Wesol Adrianne, Woolley Shauna
Washington Permanente Medical Group, Department of Obstetrics and Gynecology-Midwifery, Seattle, WA, United States.
University of Washington Medical Student, Seattle, WA, United States.
Eur J Obstet Gynecol Reprod Biol. 2017 Aug;215:41-44. doi: 10.1016/j.ejogrb.2017.05.015. Epub 2017 May 21.
This study was a quality improvement project investigating patterns of hysterectomy practice including changes in surgical techniques and patient outcomes after manufacturer withdrawal of a laparoscopic power morcellator from our hospitals in July 2014.
This time-series pre and post retrospective review examined data from electronic health records, comparing one year when a laparoscopic power morcellator was available (Year 1, mid-2013 to mid-2014) to one year after withdrawal (Year 2, mid-2014 to mid-2015). Data were from patients of 8 gynecologists in a multispecialty group associated with a large, integrated care and coverage delivery system in Washington State. Analyzed were 100 patients for Year 1 and 133 patients for Year 2. Analysis was by two-sided chi-square tests comparing practice patterns and outcomes in the two years.
For hysterectomy route, no significant difference was seen between Years 1 and 2 in percent surgeries that were abdominal or laparoscopic (including robotic). For minimally invasive hysterectomies, significantly more transvaginal hysterectomies were performed in Year 2 (22%) than Year 1 (14%) (p<0.05). In Year 2, no laparoscopic supracervical hysterectomies occurred, with total laparoscopic or vaginal hysterectomies performed instead. Transvaginal uterus morcellation increased from 13% in Year 1 to 24% in Year 2 (p<0.05). Bilateral salpingectomies increased in Year 2 as well (p<0.05). Among patient factors, estimated blood loss, surgical site infection, total operative time, and hospital length of stay were not significantly different between Years 1 and 2. Body mass index, race/ethnicity, and age did not differ between years. No patients had occult uterine sarcoma.
Surgical practice patterns changed for our group of 8 gynecologists in the year after a laparoscopic power morcellator was withdrawn. Though open hysterectomies did not increase, no laparoscopic supracervical hysterectomies were performed. Total laparoscopic and vaginal hysterectomies and bilateral salpingectomies increased, with reliance on transvaginal uterine tissue-removal techniques. Patient outcomes including surgical infections, length of surgery, estimated blood loss and total hospital stay did not change. Our results suggest that experienced vaginal surgeons can adapt to removal of important surgical equipment and continue to provide minimally invasive hysterectomies without compromising patient outcomes and safety.
本研究是一项质量改进项目，旨在调查子宫切除术的实施模式，包括2014年7月制造商从我们医院撤回腹腔镜动力粉碎器后手术技术的变化和患者预后。
本回顾性前后时间序列研究检查了电子健康记录中的数据，将腹腔镜动力粉碎器可用的一年（第1年，2013年年中至2014年年中）与撤回后的一年（第2年，2014年年中至2015年年中）进行比较。数据来自华盛顿州一个与大型综合医疗保健和覆盖提供系统相关的多专科团队中的8名妇科医生的患者。第1年分析了100例患者，第2年分析了133例患者。通过双侧卡方检验分析比较两年中的手术模式和结果。
对于子宫切除途径，第1年和第2年腹部或腹腔镜（包括机器人辅助）手术的百分比没有显著差异。对于微创子宫切除术，第2年经阴道子宫切除术的实施比例（22%）显著高于第1年（14%）（p<0.05）。在第2年，没有进行腹腔镜次全子宫切除术，而是实施了全腹腔镜或经阴道子宫切除术。经阴道子宫粉碎术从第1年的13%增加到第2年的24%（p<0.05）。双侧输卵管切除术在第2年也有所增加（p<0.05）。在患者因素方面，第1年和第2年之间估计失血量、手术部位感染、总手术时间和住院时间没有显著差异。体重指数、种族/民族和年龄在两年间没有差异。没有患者患有隐匿性子宫肉瘤。
在腹腔镜动力粉碎器撤回后的一年里，我们团队的8名妇科医生的手术模式发生了变化。虽然开放性子宫切除术没有增加，但没有进行腹腔镜次全子宫切除术。全腹腔镜和经阴道子宫切除术以及双侧输卵管切除术增加，对经阴道子宫组织切除技术的依赖增加。包括手术感染、手术时长、估计失血量和总住院时间在内的患者预后没有改变。我们的结果表明，经验丰富的阴道外科医生可以适应重要手术设备的移除，并继续提供微创子宫切除术，而不会影响患者的预后和安全。
