Laparoscopic Supracervical Hysterectomy
Frank Tu
INTRODUCTION
Hysterectomy is performed for a wide variety of female health indications, including symptomatic uterine fibroids, uncontrolled uterine bleeding, persistent pelvic pain, and malignancy. In the United States, most hysterectomies continue to be performed by an abdominal approach. However, laparoscopic approaches to hysterectomy need to be understood better, due to their improved recovery, reduced infection risk, and faster recovery relative to abdominal hysterectomy.
The technique of laparoscopic hysterectomy has the same surgical risks as abdominal or vaginal approaches (see Complications box on page 50). The use of electrosurgery is more common when performing laparoscopy, so the surgeon should strive to keep the active elements of all energy devices in clear view at all times during the procedure to minimize the risk of an iatrogenic injury. The reduced ability to retract tissue during laparoscopy also may be a source of increased complications and prolonged operating time, and surgeons should be aware of the number of tissue and uterine retractors available in the modern operating room. The decision to remove the cervix or adnexa at the time of surgery must be individualized. However, with modern cervical screening methodology, only a minority of women will need invasive cervical evaluation and far fewer a subsequent removal of the cervix after a laparoscopic supracervical hysterectomy is performed. Performance of a laparoscopic supracervical hysterectomy may require that the surgeon be familiar with the use of the laparoscopic morcellator.
PREOPERATIVE CONSIDERATIONS
Initial workup of a uterine disorder such as symptomatic uterine leiomyoma or menorrhagia should follow normal practice, including a history, physical exam, laboratory studies, and appropriate imaging. A preoperative endometrial biopsy, when appropriate, may also reduce the risk of morcellating a malignant uterus. However, even with a rapidly enlarging uterus, the risk of an undetected sarcoma is estimated at less than 0.1%. Documentation of an up-to-date normal pap smear, and a clear understanding of the patient’s history of cervical pathology, is essential. Careful patient selection is very important in completing a laparoscopic hysterectomy in a timely, safe fashion. Roughly 80% of hysterectomies done are for uteri 12 weeks in size or less, and should not present problems for most surgeons otherwise comfortable with operative laparoscopic surgery. However, if uterine size is a concern, the most important issue is to determine how accessible the uterine pedicles are to the laparoscopic surgeon. A bimanual exam can determine whether the lower uterine segment is free, and usually the presence of subserosal leiomyoma does not influence the likelihood of surgical success.
General contraindications to undergoing laparoscopy (cardiopulmonary compromise, history of severe pelvic infections, etc.) and relative contraindications (morbid obesity or multiple prior laparotomies, especially those involving bowel surgery) need to be considered before choosing the appropriate route of surgery, but the vast majority of patients will be able to take
advantage of the smaller incisions and faster outpatient recovery of laparoscopic surgery. Preoperative bowel preparation in selected patients, based on the preferences of the surgeon or colorectal consultant, may be of value in high-risk patients where extensive bowel dissection is anticipated. A single preoperative dose of a third-generation cephalosporin as first-line prophylaxis is recommended; alternatively, penicillin-allergic patients can be given macrolide and aminoglycoside combinations. Use of thromboembolic prevention measures such as sequential compression devices, or low-dose molecular weight heparin should be applied based on individual risk profiles. Following is a brief description of the surgical procedure used (see also video: Laparoscopic Supracervical Hysterectomy).
advantage of the smaller incisions and faster outpatient recovery of laparoscopic surgery. Preoperative bowel preparation in selected patients, based on the preferences of the surgeon or colorectal consultant, may be of value in high-risk patients where extensive bowel dissection is anticipated. A single preoperative dose of a third-generation cephalosporin as first-line prophylaxis is recommended; alternatively, penicillin-allergic patients can be given macrolide and aminoglycoside combinations. Use of thromboembolic prevention measures such as sequential compression devices, or low-dose molecular weight heparin should be applied based on individual risk profiles. Following is a brief description of the surgical procedure used (see also video: Laparoscopic Supracervical Hysterectomy).
