Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center & Harvard Medical School, 330 Brookline Ave, Kirstein 3, Boston, MA, 02215, USA.
Surg Endosc. 2020 Jul;34(7):2980-2986. doi: 10.1007/s00464-019-07083-4. Epub 2019 Sep 3.
Adnexal surgery is believed to be more complex in patients with prior hysterectomy; however, there is little data regarding surgical outcomes. Understanding of individualized risks improves counseling, informed consent, and preoperative planning.
We performed a retrospective cohort study with a control group; we evaluated 744 patients undergoing laparoscopic adnexal surgery at an academic tertiary care center from 2011 to 2015. Comparisons were made using Chi square, Fisher's exact, or Wilcoxon-rank sum tests. We used log-binomial regression to calculate risk ratio and 95% confidence interval.
Patients with prior hysterectomy were more likely to have intraoperative or postoperative complications at the time of laparoscopic adnexal surgery when compared to patients without prior hysterectomy [17.7% vs. 10.2%, p = 0.02, risk ratio (RR) 1.7, 95% confidence interval (CI) 1.1-2.7]. Patients with prior hysterectomy were four times more likely to have intraoperative complications (3.2% vs. 0.8%, p = 0.047, RR 4.0, 95% CI 1.1-14.7), and five times more likely to have conversion to laparotomy (5.6% vs. 1.1%, p = 0.004, RR 5.0, 95% CI 1.8-14.0). Patients with prior hysterectomy were more likely to need additional procedures, including lysis of adhesions (69.4% vs. 26.0%, p < 0.001), ureterolysis (15.3% vs. 4.8%, p < 0.001), and cystoscopy (28.2% vs. 8.1%, p < 0.001). They had longer operative time [101.5 min (IQR 59.5-135.0) vs. 78.0 min (IQR 53.0-109.0, p < 0.001)], and were less likely to have outpatient surgery (56.5% vs. 84.8%, p < 0.01). Postoperative complications were also more common (15.3% vs. 9.4%, p = 0.046).
Patients with prior hysterectomy were 70% more likely to have a complication at the time of laparoscopic adnexal surgery than patients without hysterectomy. Increased risk of complications in subsequent adnexal surgery may influence the informed consent process or decisions regarding ovarian conservation. Awareness of potential need for additional surgical procedures may guide availability of equipment, choice of operating site, or referral to an advanced pelvic surgeon.
既往行子宫切除术的患者行附件手术时被认为更为复杂；然而，目前针对手术结果的数据较少。了解个体化风险有助于提供咨询、知情同意和术前规划。
我们进行了一项回顾性队列研究，并设立了对照组；我们评估了 2011 年至 2015 年在一家学术性三级护理中心行腹腔镜附件手术的 744 例患者。采用卡方检验、Fisher 确切概率法或 Wilcoxon 秩和检验进行比较。我们采用对数二项回归计算风险比和 95%置信区间。
与无既往子宫切除术的患者相比，既往行子宫切除术的患者在接受腹腔镜附件手术时，术中或术后并发症的发生率更高[17.7% vs. 10.2%，p=0.02，风险比（RR）1.7，95%置信区间（CI）1.1-2.7]。既往行子宫切除术的患者术中并发症的发生率高 4 倍（3.2% vs. 0.8%，p=0.047，RR 4.0，95% CI 1.1-14.7），中转开腹的发生率高 5 倍（5.6% vs. 1.1%，p=0.004，RR 5.0，95% CI 1.8-14.0）。既往行子宫切除术的患者更有可能需要额外的手术，包括粘连松解术（69.4% vs. 26.0%，p<0.001）、输尿管松解术（15.3% vs. 4.8%，p<0.001）和膀胱镜检查（28.2% vs. 8.1%，p<0.001）。与无既往子宫切除术的患者相比，其手术时间更长[101.5 分钟（IQR 59.5-135.0）vs. 78.0 分钟（IQR 53.0-109.0，p<0.001）]，门诊手术的可能性更低（56.5% vs. 84.8%，p<0.01）。术后并发症也更为常见（15.3% vs. 9.4%，p=0.046）。
与无子宫切除术的患者相比，既往行子宫切除术的患者在接受腹腔镜附件手术时发生并发症的可能性高 70%。在随后的附件手术中发生并发症的风险增加可能会影响知情同意过程或卵巢保留决策。对潜在需要额外手术的认识可能会指导设备的可用性、手术部位的选择或转介给高级盆腔外科医生。
