Abstract
Hysterectomy is one of the most common major gynaecological procedures and has been reported in early Greek manuscripts as early as 50 BC and AD 120, though proof that it was performed is limited. However, it was not until the 1800s that the first planned vaginal hysterectomy was recorded [1]. Traditionally, hysterectomy is done either by an open abdominal approach via a midline or transverse incision, or by a vaginal approach. The first laparoscopic hysterectomy was described by Harry Reich and colleagues in 1989 [2]. With advances in technology, development of new instruments and standardization of surgical techniques, the laparoscopic approach has fast gained popularity across gynaecological practice and has become an independent alternative treatment option [3–6].
11.1 Introduction
Hysterectomy is one of the most common major gynaecological procedures and has been reported in early Greek manuscripts as early as 50 BC and AD 120, though proof that it was performed is limited. However, it was not until the 1800s that the first planned vaginal hysterectomy was recorded [1]. Traditionally, hysterectomy is done either by an open abdominal approach via a midline or transverse incision, or by a vaginal approach. The first laparoscopic hysterectomy was described by Harry Reich and colleagues in 1989 [2]. With advances in technology, development of new instruments and standardization of surgical techniques, the laparoscopic approach has fast gained popularity across gynaecological practice and has become an independent alternative treatment option [3–6]. Performance of a hysterectomy through the laparoscopic route has clear advantages to the patient from the point of view of recovery and return to normal activity. Open hysterectomy is now often reserved for very large uteri or in settings where the appropriate expertise is not available. Laparoscopic hysterectomy includes total laparoscopic hysterectomy (TLH) and laparoscopic subtotal hysterectomy (LASH). The presence of fibroids can present a technical challenge to performing laparoscopic hysterectomy, but with knowledge of these challenges and how to address them, performing a laparoscopic hysterectomy even in the presence of relatively large or numerous fibroids can be made feasible. These challenges will be covered in this chapter.
11.2 Indications and Contraindications
The indications for laparoscopic hysterectomy are similar to other forms of hysterectomies and include leiomyoma, abnormal uterine bleeding, adenomyosis, gynaecological cancers and pelvic organ prolapse. Laparoscopic hysterectomy for a large fibroid uterus (>500 g) can be associated with a longer operating time, higher intraoperative blood loss, high risk of conversion to laparotomy and longer hospital stay [7]. These challenges mean that a laparoscopic hysterectomy for a fibroid uterus merits special tips and tricks to facilitate safe surgery and reduce morbidity. The fibroid uterus is usually large, and the upper limit for a safe and successful laparoscopic approach is dictated to a large extent by the skill of the surgeon, the location of uterine bulk/fibroid, the patient’s medical comorbidities, and ease of access to uterine vasculature, and to some extent it depends on the nature of the pathology being treated. Examples of situations where a laparoscopic approach is contraindicated include known cases of gynaecological cancer where the specimen may not be removed intact by a laparoscopic approach, or patients with significant cardiopulmonary disease with associated intolerance to increased intra-abdominal pressure or deep Trendelenburg position which in turn may limit visualization of pelvic anatomy, or where the skill of the surgeon is inadequate.
11.3 Procedure and Complications
The surgical steps may have minor variations between surgeons, but the detailed procedure is outside the scope of this chapter. In general, the steps include uterine manipulation, laparoscopic entry, round ligament transection, preparation of the vesicouterine space and development of the bladder flap, securing and dividing the upper and lower pedicles, colpotomy and removal of uterus and finally colporrhaphy. The risk of minor and major complications with laparoscopic hysterectomy is generally low (<2%) but can be higher in the presence of large uterine fibroids that add to the technical difficulty of the case. Recognized complications include infections (wound, urinary tract, infected haematoma, peritonitis), bleeding, bowel injury, vaginal vault complications (haematoma, dehiscence), urinary tract injuries (ureters, bladder), venous thromboembolism, conversion to laparotomy, anaesthetic risks and rarely nerve injury [8, 9].
Complications are therefore directly related to the skill of the surgeon. Surgeons still at the early stages of training to preform laparoscopic hysterectomy, needless to say, need to carefully select cases within their skill limit. With more experience, technically challenging cases such as those with uterine fibroids can be tackled with relative ease. The key is to know the challenges and how to pre-emptively avoid them. The surgeon should also have a diversity of techniques and the flexibility to switch from one technique to the other as the case dictates.
