1 Service de Chirurgie Gynécologique (Pr Dubuisson), Clinique Universitaire Baudelocque, CHU Cochin Port-Royal, 123, Boulevard Port-Royal, 75014 Paris, 2 Direction Départementale des Affaires Sanitaires et Sociales (DDASS) du Loiret, 131 rue du Faubourg Bannier, F-45042 Orléans and 3 Unité INSERM 149, CHU Cochin Port-Royal, 123, Boulevard Port-Royal, 75014 Paris, France
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Abstract |
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Key words: laparotomy/operative laparoscopy/total hysterectomy/vaginal surgery
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Introduction |
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The progress in laparoscopic surgery made over the past few years has proved that total laparoscopic hysterectomy (TLH) is a feasible (Reich et al., 1989) and repeatable technique (Summitt et al., 1992
; Boike et al., 1993
; Daniell et al., 1993
; Chapron et al., 1994
). Laparoscopic surgery has many advantages over laparotomy, including a better cosmetic result, a significantly lower rate of infection and abdominal-wall complications, and shorter hospital stays and recovery periods. The use of laparoscopic surgery may reduce the number of hysterectomies carried out by laparotomy. In this connection, laparoscopic surgery is indicated when it enables diagnostic and/or therapeutic procedures to be performed that would be difficult if not impossible by the vaginal route (Chapron and Dubuisson, 1995
). The use of laparoscopy may have advantages when there is a history of adhesions following surgery (Chapron and Dubuisson, 1996
), when adnexectomy must be performed in addition to hysterectomy (Chapron et al., 1996c
) or when vaginal access is poor (Chapron et al., 1996a
), although none of these situations excludes the performance of vaginal surgery.
Ten years after the first TLH was performed (Reich et al., 1989), the purpose of this study is twofold: firstly to establish the current mode of performance of hysterectomies, and secondly to establish how widespread the performance of TLH has become. To this end we conducted a transversal multicentre study.
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Materials and methods |
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Patients
The study population consisted of all those patients with no malignant pathologies, no genital prolapse, and no urinary stress incontinence who were scheduled for a total hysterectomy during this period. Patients undergoing subtotal hysterectomies and obstetric emergency hysterectomies were excluded.
The following parameters were determined: the route of hysterectomy [laparotomy, vaginal route, laparoscopic surgery (TLH)], patient characteristics (age, weight, body mass index (BMI), parity, menopausal status, uterine weight, past history of surgery), indications for hysterectomy, peri- and postoperative complications, and duration of hospital stay.
Statistical analysis
Data were collected by one person at each centre and then centralized for analysis. The Pearson 2 test was used to test proportions, and confidence intervals (CI) were assessed with the binomial method. Results were expressed as means and standard deviations and were compared using analysis of variance method (ANOVA). When ANOVA validity conditions were not satisfied, a non-parametric test (KruskalWallis) was used. Results were considered significant when P < 0.05 (two tailed). Statistics were performed using Epi-Info 6 software.
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Results |
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The age of patients was 49.9 ± 8.7 years (mean ± SD) (range 2283), weight was 65.6 ± 12.4 kg (range 44121), height was 161 ± 6 cm (range 140173), and BMI was 24.9 ± 4.7 kg/m2 (range 17.046.9). The parity was 2.13 ± 1.49 (range 09) and the number of pregnancies was 1.6 ± 2.4 (range 09). Sixty patients (25.5%) were menopausal (CI 95%, 20.632.4). Twenty-eight patients (11.9%) presented a history of abdomino-pelvic surgery (CI 95%, 8.116.8). The indications for hysterectomies, sometimes more than one for the same patient, are reported in Table I. The duration of hospital stay was 6.0 ± 2.7 days (range 225). The overall perioperative complications rate was 5.1% (12 cases) (CI 95%, 2.68.7). The overall rate of postoperative complications was 15.3% (36 patients) (CI 95%, 10.120.6).
