Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-trained Minimally Invasive Gynecologic Surgeons

Study ObjectiveThe objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons.DesignA retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009 and 2019 performed exclusively by fellowship-trained surgeons.SettingDivision of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston.PatientsAll patients undergoing laparoscopic hysterectomy by one of 5 surgeons with fellowship training in MIGS.InterventionsNone.Measurements and Main ResultsA total of 5160 cases were handled by MIGS surgeons between 2009 and 2019 at our institution. Of these cases, 2345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had undergone previous surgeries, and the most common indications for hysterectomy included uterine myomas, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. Most patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification.ConclusionUreteral injury, although rare, is more prevalent in gynecologic surgery than in other surgical disciplines that have some focus on the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications.     

Total laparoscopic hysterectomy: a tried and tested technique

Gynecologists are increasingly adopting total laparoscopic hysterectomy as their preferred method for performing a hysterectomy. The laparoscopic approach offers a superior view of the anatomy, facilitates meticulous hemostasis, enables the surgeon to perform adnexal surgery and pelvic reconstructive surgery, and reduces morbidity associated with large abdominal incisions. During the last 10 years, the surgeons at the Sydney Women's Endosurgery Centre (SWEC) have developed a laparoscopic technique using the same well-known steps as in the open abdominal approach. The ovarian pedicles are ligated, the uterine pedicles and vaginal vault are sutured laparoscopically, and some novel time-saving maneuvers are adopted.     

Safe total intrafascial laparoscopic (TAIL™) hysterectomy: a prospective cohort study

This study directly compares total intrafascial laparoscopic (TAIL™) hysterectomy with vaginal (VH) and abdominal (AH) hysterectomy with regard to safety, operating time and time of convalescence. The study is a prospective cohort study (Canadian Task Force classification II-2), including data from patients of a single university-affiliated teaching institution, admitted between 1997 and 2008 for hysterectomy due to benign uterus pathology. Patient data were collected pre-, intra- and postoperatively and complications documented using a standardised data sheet of a Swiss obstetric and gynaecological study group (Arbeitsgemeinschaft Schweizerische Frauenkliniken, Amlikon/Switzerland). Classification of complications (major complications and minor complications) for all three operation techniques, evaluation of surgeons and comparison of operation times and days of hospitalisation were analysed. 3066 patients were included in this study. 993 patients underwent AH, 642 VH and 1,431 total intrafascial hysterectomy. No statistically significant difference for the operation times comparing the three groups can be demonstrated. The mean hospital stay in the TAIL™ hysterectomy, VH and AH groups is 5.8 ± 2.4, 8.8 ± 4.0 and 10.4 ± 3.9 days, respectively. The postoperative minor complications including infection rates are low in the TAIL™ hysterectomy group (3.8%) when compared with either the AH group (15.3%) or the VH group (11.2%), respectively. The total of minor complications is statistically significant lower for TAIL™ hysterectomy as for AH (O.R. 4.52, CI 3.25–6.31) or VH (O.R. 3.16, CI 2.16–4.62). Major haemorrhage with consecutive reoperation is observed statistically significantly more frequent in the AH group when compared to the TAIL™ hysterectomy group, with an O.R. of 6.13 (CI 3.05–12.62). Overall, major intra- and postoperative complications occur significant more frequently in the AH group (8.6%) when compared to the VH group (3%) and the TAIL™ hysterectomy group (1.8%). The incidence of major complications applying the standardised TAIL™ hysterectomy technique is not related to the experience of the surgeons. We conclude that a standardised intrafascial technique of total laparoscopic (TAIL™) hysterectomy using an anatomically developed special uterine device is associated with a very low incidence of minor and major intra- and postoperative complications. The direct comparison of complication rates with either vaginal or abdominal hysterectomy favours the total laparoscopic technique, and therefore, this technique can be recommended as a relatively atraumatic procedure. The operation times are comparable for all three techniques without any statistically significant differences. This technique for laparoscopic hysterectomy is shown to be equally safe when applied by experienced gynaecologic surgeons or by residents in training.     

