AAGL Practice Report: Practice Guidelines for Laparoscopic Subtotal/Supracervical Hysterectomy (LSH)

The first subtotal abdominal hysterectomy was described by Charles Clay in 1843, and the first laparoscopic subtotal hysterectomy (LSH) was described by Semm [1] in 1991. Whether to retain or remove the cervix remains controversial, with surgeons citing sexual satisfaction and prevention of pelvic organ prolapse as indicators for retention [2]. Because the only absolute indication for cervical removal is malignancy or its precursors, debate has continued as to the optimum surgical approach to hysterectomy for other indications. The evidence obtained from evaluating the effects of retaining the cervix, via any surgical approach, on sexual, urinary, and bowel function remains controversial 3, 4, 5, 6, 7, 8, 9, 10, 11. The literature evaluating LSH is limited, and only 3 randomized controlled trials (RCTs), including 342 women, have reported psychologic outcomes, complications, and additional cervical procedures 4, 12, 13. For the abdominal equivalent, there are 9 RCTs, including 1553 women, and a Cochrane review reported few important differences between the 2 approaches [8]. No such comparative data are available for LSH. This practice guideline will evaluate the evidence for LSH. This report was developed under the direction of the Practice Committee of the AAGL as a service to their members and other practicing clinicians.     

Laparoscopic hysterectomy with manual morcellation of the uterus: an original technique that permits the safe and quick removal of a large uterus

We present an original technique to rapidly extract a large uterus during laparoscopic hysterectomy. Manually morcellating the uterus is a safe and effective technique that overcomes the technical difficulties associated with traditional electrical morcellators.     

Pelvic Pain and Patient Satisfaction After Laparoscopic Supracervical Hysterectomy: Prospective Trial

Study ObjectiveTo evaluate the occurrence and intensity of cyclic pelvic pain and patient satisfaction after laparoscopic supracervical hysterectomy and to explore the effect of the procedure on pelvic pain relief in women with perioperative detection of endometriosis and in women with histologic confirmation of adenomyosis.DesignProspective observational study with 12-month follow-up after laparoscopic supracervical hysterectomy (Canadian Task Force classification II-2).SettingUniversity teaching hospital in Norway.PatientsOne hundred thirteen premenopausal women with preoperative cyclic pelvic pain treated via laparoscopic supracervical hysterectomy.InterventionsStudy participants underwent laparoscopic supracervical hysterectomy and were followed up at the outpatient clinic at 12 months after the procedure.Measurements and Main ResultsThe main outcomes were occurrence, intensity, and reduction of cyclic pelvic pain and patient satisfaction measured using an ordinal and a visual analog scale at 12 months after the procedure. Of the 113 women included in the study, 8 were lost to follow-up. Consequently, 105 women (92.9%) were followed up at 12 months after surgery. All women had cyclic pelvic pain preoperatively, but only 34 (32.4%) experienced this pain at 12 months after the procedure. The intensity of pelvic pain was reduced from a mean (SD) of 5.5 (2.4) preoperatively to 0.7 (1.5) at 12 months after the procedure on a visual analog scale of 0 to 10 (p < .01). Endometriosis was diagnosed perioperatively in 14 women (12.4 %), and adenomyosis was confirmed at histologic analysis in 19 (18.1%). In women with perioperative detection of endometriosis or histologic confirmation of adenomyosis, there were no significant differences in main outcomes at 12 months after laparoscopic supracervical hysterectomy when compared with women without these diagnoses.ConclusionLaparoscopic supracervical hysterectomy is associated with high patient satisfaction and reduces cyclic pelvic pain to a minimum by 12 months after the procedure.     

Comparison of re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH)

Objective

To compare re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH).

Study design

Retrospective analysis of 867 women who underwent laparoscopic hysterectomy between January 2002 and December 2009 for benign gynaecological diseases. Total laparoscopic hysterectomy was performed in 567 women (TLH group) and laparoscopy-assisted supracervical hysterectomy was performed in 300 women (LASH group).

Results

The women in the LASH group were significantly younger (45.6 years) than those in the TLH group (47.9 years) and the uteri removed with LASH were significantly heavier (326.4 g) than those removed with TLH (242.7 g). The rate of salpingo-oophorectomy was significantly lower in the LASH group. The overall re-operation rates were equivalent in the two groups. Two method-specific reasons for re-operations were identified. A method-specific procedure after LASH was extirpation of the cervical stump, which was performed in 2.7% of the women. Vaginal cuff dehiscence was a method-specific problem leading to secondary operation after TLH and was observed in 0.7% of the patients. No differences between the intraoperative and postoperative complication rates were observed, although there was a trend toward lower complication rates after LASH.

