Consultant Minimal Access Gynaecologist

(with special interest in Endometriosis and Keyhole Surgery)

 

 
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MR TREHAN'S OUTCOME RESULTS (AUDITS)

Different audits have been presented here:

Audit 1 - This is an audit of Keyhole hysterectomy in detail.

LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMIES

Audit 2 - This is an audit of Keyhole major gynaecological surgery on other gynaecological conditions, excluding keyhole hysterectomy.

LAPAROSCOPIC [KEYHOLE]
MAJOR  GYNAECOLOGICAL SURGERY
[EXCLUDING KEYHOLE HYSTERECTOMY]

Audit 3 -  This is an audit of Endometriosis surgery.

LAPAROSCOPIC TOTAL PERITONEAL EXCISION
A SAFE SURGICAL PROCEDURE
FOR THE MANAGEMENT OF ENDOMETRIOSIS

AUDIT 1
AUDIT SEPTEMBER 2000

LAPAROSCOPIC [KEYHOLE] ASSISTED VAGINAL HYSTERECTOMIES
265 CONSECUTIVE HYSTERECTOMIES

LAVH +/- BSO +/- ADHESIOLYSIS +/-
ENDOMETRIOSIS EXCISION +/-
OVARIAN CYSTECTOMY +/- SALPINGECTOMY

 ALL OPERATIONS UNDERTAKEN
BY
MR A K TREHAN FRCOG FRCS [Edin]
CONSULTANT MINIMAL ACCESS GYNAECOLOGIST
AT
DEWSBURY AND DISTRICT HOSPITAL

TYPE OF OPERATION – TABLE NO 1

OPERATION

LAVH ONLY       

LAVH &  USO/ BSO ONLY

 

ADDITIONAL PROCEDURE

WITH LAVH/LAVH & SO

NUMBER 265

38  (14.3%)

59 (22.3%)

168 (63.4%)

ADDITIONAL PROCEDURE

ADHESIOLYSIS – Uterine, adnexal and bowel, omental adhesions ( flimsy and firm and thick).

PERITONINAL EXCISION OF ENDOMETRIOSIS – Striping of peritoneum covering ovarian fossa, pouch of Douglas, utrosacral ligaments and utrovesicle fold ( stage I- IV)

DRAINAGE/EXCISION OF BENIGN OVARIAN CYST

SALPINGECTOMY for chronic tubal disease

USO – UNILATERAL SALPINGO OOPHORECTOMY
BSO – BILATERAL SALPINGO OOPHORECTOMY

Histology        Table No - 2

 

No

%

Leiomyomata

79

29.8%

Normal Histology

60

22.6%

Adenomyosis

13.2%

35

Endometriosis

29

10.9%

Leiomyomata +/- Adenomyosis +/- Endometriosis

30

11.4%

Endometrial Hyperplasia +/- Atypia +/- Complex

8

3.0%

Benign ovarian cyst

8

3.0%

Endometrial Carcinoma

4

1.5%

CIN

2

0.8%

Miscellaneous (eg. Endometritis, polyp, inflamation etc.)

10

3.8%

 

265

100%

OUTCOME COMPARISON OF 5 – 50 PATIENT SERIES – TABLE - 3

Parameter

1-50

51-100

101-150

151-200

201-265

265

 

 

 

(50)

(50)

(50)

(50)

(65)

 

 

 

 

 

 

 

 

 

Mean

Range

S.D.

Patients Age

42 yrs

44 yrs

44 yrs

43 yrs

43 yrs

43 yrs

(27- 63 yrs)

7.1

Patients Weight

68 kg

70 kg

69 kg

69 kg

70 kg

69 kg

(43- 134 kg)

14.13

Uterine Weight

157 gm

158 gm

138 gm

175 gm

136 gm

153

(47- 500 gm)

79.8

Previous L.S.C.S.

