Complications of total laparoscopic hysterectomy: A retrospective study of cases performed by a single surgeon

Abstract

Hysterectomy is the most common gynaecological surgery and there are different techniques of performing hysterectomy. With the advent of laparoscopic technology, laparoscopic hysterectomy (LH) is rapidly gaining its ground. However, every surgery has its complications which are specific but also depends on various factors such as surgical skills and experience of surgeons, levels of operative laparoscopy and patient populations.

Aims and Objective:

In this study, we evaluated the complications of total laparoscopic hysterectomy (TLH) and analysed the trend of complications, intraoperative and post-operative, over a period of time.

Methods:

It was a retrospective study conducted in the private care setting. All women who underwent hysterectomy for benign conditions from a 1 January 2003 to 31 December 2017, (15 years) were included in this study. A total of 3272 patients were operated during this period. All surgeries were performed by a single surgeon.

Results:

Intraoperative complications that occurred during surgery during the study period were 3 cases (0.09%) had bladder injury, 3 cases (0.09%) had bowel injury, 1 case (0.03%) had internal iliac vessel bleeding and 1 case(0.03%) needed conversion to vaginal hysterectomy due to cautery failure and post operative complications were 90 cases (2.75%) had vault bleeding, 2 cases (0.06%) had intestinal obstruction, 5 cases (0.15%) had paralytic ileus, 1 case (0.03%) had vesicovaginal fistula, 1 case(0.03%) had ureterovaginal fistula and 1 case (0.03%) had peritonitis.

Conclusions:

TLH is a very effective, patient-friendly and safe technique in the hands of experienced surgeons giving good quality of life to patients postoperatively.

INTRODUCTION

Hysterectomy is one of the most common major gynaecological surgery performed on women worldwide.[1,2] The incidence of hysterectomies in the US is estimated at around 60,000 per year,[3-5] whereas in India, approximately 2,310,263 women undergo hysterectomy every year.[6] For many decades, abdominal and vaginal approaches were only used for the majority of hysterectomies, but the advent of laparoscopic technology resulted in the introduction of laparoscopic hysterectomy (LH), the minimally invasive approach. LH was performed for the first time in 1989 by Harry Reich.[7,8] Approximately 30 years after its introduction, the use of laparoscopy is rapidly gaining ground and has been expanded from diagnosis and tubal sterilisation to various complicated surgeries and is now even used for the management of malignancies.

Laparoscopy, like any other surgery, is associated with complications and despite rapidly improving surgical skills, complications rates show a definitive pattern. However, it is difficult to determine the exact incidence of complications because it depends on various factors such as surgical skills and experience of surgeons, levels of operative laparoscopy and patient population. Thus, pros and cons of the LH depends on the learning curve of the surgeon.[8,9] With this background, we did a retrospective analysis of complications which occurred during total laparoscopic hysterectomy (TLH), performed by a single surgeon over a duration of 15 years.

Aims and objectives

The aim of this study was to analyse the complications of TLH over a period of time performed by a single surgeon. The objective of the study was:

1. To analyse the intraoperative complications of TLH over a period of time, when performed by the same surgeon and same surgical team

2. To analyse the post operative complications of TLH.

METHODS

This was a retrospective study, where data were retrieved from the case papers of patients, who underwent hysterectomy, without breaching the confidentiality of the patients. All women who underwent hysterectomies for the benign condition from 1^st January 2003 to 31^st December 2017, (total of 15 years of duration) were included in this study. A total of 3272 patients were operated during this period. All the patients operated in this hospital were informed that their clinical data can be used for the research purpose and publication and written informed consent was taken before undergoing surgery. No institutional board or ethical committee approval is required for this purpose.

Study site

The study was conducted at Endoworld Hospital, Aurangabad. It is a private hospital of obstetrics and gynaecology.

Inclusion criteria

1. Patients undergoing TLH for benign conditions such as fibroid, abnormal uterine bleeding (AUB) and pelvic inflammatory disease (PID).

Exclusion criteria

1. Patients have undergone TLH for malignant diseases

2. Patients with pregnancy-related complications.

After taking a detailed history and proper examination, all routine investigations were done and after pre-anaesthetic check-up, and after taking proper informed consent, the patients were posted for surgery. The type of anaesthesia used for all patients was general anaesthesia.

