Laparoscopic hysterectomy is an alternative to abdominal hysterectomy. Different techniques are described and illustrated. Most hysterectomies by laparotomy can be avoided by using the laparoscopic approach including cases of adhesions, adnexal masses and endometriosis. According to the status and the experience of the surgeon the time to perform the laparoscopic surgery can be reduced. There are many advantages from laparoscopic hysterectomy for the patient including the length of hospital stay and convalescence.
The first laparoscopic hysterectomy (LH) was performed in January 1988 by Harry Reich in Pennsylvania (1) and the first LH in Switzerland was by our team in Lausanne in 1990 (2). There has been a great increase in interest following the introducation of LH but most surgeons now perform laparoscopically assisted vaginal hysterectomy (LAVH). This new procedure was designed to be an alternative to abdominal hysterectomy and not vaginal hysterectomy.
The indications for laparoscopic hysterectomy are similar to the generally accepted indications for hysterectomy. In our centre (LEC) the main indication is abnormal uterine bleeding which we define as bleeding for over 7 days with clots and the need to wear additional protection for more than 2 cycles. Abnormal uterine bleeding includes all the usual causes such as adenomyosis, fibroids, endometriosis and also patients suffering from bleeding diastesis.
Prior to surgery the usual investigations must be performed and medical conditions such as infection, hormonal disease, etc evaluated. Evidence of anemia should be demonstrated and an indication for endometrectomy excluded. The conditions when endometrectomy is a viable alernative to hysterectomy include a normal sized uterus with a regular cavity which is less than 10 cm in length in a patient over 40 years old.
The specific indication for LH is when vaginal hysterectomy is not feasible because of, for instance, a history of previous surgery, adhésions, endometriosis, adnexal masses, a narrow vaginal space in a nulliparous woman, narrow subpubic arch and difficult vaginal exposure.
If the surgeon has limited experience in vaginal surgery that, too, may be an indication for laparoscopically assisted surgery. Reich considers that LH is also suitable for Stage I cervical and ovarian cancer (6,7,8) and laparoscopy may also be used following reconstructive surgery involving the vaginal cuff and repair of rectocele after vaginal hysterectomy. Other indications include endometrial carcinoma with pelvic lymphadenectomy and severe endometriosis with extensive involvement of the cul-de-sac. Great surgical skill is required to remove all the endometriotic nodules before hysterectomy otherwise remnants of endometriosis can persist and make subsequent surgery difficult.
Contraindications include postpartum hysterectomy and adnexal masses which cannot be removed with an endobag. The size of the uterus and access to it also limit the scope of the procedure depending on the experience of the surgeon.
When the uterus is over 12 weeks in size or when there are multiple large fibroids gonadotrophin releasing hormone (GnRH) analogues may be given. The administration of analogues for 2-3 months reduces the size of the uterus and myoma thus making surgery easier(9,10). During treatment anaemia can be corrected and if necessary autologous transfusion given.
Pubic hair need not be shaved and perineo-vulval hair only cut if excessive. Bowel preparation should be considered if difficult surgery is anticipated.
POSITIONING OF THE PATIENT
All laparoscopic surgery is performed under general anaesthesia with endotracheal intubation. The use of a naso-gastric tube avoids trocar injury to the stomach and reduces bowel distension. The patient is placed in the dorso-lithotomy position, with the legs supported by stirrups and adjusted to permit mobilization of the uterus by the nurse or the assistant surgeon. The vaginal surgical box including wall retractors is prepared.
POSITIONING OF THE OPERATING STAFF
The position of the medical staff is demonstrated in figure 1 where the surgeon is on the left side of the patient, the first assistant stands on the right side and holds the camera. There should be two monitors to allow staff on either side of the table to follow the operation. The surgeon has both hands free for surgery. The nurse is between the patient's legs and has the double role of scrub nurse and uterine manipulator.
There should be an electronic high flow CO2 insufflation apparatus which gives a minimum flow of 9 l/minute. This is necessary to compensate for the loss of CO2 and to maintain a constant pressure which should be just below 15 mmHg during the whole operation despite colpotomy and suction.
We try to avoid disposable cannulae and instruments. However a 5 mm cannula with a retention screw grid (Apple Medical, Bolton MA) is used to facilitate extra-corporeal suturing with a knot pusher. The Kleppinger bipolar forceps is used for haemostasis of large vessels including the uterine artery. The knot pusher is used for suturing pedicles. The other instruments are those for standard laparoscopy.
1. Laparoscopically Assisted Vaginal Hysterectomy (LAVH)
A single prophylactic dose of antibiotics is given intravenously. In patients with previous caesarean section, the bladder is emptied and 50 ml of Methylene blue instilled to better recognise any bladder injury during the surgery. The patient is laid flat during umbilical trocar insertion and then placed in a 30 degree Trendelenburg tilt.
