The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases.

STUDY OBJECTIVE

To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them.

DESIGN

Retrospective, comparative study (Canadian Task Force classification II-2).

SETTING

University tertiary referral center for endoscopic surgery.

PATIENTS

During 1989-1995 and 1996-1999, 695 and 952 women, respectively, with benign pathology.

INTERVENTION

Total laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

No differences in patient characteristics were found between 1989-1995 and 1996-1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22-904 g) and 292.0 g (40-980 g) and operating times 115 minutes (40-270 min) and 90 minutes (40-180 min), respectively, were recorded (p <0.005).

CONCLUSION

Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.