Total Laparoscopic Hysterectomy Case File

Total Laparoscopic Hysterectomy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 9

A 37-year-old G4P3013 woman presents to your office with menorrhagia and pelvic pain. The patient also has some feeling of incomplete emptying of her bladder. The patient has been seen by another gynecologist and placed on medical therapy, including nonsteroidal antiinflammatory drugs (NSAIDs) and oral contraceptives without alleviation. She desires a permanent solution as future fertility is not an issue and would like to have a surgical technique that would allow her to resume her daily duties in a short period of time. She has a negative past surgical history. She is 5 ft 4 in in height and weighs 165 lb (75 kg). The abdominal examination reveals an irregular midline pelvic mass. She also has left uterosacral ligament tenderness without nodularity. Grade 1 uterine prolapse is noted.

➤ What is the clinical condition?

➤ What is your next step?

ANSWERS TO CASE 9:

Total Laparoscopic Hysterectomy

Summary: This is a 37-year-old G4P3013 woman with menorrhagia and pelvic pain, which has failed medical therapy. Examination reveals a fibroid uterus of 16-week size just below the umbilicus and left uterosacral ligament tenderness without nodularity. Grade 1 prolapse is noted, and upon further questioning some urinary retention is mentioned.

➤ Clinical condition: Multiparous patient with symptomatic fibroids causing menorrhagia, and possible endometriosis and minimal prolapse.

➤ Next step: Office ultrasound of the pelvis. Then, outline the surgical options and explain the risks, benefits, and alternatives of the operation. Unfortunately, the symptoms of urinary retention are seldom volunteered by the patient seeking hysterectomy and should be ascertained by the physician during the history. The simple question is “Do you feel like you are completely emptying your bladder or do you feel that you still have to go after urinating?”

ANALYSIS

Objectives

1. Be familiar with what total laparoscopic hysterectomy (TLH) means.
2. Be familiar with a TLH technique.
3. Be familiar with complications of this operation.

Considerations

This is a 37-year-old G4P3013 woman who desires relief from menorrhagia and pelvic pain. Additionally, she would be grateful if she did not feel that she has to urinate immediately after doing so. The first step for the physician is to be able to provide proper counseling. It is important for the patient to understand that a laparoscopic approach is almost always possible. After surgical therapy is chosen, the route of surgery should be discussed. Vaginal hysterectomy (VH) is superior to the abdominal approach due to shorter hospital stay, quicker recovery, and less pain. When the VH is difficult due to lack of descensus, a laparoscopic approach is useful. Evidence-based medicine suggests that VH is the best method and should be performed when possible. Yet, VH is done in less than 20% of cases.

Most problems with VH can be solved by TLH, especially if we do the original version of TLH which includes vaginal cuff suspension by laparoscopic suturing!

Recent studies suggest that the incidence of pelvic organ prolapse (POP) surgery is high after all modes and routes of hysterectomy for benign indications. In a large study from Sweden, overall risk of subsequent prolapse surgery increased by 50% after TAH, doubled after subtotal hysterectomy, and quadrupled after vaginal hysterectomy.

Indications for TLH include whenever abdominal hysterectomy is considered and VH not possible or available, including limited vaginal access, large fibroid uterus, endometriosis, extensive adhesions, most endometrial cancer hysterectomies, and pelvic support procedures. Of course, LAVH is the wrong operation for cul-de-sac endometriosis. TLH should include vaginal cuff suspension from above usually by high McCall cuff suspension.

APPROACH TO

Total Laparoscopic Hysterectomy

DEFINITIONS

Many physicians use the phrase “laparoscopic hysterectomy” as an umbrella term encompassing all types of laparoscopically associated surgical procedures in which the uterus is removed.

In reality, laparoscopic hysterectomy (LH) is a distinct procedure. Its sine qua non is laparoscopic ligation of the uterine arteries by means of electrosurgical desiccation or suture ligature. All the following maneuvers or methods of laparoscopic-associated hysterectomy (LAH) can be accomplished either vaginally or laparoscopically.

