Laparoscopic supracervical hysterectomy (LASH) is an alternative minimally invasive approach to total laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy. It is a safe and effective treatment of bleeding disorders and dysmenorrhoea in uterine myomatosis and/or adenomyosis. LASH has a low rate of major and minor complications, and patient satisfaction is very high. In order to extract the transected tissue from the abdomen, one essential condition for LASH is the intra-abdominal disruption of the uterine tissue by transabdominal, transcervical or transvaginal morcellation. In the following, complications in LASH, especially those related to electronic power morcellation, are described evaluating the recent literature.
Highlights
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LASH mostly is a fast minimal-access surgery without any complication.
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The use of electric power morcellation can cause inadvertent cell dissemination.
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Cell dissemination can cause peritoneal myoma, endometriosis and a dispersion of occult malignancy.
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The risk of occult uterine sarcoma in LASH is estimated to be <0.5%.
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In-bag morcellation could help avoid the risk of cell dissemination.
Laparoscopic supracervical hysterectomy
The laparoscopic supracervical hysterectomy (LASH) with electronic morcellation has become one of the most frequent minimally invasive approaches in hysterectomy for benign pathologies. The main indications are bleeding disorders, dysmenorrhoea caused by uterine myomatosis and/or adenomyosis uteri. LASH became popular with the implementation of electronic power morcellation which facilitated the extraction of the transected uterine body laparoscopically. Therefore, patient’s satisfaction after LASH is high, as the procedure is associated with all the advantages of minimally invasive surgery. Of the 1431 cases of LASH in a single-centre retrospective questionnaire, 93.9% were highly satisfied and 5.6% were satisfied with the outcome . These results are based on the low rate of major and minor complications in LASH. Bojahr et al. reported that of the 1706 cases, 0.3% were major and 1.2% minor complications . Donnez et al. reported a complication rate of 1.35% in 148 cases ; a major complication rate of 0.37% and a minor complication rate of 0.99% in 1613 cases . However, even if LASH is a safe and fast minimal-access hysterectomy, there are complications that are described in the following sections. The rate of these complications depends on the surgeon’s experience, the uterine size, previous pelvic surgeries, the existence of adhesions, the accuracy of the surgical technique, the histology of the uterine tissue and the special instruments used in LASH-like electronic power morcellators and monopolar cutting tools.
Cervical bleeding after LASH
Patient’s satisfaction after LASH correlates with the occurrence of post-operative vaginal bleeding. In the literature, a rate of 1–25% of post-operative vaginal bleeding after LASH has been published . Tchartchian et al. reported a post-operative bleeding rate of 21.4% in the group of highly satisfied patients and a rate of 71.4% in the group of poorly satisfied women undergoing LASH . The differences in the post-operative bleeding rate depend on surgical techniques, such as the amputation level of the uterine body and the coagulation of the endocervix . Lieng et al. showed that the postoperative bleeding rate thus depends on the experience of the physician . Patients should be informed about this bleeding risk as it might influence the quality of life and satisfaction after surgery.
Cervical bleeding after LASH
Patient’s satisfaction after LASH correlates with the occurrence of post-operative vaginal bleeding. In the literature, a rate of 1–25% of post-operative vaginal bleeding after LASH has been published . Tchartchian et al. reported a post-operative bleeding rate of 21.4% in the group of highly satisfied patients and a rate of 71.4% in the group of poorly satisfied women undergoing LASH . The differences in the post-operative bleeding rate depend on surgical techniques, such as the amputation level of the uterine body and the coagulation of the endocervix . Lieng et al. showed that the postoperative bleeding rate thus depends on the experience of the physician . Patients should be informed about this bleeding risk as it might influence the quality of life and satisfaction after surgery.
Cervical cancer after LASH
In dysplasia or other cervical disorders, LASH is contraindicated. A uterine cervix without pathological findings and a normal Pap smear within the last 12 months are conditions to preserve the cervix. When continuing the regular cancer prevention after LASH, the risk of cervical cancer is acceptable. It is estimated to be 0.1–0.2% . In comparison, Jenkins described a risk of 0.17% for cancer of the vaginal stump after a complete abdominal hysterectomy . Access to a cancer prevention screening is a prerequisite for LASH and the preservation of the uterine cervix: This might be important in countries without prevention systems. Patients should be informed about this before surgery, and alternatives like total hysterectomy should be discussed.
Lesion of vessels and bleeding
Of the 1584 cases of laparoscopic supracervical hysterectomies, Grosse-Drieling et al. reported six bleedings (0.38%) and one injury of the epigastric vein (0.06%) . Of the 1706 cases, Bojahr et al. reported one severe intraoperative bleeding : The dissection of the uterine artery can lead to heavy bleeding. It is recommended to coagulate the uterine arteries on both sides before cutting. During LASH, an uncontrollable uterine arterial bleeding can cause conversion to laparotomy: This especially occurs in large uteri. In addition, vessel lesions during LASH can be caused by the Veress needle or optical and auxiliary trocars. Thus, during the procedure, the risk for this type of complication is not different in comparison to other laparoscopic procedures in gynaecology. However, these accidents are rare and can be reduced by implementing the security rules in laparoscopic approaches. Intraoperative morcellator-related vessel lesions are extremely rare. Bojahr et al. reported no intraoperative complications caused by morcellation in more than 10,000 cases .
