New Hysterectomy Techniques

Manual of

This book was compiled with the assistance of my endoscopic friends who contributed their chapters and with the help of Dawn Rther and Krista OKelly of the Kiel School of Gynaecological Endoscopy.

New Hysterectomy Techniques

Manual of

Kiel School of Gynaecological Endoscopy Professor Emeritus, Department of Obstetrics and Gynaecology Christian-Albrechts University University Hospitals Schleswig-Holstein, Campus Kiel Michaelisstr. 16, 24105 Kiel, Germany Fax: 0049 431 597 2116 Tel. 0049 431 597 2086 Email: endo-office@email.uni-kiel.de

Editor Liselotte Mettler

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Manual of New Hysterectomy Techniques 2007, Liselotte Mettler

All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the publisher. This book has been published in good faith that the material provided by editor is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition: 2007 ISBN 81-8448-127-6 Typeset at JPBMP typesetting unit Printed at Ajanta Press

CONTRIBUTORS
Shirish S Sheth MD FRCOG (Ad Eundem) FACS Consultant Gynecologist Breach Candy Hospital Sir Hurkisondas Nurrotamdas Hospital and Sheth Nursing Home, Mumbai, India 2/2, Navjivan Society, Lamington Road Mumbai 400 008, India e-mail:silsal@bom2.vsnl.net.in Michael Stark Sandro Gerli Gian Carlo Di Renzo HELIOS hospitals group, Germany University of Perugia, Italy The New European Surgical Academy (NESA) Karower Str. 11/214 13125 Berlin Germany e-mail:mstark@nesacademy.org Harry Reich MD LRCPSI LM FACOG Advanced Laparoscopic Surgeons Shavertown, PA Wilkes Barre General Hospital Wilkes Barre, PA St. Lukes Hospital Bethlehem, PA Former Director, Advanced Laparoscopic Surgery Columbia Presbyterian Medical Center New York, NY 3 Crestview Drive Dallas, PA, USA 18612 e-mail:hrlscp@aol.com Shailesh Puntambekar Seema Puntambekar Anjali Patil Reshma Palen Neeraj Rayate Hans-Rudolf Tinneberg Consultant Laparoscopic Surgeon Hon. Associate Professor Sasson General Hospital Director Galaxy Laparoscopy Institute Pune, India Konstantin Zakashansky MD Division of Gynecologic Oncology Department of Obstetrics Gynecology and Reproductive Science Mount Sinai Medical Center New York, NY The Mount Sinai School of Medicine, New York, NY 1176 Fifth Avenue, Box 1173, New York, NY 10029 Farr R Nezhat MD Professor of Obstetrics and Gynecology Director, Gynecologic Minimally Invasive Surgery Department of Obstetrics Gynecology and Reproductive Science Division of Gynecologic Oncology The Mount Sinai Medical Center 5 East 98th Street, Box 1173 New York, NY 10029 tel: 212-241-9434 fax: 212-2892733 e-mail:farr.nezhat@mssm.edu Masaaki Andou MD Kurashiki Medical Center. 250 Bakuro-cho, Kurashiki-shi Okayama-ken, Japan. 710-8522. Tel : +81-86-422-2111 Fax: +81-86-422-4150 e-mail:ichi-195@mvc.biglobe.ne.jp Chyi-Long Lee MD PhD Department of Obstetrics and Gynecology Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University College of Medicine Kwei-Shan, Tao-Yuan, Taiwan. Fax: 886-3-3286700 Tel: 886-3-3281200 ext 8253 e-mail:chyilong@ms21.hinet.net Ceana Nezhat MD FACOG FACS Director Nezhat Medical Center Center for Special Minimally Invasive Surgery and Reproductive Medicine Adjunct Clinical Associate Professor of Obstetrics and Gynecology Stanford University School of Medicine

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Manual of New Hysterectomy Techniques I Meinhold Department of Obstetrics and Gynaecology University Hospitals Schleswig-Holstein Campus Kiel, Germany Fax: 0049 431 5972116 e-mail:lmettler@email.uni-kiel.de John Morrison Jr. MD FACS 1035 Temple Ave. N, Fayette Alabama 35555, USA Fax: 001 205 932 5253 e-mail:Drmorjo@aol.com B Bojahr MD PhD D Raatz G Schnleber Klinik fr MIC, Minimally Invasive Center am Ev. Krankenhaus Hubertus Kurstr. 11, 14129 Berlin Germany Phone: 00493080988155, Fax: 00493080988188 e-mail:b.bojahr@mic-berlin.de Adolf Gallinat MD Tagesklinik Altonaer Strae Altonaer Strae 59 61, Hamburg 20357 Germany Tel. 0049 -40 43 28 580, Fax. 0049 -40 43 28 5858 e-mail:Agallinat@aol.com Alfonso Rossetti Gynecological Endoscopic Division Villa Valeria Hospital, Rome Italy Ornella Sizzi Gynecological Endoscopic Division Villa Valeria Hospital, Rome Italy Alessandro Loddo Division of gynecology, obstetrics and pathophysiology of human reproduction, department of surgery, maternalfetal medicine and imaging, university of Cagliari, Cagliari, Italy Artin Ternamian MD FRCSC University of Toronto Assistant Professor, Department of Obstetrics and Gynecology Director of Gynecologic Endoscopy St. Josephs Health Centre

5555 Peachtree Dunwoody Rd., Suite 276 Atlanta, GA 30342 Phone: 1.404.255.8778 Fax: 1.404.255.5627 e-mail:Ceana@nezhat.com Bruno J van Herendael Professore a contratto Universit dellInsubria Varese Italy Coordinator Gynaecology and Gynaecological Oncology ZNA STER, Antwerp - Belgium ZNA STER Site Stuivenberg Lange Beeldekensstraat, 267, 2060 Antwerpen, Belgium + 32 475447544 e-mail:Bruno.vanherendael@beline.be www.etca.be A Salfelder Tagesklinik Altonaer Strasse Altonaer Strae 59-61 20357 Hamburg Tele. 040-432858-0 Fax. 040-432858-58 e-mail:aerzte@tka-hh.de Rakesh Sinha Bombay Endoscopy Academy and Centre for Minimally Invasive Surgery (BEAMS), Plot: 674, 16th Cross Road, Behind Khar Gymkhana, Khar Pali Road Mumbai 400 052, Maharashtra, India Tele: +91-22-2646 4049/4056/3606 Fax: +91-22-26463887 Yogesh A Nikam Bombay Endoscopy Academy and Centre for Minimally Invasive Surgery (BEAMS), Plot: 674, 16th Cross Road, Behind Khar Gymkhana, Khar Pali Road Mumbai 400 052, Maharashtra, India Tele: +91-22-2646 4049/4056/3606 Liselotte Mettler Department of Obstetrics and Gynaecology University Hospitals Schleswig-Holstein Campus Kiel, Germany Fax: 0049 431 5972116 e-mail:lmettler@email.uni-kiel.de T Schollmeyer Department of Obstetrics and Gynaecology University Hospitals Schleswig-Holstein Campus Kiel, Germany Fax: 0049 431 5972116 e-mail:lmettler@email.uni-kiel.de

Contributors 77 Truman Road Toronto Ontario Canada M2L 2L7 Tele: 416 766 1144, Fax: 416 767 1802 e-mail:artin.Ternamian@utoronto.ca Chris Sutton MA FRCOG Consultant Gynecologist and minimal Access Surgeon, Chelsea and Westminster Hospital, London Director, Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Gnildford, Surgery

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Gian Benedetto Melis Stefano Floris Mario Melis Sandra Mameli Stefano Argions Valerio Mais Anna Maria Paoletti Dipartimento Chirurgico Materno Infantile e di Fisiopatologia della Riproduczione Umana, Universita di Cagliari, Italy

FOREWORD
Written by clinicians with a wealth of experience, this book should be useful as a review of surgical options currently available for hysterectomy and for the valuable pointers into surgical techniques that have sometimes proved challenging. Furthermore, the book provokes us to consider our own patterns of practice, based on the available evidence and offers direction for further research and innovation. This is not surprising, given the editor, whose legacy in this area has been the introduction of robotics into laparoscopic surgery. Robotics significantly reduce the learning curve, and the potential for complications. Like other major surgeries in women, hysterectomy has been no stranger to controversy, not least in terms of its necessity. In terms of outcome, it has long been recognized that vaginal hysterectomy has a faster recovery with less pain for women than the abdominal approach. It is hardly surprising then, that the evolution of laparoscopic surgery, with its avoidance of pain and lengthy hospitalization, has been an appealing option. Laparoscopic hysterectomy (LH), whether as an adjunct to the vaginal approach or a substitute, faced some controversy in its early days which arose in part from rapid adoption of this new technology, without the necessary training in all cases. Furthermore, LH was an expensive, if less invasive, option, limiting its uptake and impeding training. Its early adopters faced criticism in terms of the operating time required, especially in settings where operating room time is at a premium. However, minimally invasive surgery is now becoming the norm driven in part by the search for alternatives to costly inpatient care and overall costs, explored in the book, are comparable to traditional approaches. At this time, cost is a significant barrier to the extensive use of robotics, but continued evolution would be expected to result in improved and ultimately less expensive technology. The potential if controversial role of laparoscopic hysterectomy for indications such as gynaecologic malignancy or in obese women is explored in the chapter by Dr. Ceana Nezhat, in terms of the emerging use of LH for radical hysterectomy and exenteration. As skills and technologies evolve, the outcome data will inform best practice on an individualized basis. The resurgence of supracervical hysterectomy is the focus of three chapters, though the rationale for this approach today is not only to avoid ureteric and other injuries. Having fallen into disrepute because of concerns about cervical cancer in the stump, the current debate includes yet unproven concepts such as the importance of preservation of innervation. It remains to be seen whether the rationale will ultimately be substantiated making it an option comparable to LH and laparoscopically assisted vaginal hysterectomy LAVH. Despite the exciting developments of new technologies and resurgence of old surgical approaches, the book makes it clear that there is no evidence to support LH if the vaginal approach is safe. For vaginal hysterectomy (VH), it is difficult to match the experience of Professor Sheth, who offers pearls of wisdom from his vast experience in surgical technique and understandably makes a strong case, supported by the literature, to make VH the first choice in terms of an approach. Professor Mettler, as editor and author, illustrates her ability to challenge herself and others to continue pushing the envelope of what is possible, while critically evaluating progress and saving the best of existing knowledge. There is currently no evidence to support abandoning VH for new

Manual of New Hysterectomy Techniques technologies that may be challenging to implement globally or in certain clinical situations in the foreseeable future. The applicability of LH in low resource countries in the public setting will continue to be especially challenging. This book is a stimulus to ask some difficult questions about when and where abdominal hysterectomy is indicated, based on the evidence, and for continued advances in technology and surgical procedures, with the associated training and evaluation to ensure optimal outcome. It is an appropriate topic to mark a time of reflection on an illustrious career. Dorothy Shaw
MBChB FRCSC FRCOG

Senior Associate Dean, Faculty Affairs Clinical Professor Department of Obstetrics and Gynaecology University of British Columbia 317-2194 Health Sciences Mall Vancouver, B.C., V6T 1Z3 Canada Tel: 604 822 0741 Fax: 604 822 6061 Email: dshaw@medd.med.ubc.ca

FOREWORD
It is indeed an honour for me to write this foreword in anticipation of the presentations that will be given at this truly international symposium on hysterectomy honouring Liselotte Mettler. I believe that the resulting book will be most interesting and must reading for those with interest in this subject to read and refer to for a long time to come. The international authors are writing about all sorts of tricks for the laparoscopic surgeon to be able to accomplish his/her goals. Vaginal approaches to avoid abdominal incisions and endometriosis dissections are included. The Kiel School of Gynaecological Endoscopy, under the guidance of Professor Liselotte Mettler for the last 20 years, is special and has made many contributions to the training of skilled endoscopists worldwide. We know this by looking at the surgeons who have contributed to this book honouring Lilo Mettler. In 1988 no one was thinking about doing hysterectomy by laparoscopy. The major centers in the world doing laparoscopic surgery were in Clermont Ferrand, France and in Kiel, Germany. I acknowledge that Kurt Semm, Liselotte Mettler, Maurice Bruhat, and Hubert Manhes were great influences because they also knew no boundaries. I have known Lilo and Kurt Semm for over 20 years. They were the only show in town in the early days of operative laparoscopic surgery. When I met Kurt Semm in 1986 he observed desiccation of the ovarian blood supply with reserve. He encouraged me to learn how to suture. For that I thank him very much. I think that he was right: the ability to suture defines a laparoscopic surgeon. Please realize that these operations were done with the operating surgeon visualizing the operative field with the eye with minimal assistance before 1986. Also, please realize that publication of laparoscopic gynaecological operations was very difficult in the 80s as few of the pioneers were in academic positions. Laparoscopic hysterectomy was unpublishable in 1988 and before. This has been a major struggle. Many papers of substance on laparoscopic surgery in the early 90s were in a journal that never got Index Medicus acceptance: Gynaecological Endoscopy. Professor Mettler has been a star before, during, and after her long association with Kurt Semm. Her passion for laparoscopic surgery led to its development around the world. I remember Lilo telling me that I indirectly helped Kurt and Lilo in the development of CISH, which stimulated interest in laparoscopic supracervical hysterectomy worldwide. He believed that there must be a better way to do a laparoscopic hysterectomy after watching me do one in Baltimore in 1991. Recent papers by Clayton and the Cochrane database reviewed evidence-based hysterectomy studies and conclude that vaginal hysterectomy (VH) is preferable to abdominal hysterectomy (AH). There is no evidence to support the use of LH if VH can be done safely. Compared to AH, LH is associated with less blood loss, shorter hospital stay, speedier return to normal activities, but it takes longer, costs more, and urinary tract injuries are more likely. Vaginal hysterectomy should be the preferred route when applicable. Laparoscopic hysterectomy should be considered as an alternative to abdominal hysterectomy. Abdominal hysterectomy is the preferred method of treatment based on training and remuneration. Laparoscopic hysterectomy is a substitute for abdominal hysterectomy and not for vaginal hysterectomy. Why are there so few laparoscopic hysterectomies done today? It is a major problem!

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Manual of New Hysterectomy Techniques Gynaecologists today are not trained to do laparoscopic surgery. Unfortunately they are not trained to do vaginal surgery, either! This poses an ethical dilemma. Are we offering the best choices to our patients? Lilo has done much to develop minimally invasive surgery, but we have a long way to go. With much respect, Lilo deserves to be honoured with this bookand a lot more! I look forward with great pleasure to the complete version of this volume honouring Liselotte Mettler. Harry Reich
MD LRCPSI LM FACOG

Advanced Laparoscopic Surgeons Shavertown, PA Wilkes Barre General Hospital Wilkes Barre, PA St. Lukes Hospital Bethlehem, PA Former Director, Advanced Laparoscopic Surgery Columbia Presbyterian Medical Center New York, NY Email: hrlscp@aol.com

PREFACE
Internationally, there still exists striking divergence on the pros and cons of hysterectomies. In our age of organ-preserving surgery, hysterectomies, though technically feasible in various modalities, have decreased in number over the last century. This compilation of chapters by renowned gynaecological surgeons focuses on vaginal and laparoscopic hysterectomy in benign and malignant disease of the uterus. The decision to perform a hysterectomy is always taken jointly by the patient and her gynaecologist. Culture, religion and lifestyle can influence this decision. All hysterectomy procedures laparotomic; vaginal; laparoscopic subtotal, total and radical approaches are well described in the literature and every gynaecologist is free to select, within the limits of good standard practice, the hysterectomy modality he/she chooses. This decision is also influenced by other factors, such as the location of the hospital, the instrumentation available and whether the patient can be seen again as an outpatient. This book provides a survey of the technical possibilities for hysterectomies in the first decade of the 21st century. The editor knows quite well that worldwide the laparotomic hysterectomy approach still prevails; however, these chapters document the current hysterectomy modalities in the hope that a scientifically-based consensus for hysterectomies can be found in the years to come. Liselotte Mettler

CONTENTS
1. History and Future of Hysterectomy .............................................................................................1
Chris Sutton

2. Vaginal Route: Primary Route for Hysterectomy ........................................................................ 14

Shirish S Sheth

3. Vaginal Approach to Hysterectomy and Treatment of Incontinence ...................................... 25

Gian Benedetto Melis, Stefano Floris, Mario Melis, Sandra Mameli, Stefano Argioni, Vaterio Mais, Anna Maria Paoletti

4. The Ten Step Vaginal Hysterectomy: A Method Description ................................................... 30

Michael Stark, Sandro Gerli, Gian Carlo Di Renzo

5. Total Laparoscopic Hysterectomy: Indications, Techniques and Outcomes ............................ 36

Harry Reich

6. Laparoscopic Anterior Exenteration ............................................................................................ 46

Shailesh Puntambekar, Seema Puntambekar, Anjali Patil, Reshma Palen, Neeraj Rayate, Hans-Rudolf Tinneberg

7. Robotic Laparoscopic Radical Hysterectomy for Cervical Cancer .......................................... 57

Konstantin Zakashansky, Farr R Nezhat

8. Extraperitoneal Hysterectomy : Total Pelvic Peritonectomy Combined with the Segmental Resection of the Rectosigmoid ................................................................................ 63
Masaaki Andou

9. Laparoscopic Radical Hysterectomy .......................................................................................... 70

Chyi-Long Lee

10. The Role of Laparoscopy and Robotics in Hysterectomy ......................................................... 74

Ceana Nezhat

11. Strategies to Prevent Vaginal Vault Descent during Hysterectomy ........................................... 82

Bruno J van Herendael

12. Hysterectomies in a Day Clinic .................................................................................................. 86

A Salfelder

13. Bladder Dissection Modalities in Total Laparoscopic Hysterectomy ......................................... 90

Rakesh Sinha, Yogesh A Nikam

14. Classic Intrafascial Supracervical Hysterectomy (CISH Technique) .......................................... 95

L Mettler, T Schollmeyer, I Meinhold

15. CISH Hysterectomy (15 Years Experience in Rural US) ............................................................. 102
John Morrison Jr.

16. Laparoscopic Supracervical Hysterectomy: A Standardised Safe Minimal Invasive Technique (Experience of 3,920 Operations) .............................................. 108
B Bojahr, D Raatz, G Schnleber

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Manual of New Hysterectomy Techniques

17. Endometrial Ablation Contrahysterectomy: Who Takes the Decision? ................................... 116
Adolf Gallinat

18. Hysterectomy for Large Uteri .................................................................................................... 121

Alfonso Rossetti, Ornella Sizzi, Alessandro Loddo

19. Port Creation during Laparoscopic Hysterectomy ................................................................... 132

Artin Ternamian

20. Laparoscopic Hysterectomy: Historical Perspective ................................................................. 146

Harry Reich Index .................................................................................................................................................................................... 151

1
Chris Sutton INTRODUCTION

History and Future of Hysterectomy

The historical date December 25th, l809 should be indelibly engraved on the brain of every practising surgeon, because it was the first time that the human abdomen was deliberately opened in order to remove a diseased organ, in this case a massive ovarian cyst. The brave pioneering surgeon was Ephraim McDowell, (17711830) (Figure 1.1) a Scotsman who had trained in Edinburgh and the equally brave patient was Mrs. Jane Todd Crawford (Figure 1.2) a distant cousin of Abraham Lincoln. McDowell had visited her on the 13th of December, at her home in Greensburgh, Kentucky and found that the 47-year-old woman had such a massive tumour that it was making it difficult to breath and

making her life a complete misery. They both agreed that an operation was the only solution and she rode to McDowells home in Danville, some sixty miles away, with the massive ovarian tumour resting on the pommel of her saddle. In those days there was no anaesthesia, no antisepsis or antibiotics and the procedure was performed on McDowells kitchen table, whilst Mrs. Crawford recited psalms to distract her attention from the operation. In these litigious times surgeons are naturally apprehensive of the outcome of their work, but pity poor Ephraim McDowell who had to contend with the knowledge that several of his townsfolk were erecting a gallows for him, should the patient die at the hands of the dreadful doctor.

Figure 1.1: Ephraim McDowell (1771-1830). The father of abdominal surgery

Figure 1.2: Jane Todd Crawford (1762-1842). The first woman to have a laparotomyChristmas Day 1809

Manual of New Hysterectomy Techniques spite of these successes, it was Charles Clay (l801-1893) (Figure 1.3) who was the first to introduce the word ovariotomy and this was a strange choice for the title of this operation, in an age when surgeons were usually reared in the classics and were often pedantic but usually aetimologically correct (Morton, l965). Charles Clay was regarded as the greatest ovariotomist in Europe. He performed his first operation on the 13th September, l842, when, in the presence of several of his medical friends, he operated at the patients house at 75 Heyrod Street, in Ancoats, Manchester. The tumour he removed weighed 17lbs. 5oz and the operation took forty minutes. The patient, who only had brandy and milk for analgesia, made a satisfactory recovery. In his lifetime, Clay performed 395 ovariotomies with a mortality of only 25 and although he accepted the need for anaesthesia following its introduction by Morton in Boston in 1846, he nevertheless felt that it rather interfered with his good results, because he clearly was of the opinion that the patients who had the fortitude to undergo surgery without it were imbued with a greater will to survive.

McDowell made a nine inch long paramedian incision, ligated the left tube and the ovarian pedicle close to the uterus, then emptied some gelatinous fluid from the tumour enabling him to deliver it through the incision. The tumour weighed 10.2 kilograms and he had to tilt the patient over to her side to spill out any blood from the peritoneal cavity and then replace the bowel and sew the pedicle to the lower end of the wound, which he closed with interrupted sutures. The entire operation took only twenty-five minutes and five days later Mrs. Crawford was up and about and was found to be making her own bed in McDowells house. She rode home to Greensburgh some twenty days later in excellent health and apparently lived to a ripe old age. Although this was the first successful major abdominal operation through the peritoneum, McDowell did not publish the event until some nine years later, after which he had performed several other ovariotomies. During his life-time he performed thirteen of these procedures in all and only one patient died. This was an extraordinary record for those times when sepsis and peritonitis exacted a frightening toll following laparotomy. Others tried to emulate him and a fellow student from Edinburgh, John Lizzars, made his first attempt some fourteen years later but the patient succumbed and he then made three more successful attempts in l825. In

CHARLES CLAY AND THE FIRST ABDOMINAL HYSTERECTOMY IN THE WORLD

Charles Clay was born at Bredbury, near Stockport in 1801. He was reared in Manchester and brought up by his uncle. His school career was broken and on the whole unsatisfactory. He spent his early medical career apprenticed to Kinder-Wood, who was on the staff of St. Marys Hospital, in Manchester, England. Clay studied at the Manchester Royal Infirmary and later spent some time in Edinburgh before settling down to a busy surgical practice in Ashton-under-Lyne, ten miles to the east of Manchester. After sixteen years there, during which time he gained a reputation for his surgical work, he moved to the centre of the thriving Victorian city of Manchester where, in l839, he established his practice. His consulting rooms in Piccadilly, Manchester, are on the first floor and that is where the worlds first hysterectomy was performed over what is now a golf and sports shop. In a contemporary illustration we see him at the peak of his surgical career, complete with top hat, looking profoundly confident. He was in fact a contemporary of my great grandfather, who had established a large Chartered Surveyors and Auctioneers business in Spring Gardens, half a mile to the west. All of Clays first five ovariotomies survived, but in his fifth case he was not so lucky. He had confidently diagnosed a large ovarian tumour, but on making his

Figure 1.3: Charles Clay. Performed the first abdominal hysterectomy on 17th November 1843

History and Future of Hysterectomy massive incision the patient coughed and extruded a huge uterine fibroid, which he was unable to replace. He therefore had no choice but to continue with a subtotal hysterectomy and this took place on the 17th November, l843. A few days later, on 21st November, l843, A.M. Heath, also of Manchester, also opened the abdomen suspecting a large ovarian tumour and found a massive fibroid and in both cases the women died soon afterwards from massive haemorrhage. The following year, Charles Clay found himself in a similar situation and again proceeded to perform a subtotal hysterectomy, having placed a ligature of Indian hemp round the supravaginal cervix. On this occasion the patient survived the operation but, sadly, died on the fifteenth postoperative day, having fallen out of bed. This was sad, not only for the patient, but for Charles Clays claim to having performed the first successful hysterectomy, because she had in fact survived the critical immediate postoperative period and had not succumbed to sepsis, which was the usual mode of death, and it was not for a further twenty years that he was able to claim the first successful hysterectomy in Europe (vide infra). Reading the contemporary accounts of this patients postoperative course, it is difficult to determine the exact mode of death. Some accounts suggest that she had a secondary bleed and died of haemorrhage after falling out of bed and it is not inconceivable that his ligature included both ureters and the poor woman possibly fell out of bed due to uraemic coma. It is, however, firmly routed in Mancunian folklore that she was dropped inadvertently on the floor by a pair of incompetent porters whilst the nurses were changing the bed linen. If this were true, the death was entirely unrelated to the operation and if this accident had not occurred, Clay could have claimed to have performed the first successful hysterectomy in the world.

hysterectomies during his subsequent career which spanned thirteen years, but sadly only three survived, the rest dying from peritonitis, sepsis, haemorrhage and, somewhat surprisingly, exhaustion. The early record of the first abdominal hysterectomies reads like a disaster saga from 1843 to 1853 when Burnham produced the first survivor, but even then the diagnosis was wrong. Later that year, in September, Kimball (also from Massachusetts) carried out the first deliberate hysterectomy for a fibroid tumour, with the patient surviving the operation (Kimball, 1855; Benrubi l988). The patient made a full and complete recovery, but 8 months later the protruding ligatures were still causing inconvenience. In the early years of hysterectomy the ligatures were brought through the lower part of the incision and the ligature was left long in order to encourage the drainage of laudable pus, which was the custom of the day when the main vessel in an amputated limb was tied with a long ligature. In favourable circumstances the ligature became detached some weeks after the procedure, but it is obvious now that it was a contributing factor to the sepsis that usually brought about the demise of these patients. It is difficult to understand why gynaecologists adopted this technique and possibly it was the second case of John Lizzars of Edinburgh who, less than a month after his first successful ovariotomy, excised another cyst and on this occasion he employed a short ligature and allowed it to drop into the wound and the patient died. Whether this small series of two cases persuaded a whole generation of surgeons to employ the long ligature is difficult to say, but this extraordinary practice retarded the progress and development of gynaecological surgery for almost half a century.

