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Follow-up Study Comparing Open Hysterectomy of Expert Surgeon and Laparoscopic Approach (Learning Curve)
complications and rapid recovery of laparoscopy cover these to introduce the laparoscope and the camera. Three ancillary
4
shortages. Three characters of laparoscopy are as follows: 5-mm trocars were also placed, two in the left side (7 cm apart to
11
instruments, trained personnel, and learning curve. Nowadays, each other) and one in the right side of the patient. The surgeon
12
surgeons work on basic skills before real surgery. operated ipsilaterally and her assistant worked in contralateral side
Learning curve includes 3 phases, starting, learning rate, and and handled the camera at the same time.
stabilized performance. The speed of laparoscopic learning curve at The round ligament was sectioned at ~3 cm from the uterus,
first phase is not dependent on age, number of surgeries, or hospital by Harmonic Ace in order to prevent bleeding from the superior
setting. The first phase is rapid. The main factor effective on learning uterine vessels. The areolar tissue of the broad ligament was then
curve is the supporting surgical team. Another factor is the equipment dissected and its posterior fold fenestrated at an avascular area
5,13–15
problem which is reported to occur in 87% of procedures. above the uterine vessels. The uterine artery and the utero-ovarian
Learning curve is defined by the number of patients which ligament vs infundibulo-pelvic ligament in both sides were tied by
reduce complications and time of surgery toward the same suture and cut by Harmonic Ace.
procedure in the open method. During the learning curve, After complete dissection of the bladder, circular monopolar
complications are higher and the operative time is longer. colpotomy was then performed, and the uterus was removed
Learning curve is defined in difficult procedures, for instance, in through the vagina and sent for histological examination.
5,6,16–18
appendectomy, learning curve is about 30 patients. At this stage, the uterine manipulator was extremely effective
in completely exposing the fornices and at the same time in
Levels of Gynecological Laparoscopic Surgery avoiding CO leakage from the pneumoperitoneum, thus making
2
(HKCOG) colpotomy easier. Finally, the vaginal vault was sutured continuously
Level 1: Basic procedures such as diagnostic and tubal occlusion laparoscopically, and the pelvis was then checked in order to ensure
Level 2: Minor procedures such as salpingectomy for tubal hemostasis and to perform pelvic irrigation, thus removing blood
pregnancy or hydrosalpinx clots. At the end of the surgery, only fascia site of 10 mm trochars
Level 3: Intermediate procedures such as oophorectomy or was repaired. In the open surgery, hemostasis was performed by
cystectomy for ovarian cysts electrocautery and suturing, and in the case of hysterectomy, the
Level 4: Major procedures such as hysterectomy and myomectomy vaginal cuff was closed.
Level 5: Advanced procedures such as lymphadenectomy and The beginning of the operation was calculated as the moment
radical hysterectomy of the umbilical incision and for laparoscopic hysterectomy and as
In this study, we compare hysterectomy in learning curve the moment of cutaneous incision for the abdominal technique.
(including about 50 first surgeries) with open hysterectomy of the Cutaneous suture was considered the end of the operation in both
same surgeon, expert in open surgery, for complications, hospital cases.
stay duration, transfusion, operative time, and readmission.
Sample Size
Cases of hysterectomy were divided into 54 laparoscopy and 57
MAterIAls And Methods laparotomy method. Laparoscopy cases were considered in the
Study Area and Study Population learning curve group. So, there were two groups of hysterectomy,
In a prospective cohort study, patients undergoing hysterectomy at including laparoscopy (learning) and laparotomy.
the Imam Hossein Medical Center located in Tehran were randomly
assigned into laparoscopic and laparotomy groups from 2016 to Data Collection
2018. Complications during hospital stay and after discharge, blood
In this study, surgeon was the same in all operations. It should transfusion, duration of hospitalization, readmission, and the
be noted that the surgeon’s work experience in open surgery surgical time of patients were compared between two groups.
was about 20 years, and she was an expert, a radical gyneco-
oncologist, and a referral of difficult surgical procedures. The Statistical Method
above-mentioned surgeon began to perform laparoscopy in The normal distribution of quantitative data was performed using
hysterectomy by participating in 3 laparoscopic workshops and Shapiro–Wilk test. Quantitative data were displayed using mean,
using a trainer for a period of 6 months and clinical practice with standard deviations, mid-range, and interquartile domains. The
an expert laparoscopist for 6 months, mostly in level 3 operations; qualitative data were displayed using frequency and percent.
finally participated in the one-month compact laparoscopy course Data were analyzed by ANOVA, Kruskal–Wallis, T-independent,
again and started laparoscopic hysterectomy operations (level 4), Mann–Whitney, and Kendall–Tau coefficients for comparing
independently. quantitative responses between groups. Guerrilla post hoc test was
From the beginning, under study information, cases were used whenever necessary. Chi-square test was used to compare the
recorded regarding complications, hospital stay, operative time, qualitative responses between the studied groups, and if necessary,
and blood transfusion. the exact p value was calculated. Covariance analysis was used to
compare postoperative hemoglobin between the studied groups.
Surgical Techniques The significance level for statistical tests was considered 0.05. SPSS
The patient was placed in the lithotomy position with her legs open software version 25 was used for data analysis.
at 60°, under general anesthesia with endotracheal intubation; a
Foley urinary catheter ensured the bladder was emptied during results
the operation. A total of 111 patients underwent hysterectomy. In the hysterectomy
After a CO pneumoperitoneum was created, a 10-mm trocar group, 111 patients, including laparoscopy in learning curve group
2
was placed in the umbilical site by the modified Hasson technique (54) and laparotomy (57), were studied.
6 WorldJournalofLaparoscopicSurgery,Volume12Issue1(January–April2019)
