1. Laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy: A comparison of peri- operative outcomes Dr Kate Maclaran, Mr Nilesh Agarwal, Mr F. Odejinmi Whipps Cross University Hospital, Barts Health NHS Trust BSGE ASM 2014

2. Background Advantages of laparoscopic over open gynaecological surgery are well documented Controversy still exists surrounding the complication rates and advantages and disadvantages of LH over vaginal approach Current recommendations suggest that VH is the preferred route, with LH reserved for when it is not possible to carry out VH 2 BSGE ASM 2014 Advantages of laparoscopic vs open surgery  Post-operative pain  Surgical site infections  Hospital stay  Drop in haemoglobin  Post-operative adhesions Quicker return to daily activities 2 Nieboer 2009

3. Study Aims Determine the incidence of and evaluate risk factors for peri-operative complications in LH. Comparing – Type of LH (LASH vs TLH) – Effect of BMI, uterine size & presence of adhesions BSGE ASM 2014

4. Methods Retrospective cohort study 264 patients who underwent LH for benign conditions Whipp’s Cross hospital - Jan 2005 & Dec 13 Data collected prospectively BSGE ASM 2014

5. Methods Pre-op assessment – Demographics – Symptoms – Medical history – Uterine size estimation – USS/MRI – Endometrial sampling if indicated Exclusion criteria for LH: – confirmed or suspected malignancy – 2nd- or 3rd- degree uterine prolapse Of note: – No upper limit of uterine size excluded – Patients with endometriosis, PID, previous abdominal surgery or obesity not excluded. BSGE ASM 2014

6. Methods For large uteri: – Palmers point entry – If the uterus was sufficiently mobile to visualize the pedicles, the surgery could be performed laparoscopically. BSGE ASM 2014 LH n=264 LASH n=166 TLH n=98

7. Results – Baseline characteristics BSGE ASM 2014 n=264 Age (years)45.3 (5.2) Parity1.9 (1.3) BMI (kg/m2)30.2 (6.3) Primary symptom: Bleeding238 (90.2) Pain19 (7.2) Pressure5 (1.9) Gender reassignment2 (0.7) Concomitant oophorectomy: USO19 (7.2) BSO74 (28.0) Prior laparotomy40 (15.2) Uterine size (weeks)14.7 (range 6-32)

8. Baseline outcomes n=264 Operation duration (mins)77.1 (34.7) EBL (mls)195.5 (127.7) Hospital stay (days)1.78 (0.6) Specimen weight (g)323.1 (290.5) BSGE ASM 2014 All surgeries were performed for benign indications and histopathology confirmed no cases of endometrial carcinoma

9. Results – TLH vs LASH LASH n=166 TLH n=98p Age (years)46.7(4.2)42.8 (5.9)<0.0001 Parity1.96 (1.4)1.88 (1.2)0.621 BMI31.1 (6.5)28.6 (5.4)0.002 USO/BSO51 (30.7)42 (42.9)0.062 Uterine size (weeks)16.9 (6.4)11.0 (3.5)<0.0001 LASH – laparoscopic subtotal hysterectomy, TLH – total laparoscopic hysterectomy. Data presented as mean (SD) and analaysed by t-test or n(%) and analysed by Fishers exact test BSGE ASM 2014

10. Results – TLH vs LASH LASH n=166 TLH n=98p EBL (mls)204.7(132.3)179.9 (118.3)0.128 Op length (mins)76.3 (35.9)78.5 (32.8)0.615 Length of stay (days)1.76 (0.59)1.80 (0.62)0.656 LASH – laparoscopic subtotal hysterectomy, TLH – total laparoscopic hysterectomy. Data presented as mean (SD) and analaysed by t-test BSGE ASM 2014

11. Results – TLH vs LASH LASH n=166 TLH n=98 Bladder Injury3 (1.8)0 (0) Bowel injury0 (0) EBL> 10000 (0) Blood transfusion0 (0)1 (1.0) Secondary haemorrhage0 (0)1 (1.0) Haematoma0 (0)1 (1.0) Conversion to laparotomy0 (0) Data presented as n (%) Complication rates: BSGE ASM 2014

12. Effect of adhesions 23.5% had significant adhesions, prior laparotomy or endometriosis Presence of any RFs resulted in  op duration (95 vs 72 mins, p<0.0001) Trend towards  blood loss (223 vs 187 mls, p=0.056) No effect on length of hospital stay (p=0.512) * * p<0.0001 BSGE ASM 2014

13. Effect of BMI NormalOverweightObese Obese class 2+ n=46896563p Uterine size13.8 (5.6)15.0 (6.4)14.4 (6.5)15.4 (6.0)0.556 EBL (mls)153.3 (70)186.6 (113)214.2 (144)221.1 (153)0.024 Operation duration68.4 (30.4)75.0 (32.2)77.9 (36.8)84.6 (37.1)0.105 Length of stay1.70 (0.5)1.76 (0.7)1.88 (0.6)1.75 (0.5)0.4 BMI categories (units in kg/m 2 ): Normal= 19-24, Overweight=25-29, Obese=30- 34, Obese class 2+ = 35+. Data presented as mean (SD). ANOVA used to compare means. BSGE ASM 2014 Of note, the 3 bladder injuries occurred in women of BMI 18, 24 and 25.

14. Effect of BMI BSGE ASM 2014  44% increase in blood loss  24% increase in operation duration

15. Effect of uterine size Overall this population had enlarged uterine due to high prevalence of fibroids The largest estimated uterine size pre-operatively was 32 weeks and specimen weight ranged from 46g to 1765 g. Uterine weight (g) <300g300-599g600g+ n=159n=60n=33 EBL (mls)161.2 (95)244.9 (159)268.6 (144)p<0.0001 Operation duration (mins)65.8 (28.0)85.5 (33.8)112.9 (36.0)p<0.0001 Hospital stay (days)1.72 (0.6)1.92 (0.6)1.82 (0.7)0.08 Data presented as mean (SD). BSGE ASM 2014

16. Combined effect of BMI and uterine size Combination of elevated BMI and enlarged uterus => 94% increase in blood loss => 66% increase in operation duration BSGE ASM 2014

17. Conclusions High BMI, large uterine size, risk factors for adhesions associated with increased surgical risk Bladder injury in LH – ?higher incidence in LASH or due to inherent bias – Low/normal BMI BSGE ASM 2014

18. Conclusions This study has highlighted particular groups which might be at increased surgical risk and this should be taken into consideration when counseling patients preoperatively. Overall, with a suitably experienced operator, laparoscopic hysterectomy is a safe procedure with low risk of major complications, even in patients significant surgical risk factors. BSGE ASM 2014