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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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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 SUMMARY Hysterectomy with adnexectomy is the most common surgical procedure in the world after appendectomy and the most common gynecological surgery at all. According to the literature, each year in Great Britain is performed about 60 000 hysterectomies, which means that on average one in five women undergo this procedure at some stage in life. Published information by

1. INTRODUCTION

According to available medical history data it is believed that the first hysterectomy was made by Fabricus Haldanus (1560-1624). The first documented supracervical hysterectomy was done in 1843 by the Charles Clay. The first documented successful extripation of the uterus performed Wilhelm Alexander Freund 1878, total abdominal hysterectomy is described in 1894 by Alwin Mackenrodt, and expanded by the famous Ernst Wertheim 1897 (1, 2, 3). Subtotal hysterectomy was standard operating procedure in the forties of last century, but was rejected for fear of cancer of the remaining cervical tissue. Traditionally, hysterectomy is performed through the abdominal or vaginal. Although vaginal surgery is actually a conservative and pioneers of minimally invasive surgery, most surgeons still prefer the abdominal route. Technical innovations of instruments and improved anesthesia have enabled the laparoscopic hysterectomy in surgery. The first laparoscopic hysterectomy was performed by vol 19 no 2 JUnE 2011

ACOG’s (American Congress of Obstetricians and Gynecologists) for 2009 indicated that in the U.S. annually is performed about 600 000 hysterectomies, with the corresponding mortality rate of 0.16%. Each of the techniques described in this paper has its own indications, advantages and complications. It is important to maintain a critical review, use the knowledge and experience to evaluate the selection of the optimal surgical approach. Also, each technique has its own

“learning curve” which is short for some techniques, and for some longer, it should be appreciated, and in accordance with them build their individual surgical strategies and in doing so do not forget that the welfare of the patient comes first. Special attention is given to the technique of laparoscopic hysterectomy, which is increasingly in use. Key words: hysterectomy, laparoscopy, indications, complications.

Henry Reich 1989, unaware that he introduced us to a new technology chapter-robotics (4). In the eighties of the twentieth century in the U.S. about 70-80% of all hysterectomies was done by the abdominal approach (1), in order to compare with 2009 in report by ACOG was approximately 66% of abdominal hysterectomy, vaginal hysterectomy 22%, and only 12% of total laparoscopic hysterectomy (TLH) (2). In Germany, which still has the reputation of the old surgical school, the proportion of vaginal hysterectomies varied between 9 and 90% (average about 50%), however, thanks to continuous propaganda of laparoscopy by Semma and Raatza, laparoscopy has become not only inevitable, but in some centers also the predominant surgical technique (5).

metriosis/adenomyosis, prolapsed uterus, etc. According to ACOG indications for hysterectomy were: miomatosus uterus in 40.7% of cases, endometriosis (adenomyosis) in 17.7%, and uterine prolapse in 14.5% patients (2). Despite the fact that today there are successful treatment options for recurrent, dysfunctional bleeding in pre and perimenopausal, thanks to conservative treatment (LNG-IUD “Mirena”) and/or minimally invasive surgery (hysteroscopy ablation of endometrial polyps, resection of submucosal fibroids, electro coagulation of the endometrium, etc.), hysterectomy is still a treatment option for patients who are more satisfied than the less invasive but also less durable solutions (6). Specifically, the work of Middleton and colleagues included 30 randomized, controlled trials involving the treatment of patients for hysterectomy due to dysfunctional bleeding, hysteroscopy-endometrial destruction or the installation of the LNG-IUD. A"er the 12 monthly observations, the majority of patients

2. INDICATIONS FOR HySTeReCTOMy

The benign indications for hysterectomy include: hypermenorrea, menometrorrhagia with resultant anemia, miomatosus uterus, endo-

Professional paper | AIM 2011; 19(2): 114-117

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

were dissatisfied with the long-term outcome of hysteroscopy endometrial ablation in comparison with hysterectomy. However, shorter hospital stay and faster return to daily activities went in favor of hysteroscopy. Detailed statistical analysis nevertheless went in favor of hysterectomy. Mirena was indirectly compared with hysterectomy, although this comparison is limited. However, it is interesting that a similar estimate was observed for the Mirena. Numerous studies have been conducted to evaluate which surgical mode is optimal, of course, exclusively for benign indications. One of these respectable study and meta-analysis of Johnson and co-workers which included 27 studies and a total of 3 643 patients, all of which undergone detachment due to some benign indications such as: abdominal, vaginal, or laparoscopically (7). They analyzed the following parameters: intraoperative complications (lesions of the urethra, bladder, intestines, etc.), postoperative complications (hematoma, infection, difficulty with urination, etc.), and duration of surgery, hospital stay, recovery time and return to daily activities. According to analyzed results, faster return to normal daily activities and shorter hospitalizations were observed in vaginal and laparoscopic surgery in comparison with abdominal, but no difference between vaginal and laparoscopic approach. More lesions were observed in the urethra and urinary bladder in laparoscopic surgery, but no other lesions of visceral organs. Overall, the fastest recovery, short hospital stay, the smallest number of intraoperative and postoperative complications suggest the vaginal approach as the first method of choice, and if not possible then the laparoscopic method (7). Detailed statistical analysis showed that the comparison of laparoscopic (LAVH laparoscopic-assisted vaginal hysterectomy and TLH-total laparoscopic hysterectomy) and abdominal hysterectomy speaks in favor of the laparoscopic approach, or that this modality is significantly better in terms of fewAIM 2011; 19(2): 114-117 | Professional paper

