Venous thromboembolism, a serious postoperative risk, particularly after extensive gynecological procedures, can lead to deep vein thrombosis (DVT) and potentially fatal pulmonary embolism (PE). Without preventive measures, DVT can develop in a significant percentage of patients, often progressing to PE. This condition not only poses a threat to patients' lives but also places a substantial economic burden on healthcare systems. However, these complications are largely preventable with effective prophylactic strategies.
Evidence suggests that targeted prophylaxis, including systemic anticoagulants and non-pharmacological measures like compression devices, can significantly reduce the frequency and severity of venous thromboembolism (VTE) at a reasonable cost. Among the non-pharmacological options, graduated compression hosiery and sequential pneumatic compression devices are highly regarded for their ease of use, minimal complications, and virtually no bleeding risk. Sequential compression is especially valuable when anticoagulation is contraindicated, as it helps prevent clot formation by mimicking the muscle pump action and improving venous return.
Despite existing guidelines on VTE prophylaxis, diagnosis, treatment, and management, most studies focus on patients with malignant gynecological diseases or the safety of gynecological surgery. There is a lack of research assessing hemostatic imbalances in terms of coagulation and fibrinolysis, which are crucial for guiding perioperative and postoperative management of DVT. Some studies have attempted to measure changes in hemostasis parameters, but more comprehensive evidence is needed, especially for gynecological benign patients undergoing minimal invasion surgery.
This study aims to fill this gap by examining the effect of mechanical compression on coagulation and fibrinolysis and the occurrence of DVT in Chinese patients with benign gynecological conditions undergoing minimal invasive gynecological surgery. An intermittent pneumatic compression (IPC) device was applied to the bilateral lower extremities to provide mechanical compression. The primary outcomes assessed included prothrombin time (PT), international normalized ratio (INR), percentage of prothrombin time (PT%), activated partial thromboplastin time (APTT), plasma fibrinogen (FIB), plasma D-dimer (D-D), fibrinogen degradation products (FDP), and the rate of DVT incidence.
The study was conducted at the Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, between January 2021 and August 2022. It was approved by the Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine. The study included 119 Chinese adult female patients with benign gynecological diseases who underwent minimally invasive gynecological laparoscopy. The patients were divided into a Device group and a Non-device group based on whether they received IPC during intraoperative and perioperative nursing care.
In the Device group, the Phlebo Press® DVT device was applied to the lower limbs, delivering standard pneumatic compression therapy with circumferential, sequential, gradient compression. Bilateral calf-ankle mechanical pneumatic compression was started intraoperatively and monitored for half an hour postoperatively in the recovery room. Anti-thromboembolism stockings were not used to exclusively examine the effect of mechanical compression.
Gynecological laparoscopic surgery was performed with preoperative instrument preparation, including a gynecological laparoscopic instrument kit, ultrasonic scalpel, electrosurgery, laparoscopic system, and lithotomy stand. Endotracheal intubation anesthesia was conducted, and the perineum and abdominal skin were disinfected. Various systems were connected, and an arc-shaped incision below the umbilicus was made. An artificial pneumoperitoneum was established after the uterine manipulator was well-placed, and appropriate-sized cuffs were placed. A laparoscope was inserted into the abdomen, and the patient was placed in a lithotomy position. A lumbar puncture of pituitin was performed to reduce bleeding, and vital signs were closely monitored. The capsule of the fibroids was incised, culled, and removed, and the abdominal cavity was fully flushed after the uterine defect was sutured. Any damage and bleeding to the organs in the abdominal cavity were carefully checked before suturing the skin incision.
Blood samples were collected from the peripheral venous blood of the patients before the operation and on the morning of the second day after surgery to examine changes in hemostasis. PT, APTT, TT, INR, FIB, TT, DDi, and FDP were tested to assess abnormalities in coagulation and fibrinolysis. These parameters were detected using an automated coagulation analyzer. Samples with visible clots were excluded from the data set, and all coagulation tests were run within one hour of sampling.
Physical and ultrasonographic examinations were performed to detect DVT. Physical examination focused on signs of VTE, bleeding, breath difficulties, edema, tenderness of the gastrocnemius muscles, warmth, erythema, pain in the lower limbs, and bilateral dorsal pedis artery pulsation. The diameter of the legs was measured to monitor swelling. Ultrasonographic detection involved bilateral color-flow duplex ultrasonography, combining real-time B-mode imaging, sequential compressibility testing, and spectral Doppler analysis. All images were interpreted by a board-certified radiologist, who documented thrombus location, morphology, and hemodynamic impact.
Pharmacological thromboprophylaxis was used for patients diagnosed with acute DVT in the postoperative stage. Anticoagulation treatments included subcutaneous injections of adroparin calcium and enoxaparin sodium, followed by orally administered rivaroxaban. All patients were closely observed for symptomatic thromboembolism for at least three months.
Statistical analyses were performed using GraphPad Prism. The measurement data were expressed as mean ± standard deviation (x ± SD). Paired t-tests were used to determine differences in PT, PT%, APTT, INR, FIB, TT, DDi, and FDP between before and after the operation within the Device and Non-device groups. An unpaired t-test was used to compare the ratio of each parameter between the Non-device and Device groups. A p-value < 0.05 was considered statistically significant.
The results showed that PT and INR significantly increased after the operation in both groups, indicating a procedure-related slowing of clot formation likely due to transient factor or fibrinogen consumption. However, the pre-/post-operative increase was smaller in the Device group, suggesting that the IPC device tempered this delay and may curb bleeding propensity. PT% and TT significantly decreased after the operation, with no significant change in FIB and APTT. The values of DDi and FDP significantly increased in both groups, indicating a surgery-triggered boost in fibrinolysis. When expressed as pre-/post-operative ratios, only FDP rose less in the compression group, indicating that sequential pneumatic compression tempered this marker while leaving D-dimer largely unchanged.
The incidence rate of DVT after the operation was 3.3% in the Non-device group and 3.2% in the Device group, reflecting a similarly low post-operative incidence. The study demonstrated dynamic changes in coagulation and fibrinolytic parameters in response to IPC application after surgery. Although the occurrence of distal DVT in benign gynecological patients is low, the application of IPC can reduce the effects of surgery-induced activation of coagulation and fibrinolysis, which may guide clinicians and nurses to early identify the risk of DVT, consequently, making early prevention and management for patients undergoing gynecological laparoscopy during perioperative and postoperative care.
In conclusion, this retrospective cohort study suggests that mechanical calf-ankle compression can modestly attenuate early coagulation/fibrinolytic activation, although it did not significantly lower overall DVT incidence in this low-risk population. Prospective, adequately powered trials are needed before IPC can be recommended as stand-alone prophylaxis in minimally invasive gynecologic surgery.
