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Surgical quality control of minimally invasive procedures, fast-track surgery and implant technology in gynaecological surgery in Sweden
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
2019 (English)Licentiate thesis, comprehensive summary (Other academic)
Abstract [en]

Internationally as well as in Sweden, efforts for improvement in gynaecological surgery in recent decades have mainly focused on three new treatment concepts:

(1) Use of minimally invasive procedures: since there is an interdependency between the extent of surgical trauma and the risk for adverse outcome, increased use of supposedly atraumatic endoscopic procedures has revolutionized several aspects of surgical care

(2) A multimodal approach to eliminate harmful procedures in the peri-operative process based on evidence-based principles

(3) Introduction of implants to support damaged tissue with synthetic mesh in incontinence and pelvic organ prolapse patients.

Research question 1: Is introduction of a minimally invasive operation enough per se or is the measured improvement mediated by elimination of harmful procedures in the perioperative process?

Findings: Our study (Paper I) indicates that by applying a multimodal intervention programme for the pre- and postoperative care of patients undergoing supravaginal hysterectomy, the surgical procedure per se is of less importance than generally considered. Patient-related parameters such as length of postoperative hospital stay, number of days at home with need of painkillers, number of days before return to normal activities, and patient satisfaction did not differ between patients undergoing the laparoscopic procedure and patients undergoing abdominal supravaginal hysterectomy. When evaluating a new and presumably improved operative procedure against an established standard procedure, it is mandatory and of fundamental importance that the two methods are aligned in terms of perioperative care provided.

Research question 2: Under which circumstances can it be assumed that a new surgical procedure showing promising efficacy in one setting can be reproduced with similar results in a different clinical setting (Paper I)?

Findings: The operating surgeons concluded that, in their hands and under local conditions, laparoscopic technique for supravaginal hysterectomy was not superior to traditional open hysterectomy and stopped using laparoscopic technique. It seems necessary, prior to routine use, to monitor, using scientific tools, whether the advantages described in the literature are achievable under local conditions.

Research question 3: Do expected advantages of implants outweigh the unwanted effects and complications caused by implants in operations for recurrent cystocele (Paper II)?

Findings: Mesh has better durability but more (minor) complications. It is not possible to determine whether mesh is "generally better" than native tissue operation. Some may focus on the improved durability, others on the increased risks. The surgeon must make a risk assessment for each individual case. The patient must be sufficiently informed to understand the risks and make a personal, informed decision whether she wants an augmentation by implant. Essential for this process is a clear, comprehensible picture of both desired and unwanted effects of the planned surgery. In this context, studies like ours might be of use.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2019. , p. 28
Keywords [en]
Prolapse, mesh surgery, fast track surgery, laparoskopic hysterectomi
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
URN: urn:nbn:se:umu:diva-157812ISBN: 9789178550333 (electronic)OAI: oai:DiVA.org:umu-157812DiVA, id: diva2:1301943
Presentation
2019-05-10, Grupprum 2 Obstetrik och gynekologi,, Målpunkt QB(By27) våning 3, NUS, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2019-04-12 Created: 2019-04-03 Last updated: 2019-04-12Bibliographically approved
List of papers
1. No difference in length of hospital stay between laparoscopic and abdominal supravaginal hysterectomy: a preliminary study
Open this publication in new window or tab >>No difference in length of hospital stay between laparoscopic and abdominal supravaginal hysterectomy: a preliminary study
2006 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, no 6, p. 682-687Article in journal (Refereed) Published
Abstract [en]