0 (0 %)

2 (4%)

5 (10%)

5 (10%)

9 (16.9%)

23

(8.7%)

 

Operative Time

94 min

93 min

98 min

97min

109 min

98 min

(55- 205 min)

30.3

Hb Deficit

1.7gm%

1.86gm%

1.9gm%

1.9gm%

1.9gm%

1.85gm%

(0.1-5.5 gm%)

 

Abnormal Histology

62 %

80 %

76 %

88 %

83 %

77 %

 

 

Conversion to TAH

0 (0%)

0 (0%)

1 (2%)

0 (0%)

0%

1 (0.38%)

 

 

Re-Admission

2 (4%)

2 (4%)

1 (2%)

0 (0%)

0 (0%)

5 (1.88%)

 

 

Re-Opertaion

1(0.5%)

1(0.5%)

0(0%)

1(0.5%)

0(0%)

3(1.13%)

 

 

Total Complications(INCLUDING CONVERSION & RE – ADMISSION AND RE-OPERATION )

3 (6%)

3 (6%)

3 (6%)

3(6%)

0%

12  (4.5 %)

 

 

 

HOSPITAL STAY
Hospital stay relates to number of post operative nights in the hospital
[265  CONSECUTIVE LAVH] - TABLE 4

Patient No

Total
Patient

Total day stay
in hospital

Median day stay
in hospital

% patients with
overnight stay

1 - 50

50

107

2 (range 2-3)

-

51 - 100

50

102

2 (range 2-3)

-

101 - 150

50

92

2 (range 1-6)

28%

151 - 200

50

58

1 (range 1-4)

88%

201 - 265

65

71

1 (range 1-2)

91%

  • Overnight hospital stay hysterectomy gradually introduced

  • Most [91%] of patients left hospital after overnight stay

TABLE 5-1      TOTAL PATIENTS WITH COMPLICATIONS  [265 CONSECUTIVE LAVH]

Minor vaginal discharge/blood loss/GIT upset/vault granulation tissue which were managed by reassurance and/or outpatient basis and pre-peri-post operative blood transfusion for  pre-existing anaemia not included

TYPE OF COMPLICATION

CASE NO.

NO

%

Rash & gastroenteritis requiring re-admission
(allergy to Lactulose)

12

1

0.37

Only blood transfusion (B.T)
(2-4 units)

45, 70, 168, 186

4

1.50

Richters Hernia requiring re-operation
(Now routinly stitching 12 mm port)

46

1

0.37

Secondary bleeding
(Case no. 75 received B.T + vault stitching)

75, 92, 148

3

1.13

Conversion of TAH requiring 2 units B.T
(obese and large fibroid)

119

1

0.37

Subrectus haematoma requiring re-operation and blood transfusion

163

1

0.37

Sup wound inflammation requiring antibiotic
(very obese)

169

1

0.37

Total

265

12

4.5%

  • LAVH is low complication hysterectomy with 4.5% of patients suffering complications

  • None of the complications were major and all patients had full surgical recovery at 6 weeks post operative – except for a few patients who had granulation tissue

RE-OPERATION/BACK TO THEATRE AND READMISSION
[265 CONSECUTIVE LAVH] - TABLE 5 – II

Case No

Total patient

 Re-operation

Readmission

1 – 50

50

1 (2%)

2 (4%)

51 – 100

50

1 (2%)

2 (4%)

101 – 150

50

0 (0%)

1 (2%)

151 – 200

50

1(2%)

0 (0%)

200 - 265

65

0 (0%)

0 (0%)

Total

265

3 (1.13%)

5 (1.88%)

Details of re-operation

Case No 46 -      Richter’s hernia
Case No 75 -      Sec Bleeding – 18th post op day vault stitch x 2
Case No 163 -   Subrectus haematoma – 1st post op day

Details of re-admission

Case No 12

Rash/gastroentritis Re-admitted 5th post op day – allergy to Lactulose Stay 2 days

Case No 46

Richters hernia Re-admitted 9th post op day – re-operation

Case No 75/92/148

Sec bleeding Re-admitted 18th, 11th, 12th post op day.
Vault stitch [case 75], conservative management [case 92 & 148] stay 2, 2, 1 day respectively

