1 Minimally Invasive Therapy Unit & Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond St, Hampstead, London NW3 2QG, UK
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Abstract |
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Key words: laparoscopic surgery/procedure time
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Introduction |
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If true, the duration and unpredictability of surgical time has important financial and practical implications for the management of operating sessions and waiting lists. Fewer patients may get treated per unit time, and procedures may have to be postponed because of over-running of planned lists. To assess how long common gynaecological laparoscopic procedures actually take, we analysed 1000 operations on a procedure-by-procedure basis.
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Materials and methods |
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The main indications for surgery included one or a combination of the following symptoms or pathologies: pelvic or abdominal pain, menstrual disturbance, ectopic pregnancy, adnexal mass, fibroids and infertility. The mean age of the women was 35.2 years (range 1385), and 495 were nulliparous. A total of 460 women underwent more than one laparoscopic procedure. Patient characteristics according to the various pathological conditions are described in Table I.
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The various laparoscopic procedures were grouped and analysed under five major categories, representing the most common pathological conditions encountered in this population (ectopic pregnancy, endometriosis, ovarian cyst, fibroids, and pelvic adhesions/tubal disease). All cases of laparoscopic hysterectomy were also analysed.
In view of the large number of anaesthetics involved with the procedure over the 9 year period and variations in anaesthetic technique, the operative time was defined as the `skin-to-skin' time and excluded anaesthetic and the set-up times.
Statistical comparisons were made using Student's t-test for parametric data and the MannWhitney U-test for non-parametric data (GraphPad Prism Software, San Diego, CA, USA).
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Results |
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The operating time was not recorded in 44 cases, and these women were excluded from subsequent analysis. The average operating time for all patients was 76.9 min (range 10400); 489 (52.0%) procedures took 1 h or less, 345 (36.6%) between 1 and 2 h, 84 (9.1%) between 2 and 3 h, and 22 (2.3%) over 3 h. Excluding two cases, all the other 20 cases of operating time longer than 3 h involved laparoscopic hysterectomy or myomectomy. The operating time for the 38 women requiring laparotomy was significantly longer at 130.2 min (range 30400) compared to the 918 who were managed successfully laparoscopically (mean 75.3 min; range 10300) (P < 0.0001). The 202 emergency cases were shorter than the elective cases [mean operating time of 58.3 (SD 27) and 81.4 (SD 50) respectively, P < 0.0001].
Ectopic pregnancy (Figure 1)
A total of 139 women was treated for extra-uterine pregnancy, including two cases of cornual pregnancy managed laparoscopically. Four (2.9%) other cases were converted to laparotomy. Surgery averaged less than 1 h. Conservative surgery in the form of salpingotomy was generally quicker than salpingectomy by 7 min (52.0 versus 59.0 min respectively). The operating time was longer in 14 cases where salpingotomy was attempted but had to be converted to salpingectomy because of persistent bleeding from the Fallopian tube (mean 69.0 min, range 45100). These cases had also a major contribution to the group who bled >250 ml. In contrast, the need for adhesiolysis in 21 cases (15%) added only a few min to the total operating time.
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Discussion |
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There is no evidence that the operating times in this series are significantly different to other published data. For instance, the mean operating time for laparoscopic management of ectopic pregnancy was 64 min (range 34150), 58 min and 59.7 (SD 18.1) min in other reported series (Foong et al., 1995; Chatwani et al., 1992
; Tozer and Shaxted, 1997
respectively). Laparoscopic ovarian cystectomy for non-endometriotic cysts averaged 51.8 min (range 30100), 115 min (range 75175) and 129 min (range 40200) in three other reports, whereas laparoscopic management of endometriomas averaged 168 (SD 72) min and ranged between 20 and 150 min in two other series (Cristalli et al., 1992
; Chi et al., 1995
; Bollen et al. 1992
; Bateman et al., 1994
; Del Pozo et al., 1995
respectively). Laparoscopic adnexectomy averaged 90 min in three other studies (range 40150) (Oelsner et al., 1993
; Gal et al., 1995
; Vilos and Alshimmiri, 1995
respectively). Operating times for laparoscopic myomectomy have been reported as 157 min (range 45443), 130 min (range 30300), 116 min (range 50190) and 110 min (range 30180) (Hasson et al., 1992
; Dubuisson et al., 1996
; Nezhat et al., 1991
; Daniel and Gurley, 1991
respectively). It thus seems that the variability in operating times is not unique to our series.