SURGICAL TECHNIQUE
a. Patient placement: With the patient in the dorsal lithotomy position on the operating room table, care should be taken to ensure that the knees, hips, and ankles are in neutral positions, with the hips slightly flexed, and the knees bent at 90°. This will minimize the risk of nerve injury, while also allowing full instrument mobility, particularly when rotated low over the lower abdomen. We prefer to pad and tuck the arms at the patient’s sides to reduce risk of ulnar nerve injury.
b. Port and instrument placement: Three to four laparoscopic ports are placed to allow full use of endoscope, graspers, vessel sealers, and a morcellator. Two lower lateral quadrant ports should be placed, taking care to avoid the epigastric vessels and the ilioinguinal and iliohypogastric nerves. If a suprapubic port is chosen, the bladder can be retrofilled to identify its boundary, or else a point 2 to 3 cm above the symphysis pubis is selected. At least one 10 cm or larger port is usually needed for specimen retrieval. We routinely use a uterine manipulator such as a ZUMI™ (Cooper Surgical, Trumball, CT), and define the vaginal fornices using forniceal delineation rings. Sponge sticks inserted into the fornix are also a practical alternative when trying to dissect the bladder off the cervix. The bladder is generally decompressed with a Foley during the entire case. Gas insufflation tubing attached to one of the ports allows continuous inflow of CO2 during the case to maintain a pneumoperitoneum between 12 and 15 mmHg.
A midline endoscopic camera (5 to 10 mm) is used to guide the procedure, but can be moved to offer alternate views, particularly of the ureters’ courses. Choice of the initial entry port needs to take into account prior surgical scars, but a midline infraumbilical or left upper quadrant (LUQ or Palmer’s point) entry is the most commonly used. An orogastric tube should be used to decompress the stomach if the LUQ approach is used. Particularly with larger uteri, where the fundus approaches 16-week size or greater, a higher camera placement, usually 3 to 4 cm above the umbilicus, may afford a better view. The lower quadrant ports can be moved a similar distance superiorly, but should still be able to reach the lower pelvis. There are little differences when choosing an open entry technique versus a closed approach, using insufflation needle preinsufflation followed by trocar insertion, in reducing the risk of entry-associated bowel or vascular injury. Surgeons should use what they have the most experience with and as dictated by the clinical circumstance. In general, we insufflate through a insufflation needle placed through the umbilicus when it is accessible, even if the camera port will be placed higher, to take advantage of the easier entry into the peritoneal cavity due to the fusion of the abdominal fascia at this point.
c. Retraction and initial inspection: We begin the procedure by using atraumatic graspers to bring the mesentery of the small bowel, the ileocecal valve, and the rectosigmoid reflection of the large bowel to above the sacral promontory, thus exposing the pelvic cavity. If obstructing adhesions need to be released, these should be done carefully. Careful inspection of the entire pelvic cavity and pelvic diaphragm should be performed. Examining the peritoneum at close proximity to uncover occult disease should be done first, as positive findings may dictate converting the case immediately. The ureters’ courses should be identified next, and for complex cases, preemptive ureteral stenting may facilitate identification and dissection from dense periureteral scar tissue if necessary.
d. Uterine dissection: The round ligaments are identified, and the uterus is retracted contralaterally from the operating side. The round ligaments can be desiccated and divided with either a vessel-sealing device (monopolar, bipolar,
ultrasonic), or they can be tied off and transected sharply—most surgeons prefer to use the more efficient energy-based methods. The broad ligament is then opened up anteriorly and posteriorly with blunt and sharp dissection parallel to the infundibulopelvic vessels as far as needed. At this point the utero-ovarian ligaments (if the ovaries are to be preserved; Figure 5.1) or the infundibulopelvic ligaments (if the ovaries are to be removed) are transected (see also Chapter 8).
ultrasonic), or they can be tied off and transected sharply—most surgeons prefer to use the more efficient energy-based methods. The broad ligament is then opened up anteriorly and posteriorly with blunt and sharp dissection parallel to the infundibulopelvic vessels as far as needed. At this point the utero-ovarian ligaments (if the ovaries are to be preserved; Figure 5.1) or the infundibulopelvic ligaments (if the ovaries are to be removed) are transected (see also Chapter 8).