Hernia
The risk of trocar-site hernia depends on the diameter of the trocars used. Trocar size >10 mm is associated with an increased rate of hernia development . The electronic morcellators usually measure ≥12 mm. The risk of hernias after LASH is very low when closure of fascial incisions >10 mm is performed. However, some case reports exist that describe the herniation of 5-mm ports after laparoscopic surgery. This complication might be due to the prolonged manipulation of 5-mm trocars or drain placement at the port site with consecutive extension of the initial 5-mm incision .
Urinary tract injuries
Incidental cystotomy, ureteral lesions and postsurgical fistula formation are rare complications in LASH. In a systematic review of 43,357 cases, Adelman et al. reported an overall urinary tract injury rate of 0.23% and a bladder and ureteral injury rate of 0.05%, respectively with 0.12% for laparoscopic subtotal hysterectomy. In this review, the authors described a higher rate of ureteral lesions compared with bladder lesions in LASH (70.5% vs. 29.5%, respectively) . Usually, a ureteral injury can be easily avoided in LASH when the distance to the ureter in coagulation and dissection of the uterine arteries is secured by traction and medialisation of the uterus and/or the use of a uterine manipulator. As the uterine body is transected in the supracervical region, the preparation of the bladder can generally be avoided. The risk of bladder lesions is higher in patients with previous caesarean sections and/or adhesions. The risk of ureteral lesions increases in very large uteri, especially when the uterine body reaches the pelvic lateral walls. Very large or intraligamentary fibroids complicate the preparation of the ureter: In these cases, the positioning of the auxiliary trocars considering the switchover technique can help to reduce the risk of ureteral lesions. In case of very large and immobile uteri, the application of a pigtail catheter to the ureter can aid in avoiding lesions . Adelman et al. reported that 45.2% of the bladder lesions were recognized during surgery, but only 11.8% of the ureteral lesions . When injuries are recognized, they can be treated immediately by suturing, ureteral reanastomosis, ureteral reimplantation or stents. This extension of the surgical procedure may cause an increased operating time or conversion to laparotomy with prolonged hospital stay in some cases. However, when recognition of the lesion is delayed, a secondary surgery is warranted with added risk of fistulas. A history of caesarean section, previous abdominal surgery, endometriosis, adhesions, broad ligament and large fibroids as well as low-volume surgeons are the most common risk factors for urinary tract injuries in LASH.
Bowel lesions
Bowel lesions are rare in LASH. Of the 223 of LASH, Kafy et al. reported a case of bowel lesion by trocar injury . Of the 158 procedures, Cipullo et al. described one intestinal lesion when using a non-electronic cutting instrument . Other authors reported urinary tract injuries but no bowel lesions . An important prerequisite to avoid intestinal injuries is a full Trendelenburg positioning of the patient and a complete adhesiolysis of bowel adhesions in the pelvis before hysterectomy. Generally, bowel lesions can be caused not only by the Veress needle and trocar placement but also by using the monopolar hook or loop. Morcellator-related bowel lesions are very rare, but they have been reported .
Electronic power morcellation and complications
Complications caused by electronic power morcellation are rare. They can be divided into (1) direct intraoperative injuries like bowel or vessel lesions and (2) complications caused by dissemination of benign or occult malign uterine tissue during the use of the morcellator. Milad et al. and Naumann et al. reviewed data of the Manufacturer and User Facility Device Experience (MAUDE) Database on complications of electromechanical morcellation. Over a 10- and –11-year period, they reported 51 and 66 organ injuries by morcellation, in one and six cases of patient death, respectively . However, Bojahr et al. reported that no intra-operative complication was caused by the use of a morcellator in 10,731 laparoscopic supracervical hysterectomies . To avoid organ injuries or injuries caused due to the surgeon’s carelessness or the assistants in the operating room (OR), the morcellator should be in the switched-off mode until the initiation of the morcellation process under laparoscopic vision .
Electronic power morcellation and cell dissemination
Because of the potential tissue dissemination within the abdominal cavity, the Food and Drug Administration recently warned against the use of electromechanical power morcellation during hysterectomy and myomectomy . During the past years, many publications have discussed the risk of iatrogenic tumours in the abdominal cavity after LASH by implants of lost morcellated tissue fragments. Depending on the original uterine tissue, peritoneal myomatosis, adenomyosis, endometriosis and endosalpingiosis have been reported. In case of parasitic fibroids, Takeda et al. showed that the peritoneal myomata after laparoscopic hysterectomy are identical to the initial uterine tissue in histology and immunohistochemistry . Miyake et al. proved that the parasitic myomata are genetically benign metastasis of the original myoma . In a literature review of 44 publications, Van der Meulen et al. identified 69 women with parasitic myomas after laparoscopic morcellation. The overall complication risk was 0.12–0.95% . The median time between surgery and diagnosis was 48 months. In benign cases, the parasitic fragments can cause pelvic pain, vaginal bleeding and dysfunction of bladder, bowel and ureter with subsequent secondary surgical interventions by laparoscopy or laparotomy. Due to a parasitic fragment of a morcellated uterus 5 months after initial LASH, Holloran-Schwartz et al. reported a small bowel resection by laparotomy .
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