Laparoscopic Hysterectomy

It has now been approximately 10 years since laparoscopically assisted vaginal hysterectomy (LAVH) was first performed.¹ In that time span, the procedure seems to have followed the typical course of any new medical intervention. Initial innovation was followed by widespread adoption, which in turn produced new information about complication rates^2,3 and cost-effectiveness.^2,4 Appreciation of the challenges of laparoscopic surgery seems to have prompted a reevaluation of LAVH and attempts to define its appropriate niche.⁵ The purpose of this chapter is to review what we have learned and to propose ways of preserving the advantages of laparoscopic surgery while minimizing its risks.

Starting in the 1970s, innovative laparoscopists teamed up with surgical instrument manufacturers to devise many new laparoscopic surgical tools. These were employed in progressively more difficult laparoscopic surgical procedures over an approximately 10- to 15-year period. With the introduction of lasers in the early 1980s, operative laparoscopy entered an exponential phase of growth and development. Finally, with the development of the laparoscopic stapling devices, the strongest proponents of operative laparoscopy believed that virtually every gynecologic procedure done for benign disease could and should be performed laparoscopically. Patient demand was fostered by the labeling of such procedures as “minimally invasive,” which was hardly the case.

These rapid developments placed the practicing gynecologist in the difficult position of needing to learn an entirely new set of surgical techniques, usually without the opportunity of learning them in the way surgical techniques have traditionally been taught: by direct tutoring at the hands of those who developed the procedures, or who were well skilled in their performance. The results were predictable. Those surgeons with the natural skills suited to the task, as well as sufficient patient volume to allow a rapid climb up the learning curve, experienced remarkable success. Others less inherently inclined to laparoscopic procedures and with smaller patient volumes experienced frustration, difficulties, and complications. Several recent series have suggested that in these early years, complications in general, and injuries to the urinary tract in particular, were more common with LAVH than with other approaches.^2,3

We are now poised at a moment when new innovations such as the supercervical laparoscopic hysterectomy and the total laparoscopic hysterectomy promise to be constructive forward steps. Combined with preemptive analgesic techniques, true improvements in patient care are possible. Our challenge is to promulgate these new approaches and skills in a manner that minimizes the potential for complications.

In the 1960s and 1970s, Dr. Kurt Semm of Germany developed many approaches for basically replicating open surgery techniques using laparoscopic instruments. The technologic advantages taking place between 1975 and 1990 were largely aimed at simplifying these approaches and making them usable in the hands of endoscopic surgeons with more average skills. Staples, monopolar and bipolar cautery scissors, carbon dioxide laser, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, harmonic scalpel, the argon beam coagulator, and instruments that combine cautery and cutting functions each have their advocates as well as particular surgical situations in which an individual method may have advantages over the others. It would seem that the particular advantages of one method of dividing tissue over another lie not so much in the method itself as with the experience and comfort of the user in employing the technique. Having tried virtually all of these methods in most of the advanced endoscopic surgical procedures currently performed, I have gradually moved back to a laparoscopic surgical approach that closely replicates the techniques used during standard open procedures.

Another substantial area of concern in the field of operative laparoscopy is how new knowledge and techniques have been taught to physicians in practice. Many of the early results of operative laparoscopy were reported from those who were expert in this type of surgery. When less experienced physicians became acquainted with the techniques during brief courses, they found that their implementation represented a greater challenge than perhaps they had anticipated. In the absence of direct tutoring opportunities, physicians stretched their surgical limits on their own, perhaps with the benefit of some information from industry representatives. Although some physicians have voluntary reported laparoscopic complications,⁶ many almost certainly have not, except as suggested by frequently heard rumors of medical legal action. Pressured by apparent and real patient demand, many physicians went from the simplicity of laparoscopic tubal cauterization to the complexity of LAVH with relatively few steps in between.

In recent years, more training programs have incorporated extensive experience in operative laparoscopy. In these teaching settings, the surgery is learned by the more traditional method of direct tutoring by experienced operators. It is hoped that this will lead to improved selection of patients for the procedure and a more gradual approach to progressively more difficult cases by the individual physician.

The reader must recognize that all of the following impressions are undergoing rapid change as the field evolves. Approximately 1% to 3% of conventional vaginal hysterectomies are converted to abdominal procedures because of inability to remove an enlarged uterus, bleeding, or other complications. In reported series approximately 1.6%² to 9%⁷ of LAVHs are converted to abdominal procedures. In most situations, however, this decision has been due to difficulties with exposure rather than bleeding. It would appear that this may represent good surgical judgment, rather than a true “complication” of the LAVH procedure.

