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Laparoscopic Hysterectomy and Decision When and Which Surgical Approach

Is Indicated? Laparoscopic Hysterectomy and Decision When and Which
Surgical Approach Is Indicated?

Article  in  Acta Informatica Medica · January 2011

DOI: 10.5455/aim.2011.19.114-117

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114 Laparoscopic Hysterectomy and Decision When and Which Surgical Approach Is Indicated?

AIM 2011; 19(2): 114-117

Laparoscopic Hysterectomy and Decision When

and Which Surgical Approach Is Indicated?
Zlatko Hrgovic1, Ingrid Marton2
Faculty of medicine, University of Frankfurt am Main, Germany1
Clinic for Ginaecology and obstretics, University hospital “Sveti Duh”, Zagreb, Croatia2

Professional paper ACOG’s (American Congress of Obstetricians “learning curve” which is short for some
SUMMARY and Gynecologists) for 2009 indicated that techniques, and for some longer, it should be
Hysterectomy with adnexectomy is the most in the U.S. annually is performed about 600 appreciated, and in accordance with them
common surgical procedure in the world 000 hysterectomies, with the corresponding build their individual surgical strategies and
after appendectomy and the most common mortality rate of 0.16%. Each of the tech- in doing so do not forget that the welfare
gynecological surgery at all. According to niques described in this paper has its own of the patient comes first. Special attention
the literature, each year in Great Britain is indications, advantages and complications. is given to the technique of laparoscopic
performed about 60 000 hysterectomies, It is important to maintain a critical review, hysterectomy, which is increasingly in use.
which means that on average one in five use the knowledge and experience to Key words: hysterectomy, laparos-
women undergo this procedure at some evaluate the selection of the optimal surgical copy, indications, complications.
stage in life. Published information by approach. Also, each technique has its own

1. INTRODUCTION Henry Reich 1989, unaware that he metriosis/adenomyosis, prolapsed

According to available medical introduced us to a new technology uterus, etc.
history data it is believed that the chapter-robotics (4). According to ACOG indications
first hysterectomy was made by Fab- In the eighties of the twentieth for hysterectomy were: miomatosus
ricus Haldanus (1560-1624). The first century in the U.S. about 70-80% uterus in 40.7% of cases, endome-
documented supracervical hyster- of all hysterectomies was done by triosis (adenomyosis) in 17.7%, and
ectomy was done in 1843 by the the abdominal approach (1), in or- uterine prolapse in 14.5% patients
Charles Clay. The first documented der to compare with 2009 in report (2).
successful extripation of the uter- by ACOG was approximately 66% Despite the fact that today there
us performed Wilhelm Alexander of abdominal hysterectomy, vaginal are successful treatment options for
Freund 1878, total abdominal hyster- hysterectomy 22%, and only 12% recurrent, dysfunctional bleeding in
ectomy is described in 1894 by Alwin of total laparoscopic hysterectomy pre and perimenopausal, thanks to
Mackenrodt, and expanded by the fa- (TLH) (2). conservative treatment (LNG-IUD
mous Ernst Wertheim 1897 (1, 2, 3). In Germany, which still has “Mirena”) and/or minimally inva-
Subtotal hysterectomy was stan- the reputation of the old surgical sive surgery (hysteroscopy ablation
dard operating procedure in the for- school, the proportion of vaginal of endometrial polyps, resection of
ties of last century, but was rejected hysterectomies varied between 9 submucosal fibroids, electro coag-
for fear of cancer of the remaining and 90% (average about 50%), how- ulation of the endometrium, etc.),
cervical tissue. ever, thanks to continuous propa- hysterectomy is still a treatment op-
Traditionally, hysterectomy is ganda of laparoscopy by Semma and tion for patients who are more sat-
performed through the abdominal Raatza, laparoscopy has become not isfied than the less invasive but also
or vaginal. Although vaginal sur- only inevitable, but in some centers less durable solutions (6).
gery is actually a conservative and also the predominant surgical tech- Specifically, the work of Middle-
pioneers of minimally invasive sur- nique (5). ton and colleagues included 30 ran-
gery, most surgeons still prefer the domized, controlled trials involving
abdominal route. 2. INDICATIONS FOR the treatment of patients for hyster-
Technical innovations of instru- HySTeReCTOMy ectomy due to dysfunctional bleed-
ments and improved anesthesia have The benign indications for hys- ing, hysteroscopy-endometrial de-
enabled the laparoscopic hysterecto- terectomy include: hypermenorrea, struction or the installation of the
my in surgery. The first laparoscop- menometrorrhagia with resultant LNG-IUD. A"er the 12 monthly ob-
ic hysterectomy was performed by anemia, miomatosus uterus, endo- servations, the majority of patients

