The Impact of Systematic Laparoscopic Skills and Suture Training on Laparoscopic Hysterectomy Outcomes in a Brazilian Teaching Hospital

Gonçalves, Anna Luiza Lobão; Ayroza-Ribeiro, Helizabet Abdala; Lima, Raquel Ferreira; Yonamine, Aline Estefane Eras; Ohara, Fabio; Ayroza-Ribeiro, Paulo Augusto Galvão

doi:10.1055/s-0039-1700587

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Original Articles • Rev. Bras. Ginecol. Obstet. 41 (12) • Dec 2019 • https://doi.org/10.1055/s-0039-1700587 copy

The Impact of Systematic Laparoscopic Skills and Suture Training on Laparoscopic Hysterectomy Outcomes in a Brazilian Teaching Hospital

O impacto do treinamento laparoscópico sistematizado de habilidades e sutura nos resultados da histerectomia laparoscópica em hospital universitário brasileiro

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To evaluate the impact of systematic laparoscopic skills and suture training (SLSST) on the total laparoscopic hysterectomy intra- and postoperative outcomes in a Brazilian teaching hospital.

Methods

A cross-sectional observational study in which 244 charts of total laparoscopic hysterectomy (TLH) patients operated from 2008 to 2014 were reviewed. Patient-specific (age, parity, previous cesarean sections, abdominal surgeries and endometriosis) and surgery-related variables (hospital stay, operative time, uterine volume and operative complications) were analyzed in three different time-frame groups: 2008-09 (I-1) - TLHs performed by senior attending physicians; 2010-11 (I-2) - TLHs performed by residents before the implementation of the SLSST program; and 2012-14 (I-3) - TLHs performed by residents after the implementation of the SLSST program.

Results

A total of 244 TLH patients (mean age: 45.93 years) were included: 24 (I-1), 55 (I-2), and 165 (I-3). The main indication for TLH was uterine myoma (66.4%). Group I-3 presented a decrease in surgical time compared to group I-2 (p=0.010). Hospital stay longer than 2 days decreased in group I-3 compared to group I-2 (p=0.010). Although we observed decreased uterine volume (154.2 cm3) in group I-2 compared to group I-1 (217.8 cm3) (p=0.030), logistic regression did not find any association between uterine volume and surgical time (p=0.103).

Conclusion

The total operative time for laparoscopic hysterectomy was significantly shorter in the group of patients (I-3) operated after the systematic laparoscopic skills and suture training was introduced in our hospital.

Keywords:
hysterectomy; laparoscopic surgery; education; suture training

Grades	Definition
Grade I	Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions.The allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgesics, diuretics and electrolytes and physiotherapy. This grade also includes wound infections opened at the bedside.
Grade II	Requiring pharmacological treatment with drugs other than those allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included.
Grade III	Requiring surgical, endoscopic or radiological interventions.
IIIa	Intervention not under general anesthesia..
IIIb	Intervention under general anesthesia
Grade IV	Life-threatening complications (including central nervous system complications)* requiring management at intermediate care or intensive care unit.
IVa	Single-organ dysfunction (including dialysis).
IVb	Multiple-organ dysfunction.
Grade V	Death of a patient.

Week	Exercises
1st	Gladiator navigation
2nd	Gladiator with knot technique
3rd	Needle and guidelines
4th	Check-cross, deep and shallow stitches (staggering)
5th	Simple stitch with knot (number and resistance)
6th	Vaginal apex: x-shaped stitches, continuous suture right to left and left to right
7th	Myomectomy sutures and invaginating stitches
1st to 7th: Dominant hand on lateral trocar8th to 14th: Dominant hand on central trocar*15th to 21st: Non-dominant hand on lateral trocar*

Features		n	%
Parity	0	22	9.0%
	1	29	11.9%
	≥2	193	79.1%
Previous cesarean section		117	48.0%
Endometriosis		44	18.0%
Previous abdominal surgeries(including cesarean section)		184	75.4%
Total laparoscopic hysterectomy only		102	41.8%
plus salpingectomy		76	31.1%
plus ovarian surgery		35	14.3%
plus endometriosis		24	9.8%
plus others procedures		07	2.9%

	2008-09(I-1)	2010-11(I-2)	2012-14(I-3)	p-value
Myomatosis	70.8%	56.4%	73.5%	0.52
Endometriosis	12.5%	20.0%	18.0%	0.72
Previous cesarean section	37.5%	32.7%	54.5%	0.02
Comorbidities	50.0%	56.3%	55.1%	0.86
Previous abdominal surgeries	45.8%	60.0%	69.7%	0.03
Conversion	4.1%	1.8%	1.2%	0.04
Hospital stay > 2 days	29.1%	49%	18.1%	0.01
Intraoperative complications	0.0%	3.6%	2.4%	0.52
Postoperative complications	8.3%	3.6%	4.2%	0.21
Clavien-Dindo²¹21 Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250(02):187-196. Doi: 10.1097/SLA.0b013e3181b13ca2 https://doi.org/10.1097/SLA.0b013e3181b1... –I	0.0%	0.0%	0.0%
Clavien-Dindo – II	0.0%	0.0%	2,4%
Clavien-Dindo – IIIa	0.0%	0.0%	0,6%
Clavien-Dindo – IIIb	8,3%	1,8%	1,2%
Clavien-Dindo – IVa	0.0%	1,8%	0.0%
Clavien-Dindo – IVb	0.0%	0.0%	0.0%
Clavien-Dindo – V	0.0%	0.0%	0.0%

	2008-09(I-1)	2010-11I-2	2012-14I-3
Uterine volume (cm³; mean ± standard deviation)	217,8 ± 159,5	154,2 ± 95,9*	180,8 ± 91,4
Operative time (min; mean ± standard deviation)	219,8 ± 50,0	228,8 ± 89,1	204,5 ± 51,9**

Associations	p-value
Uterine volume (cm³) x baseline uterus disease	p= 0.02
Comorbidities	p= 0.03
Type of surgery performed	p< 0.001
Operative time (min) x baseline uterus disease	p= 0.001
Hospital stay > 2days	p= 0.002
Endometriosis	p= 0.002
Intraoperative complications	p= 0.013
Uterine volume (cm³) x operative time (min)	p= 0.10

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[1] Address for correspondence Anna Luiza Lobão Gonçalves, Master, Rua Cesário Motta Junior 61, 01221-020, São Paulo, SP, Brazil (e-mail: dra.annaluiza@gmail.com).