MAJOR COMPLICATIONS OF LAVH – TABLE 5 – III
(Major complications include injury to bowel, urinary tract and major blood vessels)

Complications

Garry & Phillip (1995)*

AAGL survey (1997)**

Mr Trehan

Bowel

0.66%*

0.54%**

0%

Urinary Tract

2.77%*

1.46%**

0%

Injury to vessels
Epigastric/iliac/
Aorta/venacava

1.63%*

2.55%**

0%

Total

5.06%*

4.55%**

0%

RE-OPERATION AND CONVERSION TO LAPAROTOMY

Total

3.70%*

3.78%**

(4 patients)1.50%

Details of re-operations and convertions
Case No 46 – Richter’s hernia – treated by surgical team
Case No 75 – Sec bleeding – 18th post operative day – vault stitch x 2 – stay 2 nights
Case No 119 – Conversion to TAH – stay 6 days
Case No 163 – Subrectus haematoma – 1st pre-operative day – stay 4 nights

*   Garry R, Phillips G – “1995” Gynaecological endoscopy  4: 77-9
** Hulka J F et al – 1997 J Am Assoc Gynaecol Laparoscop 4:167 – 171.
(AAGL American Association of Gynaecological laparoscopists).

COMPARISON OF OVERALL COMPLICATION RATES FOR HYSTERECTOMY (rate per 100 women undergoing hysterectomy)
TABLE – 5 –IV

PUBLISHED COMPLICATION RATES

Type of hysterectomy

Mr Trehan’s
complication rate

1995

1994

1993

1982

Total abdominal

-

 

47.08

47.06-7

42.81

Vaginal

-

 

 

15.05

24.51

Lap-ass vag

4.5%*

15.69

18.08

13.02-4

 

The complication rate for LAVH is less than for vaginal hysterectomy and abdominal hysterectomy.

*  Minor Vaginal discharge & vault granulation tissue not included.

  1. Dicker RC, Greenspan JR, Strauss LET et al.  Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States.  American Journal of Obstetrics and Gynaecology 1982; 144: 841-8.

  2. Reich H, De Carpio J, McGlynn F.  Laparoscopic hysterectomy.  Journal of Gynaecological Surgery 1989;5: 213-16

  3. Reich H.  Laparoscopic hysterectomy.  Surgical laparoscopy and Endoscopy 1992; 2: 85-8. 

  4. Reich H. McGlynn F, Sekel L.  Total laparoscopic hysterectomy.  Gynaecological Endoscopy 1993; 2: 59-63.

  5. Raatz D.  The vaginal hysterectomy.  Gynaecological Endoscopy 1993; 2: 85-7.

  6. Dwyer N, Hutton J,  Stirrat G.  Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia.  British Journal of Obstetrics and Gynaecology 1993; 100: 237-43.

  7. Sculpher MJ, Bryan S, Dwyer N, Hutton J, Stirrat GM.  An economic evaluationof transcervical endometrial resection vs. abdominal hysterectomy for the treatment of menorrhagia.  British Journal of Obstetrics and Gynaecology 1993; 100: 244-52.

  8. Hildebaugh D, O’Mara P, Conboy E.  Clinical and financial analyses of laparoscopic-assisted vaginal hysterectomy.  Journal of the American Association of Gynaecologic Laparoscopists 1994; 1: 357-64.

  9. Garry R, Phillips G.  How safe is the laparoscopic approach to hysterectomy? Gynaecological Endoscopy 1995; 4; 77-9. 

CONCLUSION

  • Most [91%] of patients left hospital after overnight hospital stay.

  • LAVH is a low complication hysterectomy with 4.5% of patients suffering with complication.  None of the complications were major.

  • No patients were re-admitted following overnight stay hysterectomy.