TOTAL LAPAROSCOPIC HYSTERECTOMY (TLH): TLH means laparoscopic dissection and ligation of all vascular pedicles continuing until the uterus lies free of all attachments in the peritoneal cavity. The uterus is removed through the vagina, often with laparoscopic and/or vaginal morcellation. The vagina is closed with laparoscopically placed suspension sutures. No vaginal surgery except for morcellation is done.

The surgical technique for TLH with a classification system for LAH was published in 1993 by Reich and colleagues, describing all LAHs performed from April 1983 to July 1992. The conclusion of that paper was that LH is a substitute for abdominal hysterectomy and not for vaginal hysterectomy. Laparoscopic vaginal cuff closure with incorporation of the uterosacral ligaments was an integral part of the TLH operation since its inception and still remains so.

LAPAROSCOPIC HYSTERECTOMY (LH): LH is the laparoscopic ligation of the blood supply to the uterus, including both uterine arteries either by electrosurgery desiccation, suture ligature, or staples. All surgical steps after the uterine vessels have been ligated can be done either vaginally or laparoscopically, including anterior and posterior vaginal entry, cardinal and uterosacral ligament division, uterine removal (intact or by morcellation), and vaginal closure (vertically or transversely). Laparoscopic ligation of the uterine vessels is the sine qua non for laparoscopic hysterectomy. Ureteral identification often by isolation, and more recently by cystoscopy, has always been advised.

LAPAROSCOPIC-ASSISTED VAGINAL HYSTERECTOMY (LAVH): LAVH is a vaginal hysterectomy after laparoscopic adhesiolysis, endometriosis excision, or oophorectomy.

This term is also used when the upper uterine ligaments (eg, round, infundibulopelvic or utero-ovarian ligaments) of a relatively normal uterus are ligated with staples or bipolar desiccation before vaginal hysterectomy. Most of these cases can be done without the laparoscope as completely vaginal hysterectomies.

CLINICAL APPROACH

While it is important that these different procedures are clearly delineated, some overlap is present, especially between LAVH and LH (LAVH is more vaginal hysterectomy) and between LH and TLH with cuff suspension. We need to make clear what we mean.

What is a TLH? Today, much unwarranted confusion exists. After 20 years there is finally a CPT code for billing this procedure. This coding further confuses the issue making one wonder where it came from, certainly not from the experts doing this operation.

58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(ies)

58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(ies)

Although it is not noted in the literature, there seems to be significant difference between closing the vagina vaginally, closing the vagina laparoscopically, and closing the vagina and its supportive ligaments laparoscopically. Seemingly, small differences in technique may lead to substantial differences in outcome, and are not usually included in the nomenclature.

For instance, during a vaginal hysterectomy, we know that tagging the uterosacral-cardinal complex vaginally helps in its identification for vaginal cuff repair, and affixing the uterosacral ligaments to the vaginal cuff helps to ensure its secure suspension. However, if the ligaments are divided laparoscopically and the vagina closed vaginally, it is much more difficult to identify these ligaments and incorporate them into the repair. Likewise, suturing just the vagina closed laparoscopically, often with expensive disposable devices, does little for support. These nuances may certainly lead to an

increased risk of vaginal vault prolapsed.

Since the first LH in January 1988, the vast majority of surgeons have been slow to embrace this alternative to the costlier abdominal hysterectomy and LAVH, often citing concerns about patient selection as the primary reason. There are few absolute contraindications specific to LH. The procedure shouldn’t be performed when vaginal hysterectomy can be accomplished with little vaginal repair necessary. Also, the LH should not be performed when the patient has a potentially cancerous pelvic mass too large to fit intact into an impermeable sack. Stage III ovarian cancer, which requires a large abdominal incision, is another contraindication, as is a surgeon’s inexperience. But uterine weight and size, degree of endometriosis, and similar factors should not preclude a skilled surgeon from choosing LH.