11.4 Challenges Associated with Laparoscopic Hysterectomy for Fibroids
11.4.1 Preoperative Challenges
A thorough and meticulous preoperative assessment and obtaining a thorough clinical history is vital in all patients for a successful operative and postoperative course. Management options include the following:
a. Optimization of anaemia and shrinkage of fibroid volume: a common problem of fibroid uterus is anaemia from heavy menstrual bleeding which requires correction before surgery. Options include iron therapy for iron deficiency anaemia and preoperative blood transfusion in selected cases. Another approach is to concurrently minimize menstrual blood loss or induce amenorrhoea and shrink fibroid volume, e.g. by use of GnRH analogues or selective progesterone receptor modulators (SPRMs), i.e. ulipristal acetate. These approaches minimize the likelihood of requiring postoperative blood transfusion, and the shrinkage in fibroid volume will facilitate laparoscopic hysterectomy by aiding visualization, reduce the likelihood of intraoperative blood loss and reduce operating time. There is good evidence from a Cochrane review that the use of GnRH analogues for 3–4 months before hysterectomy is associated with reduced fibroid volume, improvement in preoperative and postoperative haemoglobin and haematocrit when used prior to surgery, reduction in intraoperative blood loss and reduced risk of vertical abdominal incision. These benefits translate into reduced operating time and decreased hospital stay [10], though their use is associated with adverse side effects from pituitary down-regulation including hot flashes, night sweats, vaginal dryness, low mood and loss of bone mineral density after prolonged use [11, 12]. Ulipristal acetate has become more widely available and evidence from trials suggests that a 3-month course results in approximately 50% reduction in fibroid volume. Recent preliminary data, however, required monitoring of liver function before and during treatment due to reported rare but severe cases of liver failure with the use of ulipristal. This amount of volume reduction in the context of TLH may provide similar benefits to those seen with GnRH analogues.
b. Preoperative imaging: a pelvic ultrasound scan should be undertaken to assess the location, size and number of fibroids to help plan the surgical approach. There is a possibility that a myomectomy will need to be performed during the surgery to facilitate the procedure, and for this reason performing an MRI has clear advantages over ultrasound scan by helping to differentiate between fibroids and adenomyomas which are not amenable to surgical enucleation. Furthermore, although MRI scans cannot diagnose malignancy, they can provide some useful information regarding potential malignancy and therefore pre-empt the surgeon to consider an open rather than a laparoscopic approach where performing a myomectomy or morcellating the specimen may carry the risks of disseminating a malignancy.
c. Concurrent pelvic pathology: where concurrent pathology is expected, e.g. significant endometriosis or bowel adhesions from previous surgery, appropriate measures should be put in place, e.g. ensuring assistance from a colorectal surgeon is available where bowel adhesions is anticipated.
d. Enhanced recovery after surgery (ERAS): women with large uteri are at risk of prolonged surgery and longer operative stay and are therefore suitable for ERAS protocols. ERAS protocols aim to reduce the physical and psychological impact of elective gynaecological surgery on patients and should be undertaken for women having laparoscopic hysterectomy for large uteri. The basic components of enhanced recovery include patient education, modifying standard oral feeding, drinking policies, carbohydrate loading, avoiding dehydration, eliminating bowel preparation requirements, avoiding open procedures and using minimally invasive surgical techniques when possible, minimizing use of surgical drains, minimizing intravenous fluid infusion intraoperatively, modified analgesia intraoperatively and postoperatively, aggressive prophylaxis of perioperative nausea and vomiting and early postoperative oral nutrition [13]. ERAS provides multiple benefits including faster recovery, increased patient satisfaction and decreased healthcare costs without additional risks to women.
11.4.2 Intraoperative Challenges
a. Port placement: the most important step is planning correct port placement. Good versus poor port placement is the key difference between an easy and a difficult laparoscopic hysterectomy. Every surgeon will have a preferred port configuration when performing a laparoscopic hysterectomy but this needs to be modified when performing the procedure for a large fibroid uterus.
The first step is to perform an examination in theatre by the primary operating surgeon. The size of the uterus will determine the position of the ports. To make a large uterus smaller, the surgeon will need to move the primary port away from the uterus. Even a few millimetres can make a large difference to visibility during the procedure. Operating with the laparoscope close to the uterus makes the procedure extremely difficult. Occasionally, even the Palmer’s point can be used for the primary port. Similarly, having the secondary ports close to the uterus leaves very little room for manoeuvrability of the surgical instruments. The surgeon can therefore retain the normal port configuration but shift the ports cephalad in proportion to the size of the uterus. Care of course must be taken to avoid injury to upper abdominal viscera, particularly the stomach and transverse colon.