Laparoscopic supracervical hysterectomy versus laparoscopic total hysterectomy: a prospective randomized study

AIM: The aim of this study was to compare surgical complications and clinical outcomes after supracervical versus total laparoscopic hysterectomy for the control of abnormal uterine bleeding or symptomatic uterine leiomyomata. METHODS: We conducted a prospective randomized trial on 141 patients who had laparoscopic hysterectomy for symptomatic uterine leiomyomata, abnormal bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a supracervical or total laparoscopic hysterectomy. We compared surgical complications and clinical outcomes for 2 years after randomization. RESULTS: Seventy-one participants were assigned to supracervical laparoscopic hysterectomy (SLH) and 70 to total laparoscopic hysterectomy (TLH). Hysterectomy by either techniques led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain and urinary incontinence. Patients assigned to SLH tended to have more hospital readmissions than those randomized to TLH. There were no statistically significant differences in the rate of complications, degree of symptoms improvement, or activity limitation. Participants weighing more than 100 kg at study entry were more than twice as likely to be readmitted to the hospital during the 2-year of follow-up (OR 2.48, 95% CI 0.11; 1.91, P=0.04). CONCLUSIONS: We did not observe statistically significant differences between SLH and TLH in surgical complications and clinical outcomes during the 2-years of follow-up.     

Laparoscopic-assisted Doderlein hysterectomy: retrospective analysis of 300 consecutive cases.

OBJECTIVE: To assess the clinical outcomes of the Doderlein laparoscopic-assisted hysterectomy. DESIGN: A retrospective study. SETTING: Women's Endoscopic Laser Foundation at South Cleveland Hospital, Middlesbrough and St James's University Hospital, Leeds. POPULATION: Three hundred consecutive women who had a laparoscopic-assisted Doderlein hysterectomy. METHODS: Patients were identified from the laparoscopic hysterectomy theatre log at both sites. Case notes were requested and examined. MAIN OUTCOME MEASURES: Operative time, uterine weight, associated pelvic pathology, blood loss, hospital stay, intra-operative and post-operative complications. RESULTS: The operations were performed by eight different surgeons, seven of whom were laparoscopic trainees. The mean operating time was 102 minutes (SD 30). Additional surgery including unilateral or bilateral salpingo-oophorectomy, was carried out in 247 patients (82%). The mean uterine weight was 140 g (SD 74). One hundred and thirty-two women (44%) had a normal pelvis at hysterectomy. The mean drop in haemoglobin and haematocrit was 1.46 g (SD 0.95) and 4.4% (SD 2.8), respectively. The overall complication rate was 18%, of which 6.2% were classed as major. The major complications included four cystotomies, five unscheduled laparotomies, seven post-operative blood transfusions, one pulmonary embolus and two re-operations (within six weeks). The mean hospital stay was three days. CONCLUSIONS: Laparoscopic-assisted Doderlein hysterectomy is an alternative to standard laparoscopic hysterectomy techniques. It has the advantage of being easy to learn and is associated with low complication rates, compared with other laparoscopic and traditional techniques for hysterectomy.     

Laparoscopic myomectomy for symptomatic uterine myomas

OBJECTIVE: To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas. DESIGN: Medline literature review and cross-reference of published data. RESULTS: Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately. CONCLUSION(S): Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.     

The scope of vaginal hysterectomy

OBJECTIVE: The study was designed to check the feasibility of the vaginal route as the primary route for hysterectomy. STUDY DESIGN: All patients in whom hysterectomy was indicated were first considered for vaginal hysterectomy unless this route was contraindicated. Vaginal hysterectomy (VH) was performed in 5655 patients, and in 90.4% of these no uterine prolapse was present. The operative intervention required, preconditions and any complications were carefully studied. RESULTS: Of the 6945 cases considered, vaginal hysterectomy was possible in 5655 (81%). Successful simultaneous prophylactic oophorectomy or salpingo-oophorectomy was possible, in 1510 of 1572 cases without laparoscopic assistance. The indications are carefully discussed, with a strong emphasis on examination under anaesthesia, preoperative total uterine volume and, if required, laparoscopic evaluation and surgeons' readiness to reduce the frequency of recourse to laparotomy or laparoscopic assistance. CONCLUSION: The vaginal route is the least invasive and most economical route for hysterectomy and should be the gynaecological surgeon's first choice. A uterus with a volume up to 300 cm3 or uterine size up to 12 weeks should be dealt with vaginally, and as surgeons become more experienced larger uteri and also the adnexa can be approached in the same manner, at least as trial vaginal hysterectomy.     

Laparoskopische Operationsverfahren in der Gynäkologie

The international significance of, for example, vaginal surgical techniques has been increased by laparoscopy. Surgery for extrauterine pregnancy, or adnexectomy and partial adnexal resection are only carried out with a laparotomy in exceptional cases; for the therapy of benign uterine diseases this is used in less than 10% of cases. The spectrum of laparoscopy ranges from endometrial ablation over hysteroscopic resection and laparoscopic enucleation of myomas, to the various types of hysterectomy: laparoscopic assisted vaginal hysterectomy (LAVH), laparoscopic assisted supracervical hysterectomy (LASH) and total laparoscopic hysterectomy (TLH). In addition, tumor surgery can be carried out, either partially or completely, using laparoscopy. Laparoscopic pelvic and para-aortic lymphadenectomy are also established techniques. Endoscopic surgical techniques are still not as widely used as could be. In 2003, 60% of hysterectomies in Germany still involved abdominal surgery. Future developments in operative techniques require our particular attention, as do the establishment of already evaluated procedures in their total breadth, especially in the training of the younger generations of gynecologists.     

