Comparative Study of Laparoscopic and Total Abdominal Hysterectomies

Nigamananda Mishra, Anuja Thomas, Amrita Misri

Department of Obstetrics and Gynaecology, Bhabha Atomic Research Center Hospital, Mumbai, Maharashtra, India*

Corresponding Author: Nigamananda Mishra, Department of Obstetrics and Gynaecology, Bhabha Atomic Research Center Hospital, Mumbai, India. Email: drnmishra@yahoo.co.in
Published on 26th June, 2015

Abstract

To compare the duration of surgery, blood loss, postoperative pain, perioperative complications, and recovery of the patient undergoing laparoscopic hysterectomy (LH) and abdominal hysterectomy. This study is a longitudinal study conducted on patients admitted to BARC Hospital, Mumbai from September 2009 to August 2010, comparing the outcome of LH and total abdominal hysterectomy (TAH) in terms of duration of surgery, perioperative complications, and recovery of the patients. We studied 44 patients out of which 22 had undergone LH and 22 had undergone TAH. The duration of surgery is significantly shorter for TAH compared to LH (P<0.001). Blood loss is significantly lesser for LH in comparison with TAH. There is no difference in the incidence of major complications between the LH and TAH groups. LH offers many advantages over abdominal hysterectomy. Patients who had LH had less blood loss, less postoperative pain, required less parenteral analgesics, were able to ambulate earlier and were discharged earlier than their counterparts who had an abdominal hysterectomy. They were also able to resume full domestic activity much earlier.

Key words: Laparoscopic Hysterectomy, Total Abdominal Hysterectomy, Comparative Study

 

Introduction

Hysterectomy is the surgical removal of the uterus and it is the most common major gynecological surgical procedure worldwide. It has a broad spectrum of indications varying from malignant gynecological disease to obstetric indications. Regardless of mode, hysterectomy is most often performed for benign gynecologic conditions, and the operation is done in order to improve the patient’s quality of life.1

The use of laparoscopy has been widespread in gynecological procedures during the past two decades. It has become evident that complex gynecological procedures including hysterectomy can be performed using laparoscopic techniques.2 Minimal access surgery has allowed patients to recover faster and with lesser pain when compared to similar procedures performed through conventional open approach. Laparoscopic hysterectomy (LH) has been introduced since 1989 and represents one of the more advanced gynecological minimal access procedures. One of the claims of proponents of LH has been that the postoperative recovery of patients is superior to that of conventional abdominal hysterectomy.

There are three approaches for hysterectomy – vaginal, abdominal, and laparoscopic. Even though vaginal hysterectomy remains the approach of choice, only a minority of patients is suitable for the vaginal approach. Hence, the abdominal approach has been the predominant route for hysterectomy. LH has the potential of converting many patients who otherwise would have an abdominal hysterectomy to a total laparoscopic or laparoscopically assisted vaginal procedure. The endoscopic surgery provides the gynecologist with many advantages compared to conventional laparotomy procedures. These include a magnified and improved view of the operating field and the observation of the pelvic organs in a more natural state, with less tissue handling. Thus given adequate training of the surgeon in laparoscopic surgery, most of the patients who require a hysterectomy and have contraindications to vaginal hysterectomy may be offered laparoscopic assistance in hysterectomy with all the benefits associated with the vaginal route. The procedure requires special equipment and may only be carried out by the experienced gynecological laparoscopic surgeon. However, there is still considerable controversy as to whether all the effort put into achieving a laparoscopic approach is worthwhile, given the longer anesthetic time required even with a skilled team of surgeons.3 In LH an extensive abdominal incision is avoided, but at the same time there is increased the risk of major complications such as injury to ureter and bladder, especially during the learning curve.

In our view, LH can be considered as a substitute for abdominal hysterectomy. The benefit to patients should be first taken into account, even if the extent of laparoscopic dissection is based on the surgeon’s preference and experience with laparoscopic surgery.

The purpose of this study was to compare the clinical outcome of the patients who have undergone LH, with the patients who have undergone abdominal hysterectomy for benign gynecological pathology.

 

Materials and Methods

The study was conducted among patients admitted to BARC Hospital, Mumbai, Maharashtra, India from September 2009 to August 2010. This is a longitudinal study comparing the outcome of LH and abdominal hysterectomy in terms of duration of surgery, perioperative complications, and recovery of the patients. Forty-four patients were enrolled in the study. Women of all age groups who had an indication for hysterectomy were included in the study. Those with uterine mass above 12 weeks size, uterovaginal prolapse, proven or suspected malignancy, broad ligament fibroid, active abdominal tuberculosis, severe endometriosis (greater than Stage 2), and those with history of more than one previous major abdominal surgery were excluded.

We have studied 44 patients during this period out of which 22 had undergone LH and 22 had undergone total abdominal hysterectomy (TAH). The LH was either total LH or laparoscopic assisted vaginal hysterectomy (LAVH). Each patient was then explained about the study and a subject information sheet was given. Consent was obtained for participation in the study and as well for the surgical procedure.

The pre-operative evaluation was done by taking detailed history including age, parity, menstrual status, indication for surgery, any medical illness, and previous history of any abdominal surgery. Clinical examination including gynecological examination was done, and the details were noted. Routine pre-operative investigations including Pap smear and ultrasonography pelvis were also done. Uterine size measured by ultrasonography was taken for comparing patient profiles. All LH patients were given bowel preparation with axelite from the afternoon and those for abdominal hysterectomy were given simple soap water enema on the previous evening of surgery. Written informed consent was taken from all patients, and those for LH were informed about the possibility of laparotomy.

The standard technique was followed for LH and TAH under anesthesia. Intraoperative data included the type of anesthesia, intraperitoneal adhesions, duration of surgery, blood loss, and any complications. Intraoperative complications included most of the major complications such as injury to the urinary tract, injury to the bowel, severe hemorrhage requiring a blood transfusion, and unintended laparotomy.

The beginning of the operation was considered as the moment of umbilical incision for LH and as the moment of cutaneous incision for the abdominal technique. The cutaneous suture was considered the end of the operation in both cases either in the umbilicus for LH or low transverse incision for TAH. Accordingly the duration of surgery was calculated.

Blood loss during LH was calculated as the difference between the volume of fluid introduced into the pelvic cavity for irrigation purposes and the volume of fluid aspirated during the operation. If there was a vaginal component for the LH then additional blood loss was calculated with the number of sponges used. The amount of blood with one completely soaked sponge was 30 ml, and with partially soaked was 15 ml. Blood loss during TAH was calculated with the count of sponges and with the amount of fluid drained into the aspirator. If any irrigation was done, that volume of fluid introduced was deducted from the calculation.

Postoperative pain was assessed at 24 h and at 48 h after surgery using a visual analog scale, from 0 for no pain to 10 for maximum pain. All patients were put on intravenous tramadol 50 mg every 8 hourly and any need for additional analgesia was taken as a parameter for the study.

Complications were defined as major or minor. Major complications were usually defined as organ (bowel, bladder, and ureter) injury, major hemorrhage requiring blood transfusion, conversion to laparotomy in a case of LH, relaparotomy, wound dehiscence, and late urinary or bowel obstruction or fistula. Minor complications were defined as fever, urinary infection, respiratory infection, wound infection, and vault problems. Temperature ≥100°F starting from the second postoperative day was considered as postoperative fever.

After the patients were fully ambulated with normal bladder and bowel habits, the wound status was checked. If everything was normal, then the patients were discharged and called at a later day for suture removal in OPD. On the day of easy ambulation (without any support), duration of hospital stay was noted.

Again the patients were asked for a follow-up at 6-8 weeks and they were asked about the time taken for them to resume full domestic activities. Any sign of vaginal cuff infection or granulation tissue was checked. Any urinary or bowel complaints were also noted and evaluated.

Statistical analysis of the data was performed using a t-test for the numerical data and Chi-square test for categorical data. P<0.05 was considered as statistically significant. Software used was SPSS 15 for window manufacturer is IBM.

 

Results

There was no difference in the patient profile in terms of age, parity, body mass index (BMI), and uterine size of patients in both groups. The common indications for hysterectomy were the same in both LH and TAH groups which were fibroid and dysfunctional uterine bleeding (DUB). The other causes include endometriosis, adnexal cyst, and recurrent postmenopausal bleeding.

Among the hysterectomy in the LH group, 12 cases (54.5%) were done by LAVH technique, 9 cases (40.9%) were done by TLH technique. One case (4.5%) in the same group was converted to TAH in view of dense adhesions. All patients in the LH group and 15 patients (68.2%) in the TAH group were given general anesthesia. 7 patients (31.8%) in the TAH group were given spinal anesthesia. The duration of surgery is significantly shorter for TAH compared to LH but blood loss is significantly lesser for LH in comparison with TAH (Table 1). There were no statistically significant differences in the incidence of major perioperative complications between the LH and TAH groups. Minor complications such as fever, urinary tract infection, and wound infection were on a higher side in TAH. However, on statistical evaluation there was no significant difference (Table 2).

Table 1: Duration of surgery

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Table 2: Perioperative complications

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The pain score evaluation at 24 h postsurgery shows lesser pain for LH compared to TAH, but the significant difference is not seen. However, there is a significant difference in the pain score at 48 h between these two groups. Overall pain is lesser for the LH compared to TAH as evidenced by the lesser number of patients who required additional analgesia in LH group (Table 3).

Table 3: Postoperative pain

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Highest statistical significance was observed in time taken for recovery measured in terms of a number of days taken for easy ambulation, leaving the hospital, and resumption of domestic activities. Recovery was much quicker in LH compared to TAH (P<0.001).

 

Discussion

The outcome of 22 patients who underwent LH was compared with a similar group of 22 patients who had an abdominal hysterectomy for benign gynecological conditions with enlarged uteri equal to or below 12 weeks gestation size.

Patients in the two groups were similar with respect to age, parity, BMI, uterine size, any medical illness, or any previous history of abdominal surgery. Those studies which compare the clinical and functional outcome of LH and abdominal hysterectomy also had a similar profile in both groups.4-6

The indications for hysterectomy in both the laparoscopy and abdominal groups were also similar, with uterine fibroids and DUB forming the main indications.2,6

The time taken for the procedure was significantly longer in the LH group than in the abdominal hysterectomy group. The mean duration of this study was 144 min for the LH group while abdominal hysterectomy averaged 111 min (P<0.001). Our study is comparable with R. Garry7,8 and Falcone et al.9

Most of the studies show a significantly longer duration of surgery with LH. However, with more experienced laparoscopic surgeons, hysterectomies can be done laparoscopically with similar time of that of the open technique.

In most of the studies, there is a significant difference in the blood loss between these two groups with a higher blood loss in the open technique.10 However, the measurement of blood loss at hysterectomy is difficult as the method needs to be standardized to measure evacuated blood loss and blood on pads or swabs used during a hysterectomy.11 The studies in which the uterine size is comparable between the two groups failed to demonstrate any significant difference in the blood loss.12,13 However, in our study, there is a significant difference in the amount of blood loss, which is higher for TAH compared to LH.

There is no need for blood transfusion in either group of this study. Similar finding is noted in other studies also10 especially those with studies of similar uterine size.

There is no major injury to the bladder or bowel or any major vessel in this study in the LH group. Only one case of bladder injury has occurred in one TAH. One case of LH got converted to TAH which is the major complication in the LH group. The incidence of intraoperative complications in hysterectomy is 2-10%.14,13 Similar incidence of complication (4.5%) is seen in our study also.

There is no significant difference in the incidence of major complications among the two groups of this study.13,15 However, in the evaluate study there is a higher incidence of major complications in the LH.6,7 Our study was with a small sample size of 22 in each group. However, to compare the complications between two groups, a better sample size is required.

The percentage of minor complications was higher in TAH group compared to LH group though there was no statistically significant difference. In other studies, the minor complications were similar in both groups. There was statistically significantly increased the incidence of minor complications in the TAH group compared to LH group in Kapoor et al. study.10 The incidence of wound infection in the TAH group was 13.6% which is similar (11%) to other studies.16

Our study has shown a significant difference in the pain as determined by the pain scale and also there is a lesser requirement for additional analgesia. This is similar to the results obtained from many other studies by pain scale3,9,17 and by additional analgesic requirement.18

The duration of the hospital stay indirectly correlated to the day of easy ambulation and return to bladder and bowel activities. In all the prospective randomized studies, there was a significantly shorter hospital stay for the LH group.

This study shows a significant quicker recovery to the patients undergoing LH compared to TAH. Other studies such as Loh and Koa3 also show similar results.

Only one case of this study got converted from laparoscopic to abdominal hysterectomy. The duration of surgery was 180 min. Other than that, the rest of the parameters like pain, the need of analgesia, ambulation, hospital stay, and return to normal activities all were similar to the TAH group.

To summarize forty-four patients were enrolled in this study with twenty-two patients in each group. The aim of the study was to compare the outcome in terms of operating time, blood loss, perioperative complications, postoperative pain, and postoperative recovery. The mean duration of surgery was 144 min for LH and was 111 min for TAH (P<0.001). The mean blood loss was 145 ml for LH and was 202 ml for TAH (P<0.001). The incidence of major perioperative complications was same in LH (4.5%) and in TAH (4.5%). The incidence of minor perioperative complications was 22.7% in LH and 50% in TAH (P=0.06). The mean pain score at 24 h postsurgery was 5.05 for LH and was 5.50 for TAH (P=0.06). The mean pain score at 48 h postsurgery was 3.9 for LH and 4.95 for TAH (P<0.001). The patients who required additional analgesia were 7 (33%) in LH group compared to 14 (64%) in TAH group (P<0.001). The mean day of easy ambulation was 3.4th day for LH and 4.5th day for TAH (P<0.001). The mean duration of hospital stay was 4.7 days for LH and 7.7 days for TAH (P<0.001). The mean days for the resumption of domestic activities were 16.3 days for LH and 34 days for TAH (P<0.001) (Figure 1).

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Figure 1. Recovery in terms of easy ambulation, hospital stay and resumption of domestic activities

 

Conclusion

LH offers many advantages over abdominal hysterectomy. Patients who had LH had less blood loss, less postoperative pain, required less parenteral analgesics, were able to ambulate earlier and were discharged earlier than their counterparts who had an abdominal hysterectomy. They were also able to resume full domestic activity much earlier.

It is mandatory to obtain proper experience before performing laparoscopic hysterectomies independently. The selection of patients with LH should be performed only with respect to surgeon’s experience in laparoscopic surgery. The operative time has been found to be more with the laparoscopic approach than that with abdominal hysterectomy. However, the advantages offered by laparoscopic surgery in terms of lesser blood loss, lesser postoperative pain, shorter period of hospitalization, quicker recovery at a similar complication rate are not debatable and have been proved time and again.

End Note

Author Information

  1. Nigamananda Mishra, Professor, Department of Obstetrics and Gynaecology, Bhabha Atomic Research Center Hospital, Mumbai, India. Email: drnmishra@yahoo.co.in

  2. Anuja Thomas, Assistant Professor, Department of Obstetrics and Gynaecology, MGM Medical college and Hospital, Mumbai, India.

  3. Amrita Misri, Professor and Head, Department of Obstetrics and Gynaecology, Bhabha Atomic Research Center Hospital, Mumbai, India.

 

Conflict of Interest

None declared.

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