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Discussion |
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The mean number of hysterectomies carried out by operative laparoscopy was low (13.2% of operations; 31 cases) and TLH was not carried out by two-thirds of the centres (61%; 14 teams). This cannot be explained by the risk of complications. Operative laparoscopy is a safe procedure if the surgeons are well trained (Chapron et al., 1998) and the number of complications is not greater than that observed with laparotomy or the vaginal route (Dorsey et al., 1995
; Johns et al., 1995
; Nezhat et al., 1995
; Chapron et al., 1996b
). There is also considerable variation between the centres that do use TLH. Ten years after the first case of TLH was published (Reich et al., 1989
), this operative procedure appears to be performed either where the team is particularly interested in laparoscopic surgery (centres 20, 21, 23) or where the team is learning these new techniques (centres 1, 2, 8, 17, 19, 22).
The methods for carrying out hysterectomy vary considerably from one centre to another (Table VI). Whereas all the centres carried out this operation by laparotomy, its use varied from 9.1% (centre no. 18) to 90% (centre no. 2). Similarly, although 91% (21/23) of the centres used vaginal hysterectomy, the rate varied from 20% (centre no. 5) to 91% (centre no. 18). These differences suggest that the training of the surgeons plays an essential parameter in determining the choice of technique (Kovac et al., 1991
). The use of laparoscopic surgery appears to be inversely proportional to the ability of the team to perform vaginal surgery. Three out of four of the centres carrying out at least 60% of hysterectomies by the vaginal route used no TLH at all. Similarly the mean rate of vaginal hysterectomies for the nine centres carrying out TLH was 39% (34/115) which is lower than the overall mean rate.
These results were obtained in 23 French University Gynaecology and Obstetrics Departments, and appear to be an indication of the means by which hysterectomies are carried out in France. Whether the hospital structure is private or public, or linked to a University or not, appears to be irrelevant. Another prospective multicentre study was carried out between 2 and 15 December 1996 in France to assess the spread of laparoscopic surgery (Mabille de Poncheville, 1998). During this period 1350 surgeons responded to the questionnaire and carried out 1336 hysterectomies (Table VII
). The number of hysterectomies performed using laparotomy and by the vaginal route did not depend upon the type of hospital in which the procedure was performed. The rate of TLH was low, being significantly lower in private clinics (1.5%) (P < 0.0001), but comparable in public hospitals regardless of whether they were teaching hospitals (11.5%) or not (9.6%) (Table VII
).
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The failure of TLH to achieve widespread use suggests that the technique has not been properly taught and/or that its advantages compared with laparotomy have not been fully appreciated. The task that should be achieved over the years to come is certainly not to recommend one technique rather than another (vaginal route or operative laparoscopy) but rather to ensure that young surgeons can be offered training in all three techniques: laparotomy, vaginal surgery, and operative laparoscopy. The only way to decrease the number of laparotomic hysterectomies is to enable all three types of approach to be used efficiently (Figure 1) by providing fully comprehensive surgical training.
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Acknowledgments |
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Prof. Berger (Tours); Prof. Bernard and Prof. Racinet (Grenoble); Prof. Body (Tours); Prof. Brettes (Strasbourg): Prof. Boulanger (Amiens); Prof. Crépin (Lille); Prof. Dargent (Lyon); Prof. Dubuisson (Paris); Prof. Engelman (Colombes); Prof. Frydman (Clamart); Prof. Grosieux (Angers); Prof. Landes (Nancy); Prof. Leng (Bordeaux); Prof. Lopes (Nantes); Prof. Madelenat (Paris); Prof. Magnin (Poitiers); Prof. Maillet (Besancion); Prof. Paniel (Créteil); Prof. Piana (Marseille); Prof. Pigné (Paris); Prof. Quereux (Reims); Prof. Raudrant (Lyon); Prof. Rudigoz (Lyon). The teams are listed in alphabetical order and are not coincident with the listing order of Table VI.
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Notes |
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References |
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Submitted on March 19, 1999; accepted on June 18, 1999.