Laparoscopic-assisted Doderlein hysterectomy: retrospective analysis of 300 consecutive cases

Objective To assess the clinical outcomes of the Doderlein laparoscopic-assisted hysterectomy.
Design A retrospective study.
Setting Women's Endoscopic Laser Foundation at South Cleveland Hospital, Middlesbrough and St James's University Hospital, Leeds.
Population Three hundred consecutive women who had a laparoscopic-assisted Doderlein hysterectomy.
Methods Patients were identified from the laparoscopic hysterectomy theatre log at both sites. Case notes were requested and examined.
Main outcome measures Operative time, uterine weight, associated pelvic pathology, blood loss, hospital stay, intra-operative and post-operative complications.
Results The operations were performed by eight different surgeons, seven of whom were laparoscopic trainees. The mean operating time was 102 minutes (SD 30). Additional surgery including unilateral or bilateral salpingo-oophorectomy, was carried out in 247 patients (82%). The mean uterine weight was 140 g (SD 74). One hundred and thirty-two women (44%) had a normal pelvis at hysterectomy. The mean drop in haemoglobin and haematocrit was 1.46 g (SD 0.95) and 4.4% (SD 24), respectively. The overall complication rate was 18%, of which 6.2% were classed as major. The major complications included four cystotomies, five unscheduled laparotomies, seven post-operative blood transfusions, one pulmonary embolus and two re-operations (within six weeks). The mean hospital stay was three days.
Conclusions Laparoscopic-assisted Doderlein hysterectomy is an alternative to standard laparoscopic hysterectomy techniques. It has the advantage of being easy to learn and is associated with low complication rates, compared with other laparoscopic and traditional techniques for hysterectomy.     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

Health technology assessment of surgical therapies for benign gynaecological disease

This chapter summarises the evidence of the benefits and harm of surgical therapies for benign gynaecological disease. We have limited the discussion in this chapter to three gynaecological conditions - menorrhagia, endometriosis and benign ovarian tumours - with a further section on the different surgical approaches for performing a hysterectomy for menorrhagia due to dysfunctional uterine bleeding and pelvic masses such as fibroids and benign adnexal masses. The currently available evidence suggests that there is little to choose between the four first-generation endometrial destruction techniques - laser ablation, transcervical resection of endometrium, vaporisation ablation and rollerball ablation - in terms of clinical efficacy and patient satisfaction. There is a paucity of evidence with regards to the comparison of the different second-generation endometrial-destruction techniques but current evidence suggests that bipolar radiofrequency ablation is more effective than thermal balloon ablation for treating menorrhagia. Overall, the second-generation techniques are at least as effective as first-generation methods but are easier to perform and can be done under local rather than general anaesthesia in some circumstances. Hysteroscopic endometrial ablation is an alternative to hysterectomy and should be offered to women with menorrhagia because of its high satisfaction rates, shorter operation time, shorter hospital stay, earlier recovery and reduced postoperative complications; hysterectomy remains the surgical option of choice for women with intractable menorrhagia despite repeated endometrial ablations and for those who do not wish under any circumstances to continue to have menstrual bleeding. The combined use of laparoscopic laser ablation, adhesiolysis and uterine nerve ablation has been shown to have a beneficial effect on pelvic pain associated with mild to moderate endometriosis. Current evidence also supports the use of laparoscopic treatment of minimal and mild endometriosis to improve the on-going pregnancy and live birth rate in infertile patients. The current available evidence suggests that the laparoscopic approach is superior to laparotomy for the surgical management of benign ovarian cysts. It results in less postoperative pain and a shorter postoperative hospital stay; it also costs less. With regards to the surgical approach for performing a hysterectomy for menorrhagia and benign pelvic masses, vaginal hysterectomy should be performed over laparoscopic and abdominal hysterectomy when possible. Where it is not possible to perform the hysterectomy vaginally, then laparoscopic hysterectomy can be employed instead of abdominal hysterectomy to avoid a laparotomy scar. There appears to be no significant advantage in performing a subtotal hysterectomy instead of the total removal of the uterine corpus and cervix.     

Surgical management of pelvic organ prolapse in women: laparoscopic or vaginal sacrocolpopexy?