  • Overnight hospital stay hysterectomy is possible and is safe practice

AUDIT 2

AUDIT DECEMBER 2000

LAPAROSCOPIC [KEYHOLE]
MAJOR  GYNAECOLOGICAL SURGERY
[EXCLUDING KEYHOLE HYSTERECTOMY]
336 CONSECUTIVE OPERATIONS

 

DEWSBURY DISTRICT HOSPITAL
HALIFAX ROAD
DEWSBURY
WEST YORKSHIRE

ALL OPERATIONS UNDERTAKEN By
MR A K TREHAN  FRCOG FRCS  [Edin]
CONSULTANT MINIMAL ACCESS GYNAECOLOGIST

AT
Dewsbury and District Hospital

 

LAPAROSCOPIC KEYHOLE MAJOR
GYNAECOLOGICAL SURGERY
[EXCLUDING KEYHOLE HYSTERECTOMY]

INDICATION FOR OPERATION – PELVIC PAIN, MASS & INFERTILITY

These are caused by conditions such as ectopic pregnancy, pelvic inflammatory disease, benign ovarian cysts, distal tubal disease, retroverted uterus, polycystic ovaries, adhesions and moderate to severe endometriosis.

TYPES OF OPERATION:-

COAGULATION & EXCISION OF ENDOMETRIOSIS (Stage 1-1V)

VENTROSUSPENSION
SALPINGECTOMY
ADHESIOLYSIS (Mild to severe)
OOPHORECTOMY
OVARIAN CYSTECTOMY
OVARIAN DRILLING
ECTOPIC PREGNANCY
SALPINGOSTOMY – TUBAL SURGERY

AUDIT DECEMBER 2000

TOTAL NO OF PATIENTS OPERATED

336

TOTAL NO OF DAYS STAY

387

AVERAGE DAY STAY

1.15 Days

% OF PATIENTS STAYING OVERNIGHT IN 1999

88%

% OF PATIENTS STAYING OVERNIGHT IN 2000

96%

MAJOR GYNAECOLOGICAL SURGERY
EXCLUDING HYSTERECTOMY

TOTAL NUMBER OF  CONSECUTIVE PATIENTS OPERATED

336

 

SURGICAL COMPLICATIONS

3

0.90%

Details of complications

 

 

Weeping wound following ventrosuspension
[allergy to silk thread]

2

 

Blood transfusion – 2 units (stage 4 endometriosis)

1

 

ANAESTHETIC COMPLICATIONS

2

0.60%

Laryngeal spasm – Pulmonary oedema-haemoptesis, blood transfusion
Pneumothorox – Conservative treatment, Hospital stay – 3 nights

 

 

RE-ADMISSION WITHIN 6 WEEKS (No surgical complication)

5

1.5%

(Reasons for re-admission- anxiety due to bleeding caused by early onset of menstruation and dysmenorrhoea following the surgery and/or constipation)

 

 

 

 

 

CONVERSION

0

0%

INJURY TO IMPORTANT ORGANS SUCH AS BOWEL, BLADDER, URETHRA & BLOOD VESSEL ETC

0

0%

LONG TERM PROBLEM DUE TO OPERATION

0

0%

RECOVERY FROM OPERATION WITHIN 2 – 4 WEEKS

 

100%

SUMMARY
AVERAGE HOSPITAL STAY FOLLOWING LAPAROSCOPIC MAJOR GYNAECOLOGICAL OPERATION IS 1.15 DAYS

96% OF THE PATIENTS DISCHARGED HOME AFTER OVERNIGHT HOSPITAL STAY FOLLOWING MAJOR GYNAECOLOGICAL SURGERY IN 2000

NO CONVERSION OR MAJOR COMPLICATIONS AMONG 336 OPERATIONS

CONCLUSION
KEYHOLE LAPAROSCOPIC MAJOR GYNAECOLOGICAL SURGERY HAS VERY LOW COMPLICATION RATES AND IS VERY SAFE IN EXPERIENCED HANDS

 

AUDIT 3
AUDIT 2004

ENDOMETRIOSIS SURGERY AUDIT

 ALL OPERATIONS UNDERTAKEN
BY
MR A K TREHAN FRCOG FRCS [Edin]
CONSULTANT MINIMAL ACCESS GYNAECOLOGIST
AT
DEWSBURY AND DISTRICT HOSPITAL

Click here to view audit 3

 

  
      ©Mr A K Trehan