THE INTRODUCTION OF ANAESTHESIA

Kimballs patient was also the first to be lucky enough to reap the benefits of the introduction of anaesthesia, in this case chloroform. In these early days, surgery made very slow progress, because of the severe limitation of effective pain relief during operations, as well as devastating postoperative infections. Before the discovery of anaesthesia, surgeons had to rely on opiates, plants containing hyoscyamus and mandragora and, of course, alcohol was known to make patients oblivious enough to pain to permit surgical procedures to be undertaken. In 1772, Joseph Priestly discovered nitrous oxide gas and later this was used as a party piece, because it induced amusement and euphoria and became known as laughing gas. Humphrey Davey (l778-1829), the

ELLIS BURNHAM PERFORMS THE WORLDS FIRST SUCCESSFUL ABDOMINAL HYSTERECTOMY

Ellis Burnham, of the United States of America, performed the first hysterectomy with a patient surviving. (Graham l951; Benrubi l988). This was performed in the town of Lowell, Massachusetts in 1853 and again the diagnosis was incorrect and Burnham thought he was operating on a massive ovarian cyst. On this occasion when the abdomen was opened the patient vomited and, as with Clays case, extruded a large fibroid uterus. Burnham tied off both uterine arteries and carried out a sub-total hysterectomy and the patient survived. This was an amazing achievement and he performed fifteen further

Manual of New Hysterectomy Techniques

inventor of the miners safety lamp, noted a reduced sensitivity to pain in these revellers and suggested that it might be useful during surgery, but unfortunately no one followed up his suggestion. By 1831, all three basic anaesthetic agentsether, nitrous oxide gas and chloroformhad been discovered, but no medical applications of their pain relieving properties had been made. Probably the first historical use of anaesthesia in surgery was Dr. Crawford W. Long (l815-78) of Georgia who, in l842 applied his social experiences with laughing gas to perform three minor surgical procedures. He did not realise the significance of what he had done and made no effort to publicise his discovery until several years later when anaesthesia had been hailed as a major breakthrough. Oddly enough, it was the dentists who were the first to utilise anaesthesia, presumably because of the extreme sensitivity of the teeth and gums. Dr. Horace Wells (l815-48), a Connecticut dentist, learnt of the peculiar properties of nitrous oxide in 1844 and tested them by having one of his own teeth removed whilst under the influence of the gas. Delighted with the results, he administered it to several patients and then demonstrated it at Harvard, but unfortunately the patient cried out in agony and Wells was booed and hissed out of the room. It therefore fell to his colleague and dental student, William T.G. Morton (l819-68) to demonstrate before the same medical class of Dr. John C. Warren the effectiveness of sulphuric ether in inducing dental anaesthesia. Morton gave the first successful public demonstration of surgical anaesthesia on October 16th 1846 at the Massachusetts General Hospital on what has become known as Ether Day (Figure 1.4). Morton is universally regarded as the worlds first anaesthetist and he turned up twenty minutes late for the operation, thereby setting a precedent that anaesthetists have adhered to even in present times. Although ether became immediately extremely popular, Oliver Wendel Holmes was the first to supply the name anaesthesia because the Boston medical community were at a loss to describe the condition induced by this new agent. James Simpson of Edinburgh abandoned it in favour of chloroform, because of its disagreeable odour, irritating properties and long induction period. During the next century, chloroform continued to be the agent of choice in Europe until its unmanageable toxicity and delayed damage to the liver became appreciated. Simpson employed anaesthesia in childbirth and was vehemently opposed and condemned by the Calvinist Church fathers in Edinburgh, because it was contrary to the biblical admonition that a woman must bring forth her child in pain. Luckily the fact that

Figure 1.4: Ether Day. William Morton administers the first anaesthetic on 16th October, 1846 John Snow (1813-58) used it for Queen Victorias delivery of Princess Charlotte, went a long way to make it acceptable and it is indeed fortunate that she did not herself suffer the liver damage that was frequently associated with its use. Charles Clay, when he presented his results to the Obstetrical Society of London in March 1863 described one hundred and eight operations for ovarian tumours with thirty-four postoperative deaths. He was inclined to lay the blame for the worsening results on the advent of general anaesthesia. He said: I am not certain if chloroform has really added to the success of ovarian operations. The first fourteen of my cases were undertaken before it was discovered and of these fourteen, nine recovered. But though I willingly admit the almost impossibility of obtaining the consent of females to submit to so formidable operation without the aid of this valuable agent - .... if it could be accomplished, I would infinitely prefer to operate without it, as the patient would bring to bare on her case a nerve and determination which would assist beyond all value the after treatment. In spite of his reservations there was no doubt that the invention of anaesthesia went a long way to make surgery more acceptable. Nowadays one can only wonder at the horrendous suffering that these women had to endure when they were split from sternum to symphysis pubis by a cold surgical knife, having little to comfort

History and Future of Hysterectomy them but some milk and brandy or, in the case of Jane Todd Crawford, the comfort of reciting the psalms.

THOMAS KEITH AND THE DAWN OF THE NEW ERA

Charles Clay used the long ligature throughout his career and Lawson Tate, from Birmingham, who was the first surgeon to successfully operate on an ectopic pregnancy, believed that had he cut the ligature short and completely closed the wound, the mortality rate would probably have fallen to 6 or 8%. Interestingly enough, results such as this were achieved by Isaac Baker Brown, who cauterised the ligated ovarian pedicle, dropped it and closed the abdominal wound on 40 occasions with only 4 deaths. This man came from Londons greatest teaching hospital, St. Marys Hospital in Paddington - and sadly went the way of so many in our profession in the past and even in present times. He somehow went off at a tangent and in 1865 published a paper on The cureability of some forms of insanity, epilepsy and hysteria by clitoridectomy. Unfortunately, he also advertised the success of this procedure and as a result he fell from grace and was expelled from the Obstetrical Society of London and died in obscurity. Because of this, his technique of ovariotomy failed to be adopted and it fell to Thomas Keith, an apprentice of James Young Simpson, to rediscover this manoeuvre. Thomas Keith was probably the greatest analytical surgeon in our speciality during the late nineteenth century. He was a wild looking man, born in the Manse of St. Cyrus, near Montrose in the Scottish Borders and was a lifelong sufferer from cysteine stones for which he required many operations which probably accounts for his rather startling appearance (Figure 1.5). His brother George was present at Simpsons first chloroform experimentas was Matthews Duncan of placenta fame and one can only hope that Thomas availed himself of chloroform when he underwent his repeated lithotomies. Thomas Keith performed his first ovariotomy in September 1862, but his initial mortality was high. This was around the time when Lister was preaching his principles of antiseptic surgery, but Keith found that the carbolic spray did not help to reduce his operative mortality. Keith therefore turned his attention to the method of wound closure and abandoned the long ligature and the exteriorised clamp that Spencer Wells had popularised (Figure 1.6) and instead cauterised the pedicle and dropped it into the peritoneal cavity, which he then drained. He was also a vigorous opponent of the technique of blood-letting and produced the best results

Figure 1.5: Thomas Keith. Dispensed with the long ligature and made hysterectomy a safer operation

Figure 1.6: Spencer Wells. Clamp to exteriorise the cervix obtained so far-156 cases with only 6 deaths (3.8% mortality). His hysterectomy results were no less impressive and by the time he left Edinburgh to emigrate south to London he had recorded 33 cases with only 3 deaths. Spencer Wells, (Figure 1.7) a Society dilettante who considered himself the greatest gynaecological surgeon in Europe at that time and drove from hospital to hospital in London in his brougham and silver grey four produced results that were appalling and out of 40 hysterectomies performed for fibroids, there were 29 deathsa mortality rate of 73%! Lawson Tate, (Figure 1.8) a rather aggressive character who loathed Spencer Wells, found that using the carbolic spray he still had a 38% mortality with his first 50 ovariotomies. He then realised that it was not the spray that had given Keith his excellent

Manual of New Hysterectomy Techniques

Figure 1.7: Spencer Wells (1818-1895). Seen here at the Garden party of Baroness Burdett-Couts

Figure 1.9: Jules Pean (1830-1898). A famous French Surgeon first abdominal engagements were fought. Whereas ovariotomy undoubtedly opened the gateway to abdominal surgery, Spencer Wells by his outmoded technique and resultant mortality of 25% undoubtedly held back progress, because no one would submit women to such fearful risk unless life were already threatened. Dr. Thomas Keith ended this dark period by showing us how to operate on the abdomen without fear and with little risk.

Figure 1.8: Lawson Tait (1845-1899). A successful Birmingham surgeon who loathed Spencer Wells resultsand indeed there is no evidence that Keith ever used the carbolic spraybut it was the intraperitoneal method of dealing with the pedicle. He immediately adopted this technique, abandoned the carbolic spray and lost only 2 of his next 73 patients. He also learned from both Lister and Keith the value of cleanliness and this was unusual in those days, because none of the surgeons wore gloves and very few even deigned to wash their hands before operating. The early hysterectomies were extremely sociable affairs and it was considered good form to bring along ones friends, both medical and non- medical, to witness these momentous surgical events. Figure 1.9 shows the famous French gynaecologist, Pean operating in much the same way as Pavarotti might sing to a social soire. Lawson Tate summed up the end of this rather dark era in gynaecological surgery with the following words the ovarian tumour was the battlefield whereupon the

CHARLES CLAY AND THE FIRST SUCCESSFUL HYSTERECTOMY IN EUROPE

Although Charles Clay took great pride in his experience with ovariotomy, in his important presentation to the Obstetrical Society of London, almost as an aside, he mentioned a successful case of the entire removal of the uterus and its appendages (Clay, 1863). This was the first successful hysterectomy in Europe and it is important to emphasise this, because many reference books give priority to Koeberle of Strasbourg who performed his operation on the 2nd April, 1863. Charles Clay performed his first successful hysterectomy with oophorectomy and salpingectomy on the 3rd January, l863, three months before Koeberle, and described it in his presentation to the Obstetrical Society of London on the 3rd March, 1863. He therefore had the priority by three months and indeed had very bad luck in not being able to make this claim

History and Future of Hysterectomy 19 years earlier when the patient fell out of bed on the fifteenth postoperative day. Clays operation was well authenticated by three doctors from Preston, Sheffield and Manchester and immediately after the operation Professor J.Y. Simpson of Edinburgh arrived unexpectedly. He was greatly interested in the case and took the specimen back to Edinburgh from whence, sometime later, he returned a description and a sketch, ending his letter with your case may turn out as a precedent for operative interference in some exceptional cases of large fibroids of the uterus and I congratulate you most sincerely on the happy recovery of your patient. Koerberle of Strasbourg used a slightly different technique when he performed his operation on 2nd April, l863. The operation was planned and the diagnosis of fibroids was correct, but to obtain haemostasis he used a device called the serre-noeud (Figure 1.10) whereby wires were twisted around each half of the cervix, which was then exteriorised through the abdominal wound until eventually it sloughed off and fell internally and the clamp could be removed. Unfortunately, recovery was by no means the commonest outcome and the mortality from the abdominal approach to hysterectomy was reported as exceeding 70%, even as late as 1880.

Figure 1.10: The serre-noeud. Used by Eugene Koeberle from Strasbourg who Performed the second successful abdominal hysterectomy in Europe

died. Nevertheless, in the writings of the eleventh century Arabic physician, Alsaharavius, he clearly states that if the uterus had prolapsed externally and could not be reinserted, then he advised his pupils that it should be surgically excised (Benrubi 1988) and it is unlikely that he would have advocated this practice if death was the invariable result of their intervention. In fact there are several reports of patients surviving vaginal hysterectomy in the middle ages, and these are referred to in medical writings in the sixteenth and seventeenth centuries. The first authenticated case was reported by Berengarius da Carpi who lived in Bologna in AD 1507 and was reputed to have performed a partial vaginal hysterectomy. Schenck of Grabenberg reported 26 cases during the early part of the seventeenth century and the operation was also performed by Andreas da Crusce in 1560 and Valkaner of Nuremburg in 1675, when the patients appeared to have survived. Modern medical historians are somewhat sceptical about some of these early reports and, as usual, have largely ignored the contribution of the midwives of Europe who, from time to time, amputated prolapsed or inverted puerperal uteri. They have also overlooked an early example of self-help: the case of Faith Howard, a 46-year-old peasant woman who performed the operation on herself. This case was well documented and reported in 1670 by Percival Willoughby, an early man-midwife and lifelong friend of William Harvey, the discoverer of the circulation. Apparently, whilst she was carrying a heavy load of coal one day, Faiths uterus prolapsed completely and, frustrated by this frequent occurrence, she grabbed the offending organ, pulled as hard as possible and cut the whole lot off with a short knife. In his report, Willoughby states that there was a mighty bleeding which eventually stopped and Faith lived on for many years after this, water passing from her insensible day and night, obviously from a vesico-vaginal fistula.

EARLY VAGINAL HYSTERECTOMIES

The origins of vaginal hysterectomy are lost in the mists of antiquity, but the first was reputedly performed by Soranus in the Greek city of Ephesus in AD 120, although there is an even more vague reference to the procedure having been performed 50 years before the birth of Christ by Themison of Athens (Lameras 1975). According to the medical historian Richard Leonardo, the procedure performed by Soranus was the removal of an inverted uterus that had become gangrenous (Leonardo 1944). The ureters and often the bladder, were invariably part of these early surgical excisions and the patients invariably

THE FIRST ELECTIVE VAGINAL HYSTERECTOMIES

Baudelocque from France introduced the technique of artificially prolapsing and then, in favourable cases, of cutting away the uterus and appendages. He performed 23 such procedures during the 16 years following 1800, but gave Lauvariol the credit for having performed the first operation in France. This was well before the time of the first abdominal operation performed by Charles Clay in 1843. Most of these procedures were performed on puerperal uteri and were undertaken on an emergency basis, but the first planned procedure was by Osiander

Manual of New Hysterectomy Techniques not to enter the peritoneal cavity. Unfortunately, towards the end of the operation he encountered very heavy bleeding and called upon his assistant to help him. Unfortunately his assistant, a Surgeon Commander debilitated by gout, was unable to rise from his chair when called upon to render assistance. Langenbeck had no option but to grasp the bleeding artery with his left hand and with his right hand he passed a needle carrying a ligature through the tissues beyond the bleeding point. With no one to assist him, he had to tie the ligature by grasping one end between his teeth and secured the pedicle with a one handed slip knot tied with his right hand. Following the procedure he could detect no opening into the peritoneal cavity and the patient made a surprising and uneventful recovery. Sadly, after such a display of surgical virtuosity, none of his colleagues would believe the report of his operation when it was published four years later. The specimen had somehow been lost and never reached the pathology department and the assistant with gout died some two weeks later, so there was no one to testify that the procedure had in fact taken place. The patient herself was demented and thus an unreliable witness and died of senility some 26 years later and only then could he prove by post-mortem examination that he had performed the operation. During that 26 years he was ridiculed and subjected to the jibes of his colleagues and no one gave him credit at the time for this spectacular achievement.

of Gottingen in 1801. Wisely, he did not report the case until he had operated on his ninth patient. In 1810, Wrisberg , in a prize essay read before the Vienna Royal Academy of Medicine, advocated vaginal hysterectomy for cancer and two years later, Paletta performed the operation. He was not entirely certain, however, that he had extirpated the entire uterus.

CONRAD LANGENBECK, SURGEON-GENERAL TO THE HANNOVERIAN ARMY

Conrad Langenbeck, (Figure 1.11) who came from Gottingen, was a surgeon of such supreme swiftness that he once amputated a shoulder while a colleague, who had come to observe the procedure, turned his back for a moment to take a pinch of snuff. Langenbeck was Surgeon-General to the Hannoverian Army and also a Professor of Anatomy and Surgery and was certainly the most distinguished surgeon of his day. He had read Wrisbergs paper and also the report of Paletta and this encouraged him to perform the first deliberate planned vaginal hysterectomy for carcinoma in 1813. He did not however, report the operation until 1817 and because of the abuse that he was subjected to, he probably regretted ever doing it.

FURTHER DEVELOPMENTS IN TECHNIQUE AT THE END OF THE NINETEENTH CENTURY

The latter years of the last century witnessed further development and the technique for abdominal hysterectomy was refined and standardised by Freund. Czerny, following Conrad Langenbecks original description, did the same for vaginal hysterectomy (Ricci 1945). The first planned hysterectomy performed on a gravid uterus took place in 1876 by Porro from Milan (Speert, 1980). Radical hysterectomy for cervical cancer was introduced by the German surgeon Schuchardt and was later refined and popularised by Ernst Wertheim, the famous Austrian surgeon from Vienna, after whom the operation is now somewhat unfairly named. The end of the nineteenth century and the early years of the twentieth century witnessed the introduction of specially modified instrumentation, anaesthesia and antisepsis and the mortality rate for vaginal hysterectomy dropped precipitously and by 1886 was approximately 15%; by 1890 it had reached 10% and by 1910 it was as low as 2.5%.

Figure 1.11: Conrad Langenbeck. Surgeon-General of the Hannoverian Army performed the first vaginal hysterectomy for endometrial cancer in 1813 He had little precedent to follow, so he had to devise his own plan for the removal of the entire uterus. He performed a retroperitoneal dissection, taking great care

History and Future of Hysterectomy Abdominal hysterectomy lagged far behind and at one time it was formally condemned by the Academy of Medicine of Paris, when they met in 1872. Even 8 years after that, T.G. Thomas reported on 365 collected cases which revealed a staggering mortality of 70%. It is extraordinary that given this high mortality, women allowed themselves to be subjected to this procedure and there was a time that it was advocated for hysteria and menstrual melancholia, the modern equivalent of which is the pre-menstrual syndrome. In spite of these disastrous results, progress in abdominal hysterectomy was being made. Mikulicz abandoned the serre-noeud after using it for 15 years and instead placed triple ligatures on the broad ligaments and tied each one of them separately. In 1878, Freund introduced techniques for packing off the intestines, ligating the major blood vessels and covering the cervical stump with peritoneum, which, in the same year, had been practised independently by both Schroeder and Spencer Wells. In 1889, Lewis Stimpson had advocated the systematic ligation of the main ovarian and uterine vessels instead of tying off the entire broad ligament and three years later, Bare of Philadelphia, the father of the modern sub-total hysterectomy, tied the uterine vessels outside of, but close to, the cervix. He was also the first to advocate care...to avoid the ureter! This technique was further refined in 1896 by Howard Kelly, who described an immaculate technique for sub-total hysterectomy little different from that employed today. Thus, in the space of one decade, exterior fixation of the uterus by the serre-noeud or a cervical clamp, such as that designed by Spencer Wells, had been replaced by intraperitoneal treatment of the cervical stump, which itself was modified and became extraperitoneal again, by covering the stump with pelvic peritoneum. These new techniques are reflected in the dramatic fall in mortality shown in the figures from the London teaching hospitals in 1896 and 1906, showing an impressive drop in mortality from 22 to 3.4%, allowing one of my distant relatives, John Bland Sutton to write in 1904: The removal of the uterus is followed less frequently by unpleasant sequelae than any other major operation in surgery. Hysterectomy has a wonderful future, and this is a great thing to say of an operation which 40 years ago had no more reality than Jack the Giant Killer.

THE DEVELOPMENT OF HYSTERECTOMY IN THE TWENTIETH CENTURY

Up until the end of the Second World War, the universal approach to hysterectomy was the sub-total procedure,

with the reduced chance of pelvic infection and ureteric injury, but mainly in the pre-antibiotic era, to reduce the chance of ascending infection and peritonitis, which was almost invariably fatal. Once this problem had been eradicated by the development of antibiotics, hysterectomy almost invariably included removal of the cervix and the man who has pride of place for performing the first total hysterectomy was E.H. Richardson from the United States of America in 1929 (Richardson, l929). His main concern in moving away from the traditional subtotal procedure, was to prevent the occurrence of stump carcinoma, yet even in the days before cervical screening was available, the actual incidence of neoplastic change in retained cervical stumps was only 0.4% in 6,600 cases in the United States of America (Cutler and Zolenger, l949) and 0.1% in Finland (Kilkku, Gronroos and Rauramo, l985). As Tom Lyons (1993) has pointed out, this is similar to the rate of vaginal cancer following total abdominal hysterectomy and yet no one has seriously recommended the removal of the vagina at hysterectomy as prophylaxis against this. Apart from the change from sub-total to total hysterectomy during the twentieth century, the only change in the abdominal procedure was the almost universal adoption of the less disfiguring transverse scar introduced by Johannes Pfannenstiel from Breslau in l900. Unfortunately this great surgeon died at the young age of 47, following a needle-stick injury in much the way as his Viennese colleague Semmelweiss, who taught the world the value of antisepsis in the prevention of puerperal fever, had done before him. Apart from the obvious cosmetic attraction of the transverse scar, it has a much higher tensile strength and was less prone to wound dehiscence and subsequent incisional hernia. Nevertheless it took many years to be universally accepted and my predecessor in Guildford was still employing large vertical incisions even in the 1980s. Increased surgical skill and prowess from an apprenticeship type of training has ensured that the operation now is extremely safe with an incidence of ureteric injury of 0.2-0.5% and mortality of 0.12%. (Amirikiah, Evans, 1979; Daly and Higgins 1988). The advent of prophylactic anticoagulants and antibiotics has further increased the safety of this procedure. The oft quoted figures of Dicker (1982) showing the superiority of vaginal hysterectomy with a morbidity of 24.5% compared with that of abdominal hysterectomy with a morbidity of 42.8%, are an eloquent testimony of the efficacy of prophylactic antibiotics, since those who had a vaginal hysterectomy had the benefit of these drugs, whereas those having an abdominal hysterectomy did not.