OBJECTIVE: To compare the safety and the efficacy of the laparoscopic and vaginal technique for the surgical management of pelvic organ prolapse, with systematic support of the three compartments and prosthetic reinforcements. PATIENTS AND METHODS: Retrospective study of 154 patients presenting a stage 3 or 4 prolapse on one of the three compartments. Laparoscopic procedures were performed with subtotal hysterectomy, double synthetic prosthesis attached to promontory, and douglassectomy. Vaginal procedures were performed with vaginal hysterectomy, anterior colporrhaphy with a hammock using porcine skin collagen implant fixed by transobturator passages, unilateral sacral colpopexy and posterior colporrhaphy. Monitoring was performed at six months and then annually. RESULTS: The laparoscopic technique requires a more important operating time, but a shorter hospitalization. The discovery of three carcinoma reinforces the idea of the interest of uterine radical surgery in these patients. The tolerance of prostheses by laparoscopy is safe. The biological prostheses, introduced vaginally, offer the same advantages. The anatomical results in the medium term (30 months) seem more favorable to laparoscopy than transvaginal approach, as well as functional results but they still need to better evaluated. DISCUSSION AND CONCLUSION: The two techniques must coexist, ideally without competing with each other but rather complementarily, as the overall rate of recurrence, requiring additional procedure does not exceed 2%. It is therefore important that surgeons, who support prolapse, have a good comprehensive training of the laparoscopic and vaginal techniques.     

Delayed laparoscopic management of placenta increta

BackgroundTraditional methods of management of abnormal placentation are often associated with significant maternal morbidity. In an attempt to decrease such morbidity, we present a novel approach: delayed laparoscopic management.CaseA patient with placenta increta was delivered by Caesarean section, followed by closure of the uterine incision, with the placenta left in situ. The patient underwent total laparoscopic hysterectomy three weeks later. She did not receive any blood product transfusions, either at the time of Caesarean section or at the time of hysterectomy.ConclusionA laparoscopic approach may be considered for delayed surgical management of abnormal placentation. Key factors for success consist of a multi-disciplinary approach, the availability of skilled laparoscopic surgeons and advanced endoscopic equipment, and the availability of resources in the event of complications     

Laparoscopic hysterectomy in patients weighing 100 kg or more: a 7-year experience

Obesity is an increasingly prevalent condition in our society. The majority of hysterectomies are still being undertaken abdominally. Obese patients have a high rate of complications from abdominal surgery. Laparo-vaginal hysterectomy has a faster recovery than abdominal hysterectomy. If the uterine vessels are ligated laparoscopically at laparo-vaginal hysterectomy, there is a low conversion rate to abdominal hysterectomy. The aim of this study was to establish whether laparoscopic hysterectomy is a feasible alternative in obese patients. A 7-year audit of patients requiring a hysterectomy identified 27 women weighing 100 kg or more. All patients gave informed consent to an initial laparoscopic procedure, having been assessed as suitable for such, and then had a laparoscopic hysterectomy performed. Data regarding their operation was prospectively collected and retrospectively reviewed. All patients had successful laparoscopic hysterectomies with none requiring conversion to open operation, reoperation or readmission. There were no major complications. The postoperative stay was short (mean 2.4 days), but operation times were long (mean 175 min). Laparoscopic hysterectomy is a feasible alternative to abdominal hysterectomy in obese patients weighing 100 kg or more with low morbidity and fast recovery with short hospital stay.     

Retrospective study of the success rates and complications associated with total laparoscopic hysterectomy

AIMS: Laparoscopic techniques are being used increasingly more in gynecologic surgery and the introduction of modern laparoscopic instruments has allowed complex operations to be performed laparoscopically. The aim of this study is to evaluate our surgical technique with regard to the success of total laparoscopic hysterectomy (TLH) for the removal of the uterus, by analyzing its intraoperative and postoperative surgical outcomes and complications in the hope of reducing their occurrence. METHODS: A retrospective observational study was carried out at KK Hospital, Singapore, based on TLH operations performed from January 2001 to June 2005. The KOH Colpotomizer System and the RUMI Uterine Manipulator were the surgical methods used. RESULTS: 435 women consented for a TLH. 427 women (98.2%) had a successful TLH with three mini-laparotomy and five laparotomy conversions (1.8% failure rate). Injuries included bowel injury (four), bladder base bleeding (one), uterine perforation (one), uterovaginal fistula (one) and vaginal laceration (four). 21 women (4.8%) encountered major complications (defined as laparotomy conversion, excessive bleeding requiring blood transfusion, hemorrhage >or=1000 mL, ureteric injury, bowel injury and pulmonary embolus), which compares favorably with previous reports (4.0-11.0%) of laparoscopic hysterectomy. Our mean operating time, mean estimated blood loss, mean hospital stay and readmission rate are similarly comparable. CONCLUSION: TLH is associated with a high success rate, and low morbidity with few complications.     