Important details of the surgery

Ten millimetre supraumbilical port was used as a primary port. Three lateral ports were used. Bipolar electrocautery was used for the coagulation of pedicles and scissors was used for cutting purpose. Colpotomy was done with a monopolar electrocautery hook. If the patient was post-menopausal or if there was any obvious or significant pathology in the ovary then salphingo-oophorectomy was done otherwise only bilateral salpingectomy was done and ovaries were preserved. The vaginal vault was closed laparoscopically by intracorporeal knot tying technique. Bilateral ureters were traced from pelvic brim to bladder entry in all cases, especially in endometriosis and previously operated cases where the course of the ureter gets distorted because of adhesions. In cases of previous surgeries (most common caesarean sections) and pelvic endometriosis and PIDs, adhesions were encountered, which were separated with sharp and blunt dissection using bipolar electrocautery and scissors.

Statistical analysis

Statistical analysis was performed using Statistical analysis was performed using SPSS software 23.0.(IBM SPSS Inc.,Chicago,IL,USA) software 23.0.

RESULTS

A total of 3272 patients were included in this study, of which 1271 cases (38.87%) were operated between 1^st January 2003 and 31^st December 2007, 1178 cases (36%) were operated between 1^st January 2008 and 31^st December 2012 and 823 cases (25.15%) were operated between 1^st January 2013 and 31^st December 2017. All of these cases were between 30 and 60 years of age, with the maximum number of cases in the range of 41–50 years (63.6%) [Figure 1].

Figure 1.

Age distribution

All cases included were multiparous, of which 743 (22.7%) cases had a history of previous caesarean section and 14 (0.4%) cases had a history of laparotomy [Figure 2].

Figure 2.

Percentage of cases with previous surgery

The most common indication for the surgery was AUB, 1523 cases (46.54%), followed by uterine fibroid, 1071 cases (32.73%). Other indications were endometrial hyperplasia and chronic PID [Figure 3].

Figure 3.

Indications of surgery

The average hospital stay of the normal patients was of 3 days and those patients having some comorbid medical condition had stay of 1 or 2 more days.

Intraoperative complications that occurred during surgery during the entire 15 years were bladder injury, three cases (0.09%), bowel injury, three cases (0.09%), internal iliac vessel bleeding, one case (0.03%), and conversion to vaginal hysterectomy due to cautery failure, one case (0.03%). All cases were managed laparoscopically and did not need conversion to laparotomy [Table 1].

Table 1.

Intraoperative complications

Intraoperative complications	2003-2007	2008-2012	2013-2017	Total
Bladder injury	2	1	Nil	3 (0.09)
Bowel injury	2	1	Nil	3 (0.09)
Internal iliac vessel bleeding	1	Nil	Nil	1 (0.03)
Conversion to VH	Nil	Nil	1	1 (0.03)
Conversion to laparotomy	Nil	Nil	Nil	Nil

VH: Vaginal hysterectomy

The most common post operative complication was vault bleeding, seen in 90 patients (2.75%) which was managed conservatively. Other complications were intestinal obstruction in two cases (0.06%), paralytic ileus in five cases (0.15%), vesicovaginal fistula (VVF) in one case (0.03%), ureterovaginal fistula in one case (0.03%) and peritonitis in one case. One patient known case of chronic hypertension and obesity presented with features suggestive of intracranial bleeding on the 2^nd day of surgery which was a very rare complication [Table 2].

Table 2.

Post-operative complications

Post-operative complications	2003-2007	2008-2012	2013-2017	Total (%)
Intestinal obstructions	2	Nil	Nil	2 (0.06)
Paralytic ileus	2	2	1	5 (0.15)
VVF	1	Nil	Nil	1 (0.03)
Ureterovaginal fistula	1	Nil	Nil	1 (0.03)
Peritonitis	1	Nil	Nil	1 (0.03)
Vault bleeding	64	23	3	90 (2.75)
Intracranial bleeding	1	Nil	Nil	1 (0.03)

VVF: Vesicovaginal fistula

DISCUSSIONS

After the first LH in 1989, the benefits and risks of LH have been widely reported.[8,9] It was even criticised for its technical difficulty, requiring a highly modernised OT set-up and a highly expertise surgical team but its benefits such as less post-operative pain, lesser bleeding, lesser hospital stay and faster recovery outweigh its disadvantages.[10-12]

In our study, the maximum number of patients was in the range of 41–50 years of age, thus patients have to live a longer post-operative period of time. With the use of the laparoscopic procedure, quality of life can be maintained along with their sexual life.[13,14] In Kumar and Lekkala’s[3] study, the average age of patients was around 58 years.

