Human Reproduction, Vol. 14, No. 1, 39-43,
January 1999
© 1999 European Society of Human Reproduction and Embryology
How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies
1 Minimally Invasive Therapy Unit & Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond St, Hampstead, London NW3 2QG, UK
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Abstract |
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The purpose of this study was to assess the operating time of the most common gynaecological laparoscopic procedures. We analysed retrospectively 1000 consecutive operative laparoscopies on a procedure-by-procedure basis. Diagnostic laparoscopy and laparoscopic sterilization were specifically excluded from the analysis. The various laparoscopic procedures were grouped and analysed under six major categories. The average operating time for all cases was 76.9 min (range 10–400). In 38 cases (3.8%) the laparoscopic procedure was converted to laparotomy. The average operating time for treating ectopic pregnancy and tubal disease was approximately 60 min (range 13–240). Surgery for endometriosis and ovarian cysts averaged 72 min (range 10–240). Laparoscopic myomectomy and hysterectomy averaged 113 and 131 min respectively (range 25–400). Our results show that while the operating time for most operative laparoscopies is less than 75 min, the range of operating times is great. The relative lack of predictability in procedure times means that the efficient utilization of fixed theatre sessions is difficult.
Key words: laparoscopic surgery/procedure time
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Introduction |
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Until the early 1980s, intra-abdominal endoscopic procedures in gynaecology were used mainly for diagnostic purposes. Instrumental and technical developments have transformed this diagnostic procedure into a broad spectrum of intra-abdominal endoscopic surgery which could replace most of the traditional gynaecological abdominal operations (Semm and Mettler, 1980
; Tulandi, 1996). As the list of laparoscopic procedures grows constantly, it appears that any abdominal or pelvic surgical procedure can be done laparoscopically if the surgeon is persistent and innovative (Howard, 1992). Although there is clear advantage of this type of surgery in terms of duration of hospitalization and recovery, there is also a feeling that even in experienced hands endoscopic procedures can take considerably longer to perform than open surgery (Reich, 1989). The expression `foreveroscopy' has even been used by some! If true, the duration and unpredictability of surgical time has important financial and practical implications for the management of operating sessions and waiting lists. Fewer patients may get treated per unit time, and procedures may have to be postponed because of over-running of planned lists. To assess how long common gynaecological laparoscopic procedures actually take, we analysed 1000 operations on a procedure-by-procedure basis.
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Materials and methods |
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The operative coding sheets of 1000 consecutive women, who underwent elective (n = 798) and emergency (n = 202) operative laparoscopic procedures between the period June 1988 and June 1997 at the Churchill Hospital, Oxford (1988–1990) and the Royal Free Hospital, London (1990–1997) were reviewed. Diagnostic laparoscopy and laparoscopic sterilization were specifically excluded from the analysis, as were the first five operative laparoscopies of each specific procedure, representing the early learning curve of one of the authors (A.L.M.).
The main indications for surgery included one or a combination of the following symptoms or pathologies: pelvic or abdominal pain, menstrual disturbance, ectopic pregnancy, adnexal mass, fibroids and infertility. The mean age of the women was 35.2 years (range 13–85), and 495 were nulliparous. A total of 460 women underwent more than one laparoscopic procedure. Patient characteristics according to the various pathological conditions are described in Table I.
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Surgery was performed under general endotracheal anaesthesia with a CO2 pneumoperitoneum. A three- or four-puncture technique was used in the majority, utilizing a 10 mm subumbilical port for the laparoscope and two to three 5.5 mm lateral suprapubic cannulae for ancillary instruments which were sometimes replaced by 10–12 mm ports for larger instruments and staplers. All procedures were monitored using a video camera and high resolution colour monitor. Modalities used for haemostasis included monopolar and bipolar electrocoagulation, suturing, endocoagulation and, rarely, staples. Scissors, electrosurgery and CO2 laser were used for dissection and ablation of endometriosis. A total of 546 procedures involved removal of tissue from the peritoneal cavity. In 350 (64%) of these procedures tissue was removed from the peritoneal cavity via the laparoscopic ports, in 167 (31%) via posterior colpotomy and in two cases by mini-laparotomy. In 27 cases, the method of tissue removal was not stated in the coding sheets.
The various laparoscopic procedures were grouped and analysed under five major categories, representing the most common pathological conditions encountered in this population (ectopic pregnancy, endometriosis, ovarian cyst, fibroids, and pelvic adhesions/tubal disease). All cases of laparoscopic hysterectomy were also analysed.
In view of the large number of anaesthetics involved with the procedure over the 9 year period and variations in anaesthetic technique, the operative time was defined as the `skin-to-skin' time and excluded anaesthetic and the set-up times.
Statistical comparisons were made using Student's t-test for parametric data and the Mann–Whitney U-test for non-parametric data (GraphPad Prism Software, San Diego, CA, USA).
