Surgical outcomes of total laparoscopic hysterectomy with 2 ... - J-Stage

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Key words : 3-dimensional laparoscopy, total laparoscopic hysterectomy, surgical outcomes .... cesarean sections, vaginal deliveries, complication of.
H. Yazawa et al.

38Fukushima J. Med. Sci., Vol. 64, No. 1, 2018

[Original Article]

Surgical outcomes of total laparoscopic hysterectomy with 2-dimensional versus 3-dimensional laparoscopic surgical systems Hiroyuki Yazawa1), Kaoru Takiguchi2), Karin Imaizumi1), Marina Wada3) and Fumihiro Ito1) Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital1), Department of Obstetrics and Gynecology, Ohta Nishinouchi Hospital2), Department of Obstetrics and Gynecology, Fukushima Medical University3) (Received November 20, 2017, accepted February 1, 2018) Abstract Three-dimensional (3D) laparoscopic surgical systems have been developed to account for the lack of depth perception, a known disadvantage of conventional 2-dimensional (2D) laparoscopy.  In this study, we retrospectively compared the outcomes of total laparoscopic hysterectomy (TLH) with 3D versus conventional 2D laparoscopy.  From November 2014, when we began using a 3D laparoscopic system at our hospital, to December 2015, 47 TLH procedures were performed using a 3D laparoscopic system (3D-TLH).  The outcomes of 3D-TLH were compared with the outcomes of TLH using the conventional 2D laparoscopic system (2D-TLH) performed just before the introduction of the 3D system.  The 3D-TLH group had a statistically significantly shorter mean operative time than the 2D-TLH group (119±20 vs. 137±20 min), whereas the mean weight of the resected uterus and mean intraoperative blood loss were not statistically different.  When we compared the outcomes for 20 cases in each group, using the same energy sealing device in a short period of time, only mean operative time was statistically different between the 3D-TLH and 2D-TLH groups (113±19 vs. 133±21 min).  During the observation period, there was one occurrence of postoperative peritonitis in the 2D-TLH group and one occurrence of vaginal cuff dehiscence in each group, which was not statistically different.  The surgeon and assistant surgeons did not report any symptoms attributable to the 3D imaging system such as dizziness, eyestrain, nausea, and headache.  Therefore, we conclude that the 3D laparoscopic system could be used safely and efficiently for TLH. Key words : 3-dimensional laparoscopy, total laparoscopic hysterectomy, surgical outcomes

roscopic surgical system was developed to address the lack of depth perception in the 2D laparoscopic system.  In November 2014, we began to use a 3D laparoscopic surgical system (VISERA ELITE, ENDOEYE FLEX 3D, OLYMPUS®) for total laparoscopic hysterectomy (TLH), which is the first-line type of hysterectomy for benign uterine diseases such as leiomyoma or endometriosis in our hospital.  In this study, we retrospectively compared the surgical outcomes of TLH with 3D versus 2D laparoscopic surgical systems and investigated the usefulness of the 3D surgical system.

Introduction Laparoscopic surgery has been adopted as a type of minimally invasive surgery to improve quality of life relative to open surgery.  Its advantage for patients include smaller surgical incisions, less intraoperative blood loss, less postoperative pain, shorter hospital stay, and earlier resumption of normal activities, especially after gynecological surgery.  The lack of depth perception and sense of touch are drawbacks in conventional 2D laparoscopic surgery, that can increase operative time, and surgeon fatigue and stress.  Consequently, a 3D lapa-

Corresponding author : Hiroyuki Yazawa  E-mail : [email protected] https://www.jstage.jst.go.jp/browse/fms http://www.fmu.ac.jp/home/lib/F-igaku/ 38

Surgical outcomes of total laparoscopic hysterectomy with 2-dimensional versus 3-dimensional laparoscopic surgical systems 39

Objective From November 2014 to December 2015, 47 TLHs were performed using the 3D laparoscopic system, including two demonstration cases before the adoption of the 3D system at our hospital. We compared the outcomes of 3D-TLH with the outcomes of 47 cases of 2D-TLH performed just before the adoption of the 3D laparoscopic system.

Material and Methods TLH procedure at our hospital (Fig. 1) At our hospital, TLH during this study period were as follows.  We used 4 trocar ports (one 12 mm trocar at bottom of the umbilicus for the scope and three 5 mm trocars in the lower abdomen for manipulation) in a diamond position.  The uterus was controlled using a Uterine manipulator® inserted just before the operation began.  First, the vesi-

couterine peritoneal fold was opened and bladder was mobilized inferiorly with blunt dissection (Fig. 1A).  The upper uterine ligaments were then dissected using an energy sealing device LigaSure V® or Thunderbeat® (Fig. 1B).  In all cases, we identified the ureter and uterine arteries in retroperitoneal space.  We ligated and cut the uterine arteries (Fig. 1C).  The cardinal ligament was ligated and dissected using an energy sealing device (Fig. 1D).  The Uterine manipulator ® was then removed.  The uterovaginal canal was incised using monopolar electrosurgical knife (pure cutting current, 40 watts).  Identification of the dissection line was facilitated with a VAGI Pipe® inserted into the vagina (Fig. 1E).  The uterus was cut down and extracted transvaginally (Fig. 1F).  The vaginal cuff was closed with a laparoscopic one-layer Z-plasty suturing with 0-Vicryl (Fig. 1G).  Finally, the retroperitoneum was closed with continuous 2-0 Vicryl sutures (Fig. 1H).  Cystoscope was performed and urinary flow from bilateral ureters was confirmed af-

left uterine artery (ligated)

A

B

C

left ureter transvaginal procedure

D

E

F Cystoscope

G

H

I

Fig. 1. Total laparoscopic hysterectomy (TLH) procedure for this study. The vesicouterine peritoneal fold was opened and bladder hysterectomy was mobilized inferiorly with a blunt dissection (Figure 1)Total lapaoscopic (TLH) (1A).  The upper uterine ligaments were dissected using LigaSure V® or Thunderbeat® energy sealing device procedure for inthis study. space, and the uterine arteries were li(1B).  The ureters and uterine arteries were identified retroperitoneal gated and cut (1C).  The cardinal ligaments were ligated and dissected using an energy sealing device (1D).  The uterovaginal canal was incised by monopolar electrosurgical knife while the dissection line was clarified using VAGI Pipe® inserted into the vagina (1E).  The uterus was cut down and extracted transvaginally (1F).  The vaginal cuff was closed with laparoscopic one-layer Z-plasty suturing with 0-Vicryl (1G).  Finally, the retroperitoneum was closed with continuous using 2-0 Vicryl sutures (1H).

H. Yazawa et al.

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ter the vaginal cuff was sutured (Fig. 1I).  All TLHs during this study period were performed by one surgeon. Comparison of surgical outcomes ; We adopted the 3D laparoscopic surgical system in November 2014.  By December 2015, 47 cases of 3D-TLH were performed, including two demonstration cases performed before the adoption.  Operative time, intraoperative blood loss, weight of the removed uterus, and complication of these 47 3DTLH cases and 47 cases of 2D-TLH performed just before the adoption of the 3D laparoscopic system were compared.  We also compared the outcomes of 20 cases in each group, because the study period was so long (approximately 2.5 years) and the sealing devices changed during the study periods.  Additionally, we compared the outcomes between the first half (23 cases) and second half (22 cases) of 3DTHL cases. Statistical analysis was performed using the ttest and chi-square test.  A p value