Laparoscopic Hysterectomy for Benign Conditions

Chapter 36 Laparoscopic Hysterectomy for Benign Conditions



Oz Harmanli


It may be intuitive that hysterectomy would best be accomplished through the vagina, the natural orifice to the female genital system. In fact, vaginal hysterectomy (VH) can be traced back to ancient Greek history. Conrad Langenbeck, a German surgeon, presented the first successful VH in 1813. The first documented abdominal hysterectomy was by Charles Clay of England in 1843, albeit this was done without removal of the cervix. Unfortunately, the patient did not survive. The first total abdominal hysterectomy (TAH) was performed by Richardson in 1929 in the United States; TAH subsequently was used for cervical cancer in the ensuing decades. The morbidity and mortality of hysterectomy were reduced with the advent of antibiotics and availability of blood transfusion after World War II. Hysterectomy became one of the most common major surgical procedures performed by gynecologists, second only to cesarean deliveries.


In 1988, Harry Reich performed the first laparoscopic hysterectomy (LH). At this time, TAH accounted for about 75% of hysterectomies, with VH taking up the balance. The rate of LH subsequently increased from 0.3% in 1990 to 14% in 2005, predominantly at the expense of the rate of TAH, which dropped to 64% during the same period. There also was a small drop in the rate of VH, from 24% to 22%. As the laparoscopic approach became more popular, interest in supracervical hysterectomy resurfaced, and its acceptability has increased.


Of approximately 600,000 hysterectomies performed in the United States each year, about 10% are done for malignancy. Although traditionally performed through a midline incision, some gynecologic oncologists have demonstrated that hysterectomy for malignancy can be accomplished with minimally invasive technique, including robotic assistance. The scope of this chapter, however, is limited to LH performed for nonmalignant conditions.



Operative indications


Uterine leiomyoma is the most common indication for hysterectomy, accounting for 30% to 40% of all procedures, followed by abnormal uterine bleeding, pelvic organ prolapse, pelvic pain, endometriosis, and malignant and premalignant conditions. Medical treatment alternatives for uterine leiomyoma include nonsteroidal anti-inflammatory agents and hormonal agents (e.g., progestins and gonadotropin-releasing hormone analogs). Uterus-sparing procedures for uterine leiomyomas include uterine artery embolization or myomectomy. Abnormal uterine bleeding may be controlled with a progestin-releasing intrauterine device or endometrial ablation. Endometriosis may respond well to hormonal agents such as a progestin or a gonadotropin-releasing hormone analog. If the patient has pelvic pain, then a multidisciplinary evaluation that includes gastroenterology, urology, and pain specialists is imperative before consideration of hysterectomy as treatment. Nonoperative management of pelvic organ prolapse may be accomplished with pessaries. In addition, it may be possible to repair a prolapse without a hysterectomy. Successful treatment of precancerous conditions is possible with local excision of cervical intraepithelial neoplasia and with progestin treatment for endometrial hyperplasia; treatment of malignancy is beyond the scope of this chapter.



Procedures



Types of Hysterectomy


For benign uterine disease, the patient’s general condition, quality of life, childbearing plans, ovarian reserve, and response to medical therapy will determine the decision between hysterectomy and the alternatives. If the patient opts for hysterectomy, then the surgeon needs to discuss the operative approach with the patient. A systematic review of randomized trials indicated that VH was the first choice of hysterectomy, because of its superior perioperative outcomes. In fact, the American College of Obstetrics and Gynecology has published a committee opinion emphasizing the benefits of the VH. When the vaginal route was not feasible, then the systematic review favored LH over TAH, despite an approximately 25-minute longer operative time with LH. In most cases, however, the gynecologist’s comfort level and personal bias have been key factors in the selection of the type of hysterectomy.



Types of Laparoscopic Hysterectomy


A hysterectomy for benign disease may be performed laparoscopically from beginning to end. In total laparoscopic hysterectomy (TLH), all of the steps, including the division of the uterine ligaments, vaginal cuff incision (colpotomy), and vaginal cuff closure, are accomplished through the laparoscope, and the specimen usually is removed from the vagina. If the uterus is too large, then morcellation may be performed with a specialized morcellator, or by simply cutting the specimen into smaller components with conventional instruments. If laparoscopy is used as an adjunct to VH, then this procedure is considered a laparoscopy-assisted vaginal hysterectomy (LAVH). The American Association of Gynecologic Laparoscopists has standardized the terminology for minimally invasive hysterectomy (Tables 36-1 and 36-2). Based on this classification, TLH is considered a type IVE procedure. Some surgeons have promoted preservation of the cervix and perform a laparoscopic supracervical hysterectomy (LSH).


Table 36-1 Classification System for Laparoscopic Hysterectomy





















Type Laparoscopic Component of Hysterectomy
0 Laparoscopy-directed preparation for vaginal hysterectomy, including adhesiolysis and/or excision of endometriosis
I Occlusion and division of at least one ovarian pedicle, uteroovarian ligament, or infundibulopelvic ligament, but not the uterine artery
II Type I plus occlusion and division of one or both uterine arteries
III Type II plus a portion, but not all, of the cardinal-uterosacral ligament complex, unilateral or bilateral
IV Complete detachment of the cardinal-uterosacral complex, unilateral or bilateral, with or without entry into the vagina. This category includes total laparoscopic hysterectomy.