It is important to cannulate the uterus. Several devices are now available which mobilize the uterus in every direction. Some also act as vaginal plugs to prevent gas deflation. If a mobilizer is not available, a 15 cm Simm's curette may be used instead. A sponge may be used to demarcate the cul-de-sac and assist the anterior and posterior vaginal incisions. In cases of severe endometriosis, a rectal probe is also used to identify and mobillize the rectum.
LAVH may be performed through 3 incisions: one 10-12 mm umbilical incision and two 5 mm lateral incisions. If there has been previous lower abdominal surgery either open laparoscopy is performed or the Veress needle insertion is in the left ninth intercostal space because adhesions are very rare in that area.
The lower trocar sleeves are inserted under laparoscopic vision lateral to the rectus abdominis muscles to avoid deep epigastric vessels and 2cm medial to the anterior superior iliac spine.
In cases with no additional lesion such as adhesions, endometriosis or ovarian cysts, the hysterectomy is started with bipolar coagulation (Fig. 1) of the round ligament and section with monopolar scissors. The anterior leaf of the broad ligament is then opened while the nurse pushes the uterus into retro-version (Fig.2). Next the posterior leaf of broad ligament is opened (Fig. 3) to permit the utero-ovarian ligament and tubes to be defined. This is also performed with bipolar coagulation and monopolar scissors (Fig 4 - 5) and is followed by dissection of the broad ligament. The uterus is pushed towards the opposite side by the nurse using the uterine cannula or by traction with the toothed forceps by the assistant. The uterine vessels are isolated, the peritoneum of the utero-vesical pouch is opened with monopolar scissors and the bladder is pushed downwards (Fig. 6). The surgeon completes the procedure with a standard vaginal hysterectomy.
2. Total Laparoscopic Hysterectomy (TLH)
The early stages of total laparoscopic hysterectomy are performed in the same way as LAVH. When the broad ligament has been dissected the surgeon ties the uterine pedicle with a 0 Vicryl using a knot pusher. The procedure is shown in figure 7 where the needle is being inserted round the uterine vessels. Figure 8 shows the absorbable suture being brought outside the abdomen through the 5 mm cannula after cutting and parking the needle in the peritoneum. The knot is tied using the knot pusher. Figure 9 shows the internal view and figure 10 the external view. The uterine vessels should be ligated in two places and the vessels incised with scissors between the knots.
Haemostasis of the uterine vessels may also be achieved with bipolar forceps (Fig. 11) using intermittent small applications of electric energy to the end-point of cessation of flow thus avoiding excessive heating of the ureters. It is essential at all times to be aware of the position of the ureters and to ensure that all haemostatic procedures are carried out at a distance from them. Elevation of the uterus allows the ureters to separate further from the uterus.
Intra-fascial hysterectomy is continued by the same bipolar forceps and monopolar scissors, coagulating the cervico-vaginal vessels and opening the vagina. The anterior and posterior vaginal walls are incised with monopolar scissors (Fig. 12) and haemostatis is completed by bipolar coagulation (Fig. 13). After uterine extraction (Fig. 14) laparoscopic or vaginal suturing may be performed (Fig. 15).
At the completion of the hysterectomy, the intraperitoneal CO2 pressure should be reduced to allow bleeding points to be recognised. The pelvis is not reperitonized nor is drainage necessary.
Alternative methods of achieving haemostasis have been used. These include haemostatic clips (Fig 16) but they have the disadvantage of springing open when the uterus is displaced. Automatic stapling is popular with some surgeons. These devices consist of two jaws each containing a triple row of micro-titanium staples which produce haemostatis and peritonisation and a knife which passes between the jaws to incise the tissues (11). This is faster than other procedures but is also very expensive. However, in cases of large varicosities in the broad ligament, we still use staples to divide the round and the broad ligaments .
Subtotal hysterectomy is being performed more frequently when the cervix is healthy and the vault well supported. The uterus is cannulated with a Simm's curette covered by a Foley catheter. This allows the cervix to be cut electrically with no transmission of energy along the curette.
The upper part of the broad ligament is opened as in LAVH (Fig 23) and after opening the peritoneum of the utero-vesical pouch the ascending branches of the uterine artery are coagulated with bipolar forceps. The peritoneum over the uterosacral ligaments is opened (Fig 24) and the cervix cut with monopolar scissors (Fig. 25). The final cut of the cervix is around the curette covered by the Foley catheter (Fig. 26). A posterior colpotomy is then performed with monopolar scissors after pushing up the posterior fornix with the the vaginal extractor which includes a 10 cm forceps to remove the uterus (Fig. 27-28). Alternatively the uterus may be removed through a 10 mm abdominal cannula after morcellation. The cervix is then closed and the peritoneum sutured with O suture (Figure 29-30).
The commonest indication for laparoscopic assistance to hysterectomy is the presence of adhesions due to previous surgery or pelvic inflammatory disease. Adhesiolysis must be performed before starting the hysterectomy. In cases of adnexal masses, adnexectomy must be performed with bipolar or automatic stapling (while identifying the ureter) and stretching the adnexa sufficiently far away from the ureter to ensure its safety.