The finding that emergency laparoscopic procedures were significantly shorter and more consistent in duration than elective operations means that operating times should not be a disincentive to using endoscopy in such cases. Emergency procedures are typically performed outside normal working hours when prolonged or unpredictable operating times would be a particular disadvantage. However, given that most of these operations are for ectopic pregnancy, it is evident from randomized trials that laparotomy is not faster, and the range of operating times is not less than with endoscopic management (Baumann et al., 1991; Lundorff et al., 1991
; Murphy et al., 1992
; Gray et al., 1995
). Taken together, these data and our finding that laparoscopic surgery for ectopic pregnancy averaged less than 1 h, may further support the conclusion that operative laparoscopy has become the gold standard in treating ectopic pregnancy (Tulandi, 1996
; Clasen et al., 1997
).
Indeed, over two-fifths of the elective procedures such as salpingectomy, adhesiolysis, ablation of endometriosis, LUNA and ovarian cystectomy were completed within 1 h. On the other hand, when the operative findings required a combination of more than one laparoscopic procedure, or involved myomectomy or LAVH, surgery lasted much longer and was more unpredictable (75% of procedures took 90 min or more). This was especially so if myomectomy or hysterectomy involved suturing, when the mean operating time was between 2 and 3 h. This result can be partly explained by the extent of the pathology being treated, such as large or intramyometrial fibroids (Nezhat et al., 1991), but another major contributor to prolonged surgery is the inherent difficulty of current laparoscopic suturing techniques. Given the recent findings of Vossen et al. (1997) it is expected that operating times of laparoscopic operations involving suturing might shorten by further training for tying techniques.
Another finding with respect to laparoscopic hysterectomy for benign indications is that the mean operating times and the range of operating times are similar irrespective of the pathological findings. Our average procedure time of about 2 h is consistent with most other published series (Liu, 1992; Summitt et al., 1992
; Nezhat et al., 1994
; Bornstein and Shaber, 1995
; Chapron et al., 1996
; Dorsey et al., 1996
; Meikle et al., 1997
). Apart from the extent of pelvic pathology and the mode of haemostasis, the other important determinant of how long LAVH takes depends on the stage when laparoscopy is converted to vaginal surgery (Phipps and Nayak, 1993
; Richardson et al., 1995
). For this reason, our tendency is to switch to vaginal dissection early during the procedure, and we prefer to ligate the uterine vessels and operate on the vaginal vault vaginally. Whatever the technique, the comparative data clearly show that abdominal and vaginal hysterectomies are faster procedures by a time of 1 h, and the variability in operating times is also less (Howard and Sanchez, 1993
; Phipps and Nayak, 1993
; Richardson et al., 1995
; Dorsey et al., 1996
).
In conclusion, our analysis of 1000 laparoscopies on a procedure-by-procedure basis demonstrates that although half the procedures took about 1 h, operating times ranged from 10 min to over 6 h. Generally elective operations, particularly laparoscopic myomectomy and hysterectomy, took the longest and had the greatest variability in procedure times. The implication of these results is that it is difficult to plan operating lists of such cases for optimal theatre utilization. It may be that the only way to achieve a more efficient use of theatre time is to assess potential patients for operative laparoscopy by diagnostic laparoscopy first, both to judge their suitability for endoscopic surgery and also to allow estimation of the likely procedure time for their surgery. Office laparoscopy might be a convenient method for this purpose (Fester, 1996). To what extent management by laparotomy is any more predictable remains to be seen.
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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 April 7, 1998; accepted on September 25, 1998.