Conventional Laparoscopic Hysterectomy Including Laparoscopic Supracervical Hysterectomy
Stephen E. Zimberg
Michael L. Sprague
Katrin S. Arnolds
General Principles
Definition
Hysterectomy is the most common nonobstetric operation performed in the United States with 602,457 procedures performed in 2003 alone.1 It is also the most common surgical procedure performed on women in Western countries, with 23.3% of women aged 18 years or older undergoing the procedure.2 The primary indication listed for hysterectomy are fibroids (31%), uterine prolapse (14.5%), endometriosis (11%), abnormal uterine bleeding (14%), and cancers of the genital tract (10%).3 Cohen revisited this using the 2009 United States Nationwide Inpatient Sample and found a decrease in the total number of hysterectomies performed, 479,814, in women 18 years of age or greater,4 with 86.6% performed for benign indications. Note that the decrease in numbers does not necessarily reflect a drop in the actual number of hysterectomies performed as this and the previous studies looked primarily at inpatient statistics and does not reflect the shift to the outpatient performance of these procedures. In fact, Loring et al.,5 looking at a large retrospective review of hysterectomies performed between 2004 and 2012, noting that, in 2004, 2 of 194 laparoscopic hysterectomies were performed in an outpatient setting, whereas, by 2012, 85% (293/344) were performed as outpatient procedures. Still, the study is instructive in that 56% were completed abdominally, 20.4% were performed laparoscopically, 18.8% done vaginally, and 4.5% performed with robot assistance. Furthermore, Wright et al.6 documented a change in the performance of hysterectomy for benign indications with the introduction of the robot between 2007 and 2010. In his study, there were 40% abdominal, 30.5% laparoscopic, 9.5% robot-assisted, and 19.9% vaginal showing that robotic and conventional laparoscopic approaches continue to decrease the numbers of abdominal procedures, although 40% or more are still done as an open laparotomy.
The access to laparoscopic minimally invasive hysterectomy also appears to be related to patient socioeconomic status and geographic location. Patel et al.7 studied a retrospective cohort of 32,436 patients from the 2010 Healthcare Cost and Utilization Project and noted 32% of the patients underwent laparoscopic hysterectomy (LH) compared to 67% abdominal hysterectomy. Stratifying this, women most likely to undergo LH were less than 35, Caucasian, and privately insured. Geographically in the United States, women in the Northeast were far more likely to have an LH compared to the Midwest and South. Our urban hospitals were more likely than rural, and teaching hospitals more likely than nonteaching, to offer LH with government-owned hospitals least likely to offer LH.
The goal of this chapter is to give the reader the tools to advance from the performance of hysterectomy by laparotomy to a laparoscopic, minimally invasive approach for most procedures.
Anatomic Considerations
Minimally invasive hysterectomy includes total laparoscopic hysterectomy (TLH), laparoscopic supracervical hysterectomy (LSH), robotic-assisted hysterectomy (RAH), and laparoscopic-assisted vaginal hysterectomy (LAVH). The basic technique for the laparoscopic portion of all of the subgroups is similar and will be described below as either the TLH or LSH.
There are few contraindications for the TLH approach because this technique can be used in both benign and malignant conditions. Additionally, most large uteri can be efficiently addressed using conventional laparoscopic techniques by an experienced surgical team. Kovac8 outlined three basic technical issues to determine the route of hysterectomy for benign disease as they are the difficulties that make most gynecologists apprehensive:
Adequacy of the vaginal passageway (e.g., virginity, orthopedic restrictions to the lithotomy position, and a narrow vagina of <2 fingerbreadths, especially at the apex of the vagina)
The size of the uterus (e.g., leiomyomata)
Potential, severe, extrauterine risk factors suggestive of serious pelvic disease (e.g., endometriosis, adnexal pathology, and adhesions)
Though Kovac originally described an algorithm of obstacles for the performance of vaginal hysterectomy, the use of conventional laparoscopy circumvents these obstacles and allows for a minimally invasive solution for each issue.
