To determine the indications and complications of Total Laparoscopic Hysterectomy Post procedure Hemoglobin fall, pain scoring and total hospital stay Time interval for regain to work and associated delayed complications

1. Post Operative status in patients
undergoing
Total Laparoscopic Hysterectomy
Dr. Indraneel Jadhav
MBBS, DGO, DNB
Consultant Gynecologist and IVF
Indira IVF, Kolhapur

2. INTRODUCTION
 Laparoscopic hysterectomy has a longer learning curve,
takes longer to perform, and has a higher complication
rate during the learning curve
 On the other hand, there is less blood loss and febrile
morbidity resulting in shorter hospital stay

3. AIMS AND OBJECTIVES
 To determine the indications and complications of Total
Laparoscopic Hysterectomy
 Post procedure Hemoglobin fall, pain scoring and total
hospital stay
Time interval for regain to work and associated delayed
complications

4. MATERIALS AND METHODS
Study design :
Hospital based –Retrospective analysis of prospectively collected data
Place of study :
Department of Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, Jharkhand.
Duration of study :
1 year (Nov 2013 to Oct 2014)
Sample size :
50
Approval for the study has been taken from the hospital ethical committee.

5. METHODOLOGY
Inclusion criteria
 Women who needed to undergo Hysterectomy and were willing to
prefer Laparoscopic route
 A patient in whom vaginal hysterectomy is not feasible because of
previous surgery, large volume of uterus, adhesions, endometriosis,
adnexal masses, etc.
 Nulliparous women with narrow vaginal space
 A patient having narrow subpubic arch and difficult vaginal exposure.

6. METHODOLOGY
Exclusion criteria
 Pelvic infection
 Paralytic ileus
 Peritonitis
 Bowel obstruction
 Diaphragmatic hernia
 Severe cardio-respiratory disease
 Gynecological malignancy
 Anesthetic concerns during preoperative anesthetic check up

7. ANALYSIS OF STUDY VARIABLES
 Indication of surgery
 Duration of surgery
 Post operative stay
 Decrease in hemoglobin after surgery
 Post operative pain
 Complications associated with the procedure

8. Women included in study ( n = 50)
Conversion to open surgery
Transfer to CCU
Post Operative
Complications
1
Anesthetic problems
3 Post operative infection-2
Port site infection-0
Port site hernia-0
 Sigmoid colon injury –exploratory laparotomy with defunctioning colostomy done
 Dense adhesions –TLH is converted into TAH WITH RSO
 Broad ligament fibroid-TLH is converted to TAH with BSO due to lack of morcellator
CONSORT STATEMENT
Previous LSCS 13
Vaginal delivery 37

9. INDICATION OF SURGERY
41%
23%
10%
8%
8%
6%
2%2%
FIBROID UTERUS
AUB
OVARIAN PATHOLIOGY
ADENOMYOSIS
CIN
ENDOMETRIAL HYPERPLASIA
ENDOMETRIAL CARCINOMA
POST MENOPAUSAL BLEEDING
FIBROID UTERUS
21
AUB 12
OVARIAN PATHOLIOGY 5
ADENOMYOSIS 4
CIN 4
ENDOMETRIAL HYPERPLASIA 3
ENDOMETRIAL CARCINOMA 1
POST MENOPAUSAL BLEEDING 1

10. AGE OF THE PATIENT IN THE STUDY
0 1
25
14
7 2 1
0
5
10
15
20
25
30
AGE IN
YEARS
36-40 41-45 46-50 51-55 56-60 61-65
AGE IN
YEAR(IN
RANGE)
NO OF
PATIENTS
36-40 1
41-45 25
46-50 14
51-55 7
56-60 2
61-65 1
NO OF PATIENT
OBSERVED
MEAN AGE
STANDARD
DEVIATION
MINIMUM AGE MAXIMUM AGE
50 46.14 5.66 39 62

11. BMI OF OPERATED PATIENT
NORMAL(18.5
TO 24.5), 24,
48%OVERWEIGHT
(25 TO 29.9),
24, 48%
OBESE(>30 ),
2, 4%
BMI OF PATIENT IN STUDY
NORMAL(18.5 TO 24.5) OVERWEIGHT (25 TO 29.9)
OBESE(>30 ) MORBIT OBESITY (>40)
NO OF
PATIENTS
NORMAL 24
OVERWEIGHT 24
OBESE 2
MORBID
OBESITY
0
NO OF
PATIENT
OBSERVED
MEAN BMI
STANDARD
DEVIATION
MINIMUM
BMI
MAXIMUM
BMI
VARIANCE SKEWNESS KURTOSIS
50 24.9 2.66 19.17 30.1 6.94 -0.203 2.609