One large Finnish series of 1186 LAVHs³ and a recent meta-analysis² have reported similar complication rates. In the Finnish series, 2.1% of the procedures were converted to laparotomy. There were urinary tract complications in 2.7% of cases (1.5% were bladder perforations and 1.2% ureteral injuries). In the meta-analysis,² a similar 4% overall major complication rate was cited, which is somewhat greater than that generally reported for total abdominal hysterectomy, but similar to that reported for vaginal hysterectomy.

The risk of febrile morbidity associated with LAVH is extremely low, especially because prophylactic antibiotics are generally employed.^8,9,10 Greatest concern has been expressed about the potential for LAVH to cause bladder and ureteral injury. I believe that these injuries are due to the use of techniques that depart from the traditional surgical basics of adequate exposure and traction-countertraction (see later discussion).

A greater amount of information is available on comparing the general outcomes of LAVH versus vaginal or abdominal approaches.^2,3 In general, the LAVH patient has a shorter hospital stay, has less postoperative pain, and returns to usual activities earlier than the patient undergoing total abdominal hysterectomy. Compared to vaginal hysterectomy, however, LAVH offers no advantages in these areas.¹¹

All published series have reported that there is substantially less postoperative pain after LAVH compared to total abdominal hysterectomy,⁴ whereas postoperative pain was similar in a randomized series of LAVH versus vaginal hysterectomy procedures.¹¹ The impact on length of stay is perhaps more difficult to evaluate, as ever-greater pressure is being placed on physicians for early discharge, most of the energy coming from the growing managed-care industry. Nevertheless, it would appear that the average LAVH patient can be discharged from the hospital on the day after surgery, whereas the average abdominal hysterectomy patient is likely to be hospitalized for 2 to 3 days after the surgery. The average hospital stay for vaginal hysterectomy, as reported in several studies, is approximately 2 days.^8,10,11

In a similar manner, return to usual activities is difficult to measure, as the choice of when to return to work may be influenced by variables other than postoperative comfort and energy alone. Nevertheless, in a meta-analysis,² the range was 2 to 6 weeks for LAVH versus 5 to 9 weeks for abdominal hysterectomy patients.

Perhaps the most difficult discussion has centered around the cost of the various procedures. Although LAVH is clearly more expensive than vaginal hysterectomy,² the differences are less clear when LAVH is compared to abdominal hysterectomy. In most studies, LAVH was found to be slightly more expensive than abdominal hysterectomy, with most of the difference being accounted for by increased operating room time and disposable instruments. Most of the published series involve data compiled before the substantial reductions that have occurred in recent years in the cost of disposable instruments.^9,12,13,14 Together with a return to more reusable laparoscopic instruments, the cost of instrumentation should decrease substantially. As more physicians move further along the learning curve, and reusable instruments are emphasized, the LAVH may prove to have a financial advantage as well as the other advantages described earlier.

The following is a review of more recent innovations that may serve to make the LAVH safer as well as applicable to a larger number of patients. The utilization of all of these approaches presumes that the operator will employ the safety measures described in the next section.

The Koh vaginal ring (“colpotomizer”) is one innovation that I have found particularly useful. I use it in conjunction with a Zumi uterine manipulator in most cases. The ring identifies the vaginal fornices exceptionally well. It is of particular benefit when used in conjunction with the method of dividing the uterine arteries (seeSpecific Techniques For Laparoscopic Hysterectomy). This combination allows the hysterectomy to be performed entirely laparoscopically, removing the uterine specimen through the vagina once it has been totally separated from all pelvic attachments. If the uterus is too large it can be morcellated via laparoscopy. Either a large 10 mm laparoscopic scissors or a Semm coring device will accomplish the task. Once the uterus has been removed by either method, the vaginal cuff can then be sutured closed either laparoscopically or vaginally, depending on which method seems easier and faster in the individual case. Using this approach, I have succeeded in performing total laparoscopic hysterectomies in nulliparous women weighing in excess of 250 lb.