vol 19 no 2 JUnE 2011 Professional paper | AIM 2011; 19(2): 114-117

 Laparoscopic Hysterectomy and Decision When and Which Surgical Approach Is Indicated? 115

were dissatisfied with the long-term Johnson und Munro und Garry, Reich Neis und
Diamond (1994) Parker (1993) und Liu (1994) Brandner
outcome of hysteroscopy endome- (1993)

trial ablation in comparison with Stage 0:

diagnostic
Was not imagined
as laparoscopic
Was not imagined
as laparoscopic
LAVH type I

hysterectomy. However, shorter hos- laparoscopy and

vaginal
hysterectomy.
Type 0:
hysterectomy.

pital stay and faster return to daily hysterectomy.

Stage 1:
laparoscopic
preparation for
Vaginal
hysterektomy with
LAVH type II

activities went in favor of hysteros- laparoscopic

adhesiolysis and/or
vaginal
hysterektomy
some laparoscopic
help.
copy. Detailed statistical analysis excision of
endometriotic
Type I:
preparation to the
plaques
nevertheless went in favor of hyster- Stage 2:
uterine artery, but
not ligation of the
LAVH LAVH type II

uni/bilater
ectomy. adnexectomy
uterine artery.
Type II: LAVH type II
Stage 3:
Mirena was indirectly compared laparoscopic Preparation and
ligation of the LH
preparation of the LH
with hysterectomy, although this urinary bladder uterine artery
Type III:
Stage 4:
comparison is limited. However, it ligation of uterine
preparation and
ligation of LH
artery
is interesting that a similar estimate Stage 5:
parametrial tissue.
Type IV:
TLH
colpotomy ane
was observed for the Mirena. evacuation of the
Preparation and
ligation of
LH
uterus
Numerous studies have been con- ligg.sacrouterina

Bradner P,Neis KJ. Die endoskopische Hysterektomie-Konzepte. In: Keckstein J, Hucke

ducted to evaluate which surgical J: Die endoskopischen Operationen in der Gynaekologie. Muenchen, Jena.
mode is optimal, of course, exclu- Urban&Fischer, 2000:233-235
sively for benign indications. One Table 1: Different classifications of laparoscopic hysterectomy.
of these respectable study and me-
ta-analysis of Johnson and co-work- er complications and faster recovery authors suggest that the first meth-
ers which included 27 studies and a compared to abdominal hysterecto- od of choice should be a vaginal
total of 3 643 patients, all of which my (p = 0.004). hysterectomy, and if it is not possi-
undergone detachment due to some Comparison of intraoperative le- ble, the method of choice would be
benign indications such as: abdomi- sions of the urethra and/or the blad- some of the laparoscopic methods
nal, vaginal, or laparoscopically (7). der during LAVH and TLH does (8). The authors of both meta-analy-
They analyzed the following param- not have a statistically significant sis have offered nearly identical con-
eters: intraoperative complications difference (7). clusions and stressed that the sur-
(lesions of the urethra, bladder, in- Almost the same results offered gical approach should certainly be
testines, etc.), postoperative compli- another meta-analysis by Nieboer discussed with the patient and joint-
cations (hematoma, infection, diffi- and associates, which included 34 ly decide on the optimal approach.
culty with urination, etc.), and du- studies and 4 495 patients. All were
ration of surgery, hospital stay, re- subjected to hysterectomy (for be- 3. ObjeCTIveS AND
covery time and return to daily ac- nign indications) on one of three DeFINITION OF
tivities. According to analyzed re- ways: vaginal, abdominal or lapa- LAPAROSCOPIC
sults, faster return to normal daily roscopic. Vaginal hysterectomy in HySTeReCTOMy
activities and shorter hospitaliza- comparison with abdominal has The aim of laparoscopic hyster-
tions were observed in vaginal and the following advantages: short- ectomy is to avoid abdominal wall
laparoscopic surgery in comparison er duration of hospitalization, few- incision, to reduce intraoperative
with abdominal, but no difference er complications, faster recovery, bleeding, reduce hospital stay and
between vaginal and laparoscop- while the advantages of laparoscop- faster recovery of patients. Laparo-
ic approach. More lesions were ob- ic compared to abdominal is: faster scopic hysterectomy is sometimes,
served in the urethra and urinary recovery, less intraoperative bleed- but not always substitute for ab-
bladder in laparoscopic surgery, but ing and in accordance
no other lesions of visceral organs. with this slight decrease
Overall, the fastest recovery, short if haemoglobine, shorter
hospital stay, the smallest number hospitalization, are rare
of intraoperative and postopera- hematoma and infection
tive complications suggest the vagi- of the wounds. Shortcom-
nal approach as the first method of ings of laparoscopic hys-
choice, and if not possible then the terectomy in comparison
laparoscopic method (7). with abdominal are fre-
Detailed statistical analysis quently the urethra and
showed that the comparison of lap- bladder injury and longer
aroscopic (LAVH laparoscopic-as- duration of surgery. The
sisted vaginal hysterectomy and advantages of LAVH and
TLH-total laparoscopic hysterecto- TLH are less common
my) and abdominal hysterectomy and nonspecific febrile ep-
speaks in favor of the laparoscopic isodes of infection, short-
approach, or that this modality is ens the surgical proce- Figure 1. Preparation and dissection of anatomical structures: lig.
significantly better in terms of few- dure. In conclusion, the Infundibulopelvicum and lig.rotundum, displaying art. uterine (5).

