the use of laparoscopy as an alternative to laparotomy in gynecologic procedures has increased in recent years , especially since the advent of laparoscopic cholecystectomy . local general hospitals in taiwan have been slow to follow this trend because of the large initial investment required for state - of - the - art equipment , patient education issues , and difficulties obtaining reimbursement . only recently has the government approved reimbursement for the following laparoscopic procedures : hysterectomy , myomectomy , ovarian cystectomy , and treatment of ectopic pregnancy . however , reimbursement levels have not been sufficient to cover basic procedural costs . in addition , costs for initial equipment setup and disposable surgical items have proven to be considerably more prohibitive in local privately owned general hospitals than in government owned hospitals . the advantages of the laparoscopic approach in these procedures have been well documented and include less patient discomfort , shortened hospital stay , and quicker recovery . specifically , laparoscopic appendectomy results in lower morbidity and shorter hospital stay than does laparotomy . similar advantages have also been shown for laparoscopically treated adnexal masses . in addition , minimizing adhesions improves the patient 's chances of remaining fertile following surgery . although the taiwanese government has approved reimbursement for a number of these procedures , concern remains regarding the potential for inexperienced surgeons performing these operations and creating iatrogenic injuries . we present a summary of 571 gynecologic laparoscopies performed at yuan 's general hospital , taiwan , in 1998 and 1999 and include a discussion of advancements in the use of these procedures at this institution . we performed a comprehensive review of all laparoscopic gynecology procedures performed at yuan 's general hospital in kaohsiung , taiwan , r.o.c . in 1998 and 1999 . all procedures were performed by 1 of 6 board - certified gynecologic surgeons or by 1 of 4 residents under the direct supervision of a board - certified surgeon . data include indications for surgery , complications , rate of conversion to laparotomy , need for transfusion , and length of hospital stay . from 1998 through 1999 , 571 gynecologic laparoscopies were performed at yuan 's general hospital , 293 in 1998 and 278 in 1999 . secondary procedures performed in combination with the hysterectomy or adnexal procedures are shown in table 3 . the most common indications for hysterectomy were fibroids , menometrorrhagia / dysmenorrhea , and pelvic mass ( table 4 ) . twelve of 280 laparoscopic hysterectomies performed during this period ( 4.3% ) required conversion to laparotomy ( 5 of 149 in 1998 , 7 of 131 in 1999 ) . reasons for conversion to laparotomy included bleeding ( 8 cases ) , adhesions ( 3 cases ) , and bladder injury ( 1 case ) . a j - p drain was inserted postoperatively in 154 of the laparoscopic hysterectomy cases ( 91 in 1998 and 63 in 1999 ) . serous adenomas and endometriomas were the most common types of adnexal masses diagnosed in this series ( table 5 ) . only 2 of the 291 adnexal procedures ( 0.7% ) required conversion to laparotomy ( 1 of 144 in 1998 due to adhesions , 1 of 147 in 1999 due to endometriosis ) . we used j - p drains in 39 adnexal cases in 1999 but in no adnexal surgeries the previous year . the mortality rate in this series was 0% , and the morbidity rate was 7.2% ( 41 of 571 ) . bleeding was the most common complication , occurring in 38 of the hysterectomy cases ( 21 in 1998 and 17 in 1999 , 13.6% of the total ) , and 1 of the adnexal laparoscopies ( < 1% ) . two patients incurred bladder injury during hysterectomy . from 1998 to 1999 , we observed a reduction in both mean surgery time ( 135.4 to 123.0 , p=0.032 ) and mean length of hospital stay ( 5.52 to 4.62 , p=0.046 ) for hysterectomies and adnexal procedures combined . patient demographics in 571 gynecologic laparoscopies performed at yuan 's general hospital , taiwan , r.o.c . , in 1998 and 1999 571 gynecologic laparoscopies performed at yuan 's general hospital , taiwan , r.o.c . , in 1998 and 1999 secondary laparoscopic procedures performed in combination with the hysterectomy or adnexal procedures performed at yuan 's general hospital , taiwan , r.o.c . , in 1998 and 1999 . indications for laparoscopic hysterectomy in 280 cases at yuan 's general hospital , taiwan , r.o.c . , in 1998 and 1999 . pathology of adnexal masses in 291 cases managed at yuan 's general hospital , taiwan , r.o.c . the use of laparoscopy in gynecologic surgical procedures has increased in recent years as more studies have been presented that support