The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases

Abstract

Study objective: To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them.

Design: Retrospective, comparative study (Canadian Task Force classification II-2).

Setting: University tertiary referral center for endoscopic surgery.

Patients: During 1989-1995 and 1996-1999, 695 and 952 women, respectively, with benign pathology.

Intervention: Total laparoscopic hysterectomy.

Measurements and main results: No differences in patient characteristics were found between 1989-1995 and 1996-1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22-904 g) and 292.0 g (40-980 g) and operating times 115 minutes (40-270 min) and 90 minutes (40-180 min), respectively, were recorded (p <0.005).

Conclusion: Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.