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Manual of New Hysterectomy Techniques from Clermont-Ferrand in France. The stage was now set for minimally invasive surgery to become a reality, and for a long time gynaecologists struggled with primitive surgical equipment and relied on advances in laser technology and electro-surgical devices to achieve cutting and coagulation. Our general surgical colleagues took an astonishingly long time to wake up from their slumbers before realising that the procedure par excellence suited for endoscopic surgery was the removal of the gall bladder. Even then, it took a gynaecologist (Philippe Mouret) from Lyon, France, to show them how it was done. The realisation of the enormous financial profits to be made from endoscopic surgery finally spurred the instrument manufacturers to produce a new generation of surgical equipment, so that finally we had scissors that actually cut and devices that could quickly and effectively secure vascular pedicles with clips, sutures or linear arrays of titanium staples. In a remarkably short space of time, enthusiasts from all over the world had adopted these techniques so that, at the time of writing, at least 80% of gynaecological operations which heretofore required major surgery with a large painful scar, could be operated on under endoscopic vision with several small access ports for the surgical instruments, resulting in a shorter hospital stay and a rapid return to domestic life and work.

Almost inevitably the increased safety of the operation led to an explosive increase in the number of hysterectomies performed, so that it is now the second most common operation undertaken in the United States of America with over 650,000 being performed annually at a cost of approximately three billion dollars. With the increasing safety the indications for the procedure have become more lax, to the extent that at the end of the last decade a Californian woman only had a fifty fifty chance of going to her grave still in possession of her uterus. Not only had the procedure become open to a certain amount of abuse, but technological advances, apart from endometrial ablation, had largely by-passed hysterectomy and during the mid part of this century, gynaecological surgery was in the doldrums.

THE DEVELOPMENT OF LAPAROSCOPIC SURGERY

Laparoscopy was introduced into continental Europe in the 1940s with the pioneering surgery of Hans Frangenheim from Konstanz and Raoul Palmer from Paris. It was largely ignored in the United Kingdom and North America until Patrick Steptoe, working in a small district hospital in Oldham, Lancashire, published the first book in the English language (Steptoe, 1967) which allowed wide dissemination of this new technique in the English speaking world. Laparoscopy became an enormously important diagnostic tool in gynaecology and even allowed the performance of relatively minor procedures, such as female sterilisation, ventrosuspension and puncture or fenestration of ovarian cysts. In the early years it was necessary to operate directly down the laparoscope in an intensely uncomfortable position, which certainly contributed to my own prolapsed intervertebral disc and I suspect many of my colleagues also developed occupational injury to their backs. The catalyst needed to catapult this new surgical approach from fantasy to reality was the development of small silicone chip cameras, enabling the entire operating team to take part in the surgery by way of a television monitor and the development of superior optics by the invention of the rod lens system and external cold light source, both of which were developed by Professor Harold Hopkins, FRS, from Reading University in the United Kingdom. Gradually gynaecological surgery became more sophisticated and much of the inspiration for this was the pioneering work of Professor Kurt Semm from Kiel University in Germany and his successor Professor Lilo Mettler and Professor Maurice Bruhat and his gifted team

LAPAROSCOPIC HYSTERECTOMY
Harry Reich performed the first laparoscopic hysterectomy in the world in 1989, in the William Nesbitt Memorial Hospital in Kingston, Pennsylvania, USA. He published his article the following year (Reich, De Caprio and McGlynn, 1989). Subsequently he demonstrated this technique in all the continents of the world where the performance was met with varying degrees of amazement and scepticism. Critics claimed that it took too long and would not be suitable for busy operating schedules in most countries and was a luxury peculiarly suited to the cosseted U.S. health system, where the average gynaecologist only performs one or two procedures a week (Sutton, 1994). The reason that he took so long was that he performed the entire procedure laparoscopically, including dissecting out part of the ureter and individually ligating and tying off the uterine artery and vein with extracorporeal sutures. He also performed the colpotomy incision laparoscopically and repaired it via the laparoscope. Other surgeons found this too time consuming and soon the procedure of laparoscopic assisted vaginal

History and Future of Hysterectomy hysterectomy became established, where the upper pedicles were ligated, electro-coagulated or stapled laparoscopically whilst the remaining part of the operation was performed as a routine vaginal hysterectomy. Unfortunately this led to a certain amount of abuse, because this procedure was designed to replace an abdominal, not a vaginal hysterectomy, and yet many cases were performed which clearly could have been completed entirely by the vaginal approach. Equally, it soon became evident that none of the laparoscopic part of the operation did anything to make the vaginal approach any easier and since there is no descent until the uterosacral and cardinal ligaments are transected, most surgeons found that with the limited access involvedotherwise they would have been done vaginallythe procedure became a very difficult vaginal hysterectomy. Cynics pointed out that this was in fact a complicated way of performing a vaginal hysterectomy, but it certainly had the advantage of honing vaginal surgical skills and allowed dissection of bowel adhesions laparoscopically, as well as the treatment of endometriosis and the easier removal of ovaries. It also had the advantage that the internal wound could be inspected at the completion of the procedure and any residual bleeding vessels could be sealed by bipolar diathermy ensuring that at the end of the procedure the field was absolutely dry. This did not however, prevent secondary haemorrhages occurring a few days later and the lack of bleeding at the end of the procedure did not necessarily prevent subsequent haematoma formation. These various criticisms led some laparoscopic surgeons to develop a purer approach to the operation and reverted to supracervical hysterectomy with removal of the transformation zone, either by coring it out with a serrated edge reamer (Semm, l993; Ewen and Sutton l994) or by simply removing the transformation zone with an electrosurgical loop from below (Donnez, l993) or coagulating it with the Nd:YAG artificial sapphire contact probe laparoscopically (Lyons, l993). The first laparoscopic hysterectomy in Europe was performed by the Classic Intrafascial SEMM Hysterectomy (CISH) technique by Professor Kurt Semm on a Saturday afternoon on September 7th 1991 in Kiel and this technique has been employed by his successor Professor Liselotte Mettler since then with good results. Employing these techniques, the possibility of cervical carcinoma should theoretically be reduced to zero, although all authors recommended annual cervical cytological surveillance, but it also allowed a purer laparoscopic approach, because it could avoid a vaginal incision and the fundus and adnexae could be removed by an electric morcellator. Additionally

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it had the advantage of avoiding any surgery in the danger zone around the ureter, was less likely to be associated with infection and abscess formation, maintained the integrity of the pelvic floor and was less prone to post hysterectomy urinary dysfunction, since there was little bladder dissection and, arguably, did not interfere with a patients sexual arousal and orgasm (Kilkku, 1983). Although this procedure enjoyed a good safety record and could be performed relatively quickly, the patients being discharged on the second or third postoperative day and return to full activity in three weeks (Ewen and Sutton, l994), we have found a disconcerting number of patients who had persistent pain and bleeding and eventually had to have the cervical stump removed. A clinical audit in our hospital (Haddad, l995) found that this was only in patients whose indication for hysterectomy was endometriosis and if this group were excluded, then it was a very satisfactory operation. Other authors (Schwarz 1993) have had a similar experience and we have found that since endometriosis is the main indication for hysterectomy in our department, its role has become somewhat limited.

THE FUTURE
Considering the length of time that Homo Sapiens has inhabited this planet, the history of hysterectomy is a short one and we have undoubtedly come a long way in a relatively small span of years. Our pioneering forefathers had to contend with a horrendous mortality rate and very high morbidity, but with technological advances made during this century, particularly with regard to antisepsis and antibiotic prophylaxis of infection, together with safe anaesthesia, intravenous fluids and blood transfusion, the procedure is now very safe with a mortality rate of approximately 12 per 10,000 (Bachman, l990) and is increasingly performed to improve quality of life, rather that to save life. It is always difficult to predict the future, but almost certainly alternatives to hysterectomy will continue to evolve and, as with general surgery, many operations will be replaced by medical treatment. A clearer understanding of the aetiology of endometriosis creating a basis for rational treatment would considerably decrease the number of procedures performed for that ill understood condition. The widespread introduction of cervical screening has reduced the incidence of cervical cancer in the western world and, in the future more effective screening for endometrial cancer could allow medical treatment in selected patients, although ovarian cancer will probably still require surgical treatment.

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Manual of New Hysterectomy Techniques

7. Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ, Peterson HB, DeStafano F, Rubin GL, Ory HW. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The collaborative review of sterilisation. Am. J. Obstet. Gynaecol, 1982;144:841-48. 8. Donnez J, Nisolle M. LASH: laparoscopic supra-cervical (subtotal) hysterectomy. In: Donnez J, Nisolle M (Eds); An Atlas of Laser Operative Laparoscopy and Hysteroscopy. Ch 20. 195-202 Parthenon, Carnforth, Lancs. UK, 1994. 9. Ewen SP, Sutton CJG. Initial experience with supracervical laparoscopic hysterectomy and removal of the cervical transformation zone. British Journal of Obstetrics and Gynaecology, 1994;101:225-28. 10. Graham H. Eternal Eve: The History of Gynaecology and Obstetrics, Garden City, N.Y., Doubleday, 1951. 11. Haddad C. Audit of the outcome of Supracervical Laparoscopic versus Total Abdominal Hysterectomy. 114pp. Royal Surrey County Hospital Clinical Audit Department, 1995. 12. Kilkku P, Gronroos M, Rauramo L. Supravaginal uterine amputation with pre-operative electro coagulation of endocervical mucosa. Acta Obstet. Gynaecol 1985;64:17577 13. Kilkku P, Gronroos M, Hirvonen T and Rauramo L. Supravaginal uterine amputation VS hysterectomy. Effects on libido and orgasm. Acta. Obstetrica. et Gynaecologica Scandinavica, 1983;62:147-52.# 14. Kimball G. Successful case of extirpation of the uterus. Boston. Med. Surg. J. 1855;52:249-55. 15. Lameras K. Galen and Hippocrates. Athens: Papyrus, 1975. 16. Leonardo RA. History of gynaecology. New York: Foben Press, 1944. 17. Lyons TL. Laparoscopic supracervical hysterectomy using the contact Nd: YAG laser. Gynaecological Endoscopy, l993;2:79-81. 18. Morton LT. Garrison and Mortons medical bibliography, second edition. 1965;527-37.(London: Andr Deutsch). 19. OConnor H. Magos A. The Medical Research Council randomised trial of endometrial resection versus hysterectomy in the management of menorrhagia. Lancet 1997;349:897-901 20. Pooley A. Ewen SP. Sutton C. Does trans-cervical resection of the endometrium really avoid a hysterectomy: life table analysis of a large series. JAAGL 1998;5:229-35 21. Ravina JH, Aymard A, Bouret JM et al. Embolisation arterielle particulaire : Un nouveau traitement des hemoragies des leiomyomes uterins. Presse Med 1998;27:299-303. 22. Reich H, De Caprio J, McGlynn F. Laparoscopic hysterectomy. J. Gynecol. Surg. 1989;5(2):213-15. 23. Ricci JV. One Hundred Years of Gynaecology. Philadelphia: Blakiston, 1945. 24. Richardson EH. A simplified technique for abdominal panhysterectomy. Surg. Gynaecol. Obstet. l929;48:248-51. 25. Semm K. Hysterectomy by pelviscopy: an alternative approach without colpotomy (CASH) in: Garry R., Reich H., (Eds) Laparoscopic hysterectomy. Oxford: Blackwell Scientific publications, l993:118-32.

Endometrial ablation with electro-resection or the neodymium YAG laser has been successful in the treatment of menorrhagia, although some scoffers have suggested that the initial one year 87% success rate, which is widely reported, (OConnor and Magos 1997) drops rapidly away and merely delays the need for hysterectomy for a period of time. This has not been the experience in our department (Pooley 1998) and we have found that even at the end of five and six years 75% of the patients are still satisfied with the treatment and this has avoided a large number of hysterectomies. This figure reflects the results of multiple surgeons in training and if one only includes the results of a single surgeon in the private sector the 6-year long-term success rate rises to 83%. Second generation methods of endometrial ablation that are already being developed, such as thermal balloons, hydrothermal, impedence-controlled and cryoablation techniques as well as new microwave systems will be expected to give much more uniform destruction of the endometrium in most cases (Sutton, 2006). Refinements in the treatment of fibroids by interruption of their blood supply by cervical occlusive devices or uterine artery embolisation first described by Ravina in Paris (Ravina 1998) have dramatically reduced the number of hysterectomies performed for this condition and our radiological colleagues have performed over 1200 of these procedures with an impressive safety record and in recent years have achieved many successful pregnancies with similar outcomes to age matched controls (Walker WJ 2006). In the future it may well be that hysterectomy will only be performed for malignant conditions and with the inclusion of para-aortic and pelvic lymphadenectomy this will be more efficiently undertaken by laparoscopic procedures in some instances assisted by increasingly sophisticated robots.

BIBLIOGRAPHY
1. Amirikiah M, Evans TN. Ten year review of hysterectomies: trends indications and risks. Am J Obstet Gynaecol, 1979;124:431-37. 2. Bachmann G. Hysterectomy. A critical review 1990; 35, 9:839-62. 3. Benrubi GI. History of Hysterectomy. J.Fla. Med. Assoc. 1988;75:533-42. 4. Clay C. Observations on Ovariotomy. Statistical and Practical. Trans. Obstet. Soc. London 1963;5:58-74. 5. Cutler EC, Zolenger RM. Atlas of surgical operations. McMillan Co. New York, 1949. 6. Daly JW, Higgins KA. Injury to the ureter during gynaecological procedures. Surg. Gynaecol. Obstet. 1988;167:19.

History and Future of Hysterectomy

26. Speert H. Obstetrics and Gynaecology in America: A History. Baltimore: Waverly Press, 1980. 27. Steptoe PC. Laparoscopy in gynaecology. London: Livingstone; 1967. 28. Sutton CJG. Whither hysterectomy? Current Opinion in Obstetrics and Gynaecology 1994,6:203-05. 29. Sutton CJG. Hysteroscopic surgery. In: Symonds I (Ed): Gynaecological Surgery : Techniques, Training, Skills and

13

Assessment. Ch 7 : 2006;20,1:105-138 Elsevier, Amsterdam, Holland. 30. Schwarz RO. Complications of laparoscopic hysterectomy. Journal of Obstetrics and Gynaecology, 1993;81:1022-24. 31. Walker WJ, McDowell SJ. Pregnancy after uterine artery embolisation for leiomyomata: A series of 56 completed pregnancies. American Journal of Obstetrics and Gynaecology Nov. 2006;195(5):1266-71.

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Manual of New Hysterectomy Techniques

2
Shirish S Sheth INTRODUCTION

Vaginal Route: Primary Route for Hysterectomy

The debate on whether the uterus should be removed vaginally or abdominally was sparked when Langenbeck first performed a vaginal hysterectomy (VH) in 1813.1 Historically, the reason gynaecological surgery became a specialty in its own right was its extensive use of the vaginal route. The vaginal approach has always been the hallmark of the gynaecological surgeon. Very often, a hysterectomy that should have been done vaginally is done abdominally only because it is more easily executed and is the favoured practice at a particular clinic. It was introduction of laparoscopic surgery, hysterectomy in particular, that has ignited the comparison between routes and techniques. All uteri that can be removed vaginally can be removed by the abdominal route or by laparoscopically assisted vaginal hysterectomy (LAVH), but the reverse is not true. The famous French Surgeon Doyen1 insisted in 1939 that no one could call himself a gynaecologist until he performed vaginal hysterectomy in private. Obtaining entry to obstetric and gynaecology related organs is inviting to the connoisseur at it has two portals of entry, one natural and the other created by surgical intervention. It is the vaginal route that gives entry or exit to the mouth and cavity of the uterus and provides a natural gynaecological route. No general surgeon or nonOb-Gyn. doctor can ever have in-depth knowledge of the art and science of making optimum use of the vaginal route for gynaecological surgery. Thus, the vaginal route is the natural one for obstetricians and gynaecologists. Only when that route cannot be considered should gynaecologist turn to an unnatural alternate door, that is, the abdominal route.2 The abdominal route is used by all and sundry general surgeons, oncologists, urologists, biliary and plastic surgeons.

Hysterectomy is one of the commonest major gynaecological operations, with over 100,000 procedures performed annually in England and 600,000 in the United States.3 All large-scale surveys of hysterectomy practice show that 70-80% of hysterectomies are performed by the abdominal approach, except in uterovaginal prolapse, for which the vaginal route is normally used. A study of more than 37,000 hysterectomies showed that about two-thirds of the operations were abdominal, just over one-quarter were vaginal, and a small proportion, 3.1%, were performed laparoscopically.4 In Sweden, more than 95% of all hysterectomies that are not performed in conjunction with a uterovaginal prolapse are performed abdominally.5 Interestingly Western Australia (WA) has 40% hysterectomies by abdominal route. WA has one of the highest hysterectomy rates in the world but performs proportionately few abdominal hysterectomies compared with most countries.6 Generally, the ratio of vaginal hysterectomy to abdominal hysterectomy (AH) varies from 1:3 to 1:4 or less, depending on the country, though this ratio is reversed in the hands of experienced vaginal surgeons to 60-90% (e.g. Brown 79%, Bezdek 82%, Hefni 65%, Hewson 80%, Kovac 90%, Magos 57% and Querleu 77%).3 Decline in AH and laparoscopically assisted vaginal hysterectomy have favourably increased the incidence of VH.3,7 In the authors personal series of 7334 hysterectomies in India, 6044, (82%) were carried out vaginally of these 92% were in the absence of uterovaginal prolapse. The vaginal route is the primary route for hysterectomy provided its superiority is beyond doubt in comparable cases. The scope of selecting one of several options from various types of hysterectomies available, should ideally depend on:

Vaginal Route: Primary Route for Hysterectomy I. What is best for the patient, and II. Absence or presence of contraindications. No other factor should interfere in this holistic decision.

15

ASPECTS THAT COMPEL TO OPT VAGINAL HYSTERECTOMY

Several aspects, cumulatively, decide what is the best or choicest to become primary route, are as follows:

COMPLICATIONS
The complication rate for AH is 70% higher than that for VH. More than 20 years later survey in UK reached a similar conclusion.4 Western Australia study of 83000 hysterectomies shared that the occurrence of a serious complication were 20% lower for vaginal hysterectomies compared with abdominal procedures.6 In the Value study of 37,298 hysterectomies from the UK, the overall operative complication rate for vaginal hysterectomy was 3.07% while 3.57% of abdominal hysterectomy patients were reported to have a complication of surgery and 6.07% of women treated by LAVH experienced a complication.4 One conclusion of the VALUE study is that laparoscopic techniques tend to be associated with higher complication rates than other methods.4 Major concern is towards urinary tract injuries. Cystotomy and ureteric injury rate is 1.38% and 0.91% respectively.5 This rate is far too high when compared with conventional vaginal hysterectomy. In a review of 1372 articles in the world literature between 1970 and 1996, the incidence of bladder injury was highest with LAVH. Postoperative fever which often matters to patient as well as relatives was significantly higher in the abdominal group (18%)

compared with 9% and 8% respectively in the vaginal and LAVH groups.3 Wound infection, which is unlikely after VH, adds 3.5 days to the hospital stay after AH.8 The chances of leaving behind a sponge are remote with VH. However, the collaborative review of sterilisation study (CREST) report shows an overall rate for the complication of bleeding of 2.6% with VH and of 1.6% with AH.8 Blood loss is more when vaginal hysterectomy is associated with repair than without. According to the data collected by the Centers for Disease Control in the USA.9 Excluding pregnancy and cancer-related cases, the mortality rate for a vaginal hysterectomy was 2.7/10,000 procedures, compared with 8.6/10,000 procedures for an abdominal hysterectomy. In an analysis of hysterectomies in USA, reported least mortality per 10000 procedure of LAVHs and maximum for abdominal hysterectomy.3

TIME AND COST

Studies have proved beyond doubt that vaginal and abdominal hysterectomy require less operative time and anaesthesia time than LAVH or LH. Operation room time is precious and can effect expenses as well as number of admissions to the hospital. The accompanying Table 2.1 distinctly points that LAVH or LH take longer in performance increasing risk, monetary inputs and efforts. Despite an increase in laparoscopic skills most gynaecologists still find that laparoscopic hysterectomy is technically demanding, takes too long and may need expensive disposable equipment. Thus, when laparoscopic surgery is used more extensively, the costs are higher. Studies that examined components of total charges indicated that laparoscopic hysterectomy was often more

Table 2.1: Summary of meta-analysis distinctly present benefits of technique used5 Measure Abdominal vs laparoscopic hysterectomy Operating time Anaesthesia time Length of stay Hospital charges Vaginal vs laparoscopic hysterectomy Operating time Anaesthesia time Length of stay Hospital charges Statistical significance p<0.01 p<0.01 p<0.01 p<0.01 p<0.01 p<0.01 p<0.05 p<0.05 Interpretation LH>AH LH>AH LH>AH No difference LH>VH LH>VH No difference LH>VH

Modified from Betram DA, Kovac SR, Cruikshank SH. The role of laparoscopy in hysterectomy. J Pelvic Surg 1997; 39: 147-58. LH, Laparoscopic hysterectomy; AH; abdominal hysterectomy; VH, vaginal hysterectomy

16

Manual of New Hysterectomy Techniques

expensive because of the use of disposable instruments, longer operating room and anaesthesia times, and intraoperative pharmacy charges.10 All studies comparing laparoscopic and vaginal hysterectomy reported laparoscopic hysterectomy to be more expensive3 and VH is the least expensive.11 If 80% or more hysterectomies are performed vaginally, the NHS could save as many as 22,000 bed days annually (National health service hospitals, UK) but the situation is far from the ideal.12 The cost factor, whether to an individual, his employer or an insurance company, cannot be ignored. In developing countries cost tilt the balance in favour of not the best. Table 2.2 argues in favour of the vaginal route from the study; still only 20 to 30% of hysterectomies are carried out via the vaginal route in the western world. Table 2.2: Complication rates among women aged 15-44 years undergoing hysterectomy by surgical approach13 Complication Complication Rate% Vaginal Abdominal (n=568) (n=1283) 15.3 8.3 1.1 0.2 0 0 0 32.3 15.4 5.9 2.2 0.2 0.2 0.2

STAY
Hospital stay for vaginal hysterectomy and LAVH is similar, and both are significantly shorter than for abdominal hysterectomy.14 There is no doubt that abdominal hysterectomy will have hospital stay longer by 24 to 72 hours and this can matter to patient, relatives, hospital and insurance company. In an interesting study, Summitt et al showed that, following simple vaginal hysterectomy , the total hospital stay could average 9.4 hours with 100% patient satisfaction.10 This study clearly announced that hospital stay can be considerably reduced, reduced to less than 48 hours. In short, vaginal hysterectomy is the procedure associated with the quickest operating time, the shortest hospital stay, and the lowest hospital costs.9

RECOVERY
Vaginal hysterectomy has following favourable facets. Hospitalisation, pulmonary complications, morbidity, and mortality are reduced. Discomfort and pain are reduced as a result of minimal or almost no handling of the bowel. Reduced operative time, better drainage, and simpler anaesthesia. Intestinal: flatulence, pain, and ileus are less, as are blood loss and shock. Reduced incidence of thrombophlebitis and emboli Hastened recovery as a result of largely extraperitoneal surgery. No abdominal scar and adhesions. For any technique route or methodology to become primary it has to prove its worth. Worth, value and recognition will come from above benefits.