Laparoscopic hysterectomy

STUDY OBJECTIVE: To determine the soundness of laparoscopic hysterectomy compared with vaginal and abdominal hysterectomy Design. Nonrandomized, uncontrolled, retrospective study (Canadian Task Force classification III). SETTING: Medium-size community hospitals. PATIENTS: One thousand six hundred forty-eight women undergoing laparoscopic hysterectomy, including those with uterine size 17 weeks' gestation or less. INTERVENTION: Laparoscopic hysterectomy staged as level 4, which includes laparoscopic dissection of the uterine artery. MEASUREMENTS AND MAIN RESULTS: The median duration of surgery was 36 minutes (range 24-104 min), compared with the usual 115 minutes for laparoscopic-assisted vaginal hysterectomy. Complication rate was 0.66%. No complications occurred in the last 3 years when the procedures included transillumination of the ureters. Although the costs associated with disposable equipment are high, the technique is cost effective. CONCLUSION: With proper training and ureteral transillumination, laparoscopic hysterectomy is safe and effective, and with stents, ureteral injury is avoided.     

Morbidity with total laparoscopic and laparoscopically assisted vaginal hysterectomy

We evaluated the operative and postoperative morbidity among 103 women who underwent total laparoscopic hysterectomy and 107 others who underwent laparoscopically assisted vaginal hysterectomy. Blood loss was significantly greater in the assisted vaginal hysterectomy group (178.0 ± 12.1 ml) than in the total hysterectomy group (130.2 ± 10.7 ml) (p < 0.001). Despite higher uterine weight in the total hysterectomy group, the operative time of both techniques was similar. The complications of both hysterectomies were also comparable. The results from our study suggest that the complication rates of laparoscopically assisted vaginal hysterectomy and total hysterectomy are similar. However, laparoscopically assisted vaginal hysterectomy is associated with increased blood loss.     

Total laparoscopic hysterectomy: indications, techniques and outcomes

PURPOSE OF REVIEW: The indications, techniques and outcomes of laparoscopic associated hysterectomy and especially total laparoscopic hysterectomy are thoroughly reviewed. RECENT FINDINGS: The original technique for total laparoscopic hysterectomy is detailed as it is still applicable. The total laparoscopic hysterectomy operation has not changed to any major degree over the past 15 years. The technique detailed works well and lessens the chance for a ureteral injury. Expansion of the technique has occurred in oncology. Evidence-based studies support the use of vaginal hysterectomy if possible over laparoscopic and abdominal hysterectomy. They also support a laparoscopic approach to hysterectomy over total abdominal hysterectomy. SUMMARY: Despite evidence-based studies, gynecologic surgical specialists have been slow to adopt both laparoscopic and vaginal hysterectomy into their practice. This trend may increase in the near future. Adoption of laparoscopic associated hysterectomy has been extremely slow.     

Laparoscopic management of early stage endometrial cancer

PURPOSE OF INVESTIGATION: The purpose of this study was to evaluate the feasibility of laparoscopic hysterectomy versus the transabdominal approach with systemic pelvic lymphadenectomy in early stage endometrial cancer. METHODS: From January 1996 to April 2002, 59 women were treated for endometrial cancer at the Department of Gynecology in Padova, Italy (29 by the laparoscopic technique and 30 by laparotomy). Every patient underwent hysterosalpingo-oophorectomy with systemic pelvic lymphadenectomy. RESULTS: Comparing the two techniques, operating time was longer and hospital stay was significantly shorter for laparoscopy; no differences were observed about the number of removed lymph nodes (range 5-33) or intra-postoperatory complications. CONCLUSION: The laparoscopic approach to endometrial cancer is certainly to be considered appropriate and efficacious, even if it requires skilled surgeons and adequate oncologic training. It is important to perform pelvic lymphadenectomy in all cases of early stage cancer.     

Total laparoscopic hysterectomy with laparosonic coagulating shears: a retrospective report of 200 consecutive cases

Despite 10 years of intensive education and training in Australia only around 14% of hysterectomies are performed with laparoscopic assistance. In particular total laparoscopic hysterectomy (TLH) has a poor penetration rate because of perceived technical difficulties that include instrumentation, prolonged operating times and an increase in complications. We present a series of 200 consecutive cases of TLH with very good results and propose that because of the many advantages that this technique offers that it should become the standard procedure for benign uterine disease.