Surgical quality control of minimally invasive procedures, fast-track surgery and implant technology in gynaecological surgery in Sweden

Sammanfattning: 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.