Conclusions

There seem to be equivalent overall re-operation rates and complication rates after both hysterectomy procedures, making the two laparoscopic approaches for hysterectomy equivalent.     

子宫肌瘤恶变及腹腔镜下播散的预防

子宫肌瘤临床常见,但子宫肌瘤发生肉瘤变则少见。子宫一旦发生肉瘤,其恶性程度高,易局部复发及远处转移,预后不佳。在早期常无有效的检查手段来进行筛查和鉴别。若将肉瘤当作肌瘤进行腹腔镜下直接旋切,必然导致肿瘤碎屑及细胞播散,引起盆腹腔的广泛转移。因此,如何早期进行鉴别诊断,术中如何避免旋切带来的播散成为治疗的关键。文章就子宫肌瘤,子宫肉瘤鉴别诊断、腹腔镜下肌瘤旋切手术播散的预防研究进行综述。     

Predictive Factors for Morcellation during Total Laparoscopic Hysterectomy: A Cohort Study

ObjectivesOur objective was to identify predictors of morcellation during a total laparoscopic hysterectomy (TLH).MethodsA retrospective cohort study (Canadian Task Force classification II-2) taking place in a university hospital center in Quebec, Canada. Participants were women undergoing a TLH for a benign gynaecologic pathology from January 1, 2017, to January 31, 2019. All women underwent a TLH. If the uterus was too voluminous to be removed vaginally, surgeons favoured in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed before surgery by ultrasound or magnetic resonance imaging to predict morcellation.ResultsA total of 252 women underwent a TLH and the mean age was 46 ± 7 (30–71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17–1572) ± 272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least 1 leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥250 vs. <250 grams; OR 3.7 [CI 1.8 to 7.7, P < 0.01]), having ≥ 1 leiomyoma (OR 4.1, CI 1.0 to 16.0, P = 0.01) and leiomyoma of ≥5 cm (OR 8.6, CI 4.1 to 17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis.ConclusionsUterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.     

Laparoscopic Single-Incision Supracervical Hysterectomy for an Extremely Large Uterus with Bag Tissue Extraction

Objective

To describe and demonstrate the single-incision laparoscopic technique with an articulated energy device for a uterus larger than 20?cm.

Total Laparoscopic Hysterectomy for Endometriosis and an Arteriovenous Malformation

Study Objective

To show laparoscopic management of an arteriovenous malformation in a patient with deep pelvic endometriosis

Transcatheter Arterial Embolization for Severe Secondary Hemorrhage after Hysterectomy

Four of 1237 patients who underwent abdominal, laparoscopic, and vaginal hysterectomy between October 2013 and May 2015 had severe secondary hemorrhage after hysterectomy (2 conventional multiport total laparoscopic hysterectomies, 1 single-port access hysterectomy, and 1 total abdominal hysterectomy). The median time interval between hysterectomy and secondary hemorrhage was 28.4 days (range, 16–52 days). All 4 cases were treated with transcatheter arterial embolization (TAE), all of whom required blood transfusions to maintain vital functions before TAE. The mean operative time was 90 minutes. The median length of hospital stay after TAE was 12 days (range, 4–24 days), and the patients were discharged without complications or additional surgery. These cases show the value of minimally invasive TAE for patients experiencing severe secondary hemorrhage after hysterectomy.     

Hysterectomy for benign gynaecological disease

Despite the advent of newer, and in some instances less invasive, interventions for the management of abnormal uterine bleeding, hysterectomy remains the most commonly performed major gynaecological operation. It continues to score highest in satisfaction rates. It is therefore imperative that all aspects of this operation are reviewed on a regular basis. For example, all evidence suggests that the vaginal route is the safest, most cost-effective approach affording rapid recovery, yet the majority of hysterectomies are still performed by the abdominal route. Newer approaches such as robotic surgery have captured the imagination of the enthusiasts, yet this approach is hugely expensive, and there are no data justifying its use over the laparoscopic or indeed the conventional approach. Quality of life should remain the principal outcome measure for hysterectomy for benign disease, and therefore the impact of the various approaches to hysterectomy should address this outcome. Complications of any new approach should be addressed, and the question that continues to elude an answer, namely why there are such widely and wildly varying rates of hysterectomy between surgeons in one hospital, between hospitals in one region, between the regions and between countries, should continue to be addressed, and perhaps one day the definitive study that will answer the question will be undertaken.     