The major indication of TLH in our study was AUB comprising 46.54% of cases. In the study of Kumar and Lekkala,[3] indications for TLH were fibroid (38%), pelvic pain (18%) and endometrial hyperplasia (1%), whereas in a study of Agarwal et al.,[8] fibroid (51.2%), AUB (28%), endometrial hyperplasia (1.6%) and others including malignancies (20%) were some major indications for TLH.

In our study, the average duration of stay of patients in the hospital was 3.5 days which was similar to the study of Chattopadhyay et al.,[6] where the average days of stay were 3.9 days, and in the study of Twijnstra et al.,[7] average duration of stay was 4.3 days, whereas in the study of Agarwal et al.,[8] average stay was 3.58 days.

In our study, major complication rates were 0.27%, whereas minor complication rates were 2.99%. However, the rates of major complications in the studies of Kumar and Lekkala, Agarwal et al. and Donnez and Donnez were 1.7%, 1.6% and 1.5%, respectively.[3,8,15]

Urinary tract-related injury comprises 0.15% in our study, in which two patients had intraoperative opening of the bladder, which was managed during the surgery itself, one patient presented postoperatively with vesicovaginal fistula which was managed by open repair, and one patient presented with ureterovaginal fistula which was managed by ureteric stenting. A maximum of these complications occurred in earlier years of study, whereas no such complication occurred in the last 5 years. In the study of Kumar and Lekkala,[3] bladder fistula was observed in 1.7% of patients and ureteral fistula in 0.8% of patients postoperatively, whereas in the study of Agarwal et al.,[8] bladder injury occurs in 1.2% of patients, that too in 1^st year of the 4 years of duration of the study period. Lafay Pillet et al.[16] reported the incidence of bladder injury during LH around 1%.

Bowel injury occurred in three patients (0.09%) in our study, and all were diagnosed and managed during surgery. All of these complications were seen in patients with a history of either two or three caesarean sections and in one patient of the previous laparotomy and treated case of abdominal tuberculosis. Postoperatively, two patients presented with features of intestinal obstruction due to adhesions to the vaginal vault, of which one was managed by laparoscopy and one required laparotomy. In a case series of Kumar and Lekkala,[3] only one patient (0.8%) had a small bowel injury during trocar entry and was diagnosed and repaired immediately. Whereas in the case series of O’Hanlan et al.,[17] 0.3% of patients had bowel injury, out of which only one was identified immediately and repaired and three more patients developed small bowel obstruction due to post-operative adhesions to the vaginal apex.

One patient with a large broad ligament fibroid, while ligating the uterine at its origin, we encountered bleeding from the internal iliac vessel, which was managed intraoperatively.

Five patients (0.15%) presented with paralytic ileus postoperatively, which were managed conservatively and one patient presented with features suggestive of peritonitis but was managed with antibiotics and conservative treatment. In the study of Lonky et al.,[18] ileus-related complications were 17.3% of cases, which required hospital readmission in this study.

In our study, 90 patients (2.75%) presented with post-operative vault bleeding, whereas in the study of Lonky et al.,[18] vaginal cuff-related complications were seen in 11.9% of cases. All patients in our study presented after getting discharged from the hospital. The causes of this bleeding after detailed history and examination were found as straining during defecation in a squatting position, vaginal trauma during sexual intercourse and vaginal infection due to poor hygiene. However, all these women were managed conservatively and did not need secondary closure of vault.

In our study, one surgery required the conversion of laparoscopy into vaginal hysterectomy due to cautery failure. However, there was no conversion of laparoscopy into laparotomy and no mortality occurred during this study duration.

One obese patient with a history of hypertension presented with intracranial bleeding postoperatively and required conservative intensive care management from a neurosurgeon.

Strength and limitation of the study

The strength of our study is the large sample size (3272 cases) and the long duration of the study period (15 years). However, since this study was based on retrospective data collection, there was no randomisation in the selection of cases. There was variability in the post-operative observational period and interpretation and informative values of some of the parameters were limited.

CONCLUSIONS

TLH is a minimally invasive surgery, very safe in hands of an experienced surgeon and has lesser intraoperative and post-operative complications. It gives a faster rate of recovery and reduced hospital stay. Although total LH requires a long training period, it is the effective and safest approach for patients of previous surgeries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.