Dewsbury District Hospital, Dewsbury, West Yorkshire, UK
Keywords ABSTRACT Objective To review the introduction of an overnight stay laparoscopically
assisted vaginal hysterectomy (LAVH) service in a district general hospital.
stay, safe practice, low complications. Design A retrospective study. Setting Dewsbury District Hospital is a 478-bedded district general hospital with 14 gynaecological inpatient beds, serving a population of 165 000. Data collection Included in the study were 265 consecutive patients who underwent LAVH, performed by one consultant between September 1995 and September 2000. These patients were unsuitable for vaginal hysterectomy according to conventional (British) criteria and in the past would be have been offered abdominal hysterectomy. The names of the patients were obtained from the hospital register. All operative notes were abstracted and data collected independently by junior medical staff working in the department. Results Postoperative stay was analysed for consecutive groups of 50 patients. Initially the median postoperative stay was 2 nights but by the last cohort, nine out of 10 patients were going home after only 1 night’s post- operative stay. None of the patients were readmitted or suffered complications as a result of this policy. Among the patients, 4.5% suffered one or more com- plications (most were minor). No patient suffered visceral injury. Patients had
full surgical recovery by 6 weeks after operation except for a few who developed
granulation tissue which needed topical treatment. Conclusion In experienced hands LAVH has few complications, and it is ac-
ceptable and safe to discharge patients home after an overnight hospital stay
provided strict guidelines are followed.
possible adhesions, endometriosis, an excessively large
uterus or potential tumours and cysts are considered poor
Hysterectomy is the second most frequently performed
candidates for traditional vaginal hysterectomy. Despite the
major surgical procedure (after Caesarean section)
obvious advantages of avoiding an abdominal incision, in
among women of reproductive age.1 It is one of the com-
most centres, the abdominal route is most commonly used.
monest elective surgical procedures: by 50 years of age,
Although vaginal hysterectomy can produce excellent
20% of UK women have undergone hysterectomy,2 and
results in experienced hands, it does not allow the facility
one in three women in the United States by 60 years
to precisely define and deal with associated pathology.
of age.3 Most of these hysterectomies are performed
LAVH has this capability and our aim is to perform a pro-
abdominally. The first report of laparoscopically assisted
cedure with a low complication rate and, for economic
vaginal hysterectomy (LAVH) appeared in 1989.4 In recent
and social reasons, a short period of hospitalization.
years there has been some controversy over the use of
My initial hypothesis was that patients who had under-
LAVH in patients who could be treated with conventional
gone LAVH could possibly be discharged considerably
vaginal hysterectomy; however, patients presenting with
earlier than was the norm for hysterectomies in our
Gynaecological Endoscopy 2002, 11, 181–187 Table 1 Patient characteristics and outcome in five successive groups of patients. ‘Overnight stay’ hysterectomy was gradually introduced from the third group onwards
conversion, readmissionand reoperation), n (%)
LSCS, lower segment Caesarean section; TAH, total abdominal hysterectomy.
hospital. As experience developed, it seemed that a
Data were analysed using SPSS (version 10).
postoperative stay of 1 night only was achievable and safe.
The patients were fully counselled about the pro-
I also wished to compare complications from LAVH with
cedure with regard to stay in hospital, need for analgesia,
reported complications of other types of hysterectomy,
postoperative recovery, home support and complica-
tions. An information sheet, which included a briefdescription of the operation technique and postoper-ative advice, was given to all patients. SUBJECTS AND METHODS
Patients were admitted to the hospital on the day of
A retrospective audit, in September 2001, of the records of
the operation for afternoon sessions and on the previous
265 consecutive women who underwent LAVH performed
evening for the morning sessions. (This was simply for
by the author was undertaken. It was not a controlled trial.