Some interest in the supercervical hysterectomy has recently developed.¹⁵ Purported advantages include avoiding the interruption of uterosacral and cardinal ligament pelvic supports and preservation of the cervix, whose nerve supply may play a role in sexual response. Critical evaluation of these applications is beyond the scope of this article, but the procedure has proved quite feasible via the laparoscopic approach. A rare complication of this procedure is chronic pain.¹⁶

Finally, superior hypogastric block carried out via laparoscopy may play a useful role by enhancing the value of laparoscopic pain mapping¹⁷ and as part of a regimen of preemptive analgesia for both laparoscopic and abdominal hysterectomy procedures. In my personal experience, a consecutive series of 20 patients undergoing laparoscopic hysterectomy—with or without other associated procedures—used approximately one half to one third the amount of postoperative narcotic compared to historical controls. A randomized double-blind trial is underway to evaluate the effectiveness of this procedure. The technique is relatively straightforward, involving the injection of 10 ml of 0.5% bupivacaine or similar local anesthetic via a 7-inch, 22-gauge spinal needle introduced in the midline under laparoscopic guidance, with its tip placed just underneath the peritoneal surface directly over the sacral promontory. Theoretically, this type of injection could cause a hemorrhage if the presacral vessels were entered, but this has not occurred in my experience. The risk of bleeding can be almost eliminated by grasping the peritoneum, creating a “tent” into which the needle can be introduced.

Practice

Attending courses that involve practice on a mechanical training device as well as laboratory animal experience is very useful. Together with viewing videos of the procedures one wishes to learn, these courses serve as a valuable introduction. The reasonable set of next steps would be to practice some of the particular techniques you plan to use in the course of regular abdominal procedures. For example, laparoscopic instruments can be rested on the edge of a self-retaining retractor in order to provide an approximation of the usual abdominal wall pivot point for laparoscopic instruments, and the instruments then used to do procedures such as isolating the infundibular pelvic ligament and practicing extracorporeal tying. When advancing to the actual laparoscopic procedure itself, it is best to at least operate with a well-trained assistant, such as a partner, or ideally to obtain tutorial supervision from a surgeon experienced with the procedure.

Follow Traditional Surgical Principles

These include, of course, adequate exposure, traction-countertraction, and maintenance of hemostasis. Adequate exposure for most of the more difficult operative procedures requires at least two if not three lower abdominal ports; I usually employ one in the midline and one in each lower quadrant. This allows the comfortable application of two traction forceps while a tissue-dividing device (e.g., scissors, unipolar needle, laser beam) is used through one of the other ports. Especially in the case of difficult adhesiolysis, this kind of attention to traditional principles is essential. In teaching laparoscopic techniques, I encourage surgeons to consider their instruments identical to those used for laparotomy, except that laparoscopic instruments have longer handles. Keeping this in mind helps one overcome the tendency to try to divide tissue as it stands at its original place rather than putting it on sufficient traction to provide good exposure. Maintaining good hemostasis is important not so much to prevent blood loss as it is to optimize the optical qualities of laparoscopic surgery and avoid anatomic confusion.

Make It Look Like an Open Procedure

I think operative laparoscopy is safest when it more closely resembles the techniques employed during open surgery. For example, when dividing the infundibulopelvic ligament, I think it is wise to follow the basic principle of incising the peritoneum lateral to the vascular pedicle, exposing the ovarian vessels as a bundle, separately identifying the ureter in its course, and ligating, cauterizing, or stapling the vascular supply first before attempting further dissection of the ovary from its surrounding pathology. This is precisely the approach traditionally recommended during open surgery, and following it laparoscopically often makes the remainder of the procedure much easier and safer to perform. In cases of ureteral injury that I have reviewed for medical-legal purposes, exactly the opposite procedure was employed in every case: the surgeon attempted to mobilize the ovary first and then loop, ligate, and divide the vascular pedicle, rather than the opposite sequence just described. Simply retracting the ovary medially and then stapling across the vascular pedicle seems to be a less rigorous technique, as the ureter can sometimes escape detection when the procedure is performed in this manner. If done in an open laparotomy, this approach would represent a significant departure from traditional methods.

Similar principles apply to identification and skeletization of the uterine vessels. After transecting the round ligaments, the anterior and posterior leaves of the broad ligament should be separately freed from the underlying uterine vessels and the areolar tissue surrounding the vessels pared back by sharp and blunt dissection, exactly in the manner employed in an abdominal hysterectomy. Properly performed, this provides a wide margin of safety for the ureter, allowing the surgeon to use the technique of his or her choice to divide the uterine vasculature.

