Twenty-first century laparoscopic hysterectomy: should we not leave the vaginal step out?

The objective of this study was to compare surgical outcomes for laparoscopically assisted vaginal hysterectomy (LAVH) with total laparoscopic hysterectomy (TLH) in three teaching hospitals in the Netherlands. This study is a multicenter cohort retrospective analysis of consecutive cases (Canadian Task Force classification II-2). One hundred and four women underwent a laparoscopic hysterectomy between March 1995 and March 2005 at one of three teaching hospitals. This included 37 women who underwent LAVH and 67 who underwent TLH. Blood loss, operating time, and intraoperative complications such as bladder or ureteric injury as well as conversion to an open procedure were recorded. In the TLH group, average age was statistically significant lower, as well as the mean parity, whereas estimated uterus size was statistically significant larger, compared to the LAVH group. Main indication in both groups was dysfunctional uterine bleeding. In the TLH group, mean blood loss (173 mL) was significant lower compared to the LAVH group (457 mL), whereas length of surgery, uterus weight, and complication rates were comparable between the two groups. The method of choice at the start of the study period was LAVH, and by the end of the study period, it had been superceded by TLH. LAVH should not be regarded as the novice’s laparoscopic hysterectomy. Moreover, with regard blood loss, TLH shows advantages above LAVH. This might be due to the influence of the altered anatomy in the vaginal stage of the LAVH procedure. Therefore, when a vaginal hysterectomy is contraindicated, TLH is the procedure of choice. LAVH remains indicated in case of vaginal hysterectomy with accompanying adnexal surgery

Gynaecologists estimate and experience laparoscopic hysterectomy as more difficult compared with abdominal hysterectomy

The level of difficulty of various types of hysterectomy differs and may influence the choice of either approach. When surgeons consider one specific approach to hysterectomy as more difficult, they may be reluctant to perform this type of hysterectomy. The main objective of this study was to investigate the potential different levels of difficulty for laparoscopic and abdominal hysterectomy. Furthermore, the accuracy of estimating the level of difficulty was examined. In a randomized controlled trial between laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH), gynaecologists were asked to record the preoperatively estimated and postoperatively experienced level of difficulty on a Visual Analogue Scale (VAS). Differences between LH and AH were examined and the correlation between the estimated uterine weight on bimanual palpation and the actual uterine weight was calculated. A difference on the VAS of three points or more (ΔVAS ≥ 3) was considered clinically relevant. In 72 out of 76 cases, both VAS scores were recorded. LH was estimated and experienced as significantly more difficult as compared with AH. In 13 (18%) cases, ΔVAS was ≥3, equally distributed between LH (n = 6) and AH (n = 7). Eleven of these 13 cases had a positive ΔVAS ≥3, meaning that surgery was experienced as more difficult than it was estimated. Surgeon’s estimation of uterine size correlated well with the actual uterine weight. LH is considered as more difficult than AH, which might be a reason for its slow implementation. In a large proportion of cases, gynaecologists seem to be able to estimate the level of difficulty of hysterectomy accurately

Long-terrn follow-up after pre-eclampsia/HELLP syndrome

Women with pre-eclampsia history are at increased risk for cardiovascular disease later in life. As pre-eclampsia is considered a vascular endothelial disease, the current interest in late cardiovascular complications is obvious. Moreover, there is much evidence that pre-eclampsia and cardiovascular disease share many risk factors. In contrast, information is scarce on possible late effects on organs commonly affected in pre-eclampsia/HELLP syndrome and eclampsia such as the kidney, the liver and the brain. Regarding the late psychosocial consequences of pre-eclampsia, there is growing evidence now that severe pre-eclampsia and/or HELLP syndrome may cause severe and long-lasting psychosomatic illness in some women postpartum. (c) 2005 Elsevier B.V. All rights reserved

Surgical staging in endometrial cancer

Endometrial cancer is the most prevalent cancer of the female genital tract. No randomised study exists to prove that pelvic and para-aortic lymphadenectomy increases survival, either by dissecting micrometastases or by altering the adjuvant treatment in all early stage (stage I grade I and 2) endometrial cancer patients. For lymph node metastases, adverse histology, deep myometrial invasion and cervical involvement are independent prognostic factors. We discuss the indication for full surgical staging in early endometrial cancer. In case a lymphadenectomy is indicated, this should always include a full pelvic and para-aortic lymphadenectomy. Lymphadenectomy does not replace adjuvant radiotherapy. (c) 2005 Elsevier B.V. All rights reserved

Intrapartum fetal surveillance: Monitoring fetal oxygenation with fetal blood sampling and umbilical cord blood analysis

Although electronic fetal heart rate monitoring remains the most popular technique for fetal surveillance during labour, there is much concern about the ever rising Caesarean section rate, probably partly due to this practice. Fetal blood sampling is still the gold standard when it comes to measuring fetal oxygenation. There is enough evidence that the combination of EFM and FBS is more efficient in detecting fetal hypoxia and prevents an unnecessary high intervention rate. Another toot to assess the efficacy of intrapartum fetal monitoring is the measurement of pH and blood gases in the umbilical cord blood. This method can also rule out fetal hypoxia in cases with unreassuring fetal heart rate patterns, meconium and low Apgar scores. Continuing inadequate fetal oxygenation during labour may lead to pathological fetal acidaemia. This means that there is a mixed acidosis in the fetal blood with hypercarbia and a substantial base deficit. A pH <7.00 may lead to later sequelae but the base deficit, indicating the duration of the insult, is a better predictor of neonatal morbidity. (c) 2005 Elsevier B.V. All rights reserved