Particular consideration must also be paid to obesity in the performance of laparoscopic surgery. This affects up to 36.5% of Europeans and more than 39.5% of American patients. Guraslan and colleagues9 completed a retrospective review of 153 patients undergoing TLH stratified by BMI. The rate of conversion to laparotomy (9.8%), blood loss, total complications (5.9%), and length of stay did not vary between the groups and they concluded that LH was safe and feasible in the obese and morbidly obese population. This was echoed by Mathews10 though they noted potential issues with increased abdominal pressure and Trendelenburg positioning resulting in increased airway pressure and end-tidal CO1, in obese versus nonobese patients. Increased BMI did not appear to be associated with differences in blood loss, duration of surgery, length of stay, or complication rates.
Additionally, a relative contraindication to laparoscopy was thought to be the presence of a ventriculoperitoneal shunt. Cobianchi and colleagues11 examined this in a case series and literature review. They concluded that the current generation valves were unlikely to cause issues with gas leakage under 80 mm Hg, which is well below that of the current standard insufflation pressures of 10 to 15 mm Hg. A possible exception is laparoscopy immediately following a newly implanted shunt for both adults and children.
Imaging and Other Diagnostics
Gynecologic diagnostic centers use pelvic ultrasound as the first-line imaging technique for evaluation of gynecologic complaints such as pelvic pain, abnormal uterine bleeding, and pelvic masses. This has been the primary imaging modality of uterine evaluation, showing the number and extent of fibroids, presence of endometrial disease, and presence and characterization of adnexal masses. With the controversies surrounding power morcellation and undetected malignancy, diffusion-weighted MRI and diffusion tensor imaging have been shown to accurately diagnose preoperatively endometrial, myometrial, and cervical malignancies with great accuracy,12 though tissue diagnosis is the gold standard. In the absence of this, traditional MRI is a reasonable diagnostic tool for use in larger uteri prior to hysterectomy, particularly in the perimenopausal age range when malignancy is more common. Blood tumor markers, most notably CA125, have been used but with limited success. CA125 is elevated with uterine tumors, dependent on size, adenomyosis, and other inflammatory conditions in the abdomen, making it of limited diagnostic use. The combination of MRI and serum fractionated LDH may have a role for planning the surgical approach in suspicious myometrial lesions.
Preoperative Planning
Proper preoperative assessment will facilitate an efficient procedure. Patients for which hysterectomy is being considered should have a recent pap smear and an endometrial biopsy, as clinically indicated, to rule out cancerous or precancerous processes. Imaging, as suggested above, should be performed to document uterine and adnexal pathology.
Decisions must be made with the patients regarding hysterectomy type and approach. The mode of surgical approach is decided between total abdominal hysterectomy (TAH), transvaginal hysterectomy (TVH), or LH, and the type of hysterectomy is determined between LSH and TLH. Decisions must be made as to whether to remove or to keep the cervix in particular. Although ACOG guidelines continue to recommend vaginal hysterectomy in most cases, recent studies question that approach. Allam et al.13 completed a randomized controlled trial which found that although TLH had a longer operating time, there was less blood loss, fewer complications, and less postoperative pain than with TAH or VH. Similarly, Pokkinen et al.14 noted reduced need for analgesics in LH compared with vaginal hysterectomy.
Though supracervical hysterectomy has been performed as long as total hysterectomy, there are no studies that conclusively define the optimal procedure. Nesbitt-Hawes15 concluded that, given the currently available evidence, all forms of hysterectomy should be offered to women requiring hysterectomy. She noted that it could not be stated that LSH prevents long-term pelvic organ prolapse, offer improved sexual function, or reduce operative risk, though it does provide faster return to work. In a recent study from Italy, however, Saccardi et al.16 noted women in their LSH group reported a greater ease of recovery of sexual function as opposed to TLH.
Complicating the decision-making on the type of hysterectomy is the effect of TLH and LSH on ovarian reserve. Yuan and colleagues17 looked at ovarian reserve in patients undergoing total versus supracervical hysterectomy by assessing anti-müllerian hormone. Their data show serum AMH levels decreased significantly at 4 months posthysterectomy in patients in their 30s and 40s, with a much greater decrease in patients having a TLH over those with LSH. These data suggest that LSH is better than TLH in preserving ovarian function, and need to be considered when discussing with your patient.