Perhaps the greatest advantage TLH offers is the surgeon’s ability to obtain better support for the vagina and to suture stretched ligaments to the top of the vagina at a point far higher than would be possible with other types of hysterectomy.

Total Laparoscopic Hysterectomy Technique

There are various techniques to this procedure, and the following is one such rendition. These steps are designed to prevent complications.

Since hysterectomy is usually an elective procedure, the patient should be counseled extensively regarding the range of currently available options appropriate to her individual clinical situation. In 2010, it is clearly not acceptable to advocate hysterectomy without detailing the risks and benefits of other intermediary procedures, such as myomectomy and/or excision of endometriosis with uterine preservation.

Whereas conversion to laparotomy when the surgeon becomes uncomfortable with the laparoscopic approach has never been considered a complication, conversion rates should be monitored to ensure that the patient has reasonable expectations. For instance, when half of attempted laparoscopic hysterectomies are converted to abdominal procedures, neither the patient nor the surgeon is well served.

Preoperative Preparation The patient’s coexisting medical problems should be best optimized. Patients are encouraged to hydrate on clear liquids the day before surgery. Fleet Phospho-soda 3 oz divided into two doses are given at 3:30 pm and 7:30 pm to evacuate the lower bowel. If the patient is prone to nausea, promethazine (Phenergan) 25 mg orally is taken 25 minutes before the bowel preparation. Lower abdominal, pubic, and perineal hair is not shaved.

All laparoscopic procedures are performed using general endotracheal anesthesia with orogastric tube suction to minimize bowel distension. The patient’s arms are placed at her side and shoulder braces at the acromioclavicular joint are positioned. Trendelenburg position up to 40 degrees is available. I use one dose of prophylactic antibiotics optimally 30 to 60 minutes prior to incision.

Incisions Three laparoscopic puncture sites including the umbilicus are used. Pneumoperitoneum 25 to 30 mm Hg is obtained before primary umbilical trocar insertion and reduced to 15 mm afterward. The lower quadrant trocar sleeves are placed under direct laparoscopic vision lateral to the rectus abdominis muscles and just beside the anterior superior iliac spines in patients with large fibroids. The left lower quadrant puncture is my major portal for operative manipulation as I stand on the patient’s left.

Sometimes, however, special entry techniques are necessary. When a patient has had numerous prior abdominal surgical procedures, may have adhesions around the umbilicus, or is extremely overweight, I insert the Veress needle in the left ninth intercostal space and the trocar at the left subcostal margin. I do this because in such a patient the peritoneum often is stuck to the undersurface of the ribs and can’t tent away from the Veress needle. The stomach must be decompressed with this entry location.

Reduction in wound morbidity and scar integrity as well as cosmesis is enhanced using 5-mm sites. The use of 12-mm incisions when a 5-mm one will suffice is not an advance in minimally invasive surgery.

Vaginal Preparation Every year, new innovations for uterine and vaginal manipulation appear. The Valtchev uterine manipulator (Conkin Surgical Instruments, Toronto, Canada) has been around for more than 20 years and allows anterior, posterior, and lateral manipulation of the uterus so that the surgeon can visualize the posterior cervix and vagina. Although newer devices are currently available that have been developed by Pelosi, Wattiez, Hourcabie, Koninckx, Koh, McCartney, Donnez, and Reich, I still use the Valtchev and the Wolf tube.

Exploration The upper abdomen is inspected, and the appendix is identified. Clear vision is maintained throughout the operation using the I.C. Medical smoke evacuator (Phoenix, Arizona). Endometriosis is excised before starting TLH. Bleeding is controlled with microbipolar forceps.

Retroperitoneal Dissection The peritoneum is opened early with scissors in front of the round ligament to allow CO2 from the pneumoperitoneum to distend the retroperitoneum. The tip of the laparoscope is then used to perform “optical dissection” of the retroperitoneal space by pushing it into the loosely distended areolar tissue parallel to the uterus to identify the uterine vessels, ureter, or both. The uterine artery is often ligated at this time, especially in large uterus patients.