convenience: to avoid travelling early in the morning
All patients presenting in a general gynaecology clinic with
and to secure a bed on our small and busy ward.) All the
indications for hysterectomy with or without salpingo -
operations were carried out by the author assisted by
oöphorectomy were offered the procedure unless they
had a uterine size of greater than 18 weeks, endometrial
Three entry ports were used: a 10-mm subumbilical
or ovarian carcinoma or prolapse. (Four women were
port for the laparoscope and 2 × 12-mm ports laterally
subsequently found to have endometrial carcinoma after
for instrumentation. After a preliminary visual examina-
initial diagnosis of atypical hyperplasia.) Various param-
tion, pelvic pathology was suitably dealt with: any adhe-
eters, which included type of operation, age, weight,
sions were divided and endometriosis excised; ovarian
uterine weight, operating time, conversion to abdominal
cysts were treated by cystectomy or oöphorectomy,
procedure, hospital stay, readmission, histological find-
and salpingectomy was performed for tubal disease if
ings and complications, were recorded. Age (maximum
63 years; Table 1), obesity (maximum weight 134 kg, body
When salpingo-oöphorectomy was to be performed,
mass index 52; Table 1), increased uterine size (maximum
the infundibulopelvic ligament and round ligament
weight 500 g; Table 1), previous Caesarean section (8.7%;
were taken together and divided and sealed as close to
Table 1) or abnormal extrauterine pathology (63.4%
the ovary as possible, using an endoscopic stapling device
of patients required additional procedures) were not
(Endo GIA45 with 2.5-mm closure height staples). If the
regarded as contraindications. The type and complexity
ovary was to be conserved, the round ligament, fallopian
of cases were no different from those described in pre-
tube and ovarian ligament were taken together with a
single stapling cartridge as close as possible to the uterus. Gynaecological Endoscopy 2002, 11, 181– 187
A single stapling cartridge was used on each side, further
Table 2 Histological diagnoses
dissection being undertaken with bipolar diathermy andendoscopic scissors. Dissection was taken to the point of
the base of the broad ligament. No attempt was made to
divide the uterovesical fold of peritoneum and reflect the
bladder or to ligate the uterine arteries laparoscopically.
The operation was completed by the vaginal route,
Leiomyomata ± adenomyosis ± endometriosis
using a standard technique with two modifications. First
Endometrial hyperplasia ± atypia ± complex
the pouch of Douglas was opened by incising the post-
erior lip of the cervix in the midline, thus enabling easier
entry into the pouch of Douglas. Secondly, the uterine
fundus was delivered through the pouch of Douglas after
On completion of the vaginal component, the pneu-
moperitoneum was re-established and a laparoscopicinspection of the pelvis carried out at an intra-abdominalpressure below capillary pressure, usually 6 – 8 mmHg.
further clinic appointment was arranged for 1 week later
Any bleeding points were cauterized with bipolar forceps.
and a final appointment for 6 – 8 weeks postoperatively.
The pelvic cavity was washed out with warm saline mixed
Special care was taken to ensure that all LAVH patients
with heparin using a suction/irrigation device, and 300 –
had a contact phone number to use in case of any prob-
500 mL of heparinized saline were left in the pelvic cavity.
lems, and arrangements were put in place for easy
Initially the 12-mm port sites were not closed, but after
the author encountered the complication of Richter’shernia, these ports were routinely closed using a needle-
point suture passer (Carter–Thomason), and 20 – 40 mL0.25% bupivacaine was injected subcutaneously around
The type and complexity of cases included in this series
the three incisions. A Foley catheter was inserted at the
are comparable to those of previously published studies
end of the procedure and remained in situ overnight.
of LAVH (see Tables 1 and 2). Various parameters and
All patients received 100 mg diclofenac and 1000 mg
results, including type of operation, age, weight, uterine
paracetamol rectally at the end of the operation. One
weight, operating time, conversion to abdominal
dose of parental morphine or pethidine was given in the
approach, hospital stay, readmission, histological find-
immediate postoperative period (usually in the recovery
ings and complications are summarized in Tables 1– 4.
room). All patients received regular diclofenac slow
An ‘overnight hospital stay’ policy was gradually intro-
release (SR) 75 mg twice daily and 1000 mg paracetamol
duced, and a total of 117 patients have been discharged
four times daily for the first 5 days. All patients received
after an overnight stay since this policy was adopted.
three doses of intravenous prophylactic antibiotics, i.e.
Currently nine out of 10 patients are discharged home
metronidazole and co-amoxiclav or cefuroxime. Patients
after a postoperative stay of a single night at the hospital
with a high risk of thrombosis received prophylaxis against
(see Table 3). Patients who stay an extra night do so
deep vein thrombosis with dalteparin sodium (2–3 doses),
purely for social and family reasons, and no patient in
the last dose being given on the day of discharge.
this group has been readmitted since the introduction of
Initially patients were discharged home after a hospital
stay of 2 nights, but as clinical experience increased the
Among the patients, 4.5% suffered one or more
majority of patients were discharged home the following
complications (see Table 4). There were no internal
day, provided the home conditions were suitable. At this
stage the women were fully mobile on the ward, passingurine normally and taking food; pain was under control
with simple analgesics. Haemoglobin was checked priorto discharge.