Johnson und Diamond (1994)

Munro und Parker (1993)

Garry, Reich und Liu (1994)

Neis und Brandner (1993)

Stage 0: diagnostic laparoscopy and vaginal hysterectomy. Stage 1: laparoscopic adhesiolysis and/or excision of endometriotic plaques Stage 2: uni/bilater adnexectomy Stage 3: laparoscopic preparation of the urinary bladder Stage 4: ligation of uterine artery Stage 5: colpotomy ane evacuation of the uterus

Was not imagined as laparoscopic hysterectomy. Type 0: laparoscopic preparation for vaginal hysterektomy Type I: preparation to the uterine artery, but not ligation of the uterine artery. Type II: Preparation and ligation of the uterine artery Type III: preparation and ligation of parametrial tissue. Type IV: Preparation and ligation of ligg.sacrouterina

Was not imagined as laparoscopic hysterectomy.

LAVH type I

Vaginal hysterektomy with some laparoscopic help.

LAVH type II

LAVH

LAVH type II

LAVH type II LH

LH

LH TLH

LH

Bradner P,Neis KJ. Die endoskopische Hysterektomie-Konzepte. In: Keckstein J, Hucke J: Die endoskopischen Operationen in der Gynaekologie. Muenchen, Jena. Urban&Fischer, 2000:233-235

Table 1: Different classifications of laparoscopic hysterectomy.

er complications and faster recovery authors suggest that the first methcompared to abdominal hysterectood of choice should be a vaginal my (p = 0.004). hysterectomy, and if it is not possiComparison of intraoperative leble, the method of choice would be sions of the urethra and/or the bladsome of the laparoscopic methods der during LAVH and TLH does (8). The authors of both meta-analynot have a statistically significant sis have offered nearly identical condifference (7). clusions and stressed that the surAlmost the same results offered gical approach should certainly be another meta-analysis by Nieboer discussed with the patient and jointand associates, which included 34 ly decide on the optimal approach. studies and 4 495 patients. All were subjected to hysterectomy (for be3. ObjeCTIveS AND DeFINITION OF nign indications) on one of three LAPAROSCOPIC ways: vaginal, abdominal or lapaHySTeReCTOMy roscopic. Vaginal hysterectomy in comparison with abdominal has The aim of laparoscopic hysterthe following advantages: shortectomy is to avoid abdominal wall er duration of hospitalization, fewincision, to reduce intraoperative er complications, faster recovery, bleeding, reduce hospital stay and while the advantages of laparoscopfaster recovery of patients. Laparoic compared to abdominal is: faster scopic hysterectomy is sometimes, recovery, less intraoperative bleedbut not always substitute for abing and in accordance with this slight decrease if haemoglobine, shorter hospitalization, are rare hematoma and infection of the wounds. Shortcomings of laparoscopic hysterectomy in comparison with abdominal are frequently the urethra and bladder injury and longer duration of surgery. The advantages of LAVH and TLH are less common and nonspecific febrile episodes of infection, shortens the surgical proce- Figure 1. Preparation and dissection of anatomical structures: lig. dure. In conclusion, the Infundibulopelvicum and lig.rotundum, displaying art. uterine (5). vol 19 no 2 JUnE 2011

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

dominal hysterectomy, but it is not indicated in cases where it is possible to perform a vaginal hysterectomy. Indications were symptomatic myomas, abnormal bleeding, adenomyosis, endometriosis, adnex masses formation, chronic pelvic inflammatory disease, atypical endometrial hyperplasia and corpus carcinoma. It is important Figure 2. Seting the stitch on the art. uterine (9). however to keep the criticism

Figure 3. Cutting cervicovaginal ties and circular culdotomy (9).

According to Henry Reich who in 1989 made the first total laparoscopic hysterectomy, surgery is divided into six steps: presentation of the urethra, mobilization of the uterus and the release of the urinary bladder, uterine ligation of the upper bound, ligation uterine blood vessels, cutting ties cervicovaginal and cervical culdotomy, stitching the vagina. When performing the vaginal TLH stitches laparoscopic or vaginal approach. It is performed when vaginal hysterectomy is not possible due to difficulties in the vaginal approach (e.g. very narrow vagina) or any other reason. Contraindication for TLH include: suspicion of uterine sarcoma, miomatous uterus, a systemic disease of a patient which is a contraindication for laparoscopic surgery and a longer insufficiently trained surgeon. TLH offers many advantages in comparison with the abdominal approach, such as: minimal bleeding, shorter recovery, less suffering, pain, shorter hospitalization and quicker return to daily activities. The fact is that the incidence of complications, especially in the beginning of using technology, especially lesions of the urethra was very high. In this respect, it is necessary