Surgical Management
Positioning and Approach
The patient is first placed in dorsal lithotomy position with laparoscopic leg cradles such as Allen stirrups. This allows the legs to be cushioned and allows for access to the perineum, with flexion of the knees and hips to avoid neuromuscular injury.18 Intermittent compression devices are also placed on the calves at this time. As basic as it sounds, having an operating room table with ability to achieve adequate patient Trendelenburg position is of paramount importance (Fig. 8.2.1). Trendelenburg is often 35 degrees or greater to allow the intestine to migrate cephalad, thereby exposing the pelvic anatomy.
Securing the patient safely on the table is often a challenge, particularly with obese patients. We have been placing the patient directly on an egg crate mattress secured to the operating table as described by Klauschie and coworkers (Fig. 8.2.2).19 This allows for the use of Trendelenburg with minimal slippage and has the advantage of working even with the morbidly obese patient without extra straps or shoulder braces that can predispose to neurologic and other injuries in longer procedures. One particular axiom is that the larger the patient, the greater the Trendelenburg angle that is required for adequate visualization. Steep Trendelenburg position is not without consequences; however, ocular complications, alopecia, as well as nerve injury have been reported.20 Gould et al.21 reported the use of less Trendelenburg angle in a blinded trial which lowered the angle from 40 to 28 degrees, and found no difference in the operative times for pelvic surgery among 16 different surgeons.
 Figure 8.2.1. Placement of patient in Trendelenburg position. |
 Figure 8.2.2. Securing the egg crate mattress to operating table. |
Procedures and Techniques
Total laparoscopic hysterectomy
Step 1: Placement of uterine manipulator and bladder catheter
Before instrumentation of the patient, standard prophylactic antibiotics and DVT prophylaxis are administered. The Caprini (ACCP) score guidelines account for the type of surgery, obesity, previous VTE, and other complicating factors such as malignancy to determine need and dosing.22 Antibiotic prophylaxis and VTE prophylaxis should be based on BMI (and volume of distribution), not ideal weight.
A standard Foley catheter is placed to drain the bladder during the procedure. One can consider the use of a dual port (three-way) catheter to allow filling and draining of the bladder when significant lower uterine segment and bladder adhesions are anticipated or when encountered. This allows for rapid installation of saline to delineate the borders of the bladder and prevent incidental cystectomy. The surgeon can use blue dye if a cystotomy is encountered to assess the water tightness of closure.
A uterine manipulator with a pericervical cup is placed to allow for greater movement of the uterus with fewer ports to achieve the desired angles at which to operate. For both TLH and LSH, we use the V-Care uterine manipulator (ConMed Endosurgery, Utica, NY) (Tech Fig. 8.2.1). Other manipulators are available and may work equally well for these procedures. The cervix is grasped with a single-tooth tenaculum and dilated to 21 French. The manipulator is introduced and the balloon inflated. For the TLH, the cup of the manipulator is sewn onto the cervix to assist in tissue removal. For the supracervical procedures, the manipulator is placed without suturing.
 Tech Figure 8.2.1. V-Care uterine manipulator. |
Van den Haak and colleagues23 recently reviewed 25 articles covering 10 uterine manipulators. Interestingly, they found that though convenient, definitive documentation of efficacy and safety was scant. Their review did not find the “optimal” manipulator. There has also been speculation that dilatation of the cervix and placement of any manipulator may upstage an undiagnosed uterine endometrial carcinoma. Iavazzo and Gkegkes24 recently reported “the assumption that uterine manipulators can induce intra-operative dissemination of tumor cells is suggested to be a derivative of common sense. The existence of cases with positive peritoneal cytology after uterine manipulation cannot be determined with certainty, and whether manipulators result in metastasis at peritoneum or disease recurrence.” In cases where it is impossible to place a manipulator, use of a standard infant nasal suction bulb or bulb top of an Asepto syringe in the vagina will often delineate the vaginal edges (Tech Fig. 8.2.2).