Ureteral Dissection (Optional) The ureter is identified medially, superiorly, or laterally (pararectal space). Stents are not generally used as they may cause hematuria and ureteric spasm. The laparoscopic surgeon should dissect (skeletonize) either the ureter or the uterine vessels during the performance of

a laparoscopic hysterectomy.

Bladder Mobilization The round ligaments are divided at their midportion, and scissors or a spoon electrode is used to divide the vesicouterine peritoneal fold starting at the left side and continuing across the midline to the right round ligament. The upper junction of the vesicouterine fold is identified as a white line firmly attached to the uterus, with 2 to 3 cm between it and the bladder dome. The initial incision is made below the white line while lifting the bladder. The bladder is mobilized off the uterus and upper vagina using scissors or blunt dissection until the anterior vagina is identified. The tendinous attachments of the bladder in this area may be desiccated or dissected (Figures 9–1 to 9–4).

Upper Uterine Blood Supply When oophorectomy is indicated or desired, the peritoneum is opened on each side of the infundibulopelvic ligament with scissors and a 2-0-Polyglycolic acid (Vicryl) free ligature is passed through the window and created and tied extracorporeally using the Clarke-Reich (Cook Medical Group, Bloomington, IN ) knot pusher. This maneuver is repeated until two proximal and one distal ties are placed and the ligament divided. This maneuver helps develop suturing skills. The broad ligament is divided to the round ligament just lateral to the utero-ovarian artery anastomosis using scissors or cutting current through a spoon electrode. I rarely desiccate the infundibulopelvic ligament as it results in too much smoke early in the operation.

When ovarian preservation is desired, the utero-ovarian ligament and fallopian tube are compressed and coagulated until desiccated with bipolar forceps, at 25 to 35 W cutting current, and then divided. Alternatively, the

Figure 9–1. Atraumatic graspers are used to elevate the left tube and ovary to help

identify the left ureter.

Figure 9–2. The left round ligament is cauterized using bipolar electrocautery, after which it will be divided.”

Figure 9–3. The bladder is mobilized by incising the vesicouterine peritoneal fold using unipolar scissors.

Figure 9–4. The utero-ovarian ligament is ligated and divided.This can be accomplished

in a number of different ways such as with bipolar cautery, endoscopic stapler,

or harmonic scalpel.

utero-ovarian ligament and fallopian tube pedicles are suture-ligated adjacent to the uterus with 2/0-Vicryl, using a free ligature that is passed through a window that is created, enabling the ligature to be positioned around the ligament. Stapling devices are rarely used.

If the ovary is to be preserved and the uterus is large, the utero-ovarian ligament/ round ligament/fallopian tube junction may be divided with a 30- or 45-mm gastrointestinal anastomosis (GIA)-type stapler. This may be time saving for this portion of the procedure, thus justifying its increased cost.

The use of staplers may decrease operative time, but can increase the risk for postoperative hemorrhage and injury to the ureter. Ligation or coagulation of the vascular pedicles generally is safer.

Uterine Vessel Ligation The uterine vessels may be ligated at their origin, at the site where they cross the ureter, where they join the uterus, or on the side of the uterus (see Figure 9–1). Most surgeons use bipolar desiccation to ligate these vessels, but in our center, we prefer suture because it can be removed if ureteral compromise is suggested at cystoscopy.

In most cases, the uterine vessels are suture-ligated as they ascend the sides of the uterus. The broad ligament is skeletonized to the uterine vessels. Each uterine vessel pedicle is suture-ligated with 0-Vicryl on a CTB-1 blunt needle (Ethicon JB260, Ethicon Inc, Somerville, NJ) (27 in), as a blunt needle reduces surrounding venous bleeding. The needles are introduced into the peritoneal cavity by pulling them through a 5-mm incision. A short, rotary movement of the needle holder brings the needle around the uterine vessel pedicle. This motion is backhand if done with the left hand from the patient’s left side and forward motion if using the right hand from the right side. In some cases, the vessels can be skeletonized completely and a 2-0-Vicryl free suture ligature is passed around them. Sutures are tied extracorporeally using a Clarke-Reich knot pusher.