Over the last decade there has been considerable inter-
On the second postoperative day a district nurse visited
est in avoiding the abdominal approach to hysterectomy
patients at home, and on the third postoperative day the
by using a vaginal or laparoscopically assisted vaginal
patient attended the gynaecology clinic or the ward. A
procedure, as the latter avoids the discomfort of a large
Gynaecological Endoscopy 2002, 11, 181– 187 Table 3 Hospital stay (number of nights in
hospital postoperatively) for successive
Table 4 Complications*
Rash and gastroenteritis requiring readmission
Richter’s hernia requiring re-operation
Patient no. 75 received blood tranfusion
Required reoperation and blood transfusion
Superficial wound inflammation requiring antibiotic
Total no. of patients suffering complications
*Minor vaginal bleeding or discharge, gastrointestinal symptoms, and vault granulation tissue, and pre-, per- and postoperative blood transfusion for pre-existing anaemia are not included in this table.
abdominal incision, facilitates early mobilization and
guidelines, can alleviate the problems of rising hospital
thus allows early discharge from the hospital. It also
costs and hospital-acquired infections.
minimizes the burden on patients, their employers and
Although the magnitude of saving resulting from the
their families by allowing early resumption of routine
shorter hospital stay following LAVH7 has been disputed8
because of high equipment costs, it is obvious that
Secondary care consumes a large proportion of the
further savings may be realized from low postoperative
health care budget and the need to spend wisely is
complication rates9 and lower rates of readmission and
ever-pressing. Length of stay is one of the main clinical
reoperation.10 In addition, a shorter convalescence of
indicators and measures of efficiency and is a major
2–4 weeks11 in an economically active group can be
determinant of the resources needed to run a service.
translated into further significant savings which all studies
The shift of minor treatment to day, ambulatory or even
to date have failed to account for. It is difficult to place
office care has become inexorable, but shortening the
a monetary value on the reduction in pain and
length of stay for more significant procedures has the
discomfort12,13 which is achieved. Even apart from costs,
potential to release many more resources.
there is an undeniable benefit of LAVH compared with
Morgan et al.5 1987 described a wide variation in post-
abdominal hysterectomy, derived from patient comfort,
operative stay following general surgery in different
pain reduction,12,13 quicker return to normal activity,11–13
areas of the UK, and its effect on hospital expenditure.
less adhesion formation14 and better cosmetic effect.15
Schwartz & Mendelson6 were of the opinion that the
Early hospital discharge following conventional vaginal
gradual reduction in costs seen in the 1980s in the United
hysterectomy has been described,16–19 but information
States would not continue into the next decade unless
regarding complications arising from such a policy is
new practice guidelines were successfully implemented.
limited. Many authors11,12,20–22 have reported a signifi-
On the basis of these findings, many observers believe
cantly shorter hospital stay of 2 –3.5 days following LAVH
that further efforts to eliminate inappropriate inpatient
compared with conventional hysterectomy. An analysis
stays, particularly through the use of new practice
by Meikle23 of the literature published between 1989 and
Gynaecological Endoscopy 2002, 11, 181– 187
September 1995 suggested that the average stay after
with bleeding on the 12th and 11th postoperative day,
LAVH was 49 h (SD 16 h). A literature review of practice
respectively, were treated conservatively and stayed in
in the UK reveals the average hospital stay for LAVH to
hospital for 1 and 2 nights, respectively. Blood trans-
fusion with all its related hazards is still used in 2–12% of
We have introduced the ‘hysterectomy overnight hos-
patients with vaginal hysterectomy.9,28,30 These studies
pital stay service’ gradually and cautiously. Initially, the
relating to transfusion rates in vaginal hysterectomies
median postoperative hospital stay for our patients was
were performed at a time when transfusion may have
2.0 days (range 2–3); this has now come down to 1 day
been considered less of a risk. In our series seven patients
(range 1–2, average 1.09 days; Table 4). A total of 117
(2.6%) needed blood transfusion. This included three
patients have been discharged home after an overnight
patients who experienced other complications including
hospital stay (see Table 3), and 91% of our patients now
secondary haemorrhage, rectus sheath haematoma and
leave hospital after an overnight stay. The 9% of patients
conversion to total abdominal hysterectomy. Only 11
who stay for a second night do so mainly for social reasons.
patients (4.15%), with a preoperative haemoglobin of
We believe we have shown that with sensible case selec-
12 g percentage and above, left hospital anaemic and
tion, efficient teamwork and an experienced surgeon,
with a haemoglobin of 10 g percentage or below. Haemo-
the majority of patients can be safely discharged on the
stasis is easily obtained at laparoscopic surgery because
of the magnification, close inspection, and routine use
In general LAVH appears to be associated with a
of irrigation and bipolar electrocoagulation. Of our
longer operating time than abdominal and vaginal
patients, 38% were found to need coagulation of bleed-
hysterectomy. Richardson et al.24 and Summit et al.8
ing and oozing points on vault inspection, which was
reported operating times for LAVH to be 125 min com-
undertaken at an intra-abdominal pressure of 6 mmHg.
pared with vaginal hysterectomy times of 51 min Simil-
In 265 consecutive LAVH procedures we encountered
arly the mean operating time for abdominal hysterectomy
no febrile morbidity, clinically recognizable vault hae-
was 75 min compared with 126 min for LAVH.11,12,20–22
matoma, or complications related to possible vault
The present author’s mean operating time was 98 min
haematoma which needed any special treatment or care.
The present author feels that this is one of the very
Two main factors, which largely contribute to longer
important advantages of LAVH over vaginal hysterectomy.
operating time are the number of adjunctive procedures
Numerous articles have been written highlighting the
and laparoscopic checking of the vault at the end of
complications relating to LAVH and comparing them
vaginal hysterectomy. Of our patients, 168 (63.4%) had
with complications of both total abdominal hysterectomy
additional procedures and 38% had oozing and bleed-
and vaginal hysterectomy.20,29,31 Complication rates of
ing of the vault at the end of the procedure which
42.8 – 47% have been reported for abdominal hyster-
needed attention. Additional procedures include adhe-
ectomy,3,32,33 of 15 –24.5% for conventional vaginal
siolysis, excision of peritoneal endometriosis, and drain-
hysterectomy33,34 and of 13 –18% for LAVH.4,32,35,36 An
age and excision of benign ovarian cysts. The extra few
analysis by Garry & Phillips37 of 29 studies produced an
minutes needed for the laparoscopic procedure allows
overall complication rate of 15.6% for LAVH.
complete removal of pathological lesions, produces
In our series, excluding minor vaginal bleeding, dis-
minimal complications and avoids reoperation at a
charge, gastrointestinal upset and vault granulation
tissue, 4.5% of patients suffered one or more complica-
Conventional vaginal hysterectomy not uncommonly
tions. It appears that LAVH has a lower complication rate
causes postoperative complications related to vault
than abdominal or vaginal hysterectomy. This is possibly
bleeding, resulting in postoperative interventions,
because LAVH combines the advantages of the abdominal
increased rate of blood transfusion, ultrasound evidence
of post-surgical haematoma and febrile morbidity. Fol-
Although the reported rate of major complications
lowing conventional vaginal hysterectomy, the reported
(injury to bowel, urinary tract or major blood vessels) is
risk of postoperative bleeding requiring intervention
around 5%,10,37 we have not experienced such a rate,
is 1–5%.9,26–30 In our series only one patient (0.38%)
and the series includes no such cases.
required intervention for postoperative bleeding. This
Our rate of reoperation and conversion is 1.5% (four
was patient no. 75 who was readmitted on the 18th post-
patients), which compares favourably with other series
operative day, had two vault stitches and stayed in hos-
where the rate is approximately 3.7%.10,37 In our series,
pital for 2 days. Two other patients who were readmitted
three patients required subsequent operation for Richter’s
Gynaecological Endoscopy 2002, 11, 181– 187
hernia, secondary bleeding or subrectus haematoma,
I believe that with adequate training this practice can
and in one case conversion to abdominal hysterectomy
be implemented widely in the National Health Service
(NHS) in the United Kingdom, following our guidelines.
Five patients required readmission (see Table 1).
Three patients were readmitted because of secondary
bleeding (on the 18th, 11th and 12th postoperative day,respectively). The remaining patients were readmitted as
It would not have been possible to develop this service
a result of a Richter’s hernia and a rash (gastroentritis-
without the support of the nursing team in theatres and
related lactulose allergy), respectively. The short hospital
stay was not a factor in these readmissions. None of thepatients who were discharged after an overnight hospitalstay were readmitted. REFERENCES
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Letter to Dermatology Benzimidazoles (albendazole, fenbendazole, oxfenbendazole, mebendazole, thiabendazole) are broad antiparasitic agents used Treatment of Scabies with Albendazole against a wide range of nematodes and cestodes. By binding to free ␤ -tubulin, benzimidazoles inhibit the polymerization of tu-bulin and the microtubule-dependant glucose uptake, leading to Univers
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