The bladder peritoneum should be sharply incised and the bladder pushed down by sharp and blunt dissection, as is done during open procedures. Some of the “feel” of pushing the bladder flap down that is experienced during abdominal procedures can be approximated by the surgeon's placing one or two fingers in the vagina while pushing against the lower uterine segment with a Kittner laparoscopic dissector. With the same approach, the vaginal fornices can be easily identified before a colpotomy is performed.

Adapt the Procedure to Fit the Situation

A good rule of thumb is this: If one cannot readily follow the basic surgical principles described, one should abandon the laparoscopic approach and proceed either vaginally or abdominally according to the demands of the case. To become a versatile laparoscopic surgeon it is good to gain experience with as many methods of hemostasis and exposure as possible, because individual situations may demand one approach or another. If a patient is a marginal candidate for vaginal hysterectomy, the surgeon can first perform laparoscopy to assess pelvic pathology and even begin the procedure laparoscopically, converting to the vaginal approach whenever it becomes clear that that is possible. Conversely, in the event of substantial difficulty with a vaginal approach, one can simply place an inflatable ring balloon in the vagina, thus creating an adequate pneumoperitoneum for a laparoscopic completion of ligation and division of the upper pedicles. The remainder of the procedure can then be performed vaginally, thus sparing the patient an abdominal incision. Obviously, this laparoscopic “rescue” needs to be performed before the onset of a substantial hemorrhage.

Stay Within One's Skills

Finally, any laparoscopic approach should obviously be selected in accordance with the skills of the surgeon. All surgeons learn by stretching their limits to a degree, but the increments should be in small steps, not quantum leaps.

Rather than review in detail all of the different ways that have been published to divide tissue and accomplish laparoscopic hysterectomy, I would like simply to list the methods I have come to prefer as my own experience has evolved over the last 10 years. Using these approaches, even though all the procedures have been performed in a training environment, I have been fortunate in that very few complications have occurred. In a series approaching 400 laparoscopic hysterectomies, 1 required a repeat operation because of bleeding (which was repaired laparoscopically), 3 were converted to the abdominal approach, 1 was complicated by a ureteral injury, and there were no bladder or bowel injuries.

As mentioned earlier, I essentially try to follow the same series of steps traditionally taught for abdominal hysterectomy. First, each round ligament is grasped with bipolar cautery forceps, cauterized, and then divided with bipolar cautery scissors. The anterior peritoneum of the broad ligament is then incised and the bladder flap developed with the scissors and sometimes with a Kittner dissector. Posteriorly, the peritoneum lateral to the infundibulopelvic ligament is divided sharply with the scissors, assuming that any interfering adhesive disease has been successfully removed. Having identified the ureter transperitoneally, the infundibulopelvic ligament is grasped in its entirety with an atraumatic grasper brought in from the contralateral side of the pelvis. Bipolar cautery scissors are then brought in from the ipsilateral side and used to find a “window” of free peritoneum posterior to the infundibular pelvic ligament. An aperture is made in this window by sharp dissection and cautery, thus allowing the atraumatic grasper to surround the ligament completely. Two 00 absorbable ligatures are then passed in laparoscopically around the infundibulopelvic ligament and tied extracorporeally. One could just as easily perform bipolar coagulation, division, and loop-ligation of the proximal pedicle, or apply a laparoscopic stapler to the isolated pedicle.

With the distal pedicle of the infundibulopelvic ligament held on traction, the peritoneal attachments of the meso-ovarium are then incised, thus revealing the edge of the posterior broad ligament. With the use of blunt dissection, this ligament is carefully lifted off the uterine vessels and then sharply divided down to the point of the uterosacral ligament.

With the uterus then directed to one side by the uterine manipulator and the ovary held aside by a retractor from a contralateral side, an atraumatic grasper and scissors are then used to skeletonize the uterine vessels further, pushing the ureter laterally in the process. If the anatomy is at all confused by retroperitoneal fibrosis, the ureter is separately identified and tunneled out to the level of the uterine vessels.