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Results |
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A total of 962 of the laparoscopies was completed successfully. Reasons for converting the remainder to laparotomy included dense intra-abdominal adhesions or other unexpected findings in 23 cases, excessive bleeding in six cases, bowel injury in two cases, bladder injury in four cases, lost needle in one case and failure to deliver large fibroids from the abdominal cavity in two cases. No deaths occurred.
The operating time was not recorded in 44 cases, and these women were excluded from subsequent analysis. The average operating time for all patients was 76.9 min (range 10–400); 489 (52.0%) procedures took 1 h or less, 345 (36.6%) between 1 and 2 h, 84 (9.1%) between 2 and 3 h, and 22 (2.3%) over 3 h. Excluding two cases, all the other 20 cases of operating time longer than 3 h involved laparoscopic hysterectomy or myomectomy. The operating time for the 38 women requiring laparotomy was significantly longer at 130.2 min (range 30–400) compared to the 918 who were managed successfully laparoscopically (mean 75.3 min; range 10–300) (P < 0.0001). The 202 emergency cases were shorter than the elective cases [mean operating time of 58.3 (SD 27) and 81.4 (SD 50) respectively, P < 0.0001].
Ectopic pregnancy (Figure 1)
A total of 139 women was treated for extra-uterine pregnancy, including two cases of cornual pregnancy managed laparoscopically. Four (2.9%) other cases were converted to laparotomy. Surgery averaged less than 1 h. Conservative surgery in the form of salpingotomy was generally quicker than salpingectomy by 7 min (52.0 versus 59.0 min respectively). The operating time was longer in 14 cases where salpingotomy was attempted but had to be converted to salpingectomy because of persistent bleeding from the Fallopian tube (mean 69.0 min, range 45–100). These cases had also a major contribution to the group who bled >250 ml. In contrast, the need for adhesiolysis in 21 cases (15%) added only a few min to the total operating time.
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Tubal disease and adhesiolysis (Figure 2
)A total of 178 patients was operated for tubal disease and/or adhesions; four procedures (2.2%) were converted to laparotomy because of severe adhesions. Salpingectomy (n = 51) was one of the shortest procedures with an average mean operating time of 46.0 min (range 20–120). Laparoscopic adhesiolysis as the sole procedure was done for 70 patients and generally took less than 1 h (mean 59.4 min, range 15–180). Multiple procedures such as salpingostomy or fimbrioplasty and adhesiolysis averaged 75 min.
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Endometriosis (Figure 3
)Endometriosis was diagnosed in 317 patients of whom 288 were treated conservatively. Of these, 282 patients (97.9%) were managed successfully by laparoscopy for whom the overall operating time was 69.5 min (range 10–180). Simple electrosurgical or CO2 ablation of mild disease took about 40 min (range 10–90). Laparoscopic uterine nerve ablation (LUNA) in association with fulguration or adhesiolysis also lasted less than 1 h. The operating time increased to around 90 min (range 40–180) in cases with more advanced endometriosis or endometriomas.
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Ovarian cysts (Figure 4
)A total of 141 women was treated conservatively for non-endometriotic ovarian cysts, ranging in diameter from 1 to 18 cm (mean 5.1). Overall, four cases (2.8%) were converted to laparotomy. The mean operating time for all procedures was 74.2 min (range 10–240). Biopsy or aspiration of the lesion was the quickest procedure, but most women underwent complete excision of the cyst wall. The average time for ovarian cystectomy as the sole procedure was 65.5 min (range 10–150); additional procedures such as adhesiolysis only added 8 min to the average case. Oophorectomy for this indication (n = 20) took 101.3 min (range 35–240).
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Fibroids (Figure 5
)A total of 61 cases of fibroids was treated laparoscopically with an average size of fibroid of 4.8 cm (range 0.5–12 cm). Ten patients (16%) in this group required laparotomy, the highest rate among all the indications. The average operating time for laparoscopic myomectomy was 113.5 min (range 40–390). The need for suturing the uterus increased the average operating time from 90 to 134 min.
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Laparoscopically assisted vaginal hysterectomy (LAVH) (Figure 6
)A total of 133 women was treated by LAVH; 10 cases (7.5%) were converted to laparotomy. LAVH was the longest procedure both in terms of mean operating time of 131.1 min and in variability (range 30–400). When analysed by indication for surgery, hysterectomy for ovarian cysts was generally the longest procedure (mean 145.8 min, range 75–270), although the range of operating times was maximum for fibroids (range 35–400 min).
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Discussion |
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The key finding of our study is that while the operating time for most operative laparoscopies is less than 1.5 h, there is a large variability in how long various procedures take. This is particularly so with elective procedures, especially laparoscopic myomectomy and hysterectomy. A practical implication of this result is that it becomes difficult to predict how long individual operations will take, and this makes the efficient utilization of fixed theatre sessions problematic. Our impression is that unpredictability of laparoscopic procedures is greater than with laparotomy, particularly for elective indications.
