Laparoskopie vs Laparotomie in der Gynäkologie - PDF

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Laparoskopie vs Laparotomie in der Gynäkologie Univ. Prof. Dr. Dr. h.c. Heinz Kölbl Klinische Abteilung für allgemeine Gynäkologie und gynäkologische Onkologie Universitätsklinik für Frauenheilkunde Wien

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Laparoskopie vs Laparotomie in der Gynäkologie Univ. Prof. Dr. Dr. h.c. Heinz Kölbl Klinische Abteilung für allgemeine Gynäkologie und gynäkologische Onkologie Universitätsklinik für Frauenheilkunde Wien Laparoskopie vs Laparotomie Allgemeine Gynäkologie Eingriffe an den Adnexen benigne Tumore schwangere Frauen nicht schwangere Frauen Myome Hysterektomie Onkologie Urogynäkologie Laparoscopy versus laparotomy for benign ovarian tumor Cochrane Database of Systematic Reviews. 11, 2010 Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Objectives To determine the benefits, harms, and costs of laparoscopic surgery compared with laparotomy or minilaparotomy in women with ovarian tumours assumed to be benign Types of studies All randomised controlled trials (RCTs) which compared laparoscopic surgery with laparotomy or minilaparotomy as a treatment for ovarian tumours assumed to be benign Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Types of participants Inclusion criteria We considered three groups of women with benign ovarian tumours who were treated surgically by either laparoscopy, minilaparotomy, or laparotomy» those with any type of benign ovarian tumour» those with dermoid cysts» those with endometriomata Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Types of participants Inclusion criteria We only included trials where women were investigated in the preoperative setting with transvaginal or transabdominal ultrasonography, or both, for analysis of the morphological scoring in order to exclude from the trial women with tumours that were likely to be malignant. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Types of participants Inclusion criteria We noted whether trials reported: (1) the use of colour Doppler transvaginal ultrasonography to assess vascular quality from the vascular resistance index (RI) and pulsatility index (PI); (2) preoperative estimation of serum CA 125 levels, levels greater than 35 U/ml were suggestive of malignancy. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Types of participants Exclusion criteria (1) Women with ovarian tumours having features suggestive of malignancy, determined during preoperative assessment. (2) Women with gynaecological cancer. (3) Trials where the author did not describe the preoperative assessment that was performed. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Types of outcome measures The major outcome measures were as follows. 1 Surgical Mean duration of surgery Change of diagnosis from benign to malignant tumour 2 Adverse events Surgical injury of the: bladder ureter vasculature small bowel colon Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Types of interventions Two surgical approaches used for the management of ovarian tumours assumed to be benign were compared: laparoscopy and laparotomy. Laparotomy was further defined as either standard laparotomy' with a Pfannanstiel incision or 'minilaparotomy', where the transverse incision was 3 to 7 cm long. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, Postoperative complications Requirement for blood transfusion Haematoma Fever Incision infection Urinary tract infection Thromboembolism Perioperative mortality 4 Any other adverse event Urinary retention Chemical peritonitis Intestinal obstruction Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, Any other adverse events of surgery either surgical injury, postoperative complications, other adverse events of surgery 6 Short-term outcomes Pain: VAS scores Pain: pain free at 24 to 48 hrs postoperation Pain: requirement for analgesia Length of hospital stay Recurrence rate after 6 to 12 months Blood loss determined by haemoglobin level 7 Economic measure Direct cost of surgical procedures Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Description of studies Initially 32 studies were identified which compared laparoscopy and laparotomy for benign ovarian tumours. Twenty of these studies were excluded because they were not randomised Twelve randomised controlled trials that were published between 1995 and 2007 met the inclusion criteria for this review The six additional primary studies in this update were RCTs Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Effects of interventions Included studies Twelve studies and 769 patients were included in this review. Nine studies compared laparoscopy and laparotomy Three studies compared laparoscopy and minilaparotomy Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Laparoscopy vs Laparotomy Surgical outcomes (a) Duration of surgery (i) In the studies of any type of benign ovarian tumour there was considerable heterogeneity in the estimates and it was inappropriate to pool the data (ii) In the subgroup of dermoid cysts there was substantial inconsistency making it inappropriate to pool the data (Chi2 = 7.67, P = 0.02, I2 = 74%) (iii) In the subgroup of ovarian endometriomata there were no statistically significant differences between treatments arms for duration of surgery Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Surgical outcome (b) Diagnosis of malignant tumour In one study, the ovarian tumours in four women were found to be malignant after frozen section was performed during laparoscopy, with subsequent conversion to laparotomy Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (a) Surgical injury Nine studies provided data for analysis of surgical injuries Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (a) Surgical injury (i) In the subgroup of any type of benign ovarian tumour no injuries to the ureter, small bowel, or colon were reported. One study reported a single case of bladder injury in the laparotomy group and two studies each reported a single case of vascular injury in the laparoscopy group. (ii) In the subgroup of dermoid cysts no surgical injuries were reported. (iii) In the subgroup of ovarian endometriomata no surgical injuries were reported. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (b) Postoperative complications (i) In the subgroup of any type of benign ovarian tumour in four studies there was a decreased risk of fever in the laparoscopy group There was a non-statistically significant difference between laparoscopy and laparotomy regarding the risk of incision infection and urinary tract infection There was also a decreased risk of urinary retention in the laparoscopy group in the one trial that reported this outcome and blood loss measured by haemoglobin levels Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (b) Postoperative complications (ii) In the dermoid cyst subgroup one study only reported a single case of fever in the laparotomy group. There were no reported cases of incision infection or urinary tract infection in this study but this may be because all patients received prophylactic antibiotics Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (b) Postoperative complications (iii) In the subgroup of ovarian endometriomata: no postoperative complications were reported. The pooled estimate for fever, including the subgroups of any type of benign ovarian tumour and dermoid cysts, showed a reduced odds of febrile morbidity associated with laparoscopy. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (c) Any adverse events of surgery (surgical injury, postoperative complications, and any other adverse events of surgery) The pooled estimate for total number of adverse events including the subgroups of any type of benign ovarian tumour or dermoid cysts showed a lower odds for any adverse event with laparoscopy compared to laparotomy. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events Short-term outcomes (a) Postoperative pain (VAS scores, free of pain at 24 to 48 hrs aft her surgery, requirement for analgesia) The odds for being free of pain were significantly greater for laparoscopy in each of the three subgroups. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (b) Recurrence of ovarian tumours six to 12 months after surgery Recurrence was mentioned in only two studies with a combined total of 108 participants Two cases of recurrence occurred in the group with any type of benign ovarian tumour Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Adverse events (c) Length of hospital stay The pooled estimate for these three subgroups favoured laparoscopy with heterogeneity and inconsistency detected. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Economic measures (a) Direct costs of surgical procedures Using a cost analysis from a social perspective, the total costs of laparoscopy were significantly lower when compared to laparotomy. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Results Laparoscopy versus minilaparotomy Surgical outcomes Adverse events Short-term outcomes Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Discussion The results of 12 randomised controlled trials (N = 769 women) showed that laparoscopic surgery was associated with significantly less postoperative pain, fewer adverse events of surgery (surgical injury or postoperative complications), and a shorter length of stay in hospital. Although duration of hospital stay was significantly reduced, by nearly three days, after laparoscopy when compared to laparotomy significant heterogeneity was detected. Cost is another factor that should be taken into consideration when choosing the surgical approach.the costs of laparoscopy compared to laparotomy were reported by one trial with limited sample size, with only 34 patients in each group. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Discussion Overall frequency of inadvertent rupture of the cysts during operation was larger in the laparoscopy group that in the minilaparotomy group. In patients with unrecognised neoplasms, laparoscopy may be associated with an increase in the rate of intraperitoneal spillage with consequent dissemination of tumour cells and advances in disease stage. Thus, we would suggest that careful preoperative examination, as undertaken in these studies, decreases the risk of a malignancy being identified during a laparoscopy procedure. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database of Systematic Reviews. 11, 2010 Discussion This review is limited in its ability to guide surgical practice because of the small number of women randomised in the 12 studies. The small number of randomised studies may be the result of surgeons' resistance to accept this type of study design since only 39% of all treatments validated in surgery are from randomised studies. Laparoscopic surgery for presumed benign ovarian tumor during pregnancy The Cochrane Database of Systematic Reviews Issue: Volume (4), 2009 Laparoscopic surgery for presumed benign ovarian tumor during pregnancy The Cochrane Database of Systematic Reviews Issue: Volume (4), 2009 A small number of women have tumors of the ovaries diagnosed during pregnancy. Most of these tumors are not malignant, and if they are small then treatment can be left until after the birth. In case of suspected malignant ovarian tumor, the laparoscopic surgery should be avoided due to the risk of port site metastasis and inadequate surgical staging. The serous cystadenoma and dermoid cyst are the two most common pathologies found. Laparoscopic surgery for presumed benign ovarian tumor during pregnancy The Cochrane Database of Systematic Reviews Issue: Volume (4), 2009 Ovarian tumor in pregnancy requiring surgical intervention has an incidence ranging from % to 0.36%. However, if the tumour is larger that 6 cm in diameter, it is suggested that it is better to operate and remove them during pregnancy The surgical management of ovarian tumors in pregnancy is similar to that of non-pregnant women. The procedure can be done by open surgery (laparotomy) or keyhole surgery (laparoscopy) technique. Laparoscopic surgery for presumed benign ovarian tumor during pregnancy The Cochrane Database of Systematic Reviews Issue: Volume (4), 2009 There were no randomized controlled trials identified that compared the effects of using laparoscopic surgery for benign ovarian tumor during pregnancy on maternal and fetal health and the use of healthcare resources. There are risks and benefits for both laparoscopic surgery and laparotomy in pregnancy, current sources of information are limited to only case series reports Laparoscopic surgery for presumed benign ovarian tumor during pregnancy The Cochrane Database of Systematic Reviews Issue: Volume (4), 2009 The benefits of laparoscopic surgery include shorter hospital stay, earlier return to normal activity, and reduced postoperative pain However, conventional laparoscopic surgery techniques required the infusion of gas carbon dioxide in the peritoneum to distend the abdomen and displace the bowel upward to create the room for surgical manipulation. Serious complications such as hypercarbia and perforation of internal organs have also been reported. Laparoscopic surgery for presumed benign ovarian tumor during pregnancy The Cochrane Database of Systematic Reviews Issue: Volume (4), 2009 An animal study reported decreased uterine blood flow from using the gas carbon dioxide pneumoperitoneum. To confirm the safety of laparoscopic treatment for benign ovarian tumour during pregnancy, there is a need for methodologically rigorous studies to provide direct evidence about the relative benefits and harms of and for laparoscopic surgery for benign ovarian tumor compared to laparotomy in pregnancy. This information is best obtained from randomized controlled trials. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids Cochrane Database of Systematic Reviews. 4,2012 Publication Type: Protocol Techniques and instrumentation A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: short-term outcomes Stefano Palomba, M.D.a, Errico Zupi, M.D.b, Tiziana Russo, M.D.a, Angela Falbo, M.D.a, Daniela Marconi, M.D.b, Achille Tolino, M.D.c, Francesco Manguso, M.D.d, Alberto Mattei, M.D.e, Fulvio Zullo, M.D.a a Department of Obstetrics & Gynecology, University Magna Graecia of Catanzaro, Catanzaro, Italy b Department of Obstetrics & Gynecology, University Tor Vergata of Rome, Rome, Italy c Department of Obstetrics & Gynecology, University Federico II of Naples, Naples, Italy d Department of Clinical and Experimental Medicine, University Federico II of Naples, Naples, Italy e Department of Obstetrics & Gynecology, University of Florence, Florence, Italy Fertility Sterility 2007 Oct;88(4):942-51 A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: short-term outcomes Fertility Sterility 2007 Oct;88(4): DESIGN: Randomized controlled trial PATIENT(S): One hundred thirty-six women wishing to conceive and candidate for myomectomy due to symptomatic uterine leiomyomas or unexplained infertility. INTERVENTION(S): Myomectomy through laparoscopic or minilaparotomic access. A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: short-term outcomes Fertility Sterility 2007 Oct;88(4): RESULT(S): Leiomyoma enucleation and hysterotomy suturing times were significantly shorter after minilaparotomic myomectomy the degree of surgical difficulty was significantly higher for the laparoscopic myomectomy Intraoperative blood loss, variation in hemoglobin levels, quantity of pain control drugs used postoperatively, and hospitalization were significantly lower in the laparoscopic group than in the minilaparotomic one A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: short-term outcomes Fertility Sterility 2007 Oct;88(4): RESULT(S): Surgical outcomes were significantly influenced by specific investigational centers involved, and by leiomyoma dimensions and localizations. This last variable is the strongest predictor of surgical outcome. CONCLUSION(S):... A careful evaluation of the dimensions and localizations of fibroids are needed to address to the right choice to the best approach. Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database of Systematic Reviews Issue: Volume (12), 2010 Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database of Systematic Reviews Issue: Volume (12), 2010 The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included. There were 34 studies with 4495 women included. Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database of Systematic Reviews Issue: Volume (12), 2010 Results The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections, and shorter duration of hospital stay (MD 1.1 days). Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database of Systematic Reviews Issue: Volume (12), 2010 Results The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database of Systematic Reviews Issue: Volume (12), 2010 Results The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection and shorter operation time (MD 25.3 minutes). Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database of Systematic Reviews Issue: Volume (12), 2010 Results There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding were increased in LH. Data were absent for many important long-term outcome measures. Surgical approach to hysterectomy for benign gynaecological disease Cochrane Database of Systematic Reviews Issue: Volume (12), 2010 Conclusions Because of equal or signifi
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