The uterine vessels could then be divided by a vascular stapler. If the colpotomizer is used to distend the fornices, it should not be put in place until after the vessels are stapled, because the presence of the ring prevents the stapler from getting all the way across the last of uterine vessel tributaries. More recently, I have moved away from using staplers on the uterine arteries and have instead employed a technique of cautery, clamping, transecting, and ligation. This approach begins with adequate skeletonization. The bipolar cautery forceps is then placed through a midline port alongside the lateral aspect of the uterus, across the uterine vasculature. Extensive cautery can be employed in this manner while the bladder and ureter are retracted away with the lateral port probe. Next, a loop ligature is placed through a contralateral lower quadrant port, and the uterine vessels are grasped through the loop with an atraumatic grasper. Cautery scissors can then be introduced through a midline port to cauterize and divide the vascular pedicle even further, rounding the tip of the atraumatic grasper in the process, thus developing a free vascular pedicle. The loop ligature is then tightened around the vascular pedicle as the clamp is released. An additional loop can be placed for added security if deemed necessary. If the loop malfunctions in this environment, the surgeon comfortable with laparoscopic suturing can simply place a suture ligature at the lateral and inferior margin of the clamp and perform and tie the suture ligature extracorporeally, thus completely imitating the usual procedure employed during abdominal hysterectomy.

With bilateral devascularization, the uterine fundus should become quite cyanotic. This appearance reassures the surgeon that the majority of the vascular supply has been eliminated. At this point one can make a wedgelike incision to perform a supercervical hysterectomy, convert to a vaginal approach, or incise the vaginal cuff to perform a complete laparoscopic hysterectomy. Incision of the vaginal cuff can be accomplished with a CO₂ laser or perhaps more conveniently with a monopolar probe attached to a standard bovie handle. Once the appropriate cases are chosen and the anatomy is properly prepared, this type of incision takes no more than 5 to 10 minutes, even in a training situation. The totally separated uterus and cervix can then be withdrawn through the vaginal canal if the uterus is small enough. If an inflatable vaginal balloon has been used to preserve pneumoperitoneum during this time, the balloon will, of course, need to be deflated before the specimen is retracted through the vagina. The uterine manipulator is then removed, the tenaculum placed on the cervix, and the fundus of the uterus then reinserted in the vagina. This approach separates the walls of the vagina nicely, allowing the edges to be easily grasped and suture-ligated with 0 or 00 figure-of-eight absorbable sutures. Either an endoscopic suturing device can be used or an absorbable suture on a UR-6 needle placed into the abdomen via an 11- or 12-mm trocar. I will ordinarily close the vaginal apex transvaginally when at all possible, but I have found that in the more obese nulliparous patient, the endoscopic approach is faster and easier. A McCall colposuspension stitch can be placed either laparoscopically or vaginally, as the situation demands.

Although concerns remain about the appropriateness of many hysterectomies performed in the United States, the total number has been declining over the last 15 years and the hysterectomy rate per population age group has declined.¹⁸ Many more traditionally oriented gynecologic surgeons have expressed the concern that if laparoscopic hysterectomy is used increasingly, the volume of vaginal surgery may decline, thus further detracting from training experience. The introduction of endometrial ablation with balloon devices,¹⁹ perhaps as an office procedure, may also reduce the volume of hysterectomy cases, thus further aggravating these concerns.

In training environments, however, laparoscopic hysterectomy can be used to enhance—rather than detract from—vaginal surgical training. The proper role of the LAVH is to convert a procedure that otherwise would only have been performed abdominally into one that can be performed vaginally. In properly chosen patients, even when the uterine arteries have already been divided, the remainder of the vaginal approach can still be quite challenging, thus affording a reasonable training opportunity in a safe environment. Similarly, when the procedure is applied to an enlarged uterus, morcellation techniques can be practiced from below once the laparoscopic portion of the procedure is completed.

Other forces, more in the realm of economics, may have an impact on the performance of gynecologic surgery in the future. The following impressions are obviously purely speculative, and certainly no one in practice now can predict these events with any certainty. It would appear, however, that as reimbursements decline, many gynecologists will increasingly find it economically hazardous to spend too much time in the operating room. This trend may tend to increase referrals to training centers and to surgeons with more endoscopic experience. Although this will concentrate surgery in fewer operative hands, it may provide more complete training experience for those going through training in the future. Finally, as many residency training programs in obstetrics and gynecology are “downsizing,” the laws of supply and demand may ultimately allow the surgical environment to equilibrate.

LAVH has undergone a rapid evolution from new gimmick, to potential method for the majority of hysterectomies, to an appropriate means for converting some abdominal procedures into vaginal hysterectomies. A continuing and increasing emphasis on traditional surgical principles applied to operative laparoscopy can allow the expansion of these surgical approaches while lowering both complication rates and medical expense.