the safety and efficacy of this approach . in particular , the advantages of laparoscopically assisted vaginal hysterectomy ( lavh ) over laparotomy have been well documented . these advantages include shorter hospital stay , shorter recovery time , reduced hospital charges , and comparable if not fewer complications while avoiding a large laparotomy wound . similar advantages have occurred with laparoscopic management of adnexal masses that appear benign on ultrasound . several authors have suggested that with appropriate preoperative evaluation , laparoscopy should replace laparotomy in the management of most adnexal masses . despite this information , although some institutions have reported reductions in the laparotomy rate for hysterectomy to around 10% , evidence exists from the united kingdom and the united states that more than 70% of all hysterectomies are still being performed via laparotomy . the primary obstacles cited include the large initial capital investment for equipment , the significant training necessary , and reluctance on the part of payers to reimburse for these procedures . the taiwanese surgical community has also been slow to adopt laparoscopic techniques for many of these same reasons . for example , at our institution , disposable surgical tools are often sterilized and reused to save on expenses . for those procedures approved for reimbursement , the reimbursement levels are so low they rarely cover the basic costs of the procedure . in addition , a limited number of hospitals are set up to perform training , and few qualified surgeons are available to conduct the training . no reimbursement is available for procedures performed during training prior to certification . even at our hospital , where we are making substantial progress with our laparoscopy program , patients are reluctant to consent to laparoscopic surgery not only because it is new to them , but also because they often do not understand the benefits . for example , the average length of hospital stay for our series of patients does not differ significantly from that for patients undergoing laparotomy . the majority of our laparoscopy patients could safely be discharged on the second or third day postoperatively ; however , our system allows patients to stay 4 or 5 days following gynecologic surgery . patients expect to stay in the hospital for that period of time and often choose to do so even when unnecessary . despite these obstacles , we successfully train 4 or 5 new residents each year in laparoscopic gynecology techniques and have shown improvement in our surgeons ' technique through lower complication rates , shorter procedure times , and shorter hospital stays . we believe these data support ongoing efforts to incorporate gynecologic laparoscopy as an alternative to open surgeries for treatment of appendectomy , hysterectomy , and adnexal masses at our institution . we feel these data support ongoing efforts to incorporate gynecologic laparoscopy as an alternative to open procedures at our institution . introduction of these procedures in privately owned hospitals in taiwan has been limited because of the large initial investment required for state - of - the - art equipment , patient education issues , and difficulty in obtaining reimbursement .
background and objectives : we reviewed the records for 571 gynecologic laparoscopies performed at a privately owned general hospital in kaosiung taiwan in 1998 and 1999 and discuss here the major obstacles we encountered while introducing these procedures at our institution.methods:included in this series are 293 procedures performed in 1998 ( 149 hysterectomies , 144 adnexal procedures ) , and 278 procedures performed in 1999 ( 131 hysterectomies , 147 adnexal procedures ) . 
 thirty - nine of these patients also underwent laparoscopic appendectomy . 
 mean patient age was 62 years ( range 28 to 82 ) . 
 all procedures were performed by 1 of 6 board - certified gynecologic surgeons , or by 1 of 4 residents under the direct supervision of a board - certified surgeon.results:we experienced 0% mortality and 7.2% morbidity in this series . in comparing cases from 1998 and 1999 
 , we observed a decrease in both mean surgery time ( 135.4 to 123.0 , p=0.032 ) and mean length of hospital stay ( 5.52 to 4.62 , p=0.046 ) for hysterectomies and adnexal procedures combined.conclusions:these data support ongoing efforts to incorporate gynecologic laparoscopy as an alternative to open procedures at our institution . 
 introduction of these procedures in privately owned hospitals in taiwan has been limited because of the large initial investment for equipment , patient education issues , and difficulties obtaining reimbursement .