There is no evidence that the operating times in this series are significantly different to other published data. For instance, the mean operating time for laparoscopic management of ectopic pregnancy was 64 min (range 34–150), 58 min and 59.7 (SD 18.1) min in other reported series (Foong et al., 1995; Chatwani et al., 1992; Tozer and Shaxted, 1997 respectively). Laparoscopic ovarian cystectomy for non-endometriotic cysts averaged 51.8 min (range 30–100), 115 min (range 75–175) and 129 min (range 40–200) in three other reports, whereas laparoscopic management of endometriomas averaged 168 (SD 72) min and ranged between 20 and 150 min in two other series (Cristalli et al., 1992; Chi et al., 1995; Bollen et al. 1992; Bateman et al., 1994; Del Pozo et al., 1995 respectively). Laparoscopic adnexectomy averaged 90 min in three other studies (range 40–150) (Oelsner et al., 1993; Gal et al., 1995; Vilos and Alshimmiri, 1995 respectively). Operating times for laparoscopic myomectomy have been reported as 157 min (range 45–443), 130 min (range 30–300), 116 min (range 50–190) and 110 min (range 30–180) (Hasson et al., 1992; Dubuisson et al., 1996; Nezhat et al., 1991; Daniel and Gurley, 1991 respectively). It thus seems that the variability in operating times is not unique to our series.
The finding that emergency laparoscopic procedures were significantly shorter and more consistent in duration than elective operations means that operating times should not be a disincentive to using endoscopy in such cases. Emergency procedures are typically performed outside normal working hours when prolonged or unpredictable operating times would be a particular disadvantage. However, given that most of these operations are for ectopic pregnancy, it is evident from randomized trials that laparotomy is not faster, and the range of operating times is not less than with endoscopic management (Baumann et al., 1991; Lundorff et al., 1991; Murphy et al., 1992; Gray et al., 1995). Taken together, these data and our finding that laparoscopic surgery for ectopic pregnancy averaged less than 1 h, may further support the conclusion that operative laparoscopy has become the gold standard in treating ectopic pregnancy (Tulandi, 1996; Clasen et al., 1997).
Indeed, over two-fifths of the elective procedures such as salpingectomy, adhesiolysis, ablation of endometriosis, LUNA and ovarian cystectomy were completed within 1 h. On the other hand, when the operative findings required a combination of more than one laparoscopic procedure, or involved myomectomy or LAVH, surgery lasted much longer and was more unpredictable (75% of procedures took 90 min or more). This was especially so if myomectomy or hysterectomy involved suturing, when the mean operating time was between 2 and 3 h. This result can be partly explained by the extent of the pathology being treated, such as large or intramyometrial fibroids (Nezhat et al., 1991), but another major contributor to prolonged surgery is the inherent difficulty of current laparoscopic suturing techniques. Given the recent findings of Vossen et al. (1997) it is expected that operating times of laparoscopic operations involving suturing might shorten by further training for tying techniques.
Another finding with respect to laparoscopic hysterectomy for benign indications is that the mean operating times and the range of operating times are similar irrespective of the pathological findings. Our average procedure time of about 2 h is consistent with most other published series (Liu, 1992; Summitt et al., 1992; Nezhat et al., 1994; Bornstein and Shaber, 1995; Chapron et al., 1996; Dorsey et al., 1996; Meikle et al., 1997). Apart from the extent of pelvic pathology and the mode of haemostasis, the other important determinant of how long LAVH takes depends on the stage when laparoscopy is converted to vaginal surgery (Phipps and Nayak, 1993; Richardson et al., 1995). For this reason, our tendency is to switch to vaginal dissection early during the procedure, and we prefer to ligate the uterine vessels and operate on the vaginal vault vaginally. Whatever the technique, the comparative data clearly show that abdominal and vaginal hysterectomies are faster procedures by a time of 1 h, and the variability in operating times is also less (Howard and Sanchez, 1993; Phipps and Nayak, 1993; Richardson et al., 1995; Dorsey et al., 1996).
In conclusion, our analysis of 1000 laparoscopies on a procedure-by-procedure basis demonstrates that although half the procedures took about 1 h, operating times ranged from 10 min to over 6 h. Generally elective operations, particularly laparoscopic myomectomy and hysterectomy, took the longest and had the greatest variability in procedure times. The implication of these results is that it is difficult to plan operating lists of such cases for optimal theatre utilization. It may be that the only way to achieve a more efficient use of theatre time is to assess potential patients for operative laparoscopy by diagnostic laparoscopy first, both to judge their suitability for endoscopic surgery and also to allow estimation of the likely procedure time for their surgery. Office laparoscopy might be a convenient method for this purpose (Fester, 1996). To what extent management by laparotomy is any more predictable remains to be seen.
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Notes |
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2 Present address: Department of Gynaecology, Hadassah Medical Centre, P.O.Box 12000, Jerusalem, 91120, Israel
3 To whom correspondence should be addressed
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Submitted on April 7, 1998; accepted on September 25, 1998.
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