2. Excision of Endometriosis
Complete removal of endometriosis must be performed before hysterectomy because the presence of the uterus facilitates the dissection between rectum and bladder.
Ovariectomy can be performed routinely during hysterectomy in women over 45 years old, or for benign ovarian lesions before that age. Ovariectomy may also be indicated when there is ovarian pathology or when there is little residual ovarian tissue remaining after ovarian cystectomy for endometriosis or teratoma.
The main problems faced in ovariectomy are avoidance of spillage and extraction of the specimen. The 5 mm abdominal incisions are the same as for hysterectomy. The contralateral cannula is used for forceps which apply traction on the ovary pulling it away from the pelvic side wall and the ureter. The ipsilateral cannula carries bipolar forceps to coagulate the infundibulo-pelvic ligament. Coagulation and scissor dissection are used alternately to divide the ligament. The incision should be as close as possible to the ovary to avoid injury to the identified ureter. The utero-ovarian ligament is then coagulated and divided in the same manner or the procedure may be accomplished with an automatic stapling device. An Endobag is then passed through a 12 mm cannula on the contra-lateral side. The ovarian cyst is then placed in the bag and deflated by syringe and needle or, alternatively, the incision may be enlarged with scissors to allow extraction of the endobag without spillage of the cyst contents. Closure of the 12 mm fascia incision is performed in layers to prevent herniation.
1. Intra-operative complications
a. Bladder injury
The prevalence of bladder complications in the literature is between 0,3 to 1,2 % (14,15,16 ,17) in abdominal hysterectomy, and 0,7, to 4% in vaginal hysterectomies. Liu and Reich reported 2,4 % in hysterectomy after caesarean section. In our series the prevalence of bladder complications is 2% One occurred in patient having a Burch procedure and the other occurred during dissection of endometriosis behind the bladder .
b. Ureter injury
Injuries to the ureter are uncommon in the literature the incidence being between 0,1 - 2%. Reich reported one uretro-vaginal fistula in 52 cases. Bruhat et al reported an incidence of 0.37% and treated them with a double-J catheter. Woodland reported two injuries using a Multi-Fire Endo GIA 30 application (14).
c. Bowel injury
Perineau reported an incidence of 0.13% of injuries to the bowel in a series of 768 abdominal hysterectomies. In our series (L.E.C) none of these complications have occured.
Bruhat et al reported an incidence of 3% of patients requiring conversion from laparoscopic surgery to olen surgery for haemorrhage. In our series one conversion to laparotomy was necessary in a case of advanced endometriosis.
2. Post-operative complications
a. Peritoneal complications.
Bruhat et al reported no peritoneal complication whereas Liu et al reported 2.5%. In our series, two patients required a second laparoscopy for drainage of a hematoma after using an automatic stapling device.
b. Delayed urinary tract injury
Bruhat reported three ureteric complications (1,1%) and one vesico-peritoneal fistula. Perineau reported an incidence of 0.3% of vesico-vaginal fistula.
c. Post-operative ileus
The literature suggests that the incidence of ileus is between 0.2 and 0.9% for vaginal hysterectomies and between 0.7 and 2.2% in abdominal hysterectomies. Bruhat et al reported 0.74%.
We have had 2 vaginal hematomas in our serie (2%) neither of which required drainage. No parietal hematoma was found.
Thrombo-embolism is relatively common in conventional gynaecological surgery. There has been none in our series of laparoscopic hysterectomies.
Compared to abdominal and vaginal hysterectomy, laparoscopic hysterectomy (TLH) is a very recent technique which has only been performed for the past six years. It allows the surgeon the best option provided patient safety is maintained by timely conversion to vaginal or abdominal hysterectomy when necessary.
Review of the literature as well as our own experience suggests that LH is an efficient and reproducible procedure. Analysis of the results ssshowsit to be as safe as the conventional operations. The indications for LH will probably be increased in the future as a result of the development of new instruments, especially morcellators for tissue extraction.
From the patient's point of view, the advantages are apparent in a shorter hosplital stay and a faster return to normal duties.
Cost remains a problem. Initially the short hospital stay reduced the costs considerably but, latterly, the introduction of expensive disposable instruments has increased the cost again.
The number of abdominal hysterectomies in our series has decreased in the last 10 years because of the introduction of minimal access surgery. Since the advent of laparoscopic surgery the majority of gynaecologists have reviewed their practice on the best way to remove the uterus. Endometrial ablation has reduced the incidence of hysterectomy for disordered uterine bleeding by at least 70%. The introduction of laparoscopic surgery has reduced the incidence of abdominal hysterectomy from 60% to 19%. 40% of hysterectomies are still performed vaginally.
In conclusion, laparoscopy permits the transformation of many abdominal hysterectomies into less invasive procedures. Improvment of techniques and instruments, including morcellators will allow us to reduce the problems and complications as well as the duration aand cost of surgery.
Edited by Aldo Campana,