AIM 2011; 19(2): 114-117 | Professional paper vol 19 no 2 JUnE 2011

116 Laparoscopic Hysterectomy and Decision When and Which Surgical Approach Is Indicated?

dominal hysterectomy, but it is According to Henry Reich who

not indicated in cases where it in 1989 made the first total laparo-
is possible to perform a vaginal scopic hysterectomy, surgery is di-
hysterectomy. vided into six steps: presentation
Indications were symptomatic of the urethra, mobilization of the
myomas, abnormal bleeding, ad- uterus and the release of the urinary
enomyosis, endometriosis, adnex bladder, uterine ligation of the up-
masses formation, chronic pelvic per bound, ligation uterine blood
inflammatory disease, atypical vessels, cutting ties cervicovaginal
endometrial hyperplasia and cor- and cervical culdotomy, stitching
pus carcinoma. It is important Figure 2. Seting the stitch on the art. uterine (9). the vagina.
however to keep the criticism When performing the vaginal
TLH stitches laparoscopic or vagi-
nal approach.
It is performed when vaginal hys-
terectomy is not possible due to dif-
ficulties in the vaginal approach
(e.g. very narrow vagina) or any
other reason. Contraindication for
TLH include: suspicion of uterine
sarcoma, miomatous uterus, a sys-
temic disease of a patient which is
Figure 3. Cutting cervicovaginal ties and circular culdotomy (9). a contraindication for laparoscopic
surgery and a longer insufficiently
and do not engage in surgical ac- trained surgeon.
tivities that will needlessly take TLH offers many advantages in
hours, if the surgery can be con- comparison with the abdominal
siderably shorter, and therefore approach, such as: minimal bleed-
more tolerable for the patient. ing, shorter recovery, less suffer-
There are various attempts to ing, pain, shorter hospitalization
classify a hysterectomy at which and quicker return to daily activi-
it is used and laparoscopy, but ties. The fact is that the incidence of
none has been officially accept- complications, especially in the be-
ed. The table below shows that Figure 4. Uterus removed (9). ginning of using technology, espe-
behind the name “Laparoscop- cially lesions of the urethra was very
ic Hysterectomy” is hiding a large uterus, uterine sarcoma and ovari- high. In this respect, it is necessary
number of operations that differ in an cancer.
extent of laparoscopic surgery. According to previous studies
LAVH carries a slightly higher
4. LAvH LAPAROSCOPIC- risk of injury to the urethra and
ASSISTeD vAGINAL urinary bladder in comparison
HySTeReCTOMy with the abdominal approach,
LAVH involves different varia- and a longer duration of surgery,
tions of laparoscopic and vaginal but less blood loss, faster recov-
operative segments. ery and fewer postoperative com-
It should be noted that art. uter- plications. Because of that stud-
ine can be ligated by either laparo- ies in general prefer LAVH in the
scopic or vaginal approach. Accord- abdominal approach.
ing to the ACOG, the LAVH is indi- However, it should be not-
cated in all cases where the operator ed that LAVH is not a substitute
for number of reasons (e.g. the con- for the abdominal approach and
dition a"er the previous laparosco- that each approach has its sur-
Figure 5- Closure of the vagina (9).
py, endometriosis, pelvic inflamma- gical indications, and that the
tory disease, etc.) to avoid abdomi- operator must maintain a criti-
nal hysterectomy, but is expected cal attitude towards each operative to acquire much experience in lapa-
difficult vaginal approach (e.g., due technique. roscopic surgery before entering the
to adhesions), so his approach will TLH.
make surgery much easier. 5. TLH-TOTAL In centers where it is performed
Contraindications for this surgi- LAPAROSCOPIC routinely, TLH has become an alter-
cal approach are great miomatous HySTeReCTOMy native to abdominal hysterectomy.

