][26]30,36,37 Study designs of the included studies were cohort studies (24) 4,6,14-25,27-29,31-37 and case-control studies (two) 26,30 (Tables S3 and S4). Figure 2 shows the summary of the risk of biases stratified by the type of study design.…”

“…Quality assessment among 24 cohort studies using the Newcastle-Ottawa Scale indicated that high risks for comparability and outcome assessment were, respectively, noted in 15 [14][15][16][17][18][21][22][23][24][25]27,28,33,34,36 and 12 studies. 6,14,15,17,18,22,27,29,31,33,34,37 No cohort study was judged as having a high risk of selection bias. The two case-control studies 26,30 included in this review were determined as having low-to-moderate risks of bias for all items.…”

Total Laparoscopic Hysterectomy

“…In women with previous cesarean delivery, there are adhesions between bladder and lower uterine surface and so dissection should be a little high as close to the uterus as possible to avoid bladder injury.it is important to identify and pick small bits of tissue close to the uterus and coagulate and cut them gradually moving down towards the cervix [10]. Alternatively a lateral approach of opening the broad ligament may be the preferred route [11,12]. During laparoscopic hysterectomy, if the patient has significant adhesions from prior cesarean deliveries, a reverse inferior to superior vesico-uterine fold dissection can be used to dissect the bladder from the uterus [13].…”

Complicaciones quirúrgicas intraoperatorias en laparoscopía ginecológica en el Hospital Padre Hurtado

“…1 Dentro de sus ventajas destaca una menor respuesta inflamatoria en comparación a la laparotomía, 2,3,4 menores pérdidas hemáticas, infecciones, dolor postquirúrgico y menor estadía hospitalaria postoperatoria. 5,6,7 Además, la técnica quirúrgica ofrece a los operadores una mejor visión del campo operatorio, 8,9 y según el material utilizado hasta un 50% menor costo de hospitalización comparado con la laparotomía. 9 Estos beneficios sólo se generan cuando el equipo quirúrgico tenga una adecuada formación en cirugía laparoscópica.…”