In large uterus patients, selective ligation of the uterine artery without its adjacent vein is done to give the uterus a chance to return its blood supply to the general circulation. It also results in a less voluminous uterus for morcellation.

Division of Cervicovaginal Attachments and Circumferential Culdotomy The cardinal ligaments on each side are divided. Bipolar forceps coagulate the uterosacral ligaments. The vagina is entered posteriorly over the uterovaginal manipulator near the cervicovaginal junction. A 4-cm diameter reusable vaginal delineator tube (Richard Wolf Medical, Knittlingen, Germany) is placed in the vagina to prevent loss of pneumoperitoneum and to outline the cervicovaginal junction circumferentially as it is incised using the CO2 laser to complete the circumferential culdotomy with the delineator as a backstop. The uterus is morcellated, if necessary, and pulled out of the vagina.

Morcellation (Laparoscopic and Vaginal) Morcellation can be done laparoscopically or vaginally. Vaginal morcellation is done with a no. 10 blade on a long knife handle to make a circumferential incision into the uterus while pulling outward on the cervix and using the cervix as a fulcrum. The myometrium is incised circumferentially parallel to the axis of the uterine cavity with the scalpel’s tip always inside the myomatous tissue and pointed centrally, away from the surrounding vagina.

Morcellation through anterior abdominal wall sites is done when vaginal access is limited or supracervical hysterectomy requested. Reusable electromechanical morcellators are motorized circular saws. Using claw forceps or a tenaculum to grasp the fibroid and pull it into contact with the fibroid, large pieces of myomatous tissue are removed piecemeal until the myoma can be pulled out through the trocar incision. With practice, this instrument can often be inserted through a stretched 5-mm incision without an accompanying trocar. The new Sawalhe II Supercut Morcellator (Karl Storz, Tuttlingen, Germany) comes with 12-, 15-, and 20-mm diameter circular saws.

Laparoscopic Vaginal Vault Closure and Suspension With McCall Culdoplasty The vaginal delineator tube is placed back into the vagina for closure of the vaginal cuff, occluding it to maintain pneumoperitoneum. The uterosacral ligaments are identified by bipolar desiccation markings or with the aid of a rectal probe. The first suture is complicated as it brings the uterosacral and cardinal ligaments as well as the rectovaginal fascia together. This single suture is tied extracorporeally, bringing the uterosacral ligaments, cardinal ligaments, and posterior vaginal fascia together across the midline. It provides excellent support to the vaginal cuff apex, elevating it and its endopelvic fascia superiorly and posteriorly toward the hollow of the sacrum. The rest of the vagina and overlying pubocervicovesicular fascia are closed vertically with one or two 0-Vicryl interrupted sutures.

If a high cystocele is present causing urinary retention, two or more additional sutures can be placed as follows: The second suture is placed through the uterosacral ligaments closer to the sacrum and then through the endopelvic fascia just above the uterine vessel pedicle. The third suture is placed through the uterosacral ligaments even closer to the sacrum and through the endopelvic fascia well above the cardinal ligament, resulting in a vertical vaginal closure. The last suture is usually placed into the anterior vagina/pubocervicovesicular fascia above the cuff at 12 o’clock to bring the anterior vagina much higher than the posterior wall. All sutures after the first are nonabsorbable synthetic polyester suture (0-Ethibond). The last suture also is placed at the highest level toward the sacral area. As with any suspension, special care must be taken to ensure the integrity of the rectum and ureters. The sutures must not constrict the rectum, which is identified throughout the procedure with a rectal probe inside it. This suspension achieves a physiologic position of the vagina. In addition, it provides the vagina with good depth since the vagina can go high toward the sacral region where the uterosacrals ligaments originate. The closure of the vagina in a vertical fashion avoids the ureters as the sutures stay in the midline.