The authors usually use a supraumbilical primary port, taking care to ensure the stomach has been emptied using a nasogastric tube. Secondary ports normally placed in the left and right iliac fossae are instead placed in a higher position and a third right paraumbilcal port can also be valuable to provide an additional port for the assistant and for suturing, but care needs to be taken to avoid damage to the inferior epigastric vessels.
b. Assessment of pelvic anatomy: the next step is thorough assessment of the size and anatomical position of the fibroids. Fibroids are unique in that they can vary in number and size and no two cases are exactly the same. It is important to note fibroids that may significantly alter the anatomy or preclude safe completion of the procedure, at which stage the procedure can be converted to a laparotomy if the procedure is found to be beyond the skill level of the surgeon. The following fibroids are of particular relevance:
i. Lateral or broad ligament fibroids: these can complicate safe access to the uterine vessels and also significantly alter the course of the ureter, increasing the risk of ureteric damage. Given that the surgeon has the skills to perform a laparoscopic myomectomy, these fibroids can be first removed to facilitate securing of the uterine vessels and also allow the ureter to move back to its normal position before securing the uterine vessels. The authors use 5–10 units of intramyometrial vasopressin prior to performing a laparoscopic myomectomy to minimize bleeding. Vasopressin, however, is a potentially dangerous drug and should only be used with adequate experience regarding its effects, side effects and pharmacokinetics. An alternative method is to secure the uterine vessels at their origin from the internal iliac artery. Again, this requires considerable expertise in retroperitoneal dissection. The surgeon should also have the skill to identify and dissect the ureter. When the anatomy in the lower pelvis is distorted due to the fibroid, it is best to identify the ureter at the pelvic brim and follow it down. The ureter is easily identified as the first retroperitoneal structure seen medial to the infundibulopelvic ligament at the pelvic brim.
ii. Low corporeal fibroids: these fibroids may significantly hinder access to the lower pelvis and make colpotomy more difficult. Even if the surgeon decides to resort to a laparoscopic subtotal hysterectomy, the presence of a low corporeal fibroid can make safe separation of the uterine body from the cervix more difficult. A low corporeal anterior wall fibroid can stretch the bladder and increase the risk of bladder injury. Low corporeal fibroids may therefore be removed in order to facilitate colpotomy. In cases of anterior fibroids, the uterovesical pouch needs first to be carefully dissected to minimize risk of damage to the bladder. If these fibroids need to be removed, it is better to postpone until the uterine vessels have been secured to minimize the risk of bleeding and avoid the need for vasopressin or similar measures.
c. Ergonomics: to ensure the correct ergonomics, the surgeon may stand on a footstep or lower the table as much as possible to ensure an adequate arm reach across the operating table. In addition, a tilt of the operating table towards the primary surgeon during laparoscopic suturing may be useful. These measures could help reduce the surgeon’s muscle fatigue and strain, and facilitate a more ergonomic position. Another recognized challenge with laparoscopic pelvic surgery is the mobilization of bowels during the colpotomy. In such a situation, a deep Trendelenburg position would facilitate adequate exposure to the pelvic anatomy, especially in cases where colpotomy is anticipated to be difficult.
d. Removal of uterus: removal of the uterus is arguably sometimes the biggest challenge with laparoscopic hysterectomy for fibroids. This is influenced by uterine size and location of the fibroids. Options include enucleation of a few fibroids first to decrease the uterine size, allowing it to be removed vaginally. The uterus can also be bisected laparoscopically, vaginally or using a combination of both techniques. Fibroids can also be enucleated vaginally.
Fibroids that have been separated from the uterus can be removed with the specimen vaginally or by morcellation. The procedure of morcellation has been subject to extensive debate recently and is covered in detail in other areas of this book. A laparoscopic subtotal hysterectomy (LASH) can often be considered, particularly if the colpotomy is found to be difficult. The technique is particularly suitable for patients who mainly suffer from pressure symptoms and where the fibroids are mainly limited to the uterine body. Performing a LASH will cure the pressure symptoms with minimal risk. In women with significant bleeding problems, however, a small proportion will continue to experience bleeding from retained endometrial tissue with the cervix. The endocervix should, therefore, always be ablated using electrosurgical energy. It is also important that there is no significant cervical abnormality, so the patient should have had up-to-date normal cervical smears prior to performing a LASH. Another approach is to perform a LASH in the first instance, thus facilitating the colpotomy and removal of the cervix separately.
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