Comparison of the Use of LigaSure,HALO PKS Cutting Forceps,and ENSEAL Tissue Sealer in Total Laparoscopic Hysterectomy: A Randomized Trial

Study ObjectiveThere are many instruments with different energy modalities or with different properties that are available for use in total laparoscopic hysterectomy. The aim of the study was to compare the use of LigaSure (Valleylab, Boulder, CO), HALO PKS cutting forceps (Gyrus-ACMI, Maple Grove, MA), and ENSEAL tissue sealer (SurgRx, Inc. Redwood City, CA) in total laparoscopic hysterectomy with respect to operation time and blood loss as main outcomes. Perioperative complications, return of gastrointestinal activity, and hospitalization time were assessed as secondary outcomes.DesignRandomized prospective study (Canadian Task Force classification I).SettingAdana Numune Training and Research Hospital.PatientsForty-five patients with the indication of hysterectomy were randomized into 3 groups for total laparoscopic hysterectomy. Patients with malignancies, having 3 or more previous abdominal surgeries, a uterus larger than 12 weeks of gestation, and who had to undergo additional surgical procedures during the same operation were excluded.InterventionsTotal laparoscopic hysterectomy.Measurements and Main ResultsOperations were completed in all 15 patients in the LigaSure and HALO PKS Cutting Forceps groups with the planned instruments. In 2 patients in the ENSEAL group, bleeding could not be controlled with ENSEAL, and additional instruments were used. One patient in the ENSEAL group had bladder injury. The mean operation time and blood loss were 52.4 ± 12.8, 51.86 ± 14.11, and 55.7 ± 15.7 minutes (p > .05) and 138 ± 54.3, 118 ± 63.3, and 218 ± 115.9 mL (p < .05) in the LigaSure, HALO PKS, and ENSEAL groups, respectively. Changes in hemoglobin/hematocrit levels, return of gastrointestinal activity, and hospitalization time did not differ between groups.ConclusionThese 3 novel bipolar platforms had similar results in total laparoscopic hysterectomy. These instruments were not determined to be independent predictors of operating time and amount of blood loss.     

Single port access laparoscopic subtotal hysterectomy using contained manual morcellation: Experience from a tertiary referral center in Taiwan

Objective

To describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure.

Laparoscopic and Robotic-Assisted Hysterectomy for Uterine Leiomyomas: A Comparison of Complications and Costs

Objective

Robotic surgery is increasingly being used for treatment of malignant and benign gynaecologic diseases. The purpose of our study is to compare patient perioperative complications and costs of laparoscopic versus robotic-assisted hysterectomy for uterine leiomyomas.

Implementation of a Same-Day Discharge Protocol Following Total Laparoscopic Hysterectomy

Objective

Previous studies have demonstrated that outpatient total laparoscopic hysterectomy (TLH) is both safe and feasible. Our objective was to decrease length of stay for patients undergoing TLH by implementing a same-day discharge protocol at two Canadian teaching hospitals.

Preoperative Factors That Predict the Need to Morcellate in Total Laparoscopic Hysterectomy

Study Objective

To determine which preoperative factors best predict the need for uterine morcellation at the time of total laparoscopic hysterectomy (TLH) and to identify cut-offs that can help guide clinical decision-making.

Evolution of the complications of laparoscopic hysterectomy after a decade: A follow up of the Monash experience

A retrospective review of medical records was performed to assess the incidence and types of significant complications encountered during laparoscopic hysterectomy which would affect the use of a laparoscopic approach versus other routes of hysterectomy. A total of 526 consecutive patients' medical data between January 1994 and August 2007 were reviewed. Two hundred and thirty-two laparoscopic-assisted vaginal hysterectomies and 294 total laparoscopic hysterectomies were performed at Monash Medical Centre, a Melbourne tertiary public hospital, and three Melbourne private hospitals, by or under the supervision of three surgeons. Sixteen significant complications occurred. There were two cases of ureteric fistula, two bladder injuries, two bowel obstructions, four postoperative haematomas, one case of a bladder fistula, four conversions to laparotomy and one superficial epigastric artery injury. Inpatient stay ranged from two to six days. Our complication and inpatient stay rates are consistent with the previously reported rates, although there has been a reduction of incidence of visceral injuries with experience and introduction of new equipment.     

Inpatient Laparoscopic Hysterectomy in the United States: Trends and Factors Associated With Approach Selection

Study Objective

To examine utilization patterns of different laparoscopic approaches in inpatient hysterectomy and identify patient and hospital characteristics associated with the selection of specific laparoscopic approaches.