Cystoscopy Cystoscopy is done after vaginal closure to check for ureteral patency in most cases, after intravenous administration of indigo carmine dye. This is necessary when the ureter is identified but not dissected and especially necessary when the ureter has not been identified. Blue dye should be visualized through both ureteral orifices. The bladder wall should also be inspected for suture and thermal defects.

Underwater Examination At the close of each operation, an underwater examination is used to detect bleeding from vessels and viscera tamponaded during the procedure by the increased intraperitoneal pressure of the CO2 pneumoperitoneum. The CO2 pneumoperitoneum is displaced with 2 to 4 L of Ringer lactate solution, and the peritoneal cavity is vigorously irrigated and suctioned until the effluent is clear of blood products. Any further bleeding is controlled underwater using microbipolar forceps to coagulate through the electrolyte solution, and 2 L of lactated Ringer solution are left in the peritoneal cavity.

Skin Closure The vertical intraumbilical incision is closed with a single 4-0 Vicryl suture opposing deep fascia and skin dermis, with the knot buried beneath the fascia. This will prevent the suture from acting like a wick, transmitting bacteria into the soft tissue or peritoneal cavity. The lower quadrant 5-mm incisions are loosely approximated with a Javid vascular clamp (V. Mueller, McGaw Park, Illinois) and covered with Collodion (AMEND, Irvington, New Jersey) to allow drainage of excess Ringer lactate solution.

Endometriosis Hysterectomy with excision of all visible endometriosis usually results in relief of the patient’s pain. Oophorectomy may not be necessary at hysterectomy for advanced endometriosis if the endometriosis is removed carefully.

Endometriosis nodules in the muscularis of the anterior rectum can usually be excised laparoscopically without entering the rectum. Full-thickness penetration of the rectum can occur during hysterectomy surgery, especially when excising rectal endometriosis nodules. Following identification of the nodule or rent in the rectum, a closed circular stapler (Proximate ILS Curved Intraluminal Stapler [Ethicon, Stealth] Ethicon Inc, Somerville, NJ) is inserted into the lumen just past the lesion or hole, opened 1 to 2 cm, and held high to avoid the posterior rectal wall. The proximal anvil is positioned just beyond the lesion or hole, which is invaginated into the opening, and the device closed. The instrument is fired and removed.

Complications

Complications of laparoscopic hysterectomy are those of hysterectomy and laparoscopy combined: anesthetic accidents; respiratory compromise; thromboembolic phenomenon; urinary retention; injury to vessels, ureters, bladder, and bowel; as well as infections, especially of the vaginal cuff. Ureteral injury is more common when staplers or bipolar desiccation are used without ureteral identification. Complications unique to laparoscopy include large vessel injury, epigastric vessel laceration, subcutaneous emphysema, and trocar site incisional hernias.

Infection Experience with serious wound infection after laparoscopic hysterectomy is rare. Morcellation during laparoscopic or vaginal hysterectomy results in a slightly increased risk of fever, especially if prophylactic antibiotics are not used.

Hemorrhage Intraoperative hemorrhage occurs when a previously nonanemic patient loses greater than 1000 mL of blood or requires a blood transfusion. By doing careful laparoscopic dissection, most profuse hemorrhage situations are avoided or controlled as they occur.

Ureter Complications I remain committed to prevention of ureteral injury intraoperatively by ureteral identification often with dissection and by cystoscopy at the conclusion of hysterectomies.

The ureters are commonly injured at the level of the infundibulopelvic ligament, uterosacral ligament, or pelvic sidewall due to adhesions resulting from endometriosis, pelvic inflammatory disease, or previous abdominal surgery. During laparoscopic hysterectomy, ureteral injury may occur while cutting dense adhesions and fibrotic scar tissue, trying to stop bleeding close to the ureter with bipolar cautery, or in the process of ligating the uterine vessels with bipolar electrosurgery, staples, or suture.

Most ureteral injuries are not identified or even suspected without cystoscopy. The bottom line is that an aggressive approach to ureteral protection can reduce but not eliminate ureteral injury. However, prompt recognition and management can prevent multiple surgical procedures and significant patient morbidity, including organ loss.

