Hysterectomy: towards an overnight stay

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 INTRODUCTION
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 DISCUSSION
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 ACKNOWLEDGEMENTS
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.
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