Febrile morbidity Transfusion Atelectasis Ileus Wound dehiscence Neuropathy Deep vein thrombosis/ Thrombophlebitis

Doucette9 calculated that a shift of 10% from abdominal to vaginal hysterectomy in the United States would save more than $7.5 million in hospital costs alone. This is an important message, particularly for the developing world. Kovac3 has contended that if size, access and adnexa are evaluated, 90% of hysterectomies for benign indications could be safely done vaginally, thus saving more than $200 billion each year in the United States easily more than $1000 per hysterectomy. Hospital stay did not differ in the laparoscopic and vaginal group but laparoscopic technique proved more expensive than conventional hysterectomy.3 The surgeon needs only standard instruments and sutures, and 80% of the world, i.e. the developing countries, would be better served by gynaecologists with knowledge of the techniques of vaginal surgery and expertise in their application. Availability, access, cost and affordability are important aspects of the practice of surgery.5 The economic benefit and patient friendliness of vaginal surgery are important advantages.8

BLOOD TRANSFUSION
In a study by Mintz et al, blood transfusions were required in 25%, 12.5%, and 5% of patients undergoing an abdominal hysterectomy, vaginal hysterectomy with colporrhaphy, and a vaginal hysterectomy without repair, respectively.10 The incidence of blood transfusion is greater with the abdominal rather than the vaginal route: 15.4% with the abdominal and 8.3% with the vaginal route.10 These rates appear high. Copenhaver also reports increased blood loss with an associated colporrhaphy.10 Infiltrating the cervix with a vasoconstrictor before vaginal hysterectomy appears to reduce blood loss.10 Hewson finds transfusion rate with vaginal hysterectomy was only 0.38% when compared with 2.1% with abdominal hysterectomy.15 In the days tinged with fear

Vaginal Route: Primary Route for Hysterectomy of HIV and hepatitis, the gynaecologist needs to focus heavily on reducing the incidence of blood transfusion. In the authors personal series, 2.4% women received a blood transfusion because of a low haemoglobin (8-9 gm/ dl) despite best possible treatment.

17

INVASION
Trauma associated with surgery needs to be looked at in the proper perspective and just not in the form of punctures and incisions and their size. Even though incisions or cuts are small, is the handling of tissues for long many hours and a woman remaining under anaesthesia for disproportionately longer time and bigger cuts on purse not a greater invasion? Extended operative time and invasion on operation theatre occupancy must be considered. These factors play a vital role in many geographical areas and should contribute heavily in the surgeons choice of hysterectomy.5

MORBIDITY
No surgery can be without complications, or physical price. Operative morbidity, cosmesis and recuperation favour the vaginal approach. It has advantages in recovery, cost, hospital stay, absence of scar and is the least invasive and minimal accessed hysterectomy. Jeffcoate finds advantages in the vaginal route as it is safer, with low mortality, has less postoperative shock and discomfort with early ambulation.9 There is much less bowel handling and therefore ileus and intestinal obstruction are rare. It is better tolerated by elderly and high risk patients and with a lesser risk of hernia, adhesions, and wound dehiscence besides providing the opportunity to correct prolapse/laxity. There is definitely less thrombophlebitis, atelectasis and pneumonia, pulmonary embolism and forgotten foreign bodies though it must be remembered that patients undergoing an abdominal hysterectomy have more severe disease.

(28-125), respectively. Thus concluding that traditional vaginal hysterectomy proved to be feasible and the faster operative technique compared with vaginal hysterectomy with laparoscopic assistance. The abdominal technique was somewhat faster, but time spent in theatre was not significantly shorter. Abdominal hysterectomy required on average a longer hospital stay of one day and one additional week of convalescence compared with traditional vaginal hysterectomy.9 A trial in USA concluded that vaginal hysterectomy compared with abdominal hysterectomy (AH) and laparoscopic assisted vaginal hysterectomy (LAVH), VH scored the most points in terms of patient satisfaction and well being.9 There are 20 Randomized controlled trials (RCTs) comparing TAH and VH with LH and 16 RCTs comparing LH with TAH. Almost all trials indicate that LH takes more surgical time with lesser stay and shorter recovery period. Conclusion from 27 trials with 3643 was where vaginal hysterectomy is not possible laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.16 Another four studies, though not randomized, clearly suggest that VH should be preferred for hysterectomy, unless specific indications in favour of the abdominal or laparoscopic route are present.

Scar
Just as at laparotomy, laparoscopic hysterectomy or LAVH also leave behind scars though very small. They can stand out if turns into keloid. In contrast, vaginal hysterectomy has no visible scar. Cuts inflicted to carry out vaginal hysterectomy are also the same cuts inflicted at abdominal hysterectomy, LAVH and LH.

QUALITY OF LIFE AND SATISFACTION

A more recent prospective study from the technology assessment group at Kaiser Permanente, which examined quality-of-life measures, found that patients who had vaginal hysterectomy returned to normal activity much sooner and had more favourable pain, activity, and function outcomes than patients who underwent either laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy.9 LH had lower mean increase in quality adjusted life years (QALYs) than VH. Thus, when all clinical decisions are equal, vaginal hysterectomy appears to provide the most satisfaction outcomes from the patients point of view, although quality-of-life outcomes for the laparoscopic procedure were often as favourable and both were superior to

RANDOMIZED STUDIES
A randomized study by Ottosen et al the objective was to detect differences in clinical short-term outcome between total abdominal hysterectomy, vaginal hysterectomy and laparoscopic assisted vaginal hysterectomy.9 Main outcome measures were duration of surgery, anaesthesia, time in hospital and recovery time. Mean duration (range) of surgery was significantly longer for laparoscopic assisted vaginal hysterectomy compared with vaginal hysterectomy and total abdominal hysterectomy, 102 min (50-175), 81 min (35-135) and 68 min

18

Manual of New Hysterectomy Techniques

abdominal hysterectomy. Before concluding, results require proof-evidence that convinces and this has accrued out of randomized controlled trials and various studies. All trials point to supremacy of vaginal route for hysterectomy without any scope for offering a flaccid argument with rationale. When all the parameters tilt the balance heavily in favour of taking the vaginal route for hysterectomy, decision making will now necessitate exclusion of contraindications to that route of hysterectomy.

CONTRAINDICATIONS (CI)
These are few to take away the option of choosing vaginal route as primary route for hysterectomy. They are:

COMMON
1. Uterus more than 12 weeks size or uterine volume more than 250 to 300 cm3; 2. Restriction of uterine mobility; 3. Adnexal pathology. Figure 2.1: Classic adhesions seen at laparotomy with caesarean section in the past. Deavers retractor and Allis forceps on the skin marking at the umbilical level close to the upper end of the right paramedian incision. The uterine fundus of a normal size uterus is well above half way between the symphysis pubis and the umbilicus.

UNCOMMON
1. Cervix flush with the vagina or past fothergills operation makes the cervix look most unlike a cervix. 2. Invasive cancer of the cervix. 3. Vesicovaginal and/or Rectovaginal fistula repair. 4. Inaccessible cervix: Uncommonly, after repeated uterine surgery, particularly, past caesarean section, there are dense adhesions between the uterocervical surface, the bladder and the lower abdominal wall (Figure 2.1) which makes the cervix inaccessible to an approach by the vaginal route. These adhesions can be anticipated by simple speculum examination by the presence of Sheths cervico-fundal sign.3 With a rise in the caesarean section rate, gynaecologists should be aware of such adhesions. 5. Utero-cervical angle of 90. Globular uterus mimicking small melon perched on top of cervical stump typically angle between the lateral cervical surface and the ascending uterine wall from the cervix. When the angle is reduced from usual 140 or more to 90 or thereabout (Figure 2.2) chances of failing to perform a VH rise sharply. Very often vaginal hysterectomy though recognised as the choicest method is not performed. Two classic studies give crystal clear picture of operators weakness. 1. Davies et al reviewed 500 cases of Hysterectomies; 76% were by the abdominal route in the absence of

Figure 2.2: The depicted angle between lateral cervical and uterine borders, greater than 140, makes access and reach easier. Reduction of the angle towards 90 makes access and reach very difficult or impossible. (From, Sheth SS. Uterine Fibroids. In: Sheth SS, Studd JWW (Eds): Vaginal Hysterectomy. London: Martin Dunitz Ltd., 2002, pp 79-94 permission obtained). an absolute contraindication to Vaginal Hysterectomy.3 Reasons given for not taking the vaginal route were absence of prolapse in 76%, presence of fibroid in 45%, and need for oophorectomy in 43%. 2. Much can be learned from the experience of Kovac who assessed all his patients scheduled for abdominal hysterectomy by performing a laparoscopy before opening the abdomen.3 He wanted to determine

Vaginal Route: Primary Route for Hysterectomy whether laparoscopy performed immediately before hysterectomy could be used in deciding and finalizing the route of hysterectomy. Assessment of the pelvic findings by laparoscopy changed the decision from the abdominal to the vaginal route in 91% of cases without any complications during surgery. This clearly drives home the fact that careful and thorough assessment is vital in planning this major gynaecological procedure. He and his team concluded that preoperative laparoscopy may allow more hysterectomies to be performed by the vaginal route without laparoscopic surgical assistance in lieu of reposing blind faith in the abdominal route as the method of choice. The gynaecologist who opts for LAVH or abdominal hysterectomy instead a clear indication of VH, often consoles himself with one or other reasons for doing so.1 The excuses given for avoiding the vaginal approach and favouring an abdominal or LH or laparoscopically-assisted vaginal hysterectomy include: There is no uterine prolapse/descent The uterus is large/ There is a fibroid in the uterus. The patient is nulliparous. There is a history of cesarean section or pelvic surgery in the past. There may be adhesions or endometriosis. The patient needs an oophorectomy. Inspection of the abdominal organs, particularly the appendix, is essential. Let us examine each excuse or reason given for not taking a vaginal route.

19

dysfunctional uterine bleeding. What matters is that total uterine size is not more than 12 weeks or 250 to 300 cm3 volume. If at examination under anaesthesia, particularly on applying traction to the cervix, uterine fundus descends to disappear in the pelvis, and is not palpable per abdomen the vaginal route should not pose a problem. If one expects a foetus to travel through this very passage, access should not be a problem for a smaller sized uterus?

The Patient is Nulliparous

It is not unusual to find 90% of hysterectomies in the nullipara performed abdominally as nulliparity creates concern about descent and space. However, after the advent of LAVH, VH percentage has now gone up to 40%17 from meager 10%. The authors series of 112 virgins with severe mental handicap who have had vaginal hysterectomy to eradicate problem of menstrual hygiene, is an example in strong favour of feasibility of vaginal hysterectomy for nulliparous women.18 Hysterectomy in a nullipara should not be by laparotomy unless there is a clear-cut contraindication for VH and unfavourable findings for LAVH. As long as the uterus is less than 12 weeks size, freely mobile and without adnexal pathology, vaginal hysterectomy should be possible. Nulliparity per se should never contraindicate vaginal hysterectomy.

There is a History of Cesarean Section or Pelvic Surgery in the Past

Previous abdominal or pelvic surgery Operation performed on the uterus are the most important caesarean section, hysterectomy and myomectomy demands caution but in no way contraindicates VH. It has been observed that when the bladder is adherent following a caesarean in past, it is almost always in central 3/5 and not lateral 1/5. In addition, MRI studies at the level of the cervical isthmus through different planes shows a distinct vacant space medial to the line joining the maximally bulging uterus above and the cervix below, with its continuity medially between the uterocervical surface and the bladder until they come extremely close to each other in the midline (Figure 2.3).3,20 At VH in a patient with history of caesarean in past, Khung chooses to separate lateral non-adherent portion of bladder through a surgical window lateral to the midline on the anterior cervix or Sheths utero-cervical broad ligament space (Figure 2.4)19 and the same space is often utilised at the time of abdominal hysterectomy or laparoscopic hysterectomy when separation of bladder

EXCUSES There is no Uterine Prolapse/Descent

Neither absence of prolapse is a contraindication to taking vaginal route for hysterectomy nor presence of prolapse is a pre-requisite. Every gynaecologist must notice that every freely mobile uterus without pelvic pathology has physiological descent, which permits the start of a vaginal hysterectomy. Uterine prolapse is pathological descent and non-descent of uterus occurs due to pathological connective tissue, which contraindicates VH. To gain experience in arriving at a decision, the ideal is to seize the opportunity to examine under anaesthesia (EUA) every young nulliparous woman undergoing conservative gynec surgery as if she is scheduled for hysterectomy.

The Uterus is Large/ There is a Fibroid in the Uterus

Uterus may be larger than normal due to several conditions. Commonest are uterine fibroids, adenomyosis and

20

Manual of New Hysterectomy Techniques vesico-uterine space.20 The author has routinely used this surgical window for more than 15 years to obtain access to the vesicouterine space during vaginal hysterectomy in women with a previous history of caesarean section, including many with multiple previous caesarean sections and/or myomectomy in past and rare women with a history of uterine rupture.

There may be Adhesions or Endometriosis

If indicated size uterus is freely mobile with normal adnexae and absence of pelvic pathology there is no justification to take route or technique other than vaginal route. If doubt and/or anxiety prevails, examination under anaesthesia and laparoscopic evaluation will guide the decision-making. More often adhesions are in operators mind and not in patients pelvis.

The Patient needs Oophorectomy

Figure 2.3: Transverse section magnetic resonance imaging (MRI) at the isthmic level shows clear space between the bladder in front and the uterocervical surface behind, with continuity laterally between the two leaves of the broad ligament. Clamping and suturing, pretied ligature placement, automatic stapling devices, bipolar coagulation endoloop sutures and transvaginal endoscopic oophorectomy utilising endoloop sutures or bipolar electrosurgery have helped surgeons to accomplish oophorectomy vaginally at vaginal hysterectomy without laparoscopic assistance.8 Objective is to keep invasion at minimum, i.e. do not utilise abdominal access. Author prefers conventional clamping-n-cutting fundibulo-pelvic ligament and performing salpingo-oophorectomy. This has two prerequisites (1) to cut round ligament separately, and (2) cut distally, 3-4 cm from the uterus. Sheth21 reported 95% success while performing prophylactic oophorectomy at vaginal hysterectomy in 740 cases. Davies et al22 and Hefni and Davies23 have successfully performed oophorectomy vaginally at vaginal hysterectomy. Cengiz et al24 used laparoscopic evaluation and followed successfully in 64.7% by performing vaginal hysterectomy using Heaney technique and salpingooophorectomy using Sheths technique. Kovac and Cruikshank3 found oophorectomy at vaginal hysterectomy is possible in great majority and is superior to other approaches. American College of Obstetrics and Gynaecology Guidelines clearly defines that LAVH is needed only when oophorectomy at VH is difficult. In other words, it can be done at VH and in few cases in genuinely difficult cases, LAVH rescues.

Figure 2.4: At vaginal hysterectomy, the finger is on the uterocervical surface, with the bladder anteromedially, as it insinuates further between the two leaves of the broad ligament laterally. (surgical window in cases with past caesarean). in its central portion is difficult or risky. Sizzi and Rossetti note that a safer approach is from the lateral, the surgical window described by Sheth which allows a safe, sharp dissection also through laparoscopy, starting from both sides going medially towards the medial portion of the

Inspection of the Abdominal Organs, Particularly the Appendix is Essential

This is a very uncommon requirement in a woman undergoing hysterectomy. However, if inspection is the

Vaginal Route: Primary Route for Hysterectomy need, diagnostic or evaluatory laparoscopy will answer it the best. After getting clear view of abdomino-pelvic organs, excluding suspected pathology, gynaecologist should then proceed to perform VH. Having absolved given excuses, let us inspect all the indications and/or associated conditions for which vaginal route can be primary route for hysterectomy.

21

INDICATIONS/ASSOCIATED CONDITIONS
For following, in absence of contraindication, vaginal route should be a primary route for hysterectomy and performing alternative is certainly not in the best interest of our patient. They are: 1. Uterine prolapse, 2. Dysfunctional uterine bleeding 3. Adenomyosis 4. Fibroid 5. Polyposis 6. Carcinoma in situ (CIN III) of cervix. 7. High-risk with early endometrial cancer

DYSFUNCTIONAL UTERINE BLEEDING (DUB)/ ADENOMYOSIS

Dysfunctional uterine bleeding suspected adenomyosis and fibroid can be clubbed together as the ideal set-up for VH when a hysterectomy is indicated and there is no contraindication to this route. Excepting uterine, absence of pelvic pathology as well as without contraindication for VH, several gynaecologists have now taken to performing an LAVH for these conditions, which the author thinks is a gross misuse of high technology. The redeeming feature is, however, that at least the abdomen is not opened like a cupboard! In a recent paper from England, Hutchon25 states that he has not done a single abdominal hysterectomy in the past 6 years in women with a diagnosis of dysfunctional menorrhagia. In my practice of more than 40 years, each and every case of dysfunctional uterine bleeding and/ or adenomyosis was treated with vaginal hysterectomy unless genuinely contraindicated. Whether uterus is enlarged due to fibroid or otherwise what can guide is careful clinical examination, reliable, sonographic uterine volume and examination under anaesthesia. Only when the uterine size is unduly large, i.e. greater than 12 weeks size, either debulking at VH or LAVH becomes essential.

or has a total volume not exceeding 250 to 300 cm3, the ideal route should be vaginal. The size of a fibroid is not as important as the size to which the uterus is enlarged and how accessible the fibroid is. Edward and Beebe advocate vaginal hysterectomy for myoma up to 14 weeks size.9 Navaratil goes on to state: In general, it can be said that uteri enlarged to the size of a pregnancy of approximately 3-4 months do not represent a contraindication.9 Interestingly, the route for hysterectomy in the presence of uterine fibroids was vaginal in 7.4% of Dickers series, 81% in Cossons3 and 42.6% in Mettler and Semms series.26 In select cases, debulking is done during vaginal hysterectomy and/or GnRH is administered (leuprolide acetate 3.75 mg) intramuscularly once a month for two doses to reduce the size of the fibroid; such reduction may be adequate to make the patient fit for VH and take additional benefits. Data regarding the total uterine volume and exact location of fibroid will be of immense help in decisionmaking about the route, site for debulking, and uterine delivery. Fundal height can easily mislead the size as because of adenomyosis uterus may have disproportionately grown in both or other dimensions.

MALIGNANCY
Gynec oncologist will differentiate from others by favouring to take vaginal route for the required hysterectomy for: a. Select cases of endometrial cancer early and high risk. Required lymphadenectomy is performed laparoscopically. b. Prepare vaginal cuff vaginally and turn to abdominal route for required surgery for endometrial cancer.27 Vaginal hysterectomy is also recommended for very early cancer cervix but is not without rigid limitations and therefore.. . Resorting to alternate route or technique for CIN III is non-gynec oncology.

ASSOCIATED OBESITY
The overall complication rate in the obese was fractionally less and there was no increase in comorbidity.3,28 Obesity should per se invite vaginal route and dissuade abdominal approach or assistance. One should go out of his way to spare such abdomen if findings do not contraindicate and permit VH. Following should never deter gynaecologist in taking vaginal route as primary route for hysterectomy.

FIBROIDS
In absence of contraindication and irrespective of number of fibroids when the uterus is not larger than 12 weeks

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1. 2. 3. 4. 5.

Manual of New Hysterectomy Techniques

Nulliparity History of caesarean section Oophorectomy High risk with early endometrial cancer Associated surgery at same sitting (e.g. Lap cholecystectomy and VH)

LAPAROSCOPIC EVALUATION
Laparoscopic evaluation is indicated in patients where there is reason to fear possible failure to complete VH and/or to gain confidence during the early part of the learning curve. This will pave the way to success.1 It is recommended when: When VH appears to be possible (i.e. not contraindicated), but the surgeon has some doubt or apprehension. In some cases where a trial VH has been planned. Adnexal pathology: when an experienced vaginal surgeon plans to excise a benign, mobile, adnexal mass at VH, laparoscopy will confirm the earlier findings, exclude malignancy and tuberculosis, and confirm whether removal via the vaginal route is possible.

Following can persuade reluctant operator to take vaginal as primary route. Ventral scar hernioplasty Morbid obesity. High riske.g. interstitial lung disease which markedly restricts pulmonary function, poor cardiac status, diabetes, and hypertension.10 Tuberculous abdomen. Keloids.

WHAT CAN PROMOTE VH AS PRIMARY ROUTE

EXAMINATION UNDER ANAESTHESIA (EUA)
This singularly important examination performed just before the start of hysterectomy should form an integral part of the management of a patient needing a hysterectomy. EUA is performed, after placing the patient in the lithotomy position, by careful speculum examination using a vulsellum or tenaculum on the cervix and bimanual examination and not as often performed on a patient lying in supine position.3 Every VH should be preceded by an EUA and in addition, LAVH or abdominal hysterectomy should not be considered unless there is a contraindication to VH, which is confirmed under anaesthesia.1 Examination under anaesthesia can convert many abdominal and LAVH into simple VH. Bottom line for every gynaecologist should be: Give me reliable findings of examination under anaesthesia and I will give you an unambiguous decision on the route for hysterectomy.8

PREOPERATIVE UTERINE VOLUME

When uterus is more than 8 weeks size, it is desirable that the operator religiously utilises reliably measured uterine volume rather than clinically measured uterine size. Size as measured by gestational fundal height can prove misleading and invite difficulty during vaginal hysterectomy. Uterine volume will prove to be a better measure of a uterus than fundal height. Even though fundal heights are same, uterine volumes can grossly vary and therefore, so will be surgical demand.29

DISCUSSION
The mindset of the practising gynaecologist is vital and pivotal. As an obstetrician, he recommends caesarean section or elective repeat caesarean to keep the perineum, in particular, and pelvic floor, in general, intact. Interestingly, the same obstetrician in his gynaecological practice continues to open the abdomen and perform hysterectomy for a multiparous normal-sized uterus and leaves behind a torn perineum and/or bulging lower third of the posterior vaginal wall rectocele and/or glaring cystocele unattended.2 Abdominal hysterectomy is a good choice in cases where the uterus is considered an abdominal organ, where there is associated adnexal pathology, particularly an adherent one or one suspicious of malignancy, and where there is a genuine need to visualise the abdominopelvic organs. In reality, vaginal surgery is the least invasive route because one is using the entrance designed by nature without making any additional cuts it is kinder to the patient. Place of LAVH is well crystallized by ACOG Guidelines which include (a) lysis of adhesions; (b) treatment of pelvic

TRIAL VAGINAL HYSTERECTOMY

A trial of forceps in obstetrics is used when there is a possibility of vaginal delivery, keeping facilities for caesarean section ready. Comparable to this is the concept of a trial vaginal hysterectomy1 first presented in 1993, with a facility for laparoscopic assistance and/or laparotomy kept available. After careful EUA, there are times when it is felt that VH may be difficult or may fail despite the absence of well accepted contraindication but an attempt may still be made to proceed with vaginal hysterectomy. Likely to fall in this category are: (1) Those with enlarged uterus; (2) Those who have caesarean section in past; (3) Nulliparous women; (4) Operator with doubt and anxiety without reason.

Vaginal Route: Primary Route for Hysterectomy endometriosis, uterine fibroids that complicate the performance of VH ligation of infundibulo-pelvic ligaments to facilitate difficult ovary removal and evaluation of the pelvic and abdominal cavity before hysterectomy.30 This should inspire operator to take appropriate path. All the randomized and other studies favour vaginal route and so also are the views of laparoscopic surgeons whenever VH is possible. It is only when vaginal route cannot be chosen, LAVH or LH and abdominal route need to be considered. With a personal experience of having performed more than 6044 vaginal hysterectomies, the author strongly feels that only a genuine contraindication to vaginal hysterectomy should indicate LAVH or an abdominal hysterectomy and for every woman scheduled for hysterectomy, vaginal route is proved beyond iota of doubt as primary route. In practice, 80-90% of hysterectomies for non-prolapsed uteri can be carried out via the vaginal route and only in the remaining 10-20% cases is LAVH or the abdominal route resorted to. When a hysterectomy is decided on, every gynaecologist should first consider using the vaginal route, which is the least invasive, without any laparoscopic assistance. AH must be reserved for cases in which the vaginal route is contraindicated and LAVH is either risky or difficult. If hysterectomy is possible by all three approaches, in the best interest of the patient the order of preference would be VH, LAVH, and abdominal hysterectomy. Vaginal hysterectomy differentiates the gynaecological surgeon from the general surgeon, who can easily remove the uterus through the abdomen equally competently. If vaginal surgery was marketed to patients as scarless surgery, perhaps it would become more popular in the consumer-driven society. Ideal would be to follow words of wisdom we must continue to train gynaecologists to ably perform vaginal surgery and let the public know that fewer laparoscopic techniques and equipment offer no advantage over proven vaginal hysterectomy techniques.31

23

REFERENCES
1. Sheth SS. Vaginal hysterectomy. In: Studd J. Progress in Obstetrics and Gynaecology 10th ed. London: Churchill Livingstone, 1993;317-40. 2. Sheth SS. Concentrate on per via naturales: spare cesarean section and save the abdomen (Editorial). Expert Rev. Obstet Gynecol. 2006;1:3-5. 3. Sheth SS. Vaginal Hysterectomy. Best Practice and Research Clinical Obstetrics and Gynaecology. Edited by Prof. S.Arulkumaran, (Guest Editors R. Thakar & I. Manyonda) USA: Elsevier Ltd. 2005;Vol.19 (3),307-32.