Urinary retention is a common undetected complication. More studies are necessary to determine how common and whether long-term compromise can occur.

Bladder Injury Bladder injury can occur during dissection of the bladder off the uterus and cervix or from an inflamed adnexa. In these cases the bladder is repaired using 3-0 Vicryl usually in two layers, with prolonged bladder drainage.

Bowel Injury Small bowel injury during laparoscopic hysterectomy is uncommon and is usually associated with extensive intraperitoneal adhesions. Small bowel injuries can be suture-repaired. Small bowel enterotomy may require mobilization from above, delivery through the umbilicus by extending the incision 1 cm, and repair or resection. If the hole is confined to the antimesenteric portion, the bowel can be closed with interrupted 3-0 silk or Vicryl. All enterotomies are suture-repaired transversely to reduce the risk of stricture. If the hole involves greater than 50% of the bowel circumference, resection is done. An extracorporeal segmental enterectomy with side-to-side stapled anastomosis is preferred.

Rectal injury may occur during rectal endometriosis excision or during vaginal morcellation of a large fibroid uterus. Repair is with a circular stapler.

Long-Term Complications

Bowel obstruction from adhesions: Among benign gynecologic operations, TAH was the most common cause of small bowel obstruction. The median interval between TAH and obstruction was 4 years. The adhesions were adherent to the previous laparotomy incision in 75% and to the vaginal vault in 25%. Obstruction did not occur after laparoscopic supracervical hysterectomy. TAH incisions may result in adhesions and bowel obstruction many years later.

Pelvic pain: Adhesions, adnexal remnants, and endometriosis may cause chronic pelvic pain after hysterectomy.

ADDITIONAL COMMENTS

It took 5 years for laparoscopic cholecystectomy to be universally adopted! Laparoscopic hysterectomy has been available for the last 20 years with sporadic acceptance. The low level of reimbursement has curbed the enthusiasm for training in minimally invasive surgery in our specialty in the United States. Practitioners faced with shrinking reimbursement and rising costs must spend more time in the office and less in surgery.

Abdominal hysterectomy is the preferred method of treatment based on training and economics, and this poses an ethical dilemma. Are we offering the best choices to our patients? We as specialists need to answer this question. Why would physicians take time to learn a new technique if they are going to be poorly reimbursed?

Because the reimbursement of hysterectomy is so low, there is a natural disincentive to putting forth the effort in learning new techniques. These are important issues that must be addressed.

Laparoscopic hysterectomy is clearly beneficial for patients in whom vaginal surgery is contraindicated or can’t be done. When indications for the vaginal approach are equivocal, laparoscopy can be used to determine if vaginal hysterectomy is possible. With this philosophy, patients avoid an abdominal incision with resultant decrease in length of hospital stay and recuperation time. The laparoscopic surgeon should be aware of the risks and how to minimize them and, when they occur, how to repair them laparoscopically.

A randomized trial comparing TLH to TAH may not be possible, unless the patients have no real concern about the cosmetics of incision size. If the patient has a preference, it may take a long time to explain why the trial is needed and why randomization is ethical. Recruitment to trials is very difficult when minimally invasive therapy is an available option.

I do not pretend to understand studies comparing TLH and VH as they have different indications. TLH is a substitute for TAH, not for VH. And, as discussed, there are many different variations of TLH that may give the wrong conclusions. Presently, the studies show that if the surgeon can do a VH, it is the best possible operation. That is, unless future studies prove this wrong.

I don’t think vaginal hysterectomy is better than laparoscopic hysterectomy. Vaginal and abdominal surgery will never be as precise as laparoscopic surgery. In the latter, the surgeon is right on top of the tissue with a scope and can focus it for magnification. You can see better with a laparoscope in the peritoneal cavity than with an operating room light directed toward the proximal vagina. I think we should work on removing the technical barriers to successfully accomplishing laparoscopic hysterectomy in a majority of patients. Because TLH mimics abdominal hysterectomy in almost all respects, it should be easier to assimilate its practice for the majority of patients.