Adapted from Olive DL, Parker WH, Cooper JM, et al: The AAGL classification system for laparoscopic hysterectomy. Classification Committee of the American Association of Gynecologic Laparoscopists, J Am Assoc Gynecol Laparosc 7:9–15, 2000.


Table 36-2 Subgroup Classification System for Laparoscopic Hysterectomy





















Subgroup Step Completed Laparoscopically
A Cases limited to the division of the pedicle(s) containing ovarian or uterine vessels
B Cases that include dissection of the bladder
C Cases that include performance of a posterior colpotomy
D Cases that include both bladder dissection and a posterior colpotomy
E Applies only to type IV laparoscopic hysterectomies and is reserved for total laparoscopic hysterectomies

Adapted from Olive DL, Parker WH, Cooper JM, et al: The AAGL classification system for laparoscopic hysterectomy. Classification Committee of the American Association of Gynecologic Laparoscopists, J Am Assoc Gynecol Laparosc 7:9–15, 2000.



Preoperative evaluation, testing, and preparation


Preoperative evaluation before hysterectomy depends on the surgical indication. In cases that involve anemia, it has been a common practice to transfuse the patient so that the hemoglobin is 10 g/dL or higher. If a preoperative transfusion is not feasible, then it is prudent to type and crossmatch the patient for the perioperative period. Storing autologous blood for most hysterectomy procedures was not shown to be cost-effective in a large study.


Preoperative Papanicolaou testing and endometrial sampling are indicated in the patient who has abnormal uterine bleeding, cervical intraepithelial neoplasia, or endometrial hyperplasia. If there is a suspicious pelvic mass or abnormal uterine bleeding, then transvaginal ultrasound also is indicated. More invasive procedures, such as dilation and curettage or hysteroscopy, are needed only if an adequate office biopsy cannot be obtained or, in the postmenopausal stage, if the transvaginal ultrasound demonstrates an endometrial thickness of greater than 4 mm.


Mechanical bowel preparation is prudent for the patient who has a history of previous pelvic surgery, pelvic pain, or endometriosis. Preoperative intravenous antibiotics are administered within 1 hour of skin incision. Spinal or epidural anesthesia is suitable for VH, whereas general anesthesia is necessary for LH.



Patient positioning in the operating suite


The procedure is performed in lithotomy position with padded stirrups. Sequential compression devices are used. The arms are padded and tucked alongside the body. If the patient’s bare back is placed against a silicone pad, then steep-Trendelenburg position is possible, which helps keep the intestines away out of the pelvis. The patient’s buttocks should overhang the end of the table by 1 to 2 inches to allow easy uterine manipulation, even if the patient slips slightly in Trendelenburg position. An indwelling catheter is placed in the bladder. A uterine manipulator, such as the VCare device (ConMed Endosurgery, Utica, NY) or the RUMI System (Cooper-Surgical, Trumbull, Conn.), is secured inside the uterine cavity so that the uterus can be moved in all directions and the vaginal fornices may be demarcated. Gastric intubation and decompression usually are not necessary, unless there is work planned for the upper abdomen.



Positioning and placement of trocars


Veress needle insertion, direct trocar insertion (optical and nonoptical), and minilaparotomy for open access are all acceptable techniques for peritoneal access. No definitive study has demonstrated superiority of one access technique over another. Some surgeons prefer an optical trocar that accommodates the laparoscope, allowing visualization of the tissue layers during abdominal wall penetration. A commonly used location for Veress needle or direct trocar insertion is the deepest point within the umbilicus because it provides the shortest distance to the abdominal cavity. For Veress needle or direct trocar insertion, the aim of the instrument may be 45 degrees from horizontal in a patient with a normal body habitus. Elevation of the abdominal wall can help keep the abdominal wall away from the intestines and large vessels. The direction should be increased to up to 90 degrees from horizontal in an obese patient. An intra-abdominal pressure reading below 10 mm Hg is a good indicator for safe peritoneal entry. No return of blood or other fluid and easy flow of the fluid into the abdominal cavity (e.g., the saline drop test) are reassuring signs of peritoneal entry.


After pneumoperitoneum is obtained, the operating ports should be placed under laparoscopic visualization, at least 8 cm lateral to the midline and about 4 to 5 cm cephalad to the pubic symphysis to avoid injury to the bladder and the inferior epigastric vessels (Fig. 36-1). Selection of a point 2 cm above and 2 cm medial to the anterosuperior iliac spine is another method to place the lateral ports (see Fig. 36-1). If the uterus is large or work outside the pelvis is expected, then the lateral ports may be placed more cephalad.


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FIGURE 36-1 Trocar placement for laparoscopic hysterectomy. 1, Umbilical port for camera; 2, left operating port (5 mm); 3, right operating port (12 mm); 4, accessory port (5 mm).

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Jul 20, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Laparoscopic Hysterectomy for Benign Conditions

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