12. OPERATIVE TIME
NO OF
PATIENT
OBSERVED
MEAN
OPERATIVE
TIME
STANDARD
DEVIATION
MIN MAX.
VARIANCE SKEWNESS KURTOSIS
50 136.56 25.23 100 203 636.578 0.54363 2.991024
78%
22%
OPERATIVE TIME IN
MINUTE
100 TO 150 MINUTE,39
150 TO 200 MINUTE,11
0
50
100
150
200
250
34.65
95.04
132
143.6
168
209
232.05
247
294
324
346.5
400
480
500
702
874
1056.25
operativetime
Volume of uterus removed
Correlation between uterine
volume and intraoperative
time

13. WEIGHT OF UTERUS REMOVED
11
14
10
5
4
3
1
2
WEIGHT OF UTERUS REMOVED IN GRAM
50 to 150
150 to 300
300 to 450
450 to 600
600 to 750
750 to 900
900 to 1050
1050 to 2000
WEIGHT OF
UTERUS
REMOVED
NO OF
PATIEN
TS
50 to 150 11
150 to 300 14
300 to 450 10
450 to 600 5
600 to 750 4
750 to 900 3
900 to 1050 1
1050 to 2000 2
NO OF
PATIENTNS
MEAN
WEIGHT
IN GM
STANDARD
DEVIATION
MINIMUM MAXIMUM
VARIENCE SKEWNESS KURTOSIS
50 371.64 267.77 34.65 1092 71701.81 1.137045 3.439597

14. DIFFERENCE IN PREOPERATIVE AND POST
OPERATIVE HEMOGLOBIN
0
2
4
6
8
10
12
14
16
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49
COMPARISION OF PRE AND POST OP HB
Op
Pre
Hb
Gm %
Post-op
Hb% on day2
0
1
2
3
4
5
6
0 200 400 600 800 1000 1200
Postoperativefallinhaemoglobin
volume of uterus removed
Correlation of uterine volume
with fall in haemoglobin
Corelation of uterine volume with fall in haemoglobin
Linear (Corelation of uterine volume with fall in haemoglobin)
Variable Observation Mean Std.error Std.dev. 95%conf.interval
Preop Hb 50 10.98 0.19087 1.3496 10.5964 11.3635
Postop Hb 50 9.962 0.205314 1.4517 9.54940 10.3746
Difference 50 1.018 0.13283 0.9393202 0.751048 1.2849

15. PAIN SCORING AFTER SURGERY
0
1
2
3
4
5
6
7
8
9
10
1
2 3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
2425
26
2728
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49 50
pain score day0 score
pain score day1 score
pain score day8 score
 Average pain score on
day 0 is 1.98
 Average pain score on
day 1 is 4.24
 Average pain score on
day 8 is 0.48

16. POST OPERATIVE STAY IN HOURS
0
50
100
150
200
250
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49
Post-op Stay
Post-op Stay
0
50
100
150
200
250
0 200 400 600 800 1000 1200
Postoperativestayinhour
Volume of uterus removed
Correlation of uterine volume
with post operative stay
Corelation of uterine volume with post operative stay
Linear (Corelation of uterine volume with post operative stay)
Average post operative stay is 69.8 hours

17. LIMITATIONS
 Long learning curve
 Instruments and laparoscopy set up is costly
 Medical and paramedical staff need to be trained.
 Not accessible to all patients

18. CONCLUSION
 Main Indications of total laparoscopic hysterectomy were - 42% cases were
operated for fibroid uterus , 24% for abnormal uterine bleeding 10% cases for
ovarian pathology.
 Average operative time required was 136.56 minutes
 It was observed that there is significant change in intraoperative time with volume
of uterus as volume .as volume of uterus increases, intra operative time also
increases

19. CONCLUSION
 Mean post operative stay was 69.8 hours (2.9 days )
 Average hemoglobin fall was 1.18gm% on day 2,
 Patient had average pain score of 1.98 on day 0, 4.24 on day 1 and 0.48 on day 8
 Average return period to work was 6.8 days.
 Complications are found less in Total laparoscopic hysterectomy with required
expertise

20. RECOMMENDATION
Total Laparoscopic Hysterectomy Can be used in all
tertiary care hospitals as an alternative to abdominal
hysterectomy
Option of laparoscopy should be given to all patients who
required operative intervention wherever feasible.

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