LAVH practitioners add the potential complications of laparoscopic surgery to those of vaginal surgery; that is why it seems as though there are more complications with laparoscopy. In actuality, ureteral and bladder injuries occur more often during the vaginal part of the LAVH. Peripheral nerve injuries occur secondary to stirrup changes going from above to below.

If they are recognized, most complications of laparoscopic hysterectomy can be corrected by laparoscopic surgery. Check the bladder and ureters by including cystoscopy in the procedure. Check the rectum and rectosigmoid by filling them with blue dye underwater. Check for bleeding by looking underwater at low pressure while irrigating.

Remember that laparoscopic hysterectomy used to be a substitute for abdominal hysterectomy but not for vaginal hysterectomy. In the future, the possibilities of better pelvic support from above may make TLH the best choice.

Comprehension Questions

9.1 A 43-year-old woman is counseled by her gynecologist regarding the need for hysterectomy due to significant menorrhagia that has not responded to medical therapy. A TLH is recommended. Which of the following is the best situation for a TLH?

A. 4-week-size uterus with second-degree descensus

B. 6-week-size uterus with first-degree prolapse

C. 16-week-size uterus that is irregular

D. 12-cm adnexal mass

9.2 A 28-year-old woman undergoes an LAVH. The surgeon is concerned about whether the right ureter was possibly ligated, although on laparoscopy it appears to be close but not included in the staple ligature. Which of the following is the best next step?

A. Surgical dissection of the ureter

B. Deligation of the stapling

C. Intravenous pyelogram

D. Cystoscopy

9.3 A 37-year-old woman is undergoing laparoscopic hysterectomy. The surgeon is attempting to dissect the bladder away from the uterus. Which of the following is the appropriate surgical technique on where to make the incision of the vesicouterine peritoneum?

A. Above the white line

B. At the white line

C. Below the white line

ANSWERS

9.1 C. Since TLH is most appropriate for patients who would undergo abdominal hysterectomy, the patient with a 16-week-size uterus is most appropriate for this procedure.

9.2 D. Cystoscopy is the best modality to ensure normal function of the ureter. Typically, the use of indigo carmine intravenously allows visualization of the ureteric orifices of the bladder.

9.3 C. The correct location is to incise below the white line where the vesicouterine peritoneum is adherent to the uterus.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ TLH should be considered to be a substitute for abdominal hysterectomy, not vaginal hysterectomy (Level C).

➤ Uterine vessels may be ligated by bipolar cautery, but suture ligation has the advantage that it can be removed if ureteral kinking is suspected (Level B).

➤ An aggressive approach to ureteral protection can reduce but not eliminate ureteral injury; however, prompt recognition and management can prevent multiple surgical procedures and significant patient morbidity, including organ loss (Level B).

➤ For patients who may have adhesions around the umbilicus due to prior abdominal surgery, an entry in the left midclavicular line in the subcostal region may be advantageous. The stomach must be decompressed (Level C).

REFERENCES

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7. Reich H, McGlynn F, Sekel, L. Total laparoscopic hysterectomy. Gynaecol Endosc. 1993;2:59-63. 

8. Reich H. Laparoscopic hysterectomy. Surgical Laparoscopy & Endoscopy. New York, NY: Raven Press; 1992;2:85-88. 

9. Reich H, Roberts L. Laparoscopic hysterectomy in current gynecological practice. Rev Gynaecol Pract. 2003;3:32-40 . 

10. Reich H, Clarke HC, Sekel L. A simple method for ligating in operative laparoscopy with straight and curved needles. Obstet Gynecol. 1992;79:143-147. 

11. Ribeiro S, Reich H, Rosenberg J. The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy. Hum Reprod. 1999;14:1727-1729. 

12. Reich H. Letters to the editor. Ureteral injuries after laparoscopic hysterectomy. Human Reprod. 2000;15:733-734.

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