 Tech Figure 8.2.2. Use of the bulb top of an Asepto bulb syringe. The bulb portion goes in the vagina first up against the cervix. |
Step 2: Placement of primary trocar
Our approach to initial trocar placement is predicated on factors including uterine size and type of previous abdominal surgery. For uteri 16 weeks pregnancy size or less, we place the camera port at the umbilicus (Tech Fig. 8.2.3). This is a 5-mm port for most patients, though 10-mm ports should be considered in more obese patients to prevent damage to the instruments and camera from torque. The angle of port insertion at the umbilicus should be 45 degrees for normal BMI patients and more toward a 90-degree angle with increasing obesity due to the position of the umbilicus in relation to the aortic bifurcation. We employ the direct optical insertion technique under direct vision rather than a blind Veress needle insertion. Tinelli et al.25 reported no statistically significant difference in complications between direct insertion and Veress needle, suggesting that the visual entry systems offer statistical advantage in terms of time savings and reduced minor vascular and bowel injuries. The key concept is not to be “wed to the umbilicus” or Veress needle.
 Tech Figure 8.2.3. Standard camera port placement for uteri 16 weeks or less. |
When the uterus is greater than 16 weeks size, then the camera port is placed above the umbilicus in the midline up to a level several centimeters below the lower costal margin (Tech Fig. 8.2.4). These should be placed at 90-degree angle to the abdominal wall to avoid tunneling and will give greater visualization of the pelvis. When there is a history of previous mid-abdominal or umbilical surgery such as hernia repair with mesh or colorectal surgery, the use of Palmer’s point in the left upper quadrant is preferable to avoid potential bowel injury on insertion.
 Tech Figure 8.2.4. Port placement for larger uteri with camera above the umbilicus in the midline. |
Step 3: Placement of secondary trocars
Once the patient is placed in Trendelenburg position, the abdomen is insufflated with CO1 to a final pressure of 12 to 15 mm Hg, and the secondary ports are placed under direct vision. If the operating surgeon is on the patient’s right side, then a 10-mm trocar is placed in the right lower quadrant above the anterior superior iliac spine (ASIS). The safe distances from the midline to avoid internal epigastric artery injury are 6 cm from the midline at the level of the ASIS and 9 cm off the midline at the level of the umbilicus.26 The exact placement depends on the size of the uterus as this port will migrate cephalad as the uterus enlarges. The second 5-mm trocar will be placed on the right side approximately 10 cm above the 10-mm trocar. The third 5-mm trocar is placed on the patient’s left side at approximately the same level as the right-sided port. If the surgeon is operating from the patient’s left side, then the port locations are reversed. For morbidly obese patients, consideration should be given to using all 10-mm ports to allow use of instruments with greater diameter and avoid damage to instruments due to torque.
Step 4: Instrumentation for optimal visualization
The insufflation tubing is placed on one of the lateral ports to decrease lens fogging. Efficient evacuation of smoke and water vapor from lysed tissue is essential for good visualization. We employ the AirSeal (Tech Fig. 8.2.5) insufflator (Surgiquest, Millford, CT, USA) which allows heated insufflation with CO1 and smoke evacuation from a single port (either 5 to 10 mm). Additionally, the device is calibrated to maintain a steady, preset pneumoperitoneum, even when the vaginal cuff is open, which is an advantage in TLH and obese patients.
 Tech Figure 8.2.5. AirSeal insufflation device. |
The general instrumentation used is in the standard laparoscopy sets available in most operating rooms. Soft bowel graspers, Maryland graspers, and single- and double-toothed tenaculums are the primary instruments for manipulation of tissue and bowel. Electrosurgical devices are used to coagulate blood vessels and cut tissue. We commonly use an ultrasonic device for dissection, vessel sealing, and tissue division, as one instrument can be used for most steps (Tech Fig. 8.2.6). Advanced bipolar devices (such as LigaSure [Covidien, Boulder, CO, USA], EnSeal [Ethicon Endo Surgery, Somerville, NJ, USA], PlasmaKinetic, and others) can also be used.
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