I appreciated Dr. Barbieri’s February editorial on minimally invasive hysterectomy. I’d like to tell you about steps taken at my institution.
Dr. Henrick Kehlet, a colorectal surgeon from Denmark, has developed a technique for colon resection using regional (epidural) anesthesia and early ambulation and nutrition.1 At his hospital in Copenhagen, patients begin consuming liquids the day of surgery and begin a regular diet the next day. They leave the hospital 2 to 3 days after the colectomy.
I became interested in his principles while visiting the Cleveland Clinic in 2001, and subsequently had him visit us in Minneapolis.
Since his visit, our department of 20 gynecologists has begun utilizing regional anesthesia/analgesia (spinal anesthesia with bupivacaine and morphine sulfate) with enforced ambulation and intake of liquids the day of surgery, and a regular diet and strict restriction of any narcotic analgesia on postoperative day 1 and subsequent days.
Using this regimen, 65% of our patients are discharged home on postoperative day 1, and 87% by postoperative day 2. The total number of patients seen last year was 256. All were encouraged to be as active after surgery as they were prior to surgery; many returned to work 2 weeks after surgery.
The use of a regional anesthetic and restriction of all intravenous or oral narcotics (using only scheduled nonsteroidal anti-inflammatory drugs and acetaminophen), as well as encouragement to be active immediately after surgery, are instrumental factors in the success of this program. Except for the cosmetic effect, we question whether there is any appreciable benefit to laparoscopically assisted vaginal hysterectomy.
John A. Reichert, MD
Park Nicollet Medical Center
Minneapolis, Minn
Reference
- Smedh K, Strand E, Jansson P, et al. [Rapid recovery after colonic resection. Multimodal rehabilitation by means of Kehlet’s method practiced in Vasteras.] Lakartidningen. 2001;98:2568-2574.
Dr. Barbieri responds:
Readers’ ideas thoughtful, innovative
I appreciate the insight of Dr. Sacks and Dr. Reichert. The readers of OBG Management consistently send us wonderfully thoughtful and innovative ideas.
Dr. Sacks’ letter has prompted me to contact our Blue Cross carrier to see if it would be willing to increase physician reimbursement for laparoscopic hysterectomy, provided we could ensure reduced costs related to fewer days of hospitalization.
Dr. Reichert points out the critical importance of anesthesia and intraoperative and postoperative care on the rate of recovery from hysterectomy. I agree with him that regional anesthesia and early feeding reduce the length of stay for a number of different abdominal or pelvic surgeries. However, laparoscopic hysterectomy may be associated with shorter convalescent time than abdominal hysterectomy. In 1 randomized trial, the median convalescent times for laparoscopic and abdominal hysterectomy were 16 and 35 days, respectively (P<.001>1