and do not engage in surgical activities that will needlessly take hours, if the surgery can be considerably shorter, and therefore more tolerable for the patient. There are various attempts to classify a hysterectomy at which it is used and laparoscopy, but none has been officially accepted. The table below shows that Figure 4. Uterus removed (9). behind the name “Laparoscopic Hysterectomy” is hiding a large uterus, uterine sarcoma and ovarinumber of operations that differ in an cancer. extent of laparoscopic surgery. According to previous studies LAVH carries a slightly higher 4. LAvH LAPAROSCOPICrisk of injury to the urethra and ASSISTeD vAGINAL urinary bladder in comparison HySTeReCTOMy with the abdominal approach, LAVH involves different variaand a longer duration of surgery, tions of laparoscopic and vaginal but less blood loss, faster recovoperative segments. ery and fewer postoperative comIt should be noted that art. uterplications. Because of that studine can be ligated by either laparoies in general prefer LAVH in the scopic or vaginal approach. Accordabdominal approach. ing to the ACOG, the LAVH is indiHowever, it should be notcated in all cases where the operator ed that LAVH is not a substitute for number of reasons (e.g. the confor the abdominal approach and dition a"er the previous laparoscothat each approach has its surFigure 5- Closure of the vagina (9). py, endometriosis, pelvic inflammagical indications, and that the tory disease, etc.) to avoid abdomioperator must maintain a critinal hysterectomy, but is expected cal attitude towards each operative to acquire much experience in lapadifficult 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 LAPAROSCOPIC Contraindications for this surgiroutinely, TLH has become an alterHySTeReCTOMy cal approach are great miomatous 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?

2. ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease. Obstet Gynecol 2009; 114(5):1156-1158. 3. Glesinger L. Povijest medicine. Školska knjiga, Zagreb, 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). Die endoskopische Hysterekelectrode corpus is separated from the cervix (10). tomie- Konzepte. U: Keckstein J, Hucke J: Die endoskopische should be further explained the Operationen in der Gynäkologie. necessity of regular cytological Urban&Fischer, München, Jena, control. 2000:233-235. Also, according to recent 6. Middleton LJ, Champaneria R, guidelines, patients with supraDaniels JP, i sur. Hysterectomy, cervical adenomyosis recomendometrial destruction, and lemended are hysterectomy. Many vonorgestrel releasing intrauterpatients expressed satisfaction ine system (Mirena) for heavy with this technique and their sex menstrual bleeding: systematic life a"er surgery. review and meta-analysis of dana Classical supracervical hysterfrom individual patients. BMJ ectomy 2010;341:c3929 Classic abdominal infrafas7. Johnson N, i sur. Methods oh hyscial supracervical hysterectomy terectomy: systematic review and is also one of the operative methFigure 8. Peritonisation of cervical stump (10). meta-analysis of randomized conod of choice (11). trolled triales. BMJ 2005;330:1487. 8. Nieboer TE, Johnson N, Lethaby 7. CONCLUSION A, i sur. Surgical approach to hysEach of these techniques has terectomy for benign gynaecologits indications, advantages and ical disease. Cochrane Database complications. Syst Rev 2009 Jul 8;(3):CD003677 It is important to maintain a 9. Reich H. Laparoskopische Hystercritical review, use their knowlektomie. U: Keckstein J, Hucke J. edge and experience to evaluate Die endoskopische OPerationen in the selection of the optimal surder Gynäkologie. München, Jena, gical approach. 2000:245-260. Each technique has its own Figure 9. Setting the clamps on the uterus through 10. Donnez L. Laparoskopische supra“learning curve” which is short which the uterus is reponed, after the preparation of the uterus and adnex is made supracervical hysterectomy (11). for some techniques, and for zervikale Hysterektomie (LASH). U: Keckstein J, Hucke J. Die ensome longer, it should be apdoskopische OPerationen in der 6. LSH- LAPAROSCOPIC preciated, and in accordance with Gynäkologie. München, Jena, SUPRACeRvICAL them build their individual opera2000:261-269. HySTeReCTOMy tional strategies and in doing so do 11. Metller L. Klassisch infrafasziiaLaparoscopic supracervical hysnot forget that the welfare of the pale suprazervikale Hysterektomie terectomy can be offered to patients tient is at the first place. (CISH). U: Keckstein J, Hucke J. in whom hysterectomy was indicatDie endoskopische OPerationen in ed, but ruled out cervical dysplaReFeReNCeS der Gynäkologie. München, Jena, sia, endometrial cancer, deep pel1. Garry R. Towards evidence-based 2000:270-282. hysterectomy. Gynaecol Endosc vic endometriosis (sacrouterine liga1998;7:225-233. ments). Of course, to these patients Corresponding author: prof Zlatko Hrgovic, MD, PhD. Faculty of medicine, University of Frankfurt am Main, Germany. Kaizer str 15, E-mail: [email protected]

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