4. Maresh MJ, Metcalfe MA, McPherson K, et al. The VALUE national hysterectomy study: description of the patient and their surgery. Br J Obstet Gynecol 2002;109:302-12. 5. Sheth SS, Paghdiwalla K. Do we need the laparoscopic route? J Obstet & Gynaecol of India. 2001;51:25-30. 6. Spilsbury K, Semmens JB, Hammond I, et al. Persistent high rates of hysterectomy in Western Australia: a population-based study of 83000 procedures over 23 years. Br J Obstet Gynecol. 2006;113:804-09. 7. Jones HW (Editorial comment). The VALUE national hysterectomy study: Description of the patients and their surgery. Obstet Gynecol Survey 2002;57:431-32. 8. Sheth SS. The scope of vaginal hysterectomy. Eur. J Obstet Gynecol and Rep. Bio. 2004;115:224-31. 9. Sheth SS. Vaginal or abdominal hysterectomy. In: Sheth SS, Studd JWW (Eds): Vaginal Hysterectomy. London: Martin Dunitz Ltd., 2002;301-20. 10. Sheth SS, Salvi V. Complications, morbidity and mortality of vaginal hysterectomy. In: Sheth SS, Studd JWW, (Eds): Vaginal hysterectomy. London: Martin Dunitz Ltd., 2002;341-54. 11. Lenihan JP, Kovanda C, Cammarano C. Comparison of laparoscopic-assisted vaginal hysterectomy with traditional hysterectomy for cost effectiveness to employers. Am. J Obstet Gynecol 2004;190:1714-22. 12. Bottle A, Aylin P. Variations in vaginal and abdominal hysterectomy by region and trust in England. Br J Obstet Gynecol. 2005;112:326-28. 13. Hospital Episode Statistics. 1994;3(2):415-24. 14. Lumsden MA, Twaddle S, Hawthorn R, et al. A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy. Br J Obstet Gynecol. 2000;107:1386-91. 15. Otton GR, Mandapati S, Streatfild KA, Hewson AD. Transfusion rate associated with hysterectomy for benign disease. Aust. NZ J Obstet Gynecol 2001;41:439-42. 16. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005;330:1478-85. 17. Boike GM, Elfstrand EP, Delpriore G, et al. Laparoscopically-assisted vaginal hysterectomy in a university hospital: Report of 82 cases and comparison with abdominal and vaginal hysterectomy. Am J Obstet Gynecol 1993;168:1690-95. 18. Sheth S, Malpani A. Vaginal hysterectomy for the management of menstruation in mentally retarded women. Int. J Gynecol Obstet: 1991;35:319-21. 19. Khung TTG. Use of Sheths uterocervical broad ligament space for vaginal hysterectomy in a patient with history of caesarean section. Malaysian J of Obstet & Gynaecol 1995;4:39-42. 20. Sizzi O, Rossetti A. Overcaming technical limits to laparoscopic hysterectomy. J of Gynecologic and Surgical Endoscopy. 2005. 21. Sheth SS. The place of oophorectomy at vaginal hysterectomy. Obstet Gynecol Survey 1992;47:332-33. 22. Davies A, OConner H, Magos AL. A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy: Br J Obstet Gynecol 1996;103:915-20.

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Manual of New Hysterectomy Techniques

27. Quinlan DK. Indications and contraindications. In: Sheth SS, Studd JWW (Eds): Vaginal Hysterectomy. London: Martin Dunitz Ltd., 2002;7-14. 28. Rafii A, Samain E, Levardon M, et al. Vaginal hysterectomy for benign disorders in obese women: a prospective study. Br J Obstet & Gynec 2005;111:223-27. 29. Sheth SS. Preoperative sonographic estimation of uterine volume: An aid to determine the route of hysterectomy. J Gynecol Surgery 2002;18:13-22. 30. ACOG. Appropriate use of laparoscopically assisted vaginal hysterectomy (Committee Opinion). Compendium of selected publication. Washington DC (USA): The American College of Obstetricians & Gynaecologists Womens Health Care Physicians. 2006;13-14. 31. Jones HW. (Editorial comment). Hysterectomy rates for benign indications. Obstet & Gynecol Survey 2006;61:57778.

23. Hefni AA, Davies AE. Vaginal endoscopic oophorectomy with vaginal hysterectomy: A simple minimal access surgery technique. Br J of Obstet. & Gynecol 1997;104:62122. 24. Cengiz B, Demirel LC, Dokmeci F, Gungor M, Canga A, Cengiz SD. Bilateral Salpingo-oophorectomy during vaginal hysterectomy in cases with nonprolapsed uterus: Role of laparoscopy in a residency training program without much vaginal salpingo-oophorectomy experience. J Gynecol Surgery, 2002;18:87-93. 25. Hutchon DJ. A double-blind randomised trial of leuprorelin acetate prior to hysterectomy for dysfunctional uterine bleeding. Br J Obstet Gynecol. 2000;107:1323-24 26. Mettler L, Semm K. Vaginale and abdominale hysterectomie an der Universitats-Frauenklinik Kiel, Arch Gynecol Obstet 1989;245:379-82.

3
INTRODUCTION

Vaginal Approach to Hysterectomy and Treatment of Incontinence

Gian Benedetto Melis, Stefano Floris, Mario Melis, Sandra Mameli, Stefano Angioni, Valerio Mais, Anna Maria Paoletti

Vaginal hysterectomy is the usual surgical treatment for some cases of Pelvic Organ Prolapse (POP). In fact, even if the majority of all hysterectomies are performed for dysfunctional uterine bleeding and leiomyomata1 (accounting for between 50 and 70% of cases), POP resulted as the most common indication for hysterectomy in women over 55 years of age in the United States.2 Stress Urinary Incontinence (SUI) is frequently associated with POP, because pelvic floor weakness is a common denominator for both conditions.3 Frequently, POP patients have intrinsic sphincter deficiency which may also cause SUI. Detrusor overactivity also frequently coexists in women affected by POP, with or without urgency incontinence. Some authors have suggested that women may be at an increased risk of new-onset urinary incontinence, bladder dysfunction or POP following hysterectomy.4,5 In some cases, occult SUI may be masked by significant POP, which causes compression or kinking of the urethra. Occult SUI may be unmasked by surgical intervention in upto 80% of clinicallycontinent women before intervention.6, 7 Several studies have suggested that maintenance of the uterus in situ may result in an increased risk of POP recurrence. However, hysterectomy alone often fails to address the specific defects in pelvic support that cause POP. Removal of the uterus and vaginal surgery may even influence sexual function and personal identity.8, 9 Satisfaction rates seem to be high after surgery, but between 25% and 50% of patients report complications related to the surgical procedure.10 In fact, hysterectomy has been implicated not only in the cure of urinary, bowel, and sexual problems but also in the aetiology of de novo symptoms associated with these functions. Despite some disadvantages and the continuing development of alternative treatments

(e.g. minimally invasive surgery, endometrial ablation, IUD with intrauterine hormones delivery systems, myomata embolization) hysterectomy seems to be the final resource for the treatment of several gynaecological conditions. As such, it is likely to continue to be the most important major procedure performed by gynaecologists. Many reasons are associated with the choice of vaginal hysterectomy and concomitant vaginal intervention for associated POP and/or SUI.

URODYNAMIC TESTING BEFORE HYSTERECTOMY AND POP/SUI INTERVENTIONS

Storage symptoms (frequency, urgency) and voiding symptoms (slow stream, hesitancy) are a common concern for women with POP. Sometimes urinary symptoms are related to an enlarged uterus with fibroids, so these disappear after hysterectomy. Nowadays, many surgeons consider urodynamic testing an essential part of the preoperative evaluation of POP before surgery. Recommendations from the 3rd International Consultation on Incontinence include non-invasive urodynamics (voiding and incontinence diary, post-void residual, and possibly uroflowmetry) for all incontinent patients, while invasive urodynamic studies are recommended in complicated SUI.11 POP should be considered a complicating factor because it may create doubts about the pathophysiology of incontinence and because of the associated voiding symptoms. Occult or potential SUI is defined as SUI which is demonstrated only during prolapse reduction in clinically continent women. This condition has been reported in 35 to 68% of women with high-grade POP. Once the prolapse is reduced, abdominal leak point pressure (ALPP) seems to decrease in women with severe POP. Intrinsic sphincter deficiency (ISD) and occult SUI could

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Manual of New Hysterectomy Techniques Hysterectomy at the same time as prolapse surgery has not proved to improve the durability of the repair and may be, in fact, characterised by a higher risk of complications (increase morbidity, blood loss); longer operative and recovery postoperative time, and prolonged time to return to daily activities after hospital discharge. Nevertheless, the first of these techniques, the Manchester procedure, has had limited popularity. Maher et al15 performed sacrospinous hysteropexy or total vaginal hysterectomy with sacrospinous vault fixation in 70 women, ranging from 23 to 87 years of age, with symptomatic stage 3 or 4 uterovaginal prolapse. The type of intervention was selected on the basis of personal desire of patients and 34 of them selected sacrospinous hysteropexy. The groups were similar in all preoperative parameters. Mean follow-up time was 26 months for the hysteropexy group and 33 months in the hysterectomy group, with seven patients in each group lost in followup. Assessment for subjective and objective outcomes revealed subjective success rates similar for the hysteropexy and vaginal hysterectomy groups (78% and 86%, respectively), objective success rates (74% vs. 72%), and patient satisfaction rates (85% vs. 86%). These authors concluded that sacrospinous hysteropexy is an effective alternative to hysterectomy in treating uterovaginal prolapse. Unfortunately, it was a retrospective and nonrandomized trial. There are universally recognised indications for hysterectomy, such as menorrhagia, uterine leiomyomata, and some genital tract malignancy (including some degrees of endometrial hyperplasia), which are suitable for vaginal hysterectomy and concomitant pelvic floor repair. Asymptomatic leiomyomata do not represent an absolute indication for hysterectomy but they are frequently associated with pelvic floor alterations. On the other hand, fibroids may distort the myometrial and endometrial echo pattern, complicating the endometrial measurement and survey. In postmenopausal women, who represent the majority of women submitted to surgical correction of POP and/or SUI, removal of the uterus and ovaries may have a double issue. First, it is not clear if uterus removal could be useful for pelvic floor repair and prevention of POP recurrence. In fact, because pelvic floor repair seems to be characterised by a high rate of repeated interventions,16 we need more RCTs to assess this topic, in order to avoid repeated surgery selecting the best initial procedure. Second, it is likely that the majority of women believe the first surgical procedure is the definitive intervention because of the success of the technique for SUI and/or POP and the elimination of the risk of potential uterine or adnexal malignancy.

be present respectively in almost half of women with vault prolapse.12

VAGINAL ROUTE AND MINIMALLY INVASIVE SURGERY FOR STRESS URINARY INCONTINENCE WITHOUT CONCOMITANT POP
In cases of SUI not associated with POP, removal of the uterus is not usually performed if not required for other concurrent indications and a minimally invasive surgery could offer a great possibility of success. Tension free vaginal tape (TVT) is a minimally-invasive technique for SUI first introduced in 1996 by Ulmsten13 and now in use worldwide. TVT is based on the theory of pathophysiology of SUI sustained by Petros and Ulmsten (integral theory emphasizing the central role of pubourethral ligaments). Many studies shown short-term and longterm efficacy and safety of TVT procedures. Although these authors indicate that the TVT is associated with high cure rates, there are some concerns regarding the complications related to this procedure, even if both early and late complications are very rare. International Consultation on Incontinence Conclusions and Recommendations indicate that many important studies involving TVT in the cure of SUI have high levels of evidence. Additionally, in cases of mild and asymptomatic anterior vaginal wall prolapse (AVWP), TVT or other TVT-like procedures may be used without concomitant anterior colporrhaphy.

SELECTION OF THE MOST APPROPRIATE SURGICAL PROCEDURE FOR WOMEN WITH CONCOMITANT POP
Even if it is always obvious that the completion of childbearing should be an important requisite before surgery for concomitant POP and SUI, many cases of surgery performed with aim of preserving the uterus seem to demonstrate a good improvement in quality of life. The concept of uterine preservation during surgery for POP was first suggested by Bonney who emphasised the passive role of the uterus in POP. Several authors indicate the pericervical fascia as the key to pelvic floor repair. This structure, however, is not always addressed during anterior and posterior colporrhaphy performed with concomitant vaginal hysterectomy. Farrell et al14 proposed that what a surgeon perceives to be fascia may often be another tissue layer, which could be less suitable for repair. Moreover, many surgeons performed reconstructive pelvic surgery with uterine preservation.

Vaginal Approach to Hysterectomy and Treatment of Incontinence

27

HYSTERECTOMY ASSOCIATED TO CONCOMITANT PROCEDURES FOR POP WITH OR WITHOUT SUI

Anti-incontinence procedures are usually performed at the same time as anterior vaginal wall repair at the end of hysterectomy, after the closure of the vaginal cuff. Urethral suspension procedures (such as slings, needles, retropubic suspensions) may treat mild anterior vaginal prolapse associated with urethral hypermobility without anterior colporrhaphy, but this traditional technique is necessary in cases of severe anterior vaginal wall prolapse (AVWP). Anterior colporrhaphy (also known as bladder buttress) shown a recurrence rate which varies from 20 to 40% considering only the AVWP repair. Nowadays, it could also be considered a technique for SUI in patients who prefer to sacrifice some degree of chance of becoming continent for a reduced chance of complication.3 The paravaginal repair was first described by White in 1909. The concept of this technique is to reattach detached lateral vaginal tissues to its anatomical original site, at the level of the arcus tendineous fasciae pelvis (ATFP). The approach is often combined with other techniques for SUI and therefore it is difficult to separate the contribution of paravaginal repair from overall continence rates. Increasing evidence suggests that TVT could be used with anterior colporrhaphy to treat concomitant AVWP and SUI. A recent study performed by Collinet et al17 demonstrated that concomitant hysterectomy and inverted T colpotomy are the main risk factors of mesh exposure. Thus, uterine preservation and the performance of a minor colpotomy in patients who had already undergone a hysterectomy or in those whose uterus had been preserved seem to be protective factors for mesh exposure. Many authors have suggested the concurrent anti-incontinence surgery during pelvic surgery to prevent the development of postoperative SUI, but all these procedures have potential complications. There is not a consensus on the optimal procedure and data from a larger series are needed to recommend a prophylactic TVT procedure instead of a simple suburethral plication in women with occult SUI. Another issue is represented by the effect of some anti-inconti-

nence procedures on subsequent development of POP. In fact, Burch colposuspension seems to be associated with the increase in posterior compartment defects, while almost all vaginal route procedures for SUI did not increase pelvic floor defects. In 2001 we developed a new Y-shaped polypropylene mesh for the concurrent treatment of AVWP and SUI (Figure 3.1). Main long-term outcomes of women submitted to concomitant vaginal hysterectomy and AVWP/SUI repair (using the anterior colporrhaphy associated with TVT or the Y-shaped polypropylene mesh) are shown in Table 3.1. Both types of procedures are associated with a long-term success for SUI and AVWP cure, but erosions developed only in the group of women treated with the new mesh. It is unclear if erosions are due to different amount and properties of biomaterial (polypropylene) of the two prosthetic devices. Nowadays, almost all erosions were treated without complete removal of the mesh.

Figure 3.1: A new Y-shaped polypropylene mesh for concomitant correction tension free of SUI and AVWP, (Design: GB Melis, Department of Obstetrics and Gynaecology, University of Cagliari).

UROLOGICAL COMPLICATIONS OF HYSTERECTOMY

Ureteral injuries seem to be more common with abdominal than with vaginal hysterectomies but the reasons

Table 3.1: Main outcomes in patients submitted to concomitant vaginal hysterectomy and treatment of AVWP associated with SUI Type of concomitant procedure Y-shaped mesh Anterior colporrhaphy + TVT N 21 17 follow-up >48 months >48 months SUI cure rate (dry) 19/21 (86%) 15/17 (88%) SUI cure rate (improved) 100% 100% AVWP recurrence Mesh erosion (>1 stage) 1/21 (5%) 2/17 (12%) 4 (14%) 0

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Manual of New Hysterectomy Techniques currently not available. A recent review on the role of uterine preservation at the time of surgery for POP concluded that studies involving more patients, longer follow-up, appropriate controls and objective assessment techniques are certainly necessary before we can routinely recommend uterine preservation at the time of prolapse surgery.20 Although continued evaluation of uterine preservation during pelvic floor surgery will further assist the surgeon in determining the most ideal treatment options, current literature suggests that uterine preservation at the time of pelvic reconstructive surgery may be considered in appropriately selected women who desire it. However, women should fully understand the ongoing possibility of incurring uterine, ovarian and cervical pathologies over time, and the need for continued, routine surveillance measures. The patients informed consent is very important because even if cervix, endometrium, and ovaries are virtually malignancy free at the time of hysterectomy, these have a considerable malignant potential in the subsequent years. Screening programs for cervical cancer are satisfactory enough to consider the cervical preservation in subtotal hysterectomy relatively safe. However, it has been suggested that at least 10% of ovarian cancer could be prevented by prophylactic oophorectomy.21 The possibility that hysterectomy alone may prevent or reduce the risk of ovarian cancer is controversial, even if there are some data suggesting this possibility.22-24 On the other hand, because the oophorectomy is associated with the loss of estrogen production and reduction of circulating androgens secretion, these aspects should be discussed with the patient preoperatively. Therefore, eventual estrogen replacement therapy seems to be preferable to ovarian preservation for the majority of perimenopausal women submitted to hysterectomy. In cases of loss of libido the exogenous administration of androgens could be prescribed in selected cases.25 It is surprising that many women currently operated by abdominal or laparoscopy route are suitable for the vaginal route.26 The estimated number of surgical interventions for POP and SUI is likely to increase with the current ageing of our population. This creates a close relationship between the two main challenges for gynaecologists involved in the cure of elderly women: the prevention of gynaecological neoplasms with concomitant hysterectomy and oophorectomy, and the need to reduce the inevitable high rate of repeated surgeries due to failure or relatively short durability of pelvic floor repair.

for these data are unclear.18 It is suggested that vaginal hysterectomy and inherent peculiarity may protect ureters from damage19 Other minor postoperative complications are acute urinary retention, more common after vaginal hysterectomy especially if associated with concurrent colporrhaphy. Additionally, the uterus has a close anatomical relationship with the bladder and pelvic nervous plexus. It has been suggested that hysterectomy and the associated pelvic floor repair may disrupt natural support structures, such as the uterosacralcardinal ligament complex, increase the risk of pelvic neuropathy, and damage the autonomic innervations of the pelvis. Subtotal hysterectomy was a very popular technique in past decades because of its associated reduced risk of ureteric injuries and for nerve sparing. However, at the present time, disadvantages appear more consistent than advantages and this technique is used in very selected cases. Even so, there are no RCTs with adequate power and long-term follow-up to clearly demonstrate significant differences in terms of urinary symptoms cure rate. For patients affected of POP, pelvic floor repair with subtotal hysterectomy seems to be associated to have a higher recurrence rate.

CONCLUDING MESSAGES
Improved understanding of normal and abnormal pelvic anatomy and function now permit a more rational selection of procedure and route based on what is best for the individual patient. Many contraindications for the vaginal route are no longer valid, allowing a vaginal approach in almost all women who need a concomitant pelvic floor repair. In fact, an enlarged uterus could be easily treated with morcellation, bisection, coring, and myomectomy during vaginal hysterectomy. In our series, no vaginal hysterectomy was completed by the abdominal route because of technical complications due to an enlarged uterus with fibroids. Furthermore, even ovaries with no descent (grade 0 according to Kovac) could be removed with a longer procedure, dividing the round ligament from the infundibulopelvic ligament (which allows further descent of the adnexa) and/or using forceps for bipolar electrocoagulation to cauterize ovarian artery and vein instead of sutures (as in LAVH). Our experience allowed the removal of the adnexa in 100% of vaginal hysterectomies performed since 1991 on women requiring oophorectomy, (excluding vaginal hysterectomies performed as elective LAVH at the beginning of the intervention) (data not published). Well designed comparative studies of pelvic floor reconstruction with and without hysterectomy are

Vaginal Approach to Hysterectomy and Treatment of Incontinence

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REFERENCES
1. Vessey MP, Villard MacKintosh L, McPherson K, et al. The epidemiology of hysterectomy: findings in a large cohort study. Br J Obstet Gynecol 1992; 99:402-07. 2. Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB Hysterectomy in the United States, 1988 1990. Obstet Gynecol 1994; 83:54955. 3. Abrams P, Cardozo L, Saad K, Wein A, (Eds). Incontinence. Paris: Editions 21;2005. 4. Kjerluff KH, Langenberg PW, Greenaway L, Uman J, Harvey LA. Urinary incontinence and hysterectomy in a large prospective cohort study in American women. J Urol 2002; 167: 2088-92. 5. Petros PE. Influence of hysterectomy on pelvic floor dysfunction. Lancet 2000; 356-1275. 6. Bump RC, Fantl JA,Hurt WG. The mechanism of urinary continence in women with severe uterovaginal prolapse: Results of barrier studies. Obstet Gynecol 1988; 72:291-95. 7. Richardson DA, Bent AE, Ostergard DR. The effect of uterovaginal prolapse on urethrovesical pressure dynamics. Am J Obstet Gynecol 1983; 146:901-05. 8. Tunuguntla HSGR, Gousse AE. Female sexual dysfunction following vaginal surgery: a review. J Urol 2006; 175, 43946. 9. Masters WH, Johnson V. Human sexual response. Boston: Little Brown;1996. 10. Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The Collaborative Review of Sterilization Am J Obstet Gynecol 1982; 144: 84148. 11. Griffiths D, Kondo A. Dynamic testing. In: Abrams P, Cardozo L, Saad K, Wein A, (Eds): Incontinence. Paris: Editions 21;2005. 12. Gallentine ML, Cespedes RD. Occult stress urinary incontinence and the effect of vaginal vault prolapsed on abdominal leak point pressure. Urology 2001; 57:40-44. 13. Ulmsten U, Henriksson L, Johnson P, et al. An ambulatory surgical procedure under local anaesthesia for treatment of female urinary incontinence. Int J Urogynecol 1996;7: 81-85.

14. Farrell SA, Dempsey T, Geldenhuys L. Histologic examination of fascia used in colporrhaphy. Obstet Gynecol 2001;98:794-98. 15. Maher CF, Cary MP, Slack MC, Murray CJ, Milligan M, Schluter P. Uterine preservation or hysterectomy at sacrospinous colpopexy for uterovaginal prolapse? Int J Urogynecol J 12:381-85. 16. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-06. 17. Collinet P, Belot F, Debodinance P, Ha Duc E, Lucot JP, Cosson M. Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:315-20. 18. Thompson JD. Operative injuries to the ureter: prevention, recognition, and management. In: Rock JA, Thomson JK (Eds): Te Linde Operative Gynecology, 8th edition. Philadelphia: Lippincott-Raven 1997:1135-73. 19. Chruikshank SH, Kovac SR. Role of uterosacral-cardinal ligament complex in protecting the ureter during vaginal hysterectomy. Int J Gynaecol Obstet 1983; 40:141-44. 20. Diwan A, Rardin CR, Kohli N. Uterine preservation during surgery for uterovaginal prolapsed: a review. Int Urogynecol J 2004; 15:286-92. 21. Jacobs I, Oram D. Prevention of ovarian cancer: a survey of the practice of prophylactic oophorectomy by fellow and members of the Royal College of Obstetricians and Gyenaecologists. Br J Obstet Gynecol 1989;96:510-15. 22. Parazzini F, Negri E, Vecchia C, et al. Hysterectomy, oophorectomy, and subsequent ovarian cancer risk. Obstet Gynecol 1993;81:363-66. 23. Loft A, Lidegard O, Tabor A. Incidence of ovarian cancer after hysterectomy: a nationwide controlled follow-up. Br J Obstet Gynaecol 1997;104:1296-1301. 24. Hankinson S, Hunter D, Colditz G, et al. Tubal ligation, hysterectomy, and risk of ovarian cancer. J Am Med Ass 1993; 270: 2813-15. 25. Simon J, Braunstein G, Nachtigall L, Utian W, Katz M, Miller S, et al. Testosterone for low desire in menopause. J Clin Endocrinol Metab 2005;90:5226-33. 26. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol 1995; 85:18-22.

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Manual of New Hysterectomy Techniques

The Ten Step Vaginal Hysterectomy: A Method Description

Michael Stark, Sandro Gerli, Gian Carlo Di Renzo

THE TEN STEP VAGINAL HYSTERECTOMY

Any surgical procedure should follow the principle of Nothing lacking, nothing superfluous. All operative steps should have a purpose and be precise. There are many ways to perform an operation. However, the lex parsimoniae of William of Ockham (1285-1350) tells that if we face different ways to solve or explain a phenomenon, the simplest way is the right one. Surgery should not be an exception to this rule. In the last years, abdominal hysterectomies were abandoned in favour of endoscopical operations. At the university hospital of Oslo, for example, the rate of endoscopic hysterectomies increased from 18 to 54% between 2001 and 2005 (including enlarge uteri).1 Even clinical FIGO stage I endometrial adenocarcinoma have been treated successfully with laparoscopically assisted vaginal hysterectomy (LAVH) in 41% of the patients.2 Nevertheless, vaginal hysterectomy is still a valid alternative to abdominal hysterectomy even in large uteri.3 Langenbeck introduced vaginal hysterectomy in 1813.4,5 Many modifications and variations of this technique have been reported, based on the authors interpretation of pelvic anatomy and their own skills and experience. The Porges,6 Falk,7 von Theobald,8 Heaney,9 Joel-Cohen10 and Chicago5 methods, which are common techniques, are carried out with some variations. To find out whether vaginal hysterectomies can still be optimised and simplified after two centuries of practice and accumulated experience, the six mentioned methods have been evaluated. In a first step, the common steps to all methods have been defined, and in a second step, their necessity has been re-assessed. After defining the necessary and optimal steps, their way of performance has been compared to alternatives. As a result, only the reevaluated, modified and essential steps remained. In a last

step, their logical sequence has been defined. The result is the Ten Step Vaginal Hysterectomy. This method was compared in a prospective randomized study with the Heaney-method.9 It has been shown that the operation time [34,1 minutes (20,5-50) vs. 52,3 (23,3-90) minutes] and the duration of the need for painkillers [29,6 (8-75) vs. 48,7 (19-86) hours] are significantly shorter.11 This method is logical, easy to learn, perform and teach.

METHOD DESCRIPTION
Each of the ten steps is described with its alternatives and optimal way of performance. In many hospitals, instrument-trays contain many unnecessary instruments that are not used during the operation. The Ten Step Vaginal Hysterectomy requires only ten instruments. They will be listed for every step. Vaginal hysterectomies have been recommended for the treatment of endometrial cancer in elderly women,12 but they are mostly performed for benign conditions., Endometrial malignancy, therefore, should be excluded prior to the operation. This can be done with a preliminary diagnostic curettage or hysteroscopy.

INCISION OF THE VAGINAL WALL

The way to perform the incision of the vaginal wall depends on the anatomical findings of the patient.

In a Patient with a Prolapse

Most described methods start with an incision around the cervix, followed by an inverted-T extension towards the orificium urethr externum and lateral separation of the vaginal wall from the midline. This has been challenged by the Joel-Cohen method10 which starts the vaginal wall incision under the orificium urethr externum. This

The Ten Step Vaginal Hysterectomy: A Method Description approach was found to be easy and logical compared to the other methods, mainly in multiparae where there are often adhesions around the external os, and when entering to the right cleavage from below might therefore be difficult. The cervix is grasped with two single-toothed tenaculi. A drop-like incision of the vaginal wall starts under the urethra, continuing laterally and down, encircling the uterine cervix from behind and returning back to the starting point from the contralateral side (Figure 4.1). If the depth of the initial incision is correct and the right cleavage found, the vaginal wall will separate easily laterally to the side and backwards below the cervix by a gentle traction of surgical forceps (Figure 4.2), and this should be nearly bloodless. When the separation of the vaginal wall is completed, the anterior wall colporrhaphy is already prepared.

31

Figure 4.2: Using surgical forceps to separate the vaginal wall from the cervix with surgical forceps. An active assistance is needed to help the surgeon to perform this manipulation under good vision. Instruments: Speculum, two single-toothed tenaculi, scalpel, surgical forceps. DETACHING THE BLADDER FROM THE UTERUS The border between the anterior wall of the uterus and the bladder must be identified (curved scissors are sometimes needed to reach the cleavage). Then, by pushing the bladder up being always as close as possible to the uterus, it separates and moves up until the anterior peritoneum is exposed. No effort should be made to open the anterior peritoneum. Opening the anterior peritoneum at that stage is not necessary and not recommended because it disturbs the operation dynamics. When the inter-anatomical relations between the bladder and the peritoneum are not clear due to adhesions, it might also cause damage to the bladder. Bleedings should be carefully controlled. A marked swab can be left under the bladder. Instruments: Swab, optionally scissors. OPENING POSTERIOR PERITONEUM To open the posterior peritoneum, the uterus is pulled up. The peritoneum is grasped with surgical forceps and opened with scissors. The scissors are then introduced into the Douglas cavity, and holding each blade with one hand, pulled out while staying open (Figure 4.3), so that the back side of the blades expose the insertions of the sacrouterine ligaments.13,14 Instruments: Surgical forceps, scissors.

Figure 4.1: A drop-like incision encircling the uterine cervix The tip of the drop still covering the bladder is pulled down, peeling the vaginal wall away from the bladder. When performed in the right cleavage, this step should also be nearly bloodless. This step has three main movements rather than six in the other methods.

In a Patient without Prolapse

The cervix is grasped with two single-toothed tenaculi. When there is no or only a small prolapse, a circular incision around the cervix about 5 mm above the external os is performed, and then, the vaginal wall is separated

32

Manual of New Hysterectomy Techniques Instruments: Wertheim or Heaney clamp, needle holder, scissors, two sutures.

OPENING THE ANTERIOR PERITONEUM

After both uterine arteries have been cut and ligated, the uterus is pulled down and two fingers are introduced behind the fundus to lift the anterior peritoneum, which can be opened under vision. This will ensure the safety of the bladder, as its anatomical relations with the anterior peritoneum are not always clear, in particular after previous caesarean sections. The access to the fundus in a myomatous uterus is sometimes difficult. In such a case, the surgeon should hold both tenaculi with his left hand while continuously and slowly pull them down with rotating movements. In most cases, the uterus will descend and be luxated backwards until it is possible to insert the right index and middle fingers beyond the fundus and lift the anterior peritoneum. Once in a while, more steps are necessary to separate the parametrium from the uterus. Rising up from the pelvic floor, there is no risk of damaging the ovarian arteries with this rotating and pulling manoeuvre because the larger the uterus, the longer they are. The decision about the size of a uterus to be removed vaginally solely depends on the experience of the surgeon and should be taken before starting the operation. The morcellation of the uterus, which is safe and facilitates the removal of enlarged and well-supported uteri, may be performed where needed.15 The more experience the surgeon gets with this rotating manoeuvre, the less often morcellation becomes necessary. In experienced hands, a large uterus should not be a contraindication for vaginal hysterectomy.16, 17 Instruments: Scissors.

Figure 4.3: Opening the posterior peritoneum

DISSECTION OF THE LOWER PART OF THE UTERUS

In opposition to the time honoured anatomical approach dealing with each structure separately, the sacro-uterine ligaments and the paracervical tissues, which are in different anatomical planes and directions, are clamped together. This is done with the following manoeuvre: one blade of an open clamp is placed under the insertion of the sacrouterine ligament, the instrument rotates towards the uterus while the uterus is being contra-rotated. Both anatomical structures are so included between the blades of the closed instrument. Both structures, the relatively bloodless sacro-uterine ligament and the paracervical tissues, are cut and ligated leaving the suture material in its full length. This is repeated on the other side. If properly performed, these steps are safe, bloodless, dynamically correct and timesaving. In most traditional surgical methods for vaginal hysterectomy, both elements are anyway sutured to each other at the end of the operation (there are exceptions: some surgeons perform vaginal hysterectomies without ligating the cervical ligaments.13 In a patient without a prolapsed uterus, this manoeuvre will instantly produce a significant prolapse, and with a slight traction, the uterine arteries will get exposed. Instruments: Wertheim or Heaney clamp, needle holder, surgical forceps, scissors, two sutures.

DISSECTION OF THE UPPER PART OF THE UTERUS (AND APPENDAGES)

The round and ovarian ligaments and the blood vessels are clamped together and ligated. The ligature should be placed laterally as far as possible from the clamp, leaving the ovarian ligaments as long as possible. The uterus is cut away with scissors medial to the instrument. A ligature is placed beyond the instrument and followed by a transfixion suture between the clamp and the ligature (Figure 4.4). This will prevent bleeding, if this transfixion suture came to slip away or tear by traction. The transfixion suture should never be done before the ligature. The tip of the needle might hit a blood vessel and cause bleeding in the parametrium. The same procedure is done on the contralateral side.

CUTTING AND LIGATING THE UTERINE ARTERIES

Both uterine arteries are clamped, cut and ligated.

The Ten Step Vaginal Hysterectomy: A Method Description

33

to each other respectively. An extra suture may be placed to join the sacro-uterine ligaments. The decision should be taken according to the particular anatomical relations. The question whether tying the ovarian ligaments to each other causes dyspareunia is still open and should be examined in a prospective study. Instruments: Scissors, needle holder, surgical forceps, and optionally one suture.

CLOSING THE VAGINAL WALL

If a marked swab has been left in step 2, it should be removed before closing the vaginal wall. The vaginal wall is sutured continuously. It is recommended in sexual active women to suture the vagina transversely. This will prevent dyspareunia as the suturing line is on the upper side of the anterior wall. Figure 4.4: Transfixion suture between the ligament and the forceps Instruments: Wertheim or Heaney clamp, scissors, needle holder, surgical forceps, four sutures. Instruments: Allis clamp, needle holder, surgical forceps, scissors, one suture.

DISCUSSION
Today, more and more hysterectomies are laparoscopically assisted vaginal hysterectomies (LAVH), even for big uteri.24 However, the vaginal route should always be considered when hysterectomy is indicated, because of its quick recovery, the absence of abdominal scar and the short hospital stay.9, 25 By acquiring more experience, the number of contraindications for vaginal hysterectomy will decrease.26 It has been shown that this operation can be performed with nulliparity27 and with enlarged uterus.28 Also previous caesarean sections are not considered anymore as contraindication for vaginal hysterectomy,26 and there is no justification for LAVH in the presence of significant uterine descent.29 In a prospective randomised study, no difference between vaginal hysterectomy and LAVH has been found concerning estimated blood loss, complications, hospital stay and convalescence. The costs for a LAVH were however considerably higher.30 Many studies compare the outcomes of vaginal hysterectomy to those of abdominal or laparoscopically assisted vaginal hysterectomy. Campbell et al compared the three methods in 33792 operations, with regards to the hospital stay and the involved costs and concluded that vaginal hysterectomy provides the best patient outcomes, with the shortest hospital stays and lowest complication rates at the lowest cost.31, 32 The laparoscopically assisted vaginal hysterectomy is considered an alternative to the abdominal hysterectomy.33 Shorter hospital stay and less

THE NON STAGELEAVING THE PERITONEUM OPEN

In 1980, Harold Ellis showed that closing the peritoneum at the end of abdominal surgery is not necessary.18 The thin peritoneum does not close end to end as skin does. Vascular bridges over peritoneal sutures are focus for ischaemia and adhesions. When the peritoneum is left open, the coelum cells will produce a new peritoneum within days. Indeed, leaving peritoneum open in caesarean section proved to cause fewer adhesions than when closing it.19 It was also shown that the peritoneal closure is not necessary for vaginal hysterectomy.20, 21 The British Royal College of Obstetrics and Gynaecology recommended in its guideline No. 15 from July 2002 to leave the peritoneum open with evidence level Ib.22 The pelvic parietal peritoneum is attached to the pelvic ligaments. The ligation of the ligaments to each other (step 9) will create an additional peritoneal sac between the ligaments and a closed peritoneum, with all its possible consequences. Another advantage of leaving the peritoneum open is the free drainage into the peritoneal cavity where blood will be absorbed by the peritoneum and the lymph channels. If an enterocele is to be prevented or repaired, it should be done before continuing the operation.23

RECONSTRUCTION OF THE PELVIC FLOOR

The left and right sacrouterine ligaments with the paracervical tissues as well as the ovarian ligaments are ligated

34

Manual of New Hysterectomy Techniques

7. Falk HC, Soichet S. The technique of vaginal hysterectomy. Clin Obstet Gynecol. 1972; 15 (3): 703-54 8. Von Theobald P. Simplified vaginal hysterectomy. J Chir. 2001;138(2):93-98. 9. Kalogirou D, Antoniou G, Zioris C, et al. Vaginal hysterectomy: technique and results in the last twenty years. J Gynecol Surg. 1995;11(4):201-07. 10. Joel-Cohen SJ. Abdominal and Vaginal Hysterectomy. New Techniques Based on Time and Motion Studies. London 1972. 11. Stark M, Gerli S, Di Renzo GC, The Ten-Step Vaginal Hysterectomy, Progress in Obstetrics and Gynaecology. 2006;17,358-68. 12. Susini T, Massi G, Amunni G, et al. Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly. Gynecol Oncol. 2005; 96(2):362-67. 13. Kudo R, Yamauchi O, Okazaki T, et al. Vaginal hysterectomy without ligation of the ligaments of the cervix uteri. Surg Gynecol Obstet 1990;170(4):299-305. 14. Shef S, Studd J. Vaginal Hysterectomy. Pub Martin Dunitz. 2002. 15. Taylor SM, Romero AA, Kammerer-Doak DN, et al. Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation. Am J Obstet Gynecol 2003;189(6):1579-82. 16. Harmanli OH, Gentzler CK, Byun S, et al. A comparison of abdominal and vaginal hysterectomy for the large uterus. Int J Gynaecol Obstet. 2004;87(1):19-23. 17. Switala I, Cosson M, Lanvin D, et al. Is vaginal hysterectomy important for large uterus of more than 500 g? Comparison with laparotomy. J Gynecol Obstet Biol Reprod. 1998;27(6):585-92. 18. Ellis H. Internal overhealing: the problem of intraperitoneal adhesions. World J Surg. 1980;4:303-06. 19. Stark M. Clinical evidence that suturing the peritoneum after laparotomy is unnecessary for healing. World J Surg. 1993;17(3):419. 20. Janschek EC, Hohlagschwandtner M, Nather A, et al. A study of non-closure of the peritoneum at vaginal hysterectomy. Arch Gynecol Obstet. 2003;267(4):213-16. 21. Lipscomb GH, Ling FW, Stovall TG, et al. Peritoneal closure at vaginal hysterectomy : a reassessment. Obstet Gynecol. 1996;87(1):40-43. 22. Royal College of Obstetrics and Gynaecology. Peritoneal Closure Guideline No. 15. 2002. 23. Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol. 1999;180(4):859-65. 24. Schutz K, Possover M, Merker A, et al. Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200 g. Surg Endosc 2002;16(1):121-25. 25. Cravello L, Bretelle, F, Cohen D, et al. Vaginal hysterectomy: apropos of a series of 1008 interventions. Gynecol Obstet Fertil. 2001;29(4):288-94.

need of analgesia has been reported in the laparoscopically assisted vaginal hysterectomy, but at the same time there was a higher rate of bladder injuries and a longer operation time when compared to vaginal hysterectomy.34 Traditions can prevent new thinking and new surgical developments. No operative step should be a taboo. All surgical procedures should be regularly re-evaluated in the light of new findings in pathology and physiology. A surgical procedure should be evaluated by examining not only the necessity and way of performance of all its steps, but also their combinations and sequences. Only few studies explain the outcomes of vaginal hysterectomy with variations in single operative steps. Leaving the parametrium unsutured resulted in a shorter operation time with no significant differences in other examined parameters.13 Some advantages were reported where mass closure of the vaginal cuff35 or morcellation was performed.17 The Ten Step Vaginal Hysterectomy results from the analysis of different methods and is based on up-to-date physiological and anatomical principles. It was shown that this operation is rational and simple. Unnecessary steps are avoided, and the method follows rules of aesthetics and functional minimalism. Only ten instruments and ten sutures are needed and it has been shown that this operation reduced the operation time and the use of painkillers. More randomized prospective studies will be needed to evaluate the late outcome of this method.

REFERENCES
1. Istre O, Langebrekke A, Qvigstad E. Changing hysterectomy technique from open abdominal to laparoscopic: new trend in Oslo, Norway. J Minim Invasive Gynecol. 2007;14(1):74-770. 2. Kalogiannidis I, Lambrechts S, Amant F, et al. Laparoscopy-assisted vaginal hysterectomy compared with abdominal hysterectomy in clinical stage I endometrial cancer: safety, recurrence, and long-term outcome.Laparoscopy-assisted vaginal hysterectomy compared with abdominal hysterectomy in clinical stage I endometrial cancer: safety, recurrence, and long-term outcome. Am J Obstet Gynecol. 2007;196(3):248.e1-8. 3. Benassi L, Rossi T, Kaihura CT, et al. Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial. Am J Obstet Gynecol. 2002;187(6):1561-65 4. Gray LA, Vaginal hysterectomy. Springfield, IL. 1983. 5. Leodolter S. The transvaginal surgical school in Austria. Retrospect-present-future. Gynaekol Geburtshilfliche Rundsch. 1995;35(3):142-48. 6. Paldi E, Filmar S, Naiger R, et al. Vaginal hysterectomy using the Porges method. Report on 100 cases. J Gynecol Obstet Biol Reprod. 1988;17(2):233-36.

The Ten Step Vaginal Hysterectomy: A Method Description

26. Doucette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol, 2001;184 (7):1386-89. 27. Dhainaut C, Salomon LJ, Junger M, et al. Hysterectomies in patients with no history of vaginal delivery. A study of 243 cases. Gynecol Obstet Fertil. 2005;33(1-2):11-16. 28. Li Z, Leng J, Lang J, et al. Vaginal hysterectomy for patients with moderately enlarged uterus of benign lesions. Chin Med Sci J. 2004;19 (1):60-63. 29. Balfour RP. Laparoscopic assisted vaginal hysterectomy 190 cases: complications and training. J Obstet Gynaecol. 1999;19(2):164-66. 30. Summitt RL Jr, Stovall TG, Lipscomb GH, et al. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol. 1992;80(6):895 901.

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31. Claerhout F, Deprest J. Laparoscopic hysterectomy for benign diseases. Best Pract Res Clin Obstet Gynaecol. 2005;19(3):357-75. 32. Campbell ES, Xiao H, Smith MK. Types of hysterectomy. Comparison of characteristics, hospital costs, utilization and outcomes. J Reprod Med. 2003;48(12):943-49. 33. American College of Obstetricians and Gynecologists. Appropriate use of laparoscopically assisted vaginal hysterectomy. Obstet Gynecol. 2005;105(4):929-30. 34. Meikle SF, Nugent EW, Orleans M. Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Gynecol, 1997;89(2):304-11. 35. Miskry T, Magos A. Mass closure: a new technique for closure of the vaginal vault at vaginal hysterectomy. BJOG. 2001;108(12):1295-97.

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Manual of New Hysterectomy Techniques

5
Harry Reich ABSTRACT

Total Laparoscopic Hysterectomy: Indications, Techniques and Outcomes

Table 5.1: Laparoscopic associated hysterectomy classification 1. 2. 3. 4. 5. 6. 7. 8. 9. Diagnostic laparoscopy with vaginal hysterectomy Laparoscopic-assisted vaginal hysterectomy (LAVH) Laparoscopic hysterectomy (LH) Total laparoscopic hysterectomy (TLH) Laparoscopic supracervical hysterectomy (LSH) including classical interstitial Semm hysterectomy (CISH) Vaginal hysterectomy with laparoscopic vault suspension (LVS) or laparoscopic pelvic reconstruction (LPR) Laparoscopic hysterectomy with lymphadenectomy Laparoscopic hysterectomy with lymphadenectomy and omentectomy Laparoscopic radical hysterectomy with lymphadenectomy

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 and available over laparoscopic and abdominal hysterectomy. They also support a laparoscopic approach to hysterectomy over TAH. Despite evidence-based studies, gynaecologic 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.

INTRODUCTION
The laparoscopic approach to hysterectomy is an attractive option for many women for a multitude of pelvic complaints, and as with any surgical procedure, complications can occur. Despite the argument that laparoscopy adds further risk to the procedure, the complication rate should be less with this approach with appropriate surgical technique. There are many surgical advantages to laparoscopy, particularly magnification of anatomy and pathology, access to the uterine vessels, vagina and rectum, and the ability to achieve complete hemostasis and clot evacuation. Patient advantages are multiple and are related to avoidance of a painful abdominal incision. They include reduced duration of hospitalization and recuperation and an extremely low rate of infection and ileus.

A variety of associated operations are done in which the laparoscope is used as an aid to hysterectomy, each with their particular set of problems. Of importance is that these different procedures are delineated clearly (Table 5.1).1, 2 Total laparoscopic hysterectomy (TLH) specifies that after all vascular pedicles are ligated, the laparoscopic dissection continues until the uterus lies free of all attachments in the peritoneal cavity. The uterus is removed through the vagina, often with laparoscopic and/or vaginal morcellation. The vagina is closed with laparoscopically placed suspension sutures. No vaginal surgery except for morcellation is done.3, 4 The surgical technique for total laparoscopic hysterectomy with a classification system for laparoscopic associated hysterectomy (LAH) was published in 1993, describing all LAHs that I did from April 1983 to July 1992. Of 123 LAHs, 47 were TLH. The conclusion of that

Total Laparoscopic Hysterectomy: Indications, Techniques and Outcomes paper was that LH is a substitute for abdominal hysterectomy and not for vaginal hysterectomy.3 I began doing electrosurgical laparoscopic oophorectomy in 1976, and some were associated with a vaginal hysterectomy.5 Laparoscopic hysterectomy (LH), defined as the laparoscopic dissection, ligation, and division of the uterine blood supply, is an alternative to abdominal hysterectomy with more attention to ureteral identification. First done in January, 1988, LH stimulated a general interest in the laparoscopic approach to hysterectomy.6 Laparoscopic ligation of the uterine vessels is the sine qua non for LH. A watered down version of LH called LAVH (laparoscopic-assisted vaginal hysterectomy) was taught by industry and became known as an expensive and overused procedure with indications for which skilled vaginal surgeons rarely found the laparoscope necessary. Currently, abdominal hysterectomy, like laparotomy cholecystectomy, should rarely be done if gynaecologists receive appropriate surgical training in both vaginal and laparoscopic techniques. LH remains a reasonable substitute for abdominal hysterectomy. LAH is a cost-effective procedure when performed with reusable instruments. The procedure is safe, even when performed by a variety of gynaecologists with different skill levels. The adoption of this technique can decrease abdominal incision hysterectomies.7 The goal of vaginal hysterectomy, LAVH, or LH is to safely avoid an abdominal wall incision with its known high rate of postoperative adhesions.8 Recent papers by Clayton and the Cochrane database reviewed evidenced-based hysterectomy studies and conclude that vaginal hysterectomy (VH) is preferable to abdominal hysterectomy (AH). There is no evidence to support the use of LH if VH can be done safely. Compared to AH, LH is associated with less blood loss, shorter hospital stay. Speedier return to normal activities, but it takes longer, costs more, and urinary tract injuries are more likely.9-11 So we agree with the many academics who state that a LAH is rarely indicated when vaginal hysterectomy is possible, i.e. when the uterine vessels are readily accessible vaginally. It must be realized that what is accessible vaginally by one surgeon may be impossible for another. Although hysterectomy remains one of the most commonly performed procedures in the United States and Canada, most are performed by the abdominal approach.7,12,13 More recently, oncologists are using the laparoscopic approach for gynaecologic malignancies, especially endometrial cancer. Despite the surprising increase in TLHs and other LAHs from 0.3% in 1990 to 9.9% in 1997, the deficiencies in resident and fellow

37

training programmes remain a formidable obstacle to promotion of this technique. Two distinct groups doing laparoscopic hysterectomy exist: a very large cluster doing a LAVH instead of vaginal hysterectomy and a much smaller elitist segment doing total laparoscopic hysterectomy (TLH) when vaginal hysterectomy is not possible. I believe it is time to get rid of the LAVH! Learn to do the entire operation under laparoscopic visualisation or do a vaginal hysterectomy. As TLH mimics AH in almost all respects, it should be easy to assimilate it into practice for the majority of patients.

INDICATIONS AND CONTRAINDICATIONS

Many gynaecologists consider the following as indications for an abdominal approach to hysterectomy: Uterine size greater than 12 weeks Nulliparity with lack of uterine descent Previous pelvic surgery Extrauterine pelvic pathology (endometriosis, adhesive disease) Narrow vagina Poor uterine mobility without access to the uterine vasculature Obesity Need for oophorectomy Cancer These are relative contraindications for laparoscopic surgery in gynaecology, where most surgeons would be better served by doing a laparotomy. With the assistance of expert laparoscopic training, the majority of these patients can be spared a laparotomy. In most cases where vaginal access and/or access to the uterine vessels is limited and little or no uterine mobility exists, a laparoscopic hysterectomy can be considered.14-20 LH is not advised for the treatment of a potentially malignant pelvic mass of ovarian origin that cannot be removed intact. The medical status of the patient may prohibit surgery. Age alone should rarely be a deterrent. Obesity presents special problems, as the use of Trendelenburg may be limited because of anaesthesia ventilation difficulties. Finally, inexperience or inadequate training of the surgeon is an obvious contraindication to the laparoscopic approach. A critical factor in considering the degree of difficulty of a laparoscopic operation is the number of previous surgeries the patient has had. Previous surgeries cause adhesions, and adhesions can make the next operation much more difficult.8 Severe adhesion cases can be so long and time consuming that the surgeon makes no progress and converts to a laparotomy.

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Manual of New Hysterectomy Techniques laparotomy is preferable to TLH or VH in most cases with distorted anatomy or large uterus.

The most common indication for a laparoscopic hysterectomy is a symptomatic fibroid uterus. Symptoms include hypermenorrhoea leading to anaemia, pelvic pressure, and rarely pain. Most of these cases can be done laparoscopically, with vaginal morcellation, as an overnight hospital stay. The other common indication for LH is endometriosis causing pelvic pain.21,22 Most extensive endometriosis hysterectomies are currently done by an abdominal approach with bilateral salpingo-oophorectomy using an intrafascial technique that leaves the endometriosis behind on the rectum and vagina. Or worst yet, when confronted by extensive disease with the rectum fused to the cervix, many gynaecologists do a supracervical hysterectomy and bilateral oophorectomy in the belief that castration will resolve the endometriosis left behind. These cases would be better served with laparoscopic excision of the endometriosis followed by total laparoscopic hysterectomy (TLH).22 Most extensive endometriosis hysterectomies can be done laparoscopically when symptoms warrant, and should include resection of the endometriosis. One ovary can be preserved in most of these patients. Even with extensive endometriosis, the diseased areas should be removed and not normal ovaries. Supracervical hysterectomy should not be done as endometriosis is present commonly in the posterior cervix and leaving it behind may not result in symptom relief. Rectovaginal endometriosis requires a radical resection of the endometriotic tissue, which may require a bowel resection if the endometriosis has invaded the bowel wall. The best surgeon to do this surgery should be a gynaecologist because a gynaecologist understands the disease of endometriosis better than a general surgeon or colon and rectal surgeon. Hypermenorrhoea (heavy bleeding) is a very common reason for hysterectomy. Most of these cases involve a small uterus and can be done vaginally. Our profession should discourage abdominal hysterectomy for this indication. Laparoscopic cancer treatment is done in women with endometrial cancer and cervical cancer today with a pelvic lymphadenectomy. Few absolute contraindications to laparoscopic surgery exist in gynaecology. With the assistance of expert laparoscopic training, the majority of these patients can be spared a laparotomy. One should remember that concerning the operative indication, laparoscopic hysterectomy is a substitute for abdominal hysterectomy, including difficult abdominal hysterectomy. I do not believe that hysterectomy by

TOTAL LAPAROSCOPIC HYSTERECTOMY TECHNIQUE (TLH)

My technique for a TLH is described, since other types of laparoscopic hysterectomy are simply modifications of this more extensive procedure. These steps are designed to prevent complications. Since hysterectomy is usually an elective procedure, the patient is counseled extensively regarding the range of currently available options appropriate to her individual clinical situation. In 2007, it is clearly not acceptable to advocate hysterectomy without detailing the risks and benefits of other intermediary procedures, such as myomectomy and/or excision of endometriosis with uterine preservation. Whereas conversion to laparotomy when the surgeon becomes uncomfortable with the laparoscopic approach has never been considered a complication, conversion rates should be monitored to safeguard the consumers right to have this procedure performed by a competent laparoscopic surgeon. Surgeons who do more than 25% of their hysterectomies with an abdominal incision should not taut their ability and degree of expertise with a laparoscopic approach to their patients. Perhaps, conversion to laparotomy should be considered a complication!

PREOPERATIVE PREPARATION
The patient is optimised medically for coexistent problems. Patients are encouraged to hydrate on clear liquids the day before surgery. Fleet Phosphosoda 3 oz. divided into 2 doses are given at 3:30 pm and 7:30 pm to evacuate the lower bowel. If the patient is prone to nausea, Phenergan 25 mg postoperative is taken 25 minutes before the bowel prep. Lower abdominal, pubic, and perineal hair is not shaved. All laparoscopic procedures are done using general endotracheal anaesthesia with orogastric tube suction to minimise bowel distension. The patients arms are placed at her side and shoulder braces at the acromioclavicular joint are positioned. Trendelenburg position upto 40 degrees is available. I use one dose of prophylactic antibiotics after induction of anaesthesia.

INCISIONS
Three laparoscopic puncture sites including the umbilicus are used. Pneumoperitoneum to 25-30 mm Hg is obtained before primary umbilical trocar insertion and reduced to

Total Laparoscopic Hysterectomy: Indications, Techniques and Outcomes 15 mm afterwards. The lower quadrant trocar sleeves are placed under direct laparoscopic vision lateral to the rectus abdominis muscles and just beside the anterior superior iliac spines in patients with large fibroids. The left lower quadrant puncture is my major portal for operative manipulation as I stand on the patients left. Reduction in wound morbidity and scar integrity as well as cosmesis are enhanced using 5 mm sites. The use of 12 mm incisions when a 5 mm one will suffice is not an advance in minimally invasive surgery.

39

BLADDER MOBILIZATION
The round ligaments are divided at their midportion, and scissors or a spoon electrode is used to divide the vesicouterine peritoneal fold starting at the left side and continuing across the midline to the right round ligament. The upper junction of the vesicouterine fold is identified as a white line firmly attached to the uterus, with 2-3 cm between it and the bladder dome. The initial incision is made below the white line while lifting the bladder. The bladder is mobilized off the uterus and upper vagina using scissors or bluntly until the anterior vagina is identified. The tendinous attachments of the bladder in this area may be desiccated or dissected.

VAGINAL PREPARATION
Every year, new innovations for uterine and vaginal manipulation appear. The Valtchev uterine manipulator (Conkin Surgical Instruments, Toronto, Canada) has been around for more than 15 years and allows anterior, posterior, and lateral manipulation of the uterus and permits the surgeon to visualize the posterior cervix and vagina. Newer devices are currently available developed by Pelosi, Wattiez, Hourcabie, Koninckx, Koh, McCartney, Donnez, and myself. I still use the Valtchev and the Wolf tube.

UPPER UTERINE BLOOD SUPPLY

When oophorectomy is indicated or desired, the peritoneum is opened on each side of the infundibulopelvic ligament with scissors and a 2/0-Vicryl free ligature passed through the window created and tied extracorporeally using the Clarke-Reich knotpusher. This manaoeuvre is repeated until two proximal and one distal ties are placed, and the ligament divided. This manoeuvre helps develop suturing skills.The broad ligament is divided to the round ligament just lateral to the uteroovarian artery anastomosis using scissors or cutting current through a spoon electrode. I rarely desiccate the infundibulopelvic ligament as it results in too much smoke early in the operation. When ovarian preservation is desired, the uteroovarian ligament and fallopian tube are compressed and coagulated until desiccated with bipolar forceps, at 2535 W cutting current, and then divided. Alternatively, the utero-ovarian ligament and fallopian tube pedicles are suture-ligated adjacent to the uterus with 2/0-Vicryl, using a free ligature passed through a window created around the ligament. Stapling devices are rarely used. If the ovary is to be preserved and the uterus large, the utero-ovarian ligament/round ligament/Fallopian tube junction may be divided with a 30 or 45 mm GIA type stapler. This may be time saving for this portion of the procedure, thus justifying its increased cost. Many complications are related to the use of staplers.23 Whereas it decreases operative time, it also increases the risk for postoperative haemorrhage and injury to the ureter. Ligation or coagulation of the vascular pedicles is safer.

EXPLORATION
The upper abdomen is inspected, and the appendix is identified. Clear vision is maintained throughout the operation using the I.C. Medical smoke evacuator (Phoenix, AZ). Endometriosis is excised before starting TLH. Bleeding is controlled with microbipolar forceps.

RETROPERITONEAL DISSECTION
The peritoneum is opened early with scissors in front of the round ligament to allow CO2 from the pneumoperitoneum to distend the retroperitoneum. The tip of the laparoscope is then used to perform optical dissection of the retroperitoneal space by pushing it into the loosely distended areolar tissue parallel to the uterus to identify the uterine vessels, ureter, or both. The uterine artery is often ligated at this time, especially in large uterus patients.

URETERAL DISSECTION (OPTIONAL)

The ureter is identified medially, superiorly, or laterally (pararectal space). Stents are not used as they may cause hematuria and ureteric spasm. The laparoscopic surgeon should dissect (skeletonize) either the ureter or the uterine vessels during the performance of a laparoscopic hysterectomy.

UTERINE VESSEL LIGATION

The uterine vessels may be ligated at their origin, at the site where they cross the ureter, where they join the

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Manual of New Hysterectomy Techniques morcellators are motorised circular saws. Using claw forceps or a tenaculum to grasp the fibroid and pull it into contact with the fibroid, large pieces of myomatous tissue are removed piecemeal until the myoma can be pulled out through the trocar incision. With practice this instrument can often be inserted through a stretched 5-mm incision without an accompanying trocar. The new Sawalhe Morcellator from Karl Storz comes with 12 mm, 15 mm, and 20 mm diameter circular saws.26

uterus, or on the side of the uterus. Most surgeons use bipolar desiccation to ligate these vessels, but this author prefers suture because it can be removed if ureteral compromise is suggested at cystoscopy.24, 25 In most cases, the uterine vessels are suture ligated as they ascend the sides of the uterus. The broad ligament is skeletonised to the uterine vessels. Each uterine vessel pedicle is suture-ligated with 0-Vicryl on a CTB-1 blunt needle (Ethicon JB260) (27"), as a blunt needle reduces surrounding venous bleeding. The needles are introduced into the peritoneal cavity by pulling them through a 5-mm incision.18 A short, rotary movement of the needle holder brings the needle around the uterine vessel pedicle. This motion is backhand if done with the left hand from the patients left side and forward motion if using the right hand from the right side. In some cases, the vessels can be skeletonized completely and a 2-0 Vicryl free suture ligature passed around them. Sutures are tied extracorporeally using a Clarke-Reich knot pusher. In large uterus patients, selective ligation of the uterine artery without its adjacent vein is done to give the uterus a chance to return its blood supply to the general circulation. It also results in a less voluminous uterus for morcellation.

LAPAROSCOPIC VAGINAL VAULT CLOSURE AND SUSPENSION WITH McCALL CULDEPLASTY27,28

The vaginal delineator tube is placed back into the vagina for closure of the vaginal cuff, occluding it to maintain pneumoperitoneum. The uterosacral ligaments are identified by bipolar desiccation markings or with the aid of a rectal probe. The first suture is complicated as it brings the uterosacral and cardinal ligaments as well as the rectovaginal fascia together. This single suture is tied extracorporeally bringing the uterosacral ligaments, cardinal ligaments, and posterior vaginal fascia together across the midline. It provides excellent support to the vaginal cuff apex, elevating it and its endopelvic fascia superiorly and posteriorly toward the hollow of the sacrum. The rest of the vagina and overlying pubocervicovesicular fascia are closed vertically with one or two 0-Vicryl interrupted sutures.

DIVISION OF CERVICOVAGINAL ATTACHMENTS AND CIRCUMFERENTIAL CULDOTOMY

The cardinal ligaments on each side are divided. Bipolar forceps coagulate the uterosacral ligaments. The vagina is entered posteriorly over the uterovaginal manipulator near the cervicovaginal junction. A 4-cm diameter reusable vaginal delineator tube (R. Wolf) is placed in the vagina to prevent loss of pneumoperitoneum and to outline the cervicovaginal junction circumferentially as it is incised using the CO2 laser to complete the circumferential culdotomy with the delineator as a backstop. The uterus is morcellated, if necessary, and pulled out of the vagina.

CYSTOSCOPY25,29-31
Cystoscopy is done after vaginal closure to check for ureteral patency in most cases, after intravenous administration of Indigo Carmine dye. This is necessary when the ureter is identified but not dissected and especially necessary when the ureter has not been identified. Blue dye should be visualised through both ureteral orifices. The bladder wall should also be inspected for suture and thermal defects.

MORCELLATION (LAPAROSCOPIC AND VAGINAL)

Morcellation can be done laparoscopically or vaginally. Vaginal morcellation is done with a #10 blade on a long knife handle to make a circumferential incision into the uterus while pulling outwards on the cervix and using the cervix as a fulcrum. The myometrium is incised circumferentially parallel to the axis of the uterine cavity with the scalpels tip always inside the myomatous tissue and pointed centrally, away from the surrounding vagina. Morcellation through anterior abdominal wall sites is done when vaginal access is limited or supracervical hysterectomy requested. Reusable electromechanical

UNDERWATER EXAMINATION
At the close of each operation, an underwater examination is used to detect bleeding from vessels and viscera tamponaded during the procedure by the increased intraperitoneal pressure of the CO2 pneumoperitoneum. The CO2 pneumoperitoneum is displaced with 2- 4 L of Ringers lactate solution, and the peritoneal cavity is vigorously irrigated and suctioned until the effluent is clear of blood products. Any further bleeding is controlled underwater using microbipolar forceps to coagulate through the electrolyte solution, and 2 L of lactated Ringers solution are left in the peritoneal cavity.

Total Laparoscopic Hysterectomy: Indications, Techniques and Outcomes

41

SKIN CLOSURE
The vertical intraumbilical incision is closed with a single 4-0 Vicryl suture opposing deep fascia and skin dermis, with the knot buried beneath the fascia. This will prevent the suture from acting like a wick transmitting bacteria into the soft tissue or peritoneal cavity. The lower quadrant 5-mm incisions are loosely approximated with a Javid vascular clamp (V. Mueller, McGaw Park, IL) and covered with Collodion (AMEND, Irvington, NJ) to allow drainage of excess Ringers lactate solution.

HAEMORRHAGE
Intraoperative haemorrhage occurs when a previously nonanaemic patient loses greater than 1000 ml of blood or requires a blood transfusion. By doing careful laparoscopic dissection, most profuse haemorrhage situations are avoided or controlled as they occur.

URETER COMPLICATIONS
I remain committed to prevention of ureteral injury intraoperatively by ureteral identification often with dissection and by cystoscopy at the conclusion of hysterectomies.29, 30 The ureters are commonly injured at the level of the infundibulopelvic ligament, uterosacral ligament or pelvic sidewall due to adhesions resulting from endometriosis, pelvic inflammatory disease, or previous abdominal surgery. During laparoscopic hysterectomy ureteral injury may occur while cutting dense adhesions and fibrotic scar tissue, trying to stop bleeding close to the ureter with bipolar cautery, or in the process of ligating the uterine vessels with bipolar electrosurgery, staples, or suture. Most ureteral injuries are not identified or even suspected without cystoscopy.23, 25, 31 The bottom line is that an aggressive approach to ureteral protection can reduce but not eliminate ureteral injury. However, prompt recognition and management can prevent multiple surgical procedures and significant patient morbidity including organ loss. Urinary retention is a common undetected complication. More studies are necessary to determine how common and whether long-term compromise can occur.35

ENDOMETRIOSIS
Hysterectomy with excision of all visible endometriosis usually results in relief of the patients pain. Oophorectomy may not be necessary at hysterectomy for advanced endometriosis if the endometriosis is removed carefully.22 Endometriosis nodules in the muscularis of the anterior rectum can usually be excised laparoscopically without entering the rectum. Full-thickness penetration of the rectum can occur during hysterectomy surgery, especially when excising rectal endometriosis nodules. Following identification of the nodule or rent in the rectum, a closed circular stapler [Proximate ILS Curved Intraluminal Stapler (Ethicon, Stealth)] is inserted into the lumen just past the lesion or hole, opened 1-2 cm, and held high to avoid the posterior rectal wall. The proximal anvil is positioned just beyond the lesion or hole, which is invaginated into the opening, and the device closed. The instrument is fired and removed.23, 24, 32, 33

COMPLICATIONS
Complications of laparoscopic hysterectomy are those of hysterectomy and laparoscopy combined: anaesthetic accidents, respiratory compromise, thromboembolic phenomenon, urinary retention, injury to vessels, ureters, bladder, and bowel, as well as infections, especially of the vaginal cuff.34 Ureteral injury is more common when staplers or bipolar desiccation are used without ureteral identification. Complications unique to laparoscopy include large vessel injury, epigastric vessel laceration, subcutaneous emphysema, and trocar site incisional hernias. Some complications related to laparoscopic hysterectomy are discussed.

BLADDER INJURY
Bladder injury can occur during dissection of the bladder off the uterus and cervix or from an inflamed adnexa. In these cases the bladder is repaired using 3-0 Vicryl usually in two layers.

BOWEL INJURY
Small bowel injury during laparoscopic hysterectomy is uncommon and is usually associated with extensive intraperitoneal adhesions. Small bowel injuries can be sutured repaired. Small bowel enterotomy may require mobilisation from above, delivery through the umbilicus by extending the incision 1 cm, and repair or resection. If the hole is confined to the antimesenteric portion, the bowel can be closed with interrupted 3-0 silk or Vicryl. All enterotomies are suture repaired transversely to reduce the risk of stricture. If the hole involves greater than 50% of the bowel circumference, resection is done.

INFECTION
Experience with serious wound infection after laparoscopic hysterectomy is rare. Morcellation during laparoscopic or vaginal hysterectomy results in a slightly increased risk of fever, especially if prophylactic antibiotics are not used.26

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Manual of New Hysterectomy Techniques Abdominal hysterectomy is the preferred method of treatment based on training and economics, and, this poses an ethical dilemma. Are we offering the best choices to our patients? We as specialists need to answer this question. Why would physicians take time to learn a new technique if they are going to be poorly reimbursed? Reimbursement for hysteroscopic sterilisation and/or ablation far exceed hysterectomy. Who would have thought! So, how can we train the specialists of tomorrow in minimally invasive and vaginal surgery? Unfortunately, I do not know, but the answer has a strong financial component. Laparoscopic hysterectomy is clearly beneficial for patients in whom vaginal surgery is contraindicated or cant be done. When indications for the vaginal approach are equivocal, laparoscopy can be used to determine if vaginal hysterectomy is possible. With this philosophy, patients avoid an abdominal incision with resultant decrease in length of hospital stay and recuperation time. The laparoscopic surgeon should be aware of the risks and how to minimise them and, when they occur, how to repair them laparoscopically. A randomized trial comparing TLH to TAH may not be possible, unless the patients have no real concern about the cosmetics of incision size. If the patient has a preference it may take a long time to explain why the trial is needed and why randomization is ethical. Recruitment to trials is very difficult when minimally invasive therapy is an available option. I do not pretend to understand studies comparing TLH and VH as they have different indications. TLH is a substitute for TAH, not for VH. As the studies show, if the surgeon can do a VH, it is the best possible operation. That is, unless future studies prove this wrong.53, 54

An extracorporeal segmental enterectomy with side to side stapled anastomosis is preferred. Rectal injury may occur during rectal endometriosis excision or during vaginal morcellation of a large fibroid uterus. Repair is with a circular stapler.36

LONG-TERM COMPLICATIONS
Surgeons must be aware that women who undergo hysterectomy may develop long-term complications related to their initial surgery.

Bowel Obstruction from Adhesions

Among benign gynaecologic operations, total abdominal hysterectomy (TAH) was the most common cause of small bowel obstruction. The median interval between TAH and obstruction was 4 years. The adhesions were adherent to the previous laparotomy incision in 75% and to the vaginal vault in 25%. Obstruction did not occur after laparoscopic supracervical hysterectomy. TAH incisions may result in adhesions and bowel obstruction many years later.8, 37

Pelvic Pain
Adhesions, adnexal remnants, and endometriosis may cause chronic pelvic pain after hysterectomy.38

MISCELLANEOUS
Supracervical hysterectomy, cancer hysterectomy, and robotic hysterectomy were also reviewed.39, 49 Their place in todays surgery is being determined. Also, it is good to know that hysterectomy has no effect on longevity or psychology. There is no significant risk of increased mortality from cardiovascular disease or cancer after hysterectomy regardless of age.50, 51 Cost has not been addressed very much in this review.16 It is encouraging to note that in a study from Canada, outpatient TLH were less than those having short stay VH, with costs averaging $1065 US dollars.52

REFERENCES
1. Garry R, Reich H, Liu CY. Laparoscopic hysterectomydefinitions and indications. Gynaecol Endosc 1994; 3:1-3. 2. Reich H, Roberts L. Laparoscopic hysterectomy in current gynaecological practice. Reviews in Gynaecological Practice 2003; 3:32-40 (Elsevier). 3. Reich H, McGlynn F, Sekel, L: Total laparoscopic hysterectomy. Gynaecological Endoscopy 1993;2:59-63. 4. Reich H: Laparoscopic hysterectomy. Surgical Laparoscopy and Endoscopy. Raven Press, New York 1992;2:8588. 5. Reich H, McGlynn F: Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tuboovarian disease. Journal of Reproductive Medicine 1986; 31:609.

CONCLUSION
It took 5 years for laparoscopic cholecystectomy to be universally adopted! Laparoscopic hysterectomy has been available for the last 20 years with sporadic acceptance. TLH has no billing code in the USA! The low level of reimbursement has curbed the enthusiasm for training in minimally invasive surgery in our specialty in the United States. Practitioners faced with shrinking reimbursement and rising costs must spend more time in the office and less in surgery.

Total Laparoscopic Hysterectomy: Indications, Techniques and Outcomes

6. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213-16. 7. Johns DA, Carrera B, Jones J, DeLeon F, Vincent R, Safely C. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, notfor-profit hospital. Am J Obstet Gynecol 1995;172:1709-19. 8. Lower AM, Hawthorn RJS, Ellis H, et al: The Impact of adhesions on hospital readmissions over ten years after 8849 open gyn operations. British J of OB Gyn. 2000;107: 855-62. 9. Clayton RD. Hysterectomy: best practice and research. Clinic Obstet Gynecol 2006;20:1-15. Best paper of 2006. This paper summarizes it all. It includes the results of laparoscopic versus abdominal versus vaginal approach for hysterectomy. Most aspects of previous studies are included. Emphasizes that vaginal hysterectomy should be the preferred route when applicable. Laparoscopic hysterectomy should be considered as an alternative to abdominal hysterectomy. 10. Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2005;(1): CD003677. 11. Johnson N, Barlow D, Lethaby A. Methods of hysterectomy: systematic review and meta-analysis of randomized controlled trials. BMJ 2005;330:1478-81. 12. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol 2002;99:229-34. 13. Kafy S, Huang JY, Al-Sunaidi M, et al. Audit of morbidity and mortality rates of 1792 hysterectomies. J Minim Invasive Gynecol 2006;13:55-59. 75% of hysterectomies in their teaching department are done by laparotomy with 12% vaginal hysterectomies and 12% laparoscopic supracervical hysterectomies. 14. Istre O, Langebrekke A, Qvigstad E. Changing hysterectomy technique from open abdominal to laparoscopic: New trend in Oslo, Norway. J Minim Invasive Gynecol 2007;14:74-77. The endoscopic hysterectomy rate was increased from18% to 54% from 2001 to 2005. 15. Vaisbuch E, Goldchmit C, Ofer D, et al. Laparoscopic hysterectomy versus total abdominal hysterectomy: A comparative study. Eur J Obstet Gynecol Reprod Biol 2006;126(2):234-38. New study compared 167 women who had LH with 119 women with TAH. Conversion rate was 1.8% (3 cases). Laparoscopic hysterectomy took longer. 16. Abdelmonem A, Wilson H, Pasic R. Observational Comparison of Abdominal Vaginal and Laparoscopic Hysterectomy as Performed at a University Teaching Hospital. J Reprod Med 51(12): 945-954, 2006. LAH and TAH cost the same ($16,000). VH cost $12,000. LAH had best patient satisfaction. 17. OHanlan, KA., Dibble, S.L., Fisher, D.T. Total laparoscopic hysterectomy for uterine pathology: Impact of body mass index on outcomes. Gynecol Oncol 2006;103 (3):938-41. TLH can be done in patients regardless of BMI. 18. Leung SW, Chan CS, Lo SF, et al. Comparison of the different types of laparoscopic total hysterectomy. J Minim Invasive Gynecol 2006;14:91-96. This paper suggests that there is more blood loss in LAVH type operations than in TLH.

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19. Roman JD. Patient selection and surgical technique may reduce major complications of laparoscopic-assisted vaginal hysterectomy. J Minim Invasive Gynecol 2006;13:306-310. This surgeon attributes ureteral dissection to his low complication rate. 20. Karaman Y, Bingol B, Gunenc Z. Prevention of complications in laparoscopic hysterectomy: Experience with 1120 cases performed by a single surgeon. J Minim Invasive Gynecol 2007;14:78-84. A 1% complication rate after LAH in 1,120 women. CO2 was used. LH averaged 55 minutes. 21. Reich H, McGlynn F, Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. Journal of Reproductive Medicine 1991;36:516-22. 22. Martin D. Hysterectomy for treatment of pain associated with endometriosis. J Minim Invasive Gyneco 2006;13:56672. This excellent review summarizes the use of hysterectomy for chronic pelvic pain associated with endometriosis. Ovarian preservation is addressed. 23. McMaster-Fay RA, Jones RA. Laparoscopic hysterectomy and ureteric injury: A comparison of the initial 275 cases and the last 1000 cases using staples. Gynecol Surg 2006;3:118-21. A very low ureteral injury rate using staples (5 per 1,275). (1 injury in last 1,000 cases). 24. Reich H, Clarke HC, Sekel L. A simple method for ligating in operative laparoscopy with straight and curved needles. Obstet Gynecol 1992;79:143-47. 25. Sharon A, Auslander R, Brandes-Klein O, et al. Cystoscopy after total or subtotal laparoscopic hysterectomy: The value of a routine procedure. Gynecol Surg 2006;3:122-27. 4 ureteral injuries (1 after TLH and 3 after supracervical hysterectomy) in 338 patients. None since routine use of cystoscopy. 26. Lieng M, Istre O, Busund B, Qvigstad E. Severe complications caused by retained tissue in laparoscopic hysterectomy. J Minim Invasive Gynecol 2006;13:231-33. A very important complication to be aware of. Both patients in this report had necrotic remnants of tissue intraabdominally after morcellation that led to serious infection. 27. Reich H, Orbuch I, Seckin T. Reich modification of the McCall Culdeplasty to prevent and/or repair Prolapse during Total Laparoscopic Hysterectomy. In: Complete Manual & Atlas of Laparoscopic Suturing. Edited by Nutain Jain. Jaypee Brothers, New Delhi, India 2006. pp. 78-82. How to treat the high cystocele causing urinary retention. 28. Powers K, Lazarou G, Grigorescu B. Suspension of the cervix during laparoscopic supracervical hysterectomy. Journal of Pelvic Medicine and Surgery 2006;12:273-75. This report documents that supracervical hysterectomies are being done on patients with prolapse. It was repaired in these 2 cases. 29. Ribeiro S, Reich H, Rosenberg J. The value of intraoperative cystoscopy at the time of laparoscopic hysterectomy. Hum Reprod 1999;14:1727-29.

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Manual of New Hysterectomy Techniques

40. Bojahr B, Raatz D, Schonleber G et al. Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique. J Minim Invasive Gynecol 2006; 13:183-89. Large series of laparoscopic supracervical hysterectomies. 53% with history of at least 1 previous laparotomy. Most common complication was bleeding from the cervix. 41. Morrison Jr. JE, Jacobs VR. Classic intrafascial supracervical hysterectomy (CISH): 10-year experience.JSLS 2006;10:29-29. The results of the classic Kurt Semm operation in 579 women. 42. Ghezzi F, Cromi A, Bergamini V, et al. Laparoscopic management of endometrial cancer in nonobese and obese women: A consecutive series. J Minim Invasive Gynecol 2006;13(4):269-75. A surgeon can only use 5mm trocars to do endometrial cancer laparoscopic surgery in obese women. 43. Ghezzi F, Cromi A, Bergamini V, et al. Laparoscopicassisted vaginal hysterectomy versus total laparoscopic hysterectomy for the management of endometrial cancer: A randomized clinical trial. J Minim Invasive Gynecol 2006;13(2):114-20. This study documents that obese patients benefit more from TLH than from LAVH in terms of shorter operating time. 72 patients. 44. Gil-Moreno A, Diaz-Feijoo B, Morchon S, Xercavins J. Analysis of survival after laparoscopic-assisted hysterectomy compared with the conventional abdominal approach for early-staged endometrial carcinoma: A review of the literature. J Minim Invasive Gynecol 2006; 13:26-35. A review of staging laparoscopic and conventional for endometrial carcinoma in 370 patients. Laparoscopic and conventional. 45. Nezhat F, Mahdavi A, Nagarsheth NP. Total laparoscopic radical hysterectomy and pelvic lymphadenectomy using harmonic shears. J Minim Invasive Gynecol 2006;13:20-25. Review of use of harmonic shears for stage 1 cervical cancer total laparoscopic radical hysterectomy. 46. Frumovitz M, Ramirez PT. Total laparoscopic radical hysterectomy: Surgical technique and instrumentation. Gynecol Oncol 2007;104:S13-S16. Technique article. Harmonic Scalpel used. 47. Ramirez PT, Slomovitz BM, Soliman PT, et al. Total laparoscopic radical hysterectomy and lymphadenectomy: The M.D. Anderson Cancer Center Experience. Gynecol Oncol 2006; 102:252-55. Description of 20 patients undergoing total radical hysterectomy. 48. Fiorentino RP, Zepeda MA, Goldstein BH, et al. Pilot study assessing robotic laparoscopic hysterectomy and patient outcomes. J Minim Invasive Gynecol 2006;13:60-63. Robotic surgery in 20 patients with mean operating time of 3.2 hours and anesthesia time of 4 hours. 49. Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg 2006;191(4):555-60. Robot assisted laparoscopic hysterectomy in 16 consecutive patients with mean operative time of 242 minutes and range from 170 to 432. One delayed thermal bowel injury.

30. Reich H. Letters to the Editor. Ureteral injuries after laparoscopic hysterectomy. Human Reproduction. 2000; 15:733-34. 31. Wu HH, Yang PY, Yeh GP, et al. The detection of ureteral injuries after hysterectomy. J Minim Invasive Gynecol 2006;13:403-08. Intraoperative cystoscopy is successful in diagnosing ureteral injury. 32. Breitenstein S, Dedes KJ, Bramkamp M, et al. Synchronous laparoscopic sigmoid resection and hysterectomy with transvaginal specimen removal. J Laparoendosc Adv Surg Tech A 2006;16(3):286-89. Another technique to do both hysterectomy and rectosigmoid resection laparoscopically. 33. Lakshman N, Chang R, Ho Y. Laparoscopic combined rectal anterior resection and total hysterectomy with bilateral salpingo-oophorectomy. Tech Coloproctol 2006;10(4):350-52. I believe there will be more studies documenting rectal resection with hysterectomy for extensive endometriosis. This is not that uncommon a procedure today. 34. Liu CY, Reich H. Complications of Total Laparoscopic Hysterectomy in 518 Cases. Gynaecological Endoscopy 1994;3:203-08. 35. Neumann GA, Lauszus FF, Ljungstrom B, Rasmussen KL. Incidence and remission of urinary incontinence after hysterectomy-a 3-year follow-up study. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(4)379-382.Epub 2006 Aug1. Women who had subtotal hysterectomy had significantly more often stress incontinence compared to controls. Remember that pelvic support is very important even if doing a subtotal hysterectomy. 36. Reich H, Redan JA, Orbuch IK. Laparoscopic Hysterectomy for Advanced Endometriosis including Rectosigmoid Disease. Surgical Technology International XIII. Edited by Szab Z, Coburg AJ, Savalgi RS, Reich H. 2005; 13:121-136. Universal Press, San Francisco, CA. 37. Al-Sunaidi M, Tulandi T. Adhesionrelated bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 2006;108(5):1162-66. 326 cases of women admitted with small bowel obstruction were analyzed. Total abdominal hysterectomy was the most common cause and the median interval between hysterectomy and small bowel obstruction was 4 years. 75% of the obstructions involved adhesions to the abdominal wall. This reinforces Adrian Lowers study. 38. Behera M, Vilos GA, Hollett-Caines J, et al. Laparoscopic findings, histopathologic evaluation, and clinical outcomes in women with chronic pelvic pain after hysterectomy and bilateral salpingo-oophorectomy. J Minim Invasive Gynecol 2006;13(5):431-35. Laparoscopy can often resolve post hysterectomy chronic pelvic pain. 39. Pasic R, Abdelmonem A, Levine R. Comparison of cervical detachment using monopolar lap loop ligature and conventional methods in laparoscopic supracervical hysterectomy. JSLS 2006;10(2):226-230. This works. An electrosurgical loop is the most rapid way to separate the uterine cervix from fundus during laparoscopic supracervical hysterectomy.

Total Laparoscopic Hysterectomy: Indications, Techniques and Outcomes

50. Iverson L, Hannaford P, Elliott AM, Lee AJ. Long-term effects of hysterectomy on mortality: nested cohort study. BMJ 2005;330(7506):1482. Epub 2005 Jun 1. 51. Persson P, Wijma K, Hammar M, Kjolhede P. Psychological wellbeing after laparoscopic and abdominal hysterectomy-a randomized controlled multicentre study. BJOG 2006;9:1023-30. The general psychological well being within 6 months after the operation was equal after laparoscopic and abdominal hysterectomy. 52. Thiel JA, Kamencic H. Assessment of costs associated with outpatient total laparoscopic hysterectomy. J Obstet Gynaecol Can. 2006;28(9):794-98.

45

An important paper documenting that TLH can be less expensive than VH. 53. Elkington,NM, Chou D. A review of total laparoscopic hysterectomy: Role, techniques and complications. Current Opinion in Obstetrics and Gynaecology 2006;18(4):380-384. My thanks to the work of these authors who reviewed total laparoscopic hysterectomy last year. 54. van der Wat J. Endoscopic surgery: A moment in time? J Minim Invasive Gynecol 2006;13(5):370-71. This editorial says it all. We have a long way to go. There is no evidence to support laparoscopic hysterectomy if vaginal hysterectomy can be done safely. However few places do it.

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Manual of New Hysterectomy Techniques

Laparoscopic Anterior Exenteration

Shailesh Puntambekar, Seema Puntambekar, Anjali Patil, Reshma Palen Neeraj Rayate, Hans-Rudolf Tinneberg

PELVIC ANTERIOR EXENTERATION

Pelvic anterior exenteration involves removal of bladder, lower ureters, perivesical stump, uterus, ovaries and lymph nodes up to the pelvic brim. Pelvic exenteration was first described by Alexander Brunswig in 1948,1 and remains the landmark contribution to the management of pelvic cancer. High morbidity and high mortality associated with this operation has significantly gone down with better selection of patient and refinement in surgical techniques. This procedure has become a valuable modality in the treatment of recurrent cancer after radiotherapy or in locally advanced cancer or cases complicated by vesicovaginal fistula.2,3 The recent reports of 5 years survival rates are in the range of 40-60%.4-6 There is a definite group of patients who benefit from this surgery. It can be used as a palliation in patients who are incurable by conventional modalities or those who have failed to other modalities and have intolerable local symptoms or complications and yet remain in good health without prospects of an early death. Exentration serves as an initial curative procedure in patients with primary cancers that present in an advanced stage with or without complications. The transition of pelvic exenteration from a palliative procedure to a potentially curative one in patients with advanced pelvic cancer has been established.6 The safety of the procedure and its place in the treatment of primary cases has also been emphasised.6 Laparoscopic surgery has been documented to be a reasonable alternative to its open counterpart for a variety of pelvic procedures, including advanced procedures like laparoscopic cystectomy, laparoscopic assisted vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopic radical hysterectomy. With improving surgical technology and increasing surgical experience exenteration is a logical extension of current laparoscopic practice.7

Laparoscopic pelvic exenterations both anterior pasterior and total with good results have been reported by us.7-9 Its feasibility in the treatment of advanced cervical cancers has also been documented. This chapter describes the indications contraindications inclusion criteria and steps of this procedure.

INDICATIONS
The prime indication for pelvic exenteration is recurrent cervical cancer with bladder involvement. These can be further divided into primary and secondary. Before embarking on exenteration it is imperative to evaluate the operability. The following criteria should be used to decide the operability. 1. Histological documentation of cancer in the palpable mass. 2. Absence of tumour extension to parametrium or pelvic sidewalls. 3. No involvement of the rectum by the growth. 4. Absence of gross pelvic or para-aortic lymph node enlargement. 5. No extrapelvic peritoneal implants or bowel involvement. 6. No evidence of distant metastasis. 7. The final determinant was the diagnostic laparoscopy done to inspect peritoneal deposits and nodal areas before proceeding to the definitive procedure. The absolute contra-indications for surgery are: 1. Unilateral or bilateral pedal oedema. 2. Sciatica or bone pain. 3. Poor medical condition. The preoperative investigations include: 1. Thorough general examination. 2. Routine biochemistry.

Laparoscopic Anterior Exenteration Most of the patients due for anterior exenteration as involve urinary bladder also have vesicoureteric junction involvement and obstructive uropathy. a. Blood urea b. Serum creatinine c. Serum electrolytes 3. Ultrasound. 4. CT scan or MRI. 5. Examination under anaesthesia (EUA) and cystoscopy. Preoperative bowel preparation is done with polyethyl glycol. This helps in keeping the small bowel away from the operative field. One should avoid using bowel wash and enemas as this leads to dilation of sigmoid colon. Based on these investigations the operability is established.

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In this chapter we will describe laparoscopic anterior exenteration in a stepwise manner.

INSTRUMENTATION
This being an advanced laparoscopic procedure, the use of following instruments is advocated: 1. Myoma screw 2. Two non-traumatic graspers 3. One needle holder 4. One Maryland dissector 5. Harmonic scalpel 6. Bipolar forceps 7. Allis forceps 8. Suction cannula 9. 0 degree telescope 10. Ligasure The uterus is manipulated with myoma screw and not with uterine manipulator because the uterine manipulator will have to be inserted through the cervical growth, thus going against oncological principles.

ANAESTHESIA
Regional anaesthesia either spinal or epidural was preferred in combination with general anaesthesia. The regional anaesthesia leads to sympathetic blockade and the small bowel thus remains contracted, which prevents any bowel coming in the way and avoiding inadvertent bowel injury. Inhalation agents like nitrous oxide and halothane lead to small bowel dilatation. The type of urinary diversion plays an important role in the quality of life. The various types of urinary diversions that can be done are ileal conduit, ureterosigmoid, orthotopic ileal neo bladders and Indiana pouch. Ureterosigmoidostomy can be done entirely laparoscopically while ileal conduit Indiana pouch and neo bladder have to be done by opening the abdomen. Lack of serious morbidity, good continent urinary diversion and improved survival in primary cases and good palliation in recurrent cases has established exenteration as definitive procedure in the management of pelvic tumours. A surgeon performing exenteration should not allow his surgical ego to override scientific judgments and should be ready to abandon the procedure if it is not possible to achieve negative tumour margin even if the procedure remains technically possible. The advantages of laparoscopy in exenteration are minimal blood loss, quick recovery, less postoperative pain and lower rate of adhesion formation. Early application of adjuvant chemo radiation can be done in those patients who are going to require it. This can be done following laparoscopy, as there is no incision.10

PORT POSITION
A total of 5 ports are used A 10 mm camera port in the umbilicus A 10 mm working port in the McBurneys point on the right side A 5 mm port pararectally in the midclavicular line A set of 5 mm ports in the mirror image on the left side.

POSITION OF OPERATING SURGEONS AND MONITOR

The surgeon stands on the right side, the assistant surgeon on the left side the camera person also on the left side, at the head end. The surgeon need not change his position during the contralateral dissection.

Figure 6.1A

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Figure 6.1B

Figure 6.2

DISSECTION OF THE PARA-RECTAL SPACE

The ureter is then pushed medially and the plane lateral to the ureter is dissected. This is the para-rectal space. Sweeping the harmonic forceps parallel to the ureter opens up this space (Figure 6.3). The internal iliac artery forms the lateral boundary of this space and is thus easily identified. The common iliac, external iliac and the Internal Iliac vessels are identified. The uterine artery is the only structure that crosses the para-rectal space transversely (Figure 6.4). The artery courses over the ureter medially (water under the bridge) (Figure 6.5) and laterally it can be traced to its origin. It is the first medial branch of the internal iliac artery and it arises almost six inches beyond the common iliac bifurcation. There is thus, a long segment of the internal iliac artery available for ligation (Figure 6.6). The internal iliac artery is dissected and a Maryland forceps is passed below it,

Figure 6.1C

ANTERIOR EXENTERATION PROCEDURE

The abdominal cavity is first assessed for operability. A myoma screw is introduced from the upper left port for uterine manipulation. Use of the uterine manipulator is avoided, since it goes through the tumour tissue. The uterus is anteverted and the assistant pushes the rectum to the left side. This stretches the peritoneum medial to the right infundibulopelvic ligament. The ureter is visualised underneath the peritoneum at the level of sacral promontory. It is gently probed to induce peristalsis, to confirm its identity. The peritoneum medial to the infundibulopelvic ligament is incised with the harmonic shears and the ureter is dissected on its lateral side to expose it along its length (Figure 6.2).

Figure 6.3

Laparoscopic Anterior Exenteration

49

Figure 6.4

to pull a ligature around it. It is then ligated with a 2:0 vicryl suture. Suture The internal iliac artery is ligated (Figure 6.7). It may be clipped (Figures 6.8 and 6.9) or clamped with Ligasure. The uterine artery is clipped or clamped and cut with the Ace Harmonic (Figure 6.10). Anatomically the uterine vein passes below the ureter and cannot be cut at this stage. As is generally believed, it never accompanies the uterine artery as the artery crosses above the ureter (Figure 6.11). The ureter is again pushed medially and blunt dissection is continued in the same plane (para-rectal plane), just anterior to the uterine artery, proceeding in a caudal direction. Here the space contains loose areolar tissue and fat. The fascia covering the levator ani muscles is soon seen and this is the caudal limit of dissection (Figure 6.12). A similar dissection is executed on the left side. For the left sided dissection, the myoma screw pushes the uterine fundus to the right and the assistant retracts the

Figure 6.5 Figure 6.7

Figure 6.6

Figure 6.8

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Manual of New Hysterectomy Techniques

Figure 6.9 Figure 6.12 rectosigmoid to the right. The sigmoid is usually adherent in this area and requires to be released before the left ureter can be exposed. The peritoneum infero-medial to left infundopelvic ligament is cut and further dissection continued in the same manner as on the right side (Figure 6.13).

POSTERIOR DISSECTION
The ureter is then pushed laterally and the peritoneal cut is continued medial to the ureter (Figure 6.14). This peritoneal cut is extended down into the pouch of Douglas, keeping the ureter constantly under vision. The assistant anteverts the uterus and pulls the rectum cranially so as to stretch the peritoneum in the pouch of Douglas. This peritoneum is then incised with the

Figure 6.10

Figure 6.11

Figure 6.13

Laparoscopic Anterior Exenteration

51

Figure 6.14 harmonic shears. The dissection is aided by the carbon dioxide gas, which opens the loose areolar plane between the rectum and posterior vaginal wall. The rectum is dissected off the posterior vaginal wall up to the levator ani. Anatomically, the fat belongs to the rectum. The trick of the trade is to retain this fat on the rectum and hence the dissection should be between this fat and the posterior vaginal wall. No rectal wall fibres should be visualised. During this dissection the two layers of the Denonvilliers fascia are clearly identifiable. The dissection in the pouch of Douglas is continued caudally upto the levator ani muscle and laterally up to the uterosacral ligaments (Figure 6.15). The peritoneum medial to the right uretar is cut in a similar manner as was done on the left and the two cuts are joined to complete the posterior U cut.

Figure 6.15

Figure 6.16 left uterine vein and ligaments are clamped and cut. The levator ani muscle is thus bared posteriorly and laterally upto the pelvic walls (Figure 6.17).

CUTTING THE LIGAMENTS The uterosacrals and the Mackenrodts ligaments form a single fan-shaped structure posterolaterally. Their extent is now clearly demarcated, following the dissection of the two spaces, namely the para-rectal space and the Pouch of Douglas (Figure 6.16). The right ureter is again pushed laterally and the uterine vein is seen lying in the upper part of the Mackenrodts ligament, as it passes below the ureter. It is clipped or cut with harmonic Ace or Ligasure. When dealing with large vessels the Harmonic is to be always kept on a lower setting of 1. The right uterosacral ligament is clamped and cut, taking care to protect the rectum. The Mackenrodts ligament is also cut as laterally as possible with ligasure. Similar steps are executed on the opposite side and the

BLADDER DISSECTION AND SPACE OF RETZIUS

The uterus is now pulled cranially and to the left. The right ureter is pushed medially and the dissection is continued lateral to the ureter, in the right para-rectal plane. Here the space continues anterioly into the paravesical space. The vessels to the bladder are cut with the harmonic. The round ligament is cut and the peritoneal cut is extended anteriorly over the para-vesical space. During this dissection, the obliterated hypogastric vessel should remain lateral to the plane of dissection. The peritoneum medial to obliterated hypogastric artery is cut, and the dissection is continued anteriorly.

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Figure 6.17

Figure 6.19 Finally a good length of vagina below the growth is exposed (Figure 6.21). The paracolpus is cut as laterally as possible. The levataor ani now lies completely bared on all sides of the vagina. The vagina is then opened with harