1 Minimally Invasive Therapy Unit & Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK
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Abstract |
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Key words: laparoscopic surgery/laparotomy/procedure time/variability
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Introduction |
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We have recently shown from analysis of 1000 operative laparoscopic procedures that while the average operating time was 77 min, the range of operating times was great (10400 min) (Shushan et al., 1999). These data suggest that while the average laparoscopic procedure may not take longer than traditional open surgery, endoscopic procedures are probably less predictable, having a wide range of operating times. Although there are many controlled studies comparing laparoscopic and open procedures, there are no data with respect to any differences in the variability of operating times between the two surgical approaches. The present case-control study was undertaken to compare the variability of operating times of some of the most common gynaecological procedures when done laparoscopically or by laparotomy.
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Materials and methods |
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These patients were matched with an equal number of women who had been treated during the same time period by laparotomy for similar indications. These patients were under the care of a different gynaecological team whose preferred management was by open surgery. Additional matching criteria included age of the women (±2 years), the period of amenorrhoea in cases of ectopic pregnancies, size of the lesion (±3 cm) in cases of ovarian cysts and fibroids, and uterine size and pelvic pathology in women undergoing hysterectomy. Patients' characteristics according to the various pathological conditions are described in Table I. All surgery was done by surgeons experienced in laparoscopic and open surgery.
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Statistical comparisons were made using the MannWhitney U-test for non-parametric data and unpaired t-test with Welch's correction for the F-test to compare variances (GraphPad Prism Software, San Diego, USA). A result was considered statistically significant if P < 0.05.
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Results |
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The operating time statistics are shown in Table II. Overall, there was no significant difference between the mean procedure times for laparoscopy or laparotomy, but the variability was significantly greater with endoscopy. Looking at the individual procedures, the mean procedure times were similar for the two routes of surgery with the exception of hysterectomy which took significantly longer if done laparoscopically (P < 0.01). In terms of variability of operating times, the duration of laparoscopic surgery for ectopic pregnancy (salpingectomy), ovarian cystectomy and hysterectomy was significantly less predictable than at laparotomy.
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Discussion |
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Although no previous study has examined the variability of operating times specifically, several investigators have used operating time as one of the parameters to compare surgery by laparoscopy and laparotomy. Our finding that LAVH takes longer to perform than abdominal hysterectomy and is less predictable in terms of duration is consistent with many previous reports (Summitt et al., 1992; Howard and Sanchez, 1993
; Phipps and Nayak, 1993
; Dorsey et al., 1996
; Meikle et al., 1997
). Our results regarding ovarian cystectomy and salpingectomy are also consistent with other comparative studies (Foong et al., 1995
; Mais et al., 1995
; Yuen et al., 1997
). For instance, in a randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses, it has recently been reported that the operating time for laparoscopic cystectomy was 59.5 (SD 31.6) min, while open cystectomy took 52.7 min with an SD of only 1.9 min (Yuen et al., 1997
). In another randomized comparison of laparoscopy and laparotomy in the treatment of non-endometriotic benign adnexal cysts, it has been reported that mean operating times were 70 (SD 20) min with laparoscopy and 67 (SD 12) min with laparotomy (Mains et al., 1995). It has also been reported that when laparoscopy was compared to conventional surgery in the management of ectopic pregnancy, the range with laparotomy was 45 to 100 min while with laparoscopy it was 34150 min (Foong et al., 1995
). Laparoscopic myomectomy is even less predictable, and a wide range of operating times have been reported (Hasson et al., 1992
; Dubuisson et al., 1996
).
The factors that increase the unpredictability of duration of endoscopic surgery have never been investigated. It has been shown that laparoscopic surgery requires specific skills and that operating times can be shortened with experience (Yeko et al., 1994). For example, it has recently been shown that operating times of laparoscopic operations involving suturing can be shortened by training of tying techniques (Vossen et al., 1997
). Given that in the present study factors like the nature of the operation, extent of pelvic pathology and experience of surgeon were similar, it may be that most of the delays with laparoscopic surgery may be inherent in the technique itself. Our impression is that factors such as availability of appropriate instruments, equipment breakdown, familiarity of ancillary staff assisting with the equipment, and complications which take longer to manage, are all more relevant with endoscopic surgery than with laparotomy.
In conclusion, our study confirms that in most cases, laparoscopic surgery is far more unpredictable in duration than conventional open surgery. This is a disadvantage when it comes to the planning of operating lists involving mainly laparoscopic cases. Whether careful preoperative assessment involving clinical examination, pelvic ultrasound and a prior laparoscopic evaluation can improve our estimate of the likely duration of a particular laparoscopic procedure, or whether the relative variability of duration of laparoscopic surgery is inherent in the technique itself, remains to be resolved.
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Notes |
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3 To whom correspondence should be addressed
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References |
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Submitted on October 6, 1998; accepted on February 3, 1999.