Shah Divya K, Van Voorhis Bradley J, Vitonis Allison F, Missmer Stacey A
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
J Minim Invasive Gynecol. 2016 Nov-Dec;23(7):1113-1122. doi: 10.1016/j.jmig.2016.08.003. Epub 2016 Aug 11.
Although the selection of an approach to minimally invasive hysterectomy is relatively straightforward in an ideal patient scenario, it is more difficult in patients who pose operative challenges such as high body mass index (BMI) and enlarged uteri. The objective of this study was to explore the association between surgical approach and operative morbidity after minimally invasive hysterectomy and examine whether the association varies based on patient BMI and uterine size.
Retrospective cohort (Canadian Task Force classification II-2).
Data abstracted from the American College of Surgeons National Safety and Quality Improvement Project registry.
Thirty-six thousand seven hundred fifty-seven women undergoing vaginal, laparoscopic-assisted vaginal, or total laparoscopic hysterectomy for benign indications between January 2005 and December 2012.
Associations between surgical approach, BMI, and operative morbidity were examined, stratifying by uterine size (< or >250 g) and adjusting for covariates. Adjusted means, rate ratios, or odds ratios with 95% confidence intervals (CI) were calculated using linear, Poisson, or logistic regression.
Operative times were shortest in women undergoing vaginal hysterectomy regardless of BMI or uterine size (all p < .02). Although operative time increased with BMI, the association varied with uterine size in women undergoing vaginal hysterectomy; increasing BMI had a minimal impact on operative time with small uteri <250 g but lengthened operative time in uteri >250 g. Compared with vaginal hysterectomy, total laparoscopic hysterectomy had lower odds of blood transfusion (all p < .02) and shorter hospitalizations (all p < .03) regardless of uterine size or BMI. Stratifying by uterine size, the association was strongest in morbidly obese women with small uteri; women with uteri <250 g and BMI >40 kg/m had 76% lower odds of blood transfusion (95% CI, 0.10-0.54) and 18% shorter hospitalization (95% CI, 0.75-0.90) after laparoscopic hysterectomy compared with vaginal hysterectomy.
Major operative morbidity after minimally invasive hysterectomy is rare regardless of the surgical approach. A vaginal approach to hysterectomy is associated with the shortest operative times, but increasing BMI results in a rapid escalation of operative time in women with large uteri. Total laparoscopic hysterectomy is associated with shorter hospitalizations and lower odds of blood transfusion across the BMI spectrum, particularly in women with small uteri. Laparoscopic-assisted vaginal hysterectomy appears to confer no specific advantage over the vaginal or laparoscopic approaches.
尽管在理想患者情况下选择微创子宫切除术的方法相对简单，但对于存在手术挑战的患者，如高体重指数（BMI）和子宫增大的患者，选择起来则更为困难。本研究的目的是探讨微创子宫切除术后手术方式与手术并发症之间的关联，并检查这种关联是否因患者BMI和子宫大小而异。
回顾性队列研究（加拿大工作组分类II-2）。
从美国外科医师学会国家安全与质量改进项目登记处提取的数据。
2005年1月至2012年12月期间因良性指征接受阴道、腹腔镜辅助阴道或全腹腔镜子宫切除术的36757名女性。
检查手术方式、BMI与手术并发症之间的关联，按子宫大小（<或>250 g）分层并对协变量进行调整。使用线性、泊松或逻辑回归计算调整后的均值、率比或比值比及95%置信区间（CI）。
无论BMI或子宫大小如何，接受阴道子宫切除术女性的手术时间最短（所有p <.02）。尽管手术时间随BMI增加，但在接受阴道子宫切除术的女性中，这种关联因子宫大小而异；BMI增加对子宫<250 g的小子宫女性手术时间影响最小，但会延长子宫>250 g女性的手术时间。与阴道子宫切除术相比，无论子宫大小或BMI如何，全腹腔镜子宫切除术输血几率更低（所有p <.02），住院时间更短（所有p <.03）。按子宫大小分层，这种关联在子宫小的病态肥胖女性中最强；与阴道子宫切除术相比，子宫<250 g且BMI>40 kg/m²的女性在腹腔镜子宫切除术后输血几率降低76%（95% CI，0.10 - 0.54），住院时间缩短18%（95% CI，0.75 - 0.90）。
无论采用何种手术方式，微创子宫切除术后的主要手术并发症都很少见。阴道子宫切除术的手术时间最短，但BMI增加会使子宫大的女性手术时间迅速延长。全腹腔镜子宫切除术在整个BMI范围内住院时间更短，输血几率更低，尤其是子宫小的女性。腹腔镜辅助阴道子宫切除术似乎并不比阴道或腹腔镜手术方式具有特定优势。