vol 19 no 2 JUnE 2011 Professional paper | AIM 2011; 19(2): 114-117

 Laparoscopic Hysterectomy and Decision When and Which Surgical Approach Is Indicated? 117

2. ACOG Committee
Opinion No. 444: choosing
the route of hysterectomy for
benign disease. Obstet Gyne-
col 2009; 114(5):1156-1158.
3. Glesinger L. Povijest
medicine. Školska knjiga, Za-
greb, 1978.
4. Reich H, DeCaprio
J, McGlynn F. Laparoscopic
hysterectomy. J Gynecol Surg
1989;5:213-216.
Figure 6. It is recommended to display the urethra, Figure 7. Removal of the corpus uteri using abdominal 5. Brandner P, Neis Kj.
then ligated art. uterine. Afterwards, with the unipolar morselator (10).
electrode corpus is separated from the cervix (10). Die endoskopische Hysterek-
tomie- Konzepte. U: Keck-
should be further explained the stein J, Hucke J: Die endoskopische
necessity of regular cytological Operationen in der Gynäkologie.
control. Urban&Fischer, München, Jena,
Also, according to recent 2000:233-235.
guidelines, patients with supra- 6. Middleton LJ, Champaneria R,
cervical adenomyosis recom- Daniels JP, i sur. Hysterectomy,
mended are hysterectomy. Many endometrial destruction, and le-
patients expressed satisfaction vonorgestrel releasing intrauter-
with this technique and their sex ine system (Mirena) for heavy
life a"er surgery. menstrual bleeding: systematic
Classical supracervical hyster- review and meta-analysis of dana
ectomy from individual patients. BMJ
Classic abdominal infrafas- 2010;341:c3929
cial supracervical hysterectomy 7. Johnson N, i sur. Methods oh hys-
Figure 8. Peritonisation of cervical stump (10). is also one of the operative meth- terectomy: systematic review and
od of choice (11). meta-analysis of randomized con-
trolled triales. BMJ 2005;330:1487.
7. CONCLUSION 8. Nieboer TE, Johnson N, Lethaby
Each of these techniques has A, i sur. Surgical approach to hys-
its indications, advantages and terectomy for benign gynaecolog-
complications. ical disease. Cochrane Database
It is important to maintain a Syst Rev 2009 Jul 8;(3):CD003677
critical review, use their knowl- 9. Reich H. Laparoskopische Hyster-
edge and experience to evaluate ektomie. U: Keckstein J, Hucke J.
the selection of the optimal sur- Die endoskopische OPerationen in
gical approach. der Gynäkologie. München, Jena,
Figure 9. Setting the clamps on the uterus through Each technique has its own 2000:245-260.
which the uterus is reponed, after the preparation of the “learning curve” which is short 10. Donnez L. Laparoskopische supra-
uterus and adnex is made supracervical hysterectomy (11). for some techniques, and for zervikale Hysterektomie (LASH).
some longer, it should be ap- U: Keckstein J, Hucke J. Die en-
6. LSH- LAPAROSCOPIC preciated, and in accordance with doskopische OPerationen in der
SUPRACeRvICAL them build their individual opera- Gynäkologie. München, Jena,
HySTeReCTOMy tional strategies and in doing so do 2000:261-269.
Laparoscopic supracervical hys- not forget that the welfare of the pa- 11. Metller L. Klassisch infrafasziia-
terectomy can be offered to patients tient is at the first place. le suprazervikale Hysterektomie
in whom hysterectomy was indicat- (CISH). U: Keckstein J, Hucke J.
ed, but ruled out cervical dyspla- ReFeReNCeS Die endoskopische OPerationen in
sia, endometrial cancer, deep pel- 1. Garry R. Towards evidence-based der Gynäkologie. München, Jena,
vic endometriosis (sacrouterine liga- hysterectomy. Gynaecol Endosc 2000:270-282.
ments). Of course, to these patients 1998;7:225-233.
Corresponding author: prof Zlatko Hrgovic, MD, PhD.
Faculty of medicine, University of Frankfurt am Main,
Germany. Kaizer str 15, E-mail: [email protected]

AIM 2011; 19(2): 114-117 | Professional paper vol 19 no 2 JUnE 2011

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