Background: Although a number of well-designed studies have concluded that laparoscopic hysterectomy is associated with less postoperative pain, reduced hospital stay, and shorter periods of sick leave, thus far, studies on the perioperative and postoperative outcomes of laparoscopic supravaginal hysterectomy (LSH) versus abdominal supravaginal hysterectomy (ASH) are lacking. By applying multimodal intervention program for the postoperative care of patients, the primary aim of the current study was to compare length of hospital stay, time to convalescence, and long-term patient satisfaction between LSH and ASH. Method: The study was conducted at the departments of Obstetrics and Gynecology, Skelleftea Hospital and Lycksele Hospital. Forty-seven consecutive women scheduled for supravaginal hysterectomy were randomly assigned to LSH or ASH. Perioperative and postoperative parameters were compared between the two groups. Results: The length of the postoperative hospital stay did not differ between patients undergoing LSH and ASH, but the number of disability days was greater in the ASH group. The operating time was significantly longer in the LSH group compared with the ASH group, whereas the estimated perioperative bleeding was greater in the ASH group. At the 6-month follow-up, 87.0% of patients in the ASH group and 91.3% in the LSH group were satisfied or very satisfied with the overall result of the surgical procedure. Conclusion: The present study has indicated that by applying a multimodal intervention program for the postoperative care of patients undergoing supravaginal hysterectomy, the surgical procedure per se is of less importance than generally considered for the length of postoperative hospital stay and long-term patient satisfaction.

Place, publisher, year, edition, pages
John Wiley & Sons, 2006
Keywords
laparoscopic surgery, supravaginal hysterectomy, multimodal, hospital stay, disability days, patient satisfaction
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-9364 (URN)10.1080/00016340600593455 (DOI)000238188100007 ()16752259 (PubMedID)
Available from: 2008-03-26 Created: 2008-03-26 Last updated: 2019-04-12Bibliographically approved
2. Operation for recurrent cystocele with anterior colporrhaphy or non-absorbable mesh: patient reported outcomes
Open this publication in new window or tab >>Operation for recurrent cystocele with anterior colporrhaphy or non-absorbable mesh: patient reported outcomes
Show others...
2013 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 24, no 11, p. 1925-1931Article in journal (Refereed) Published
Abstract [en]

Introduction and hypothesis: The aim of this study was to compare patient reported outcomes and complications after repair of recurrent anterior vaginal wall prolapse in routine health care settings using standard anterior colporrhaphy or non-absorbable mesh.

Methods: The study is based on prospective data from the Swedish National Register for Gynaecological Surgery. 286 women were operated on for recurrent anterior vaginal wall prolapse in 2008–2010; 157 women had an anterior colporrhaphy and 129 were operated on with a non-absorbable mesh. Pre-, and perioperative data were collected from doctors and patients. Patient reported outcomes were evaluated 2 months and 12 months after the operation.

Results: After 12 months, the odds ratio (OR) of patient reported cure was 2.90 (1.34–6.31) after mesh implants compared with anterior colporrhaphy. Both patient- and doctor-reported complications were found more often in the mesh group. However, no differences in serious complications were found. Thus, an organ lesion was found in 2.3 % after mesh implant compared with 2.5 % after anterior colporrhaphy (p = 0.58). Two patients in the mesh group (1.2 %) were re-operated compared with 1 patient (0.6 %) in the anterior colporrhaphy group (p = 0.58). The infection rate was higher after mesh (8.5 %) than after anterior colporrhaphy (2.5 %; OR 3.19 ; 1.07–14.25).

Conclusion: Implantation of synthetic mesh during operation for recurrent cystocele more than doubled the cure rate, whereas no differences in serious complications were found between the groups. However, mesh increased the risk of infection.

Place, publisher, year, edition, pages
Springer London, 2013
Keywords
Cystocele, Colporrhaphy, Non-absorbable mesh, Patient reported outcome, National register data
National Category
Obstetrics, Gynecology and Reproductive Medicine Urology and Nephrology
Identifiers
urn:nbn:se:umu:diva-82798 (URN)10.1007/s00192-013-2110-2 (DOI)000325828800018 ()23640006 (PubMedID)
Available from: 2013-11-12 Created: 2013-11-11 Last updated: 2019-04-12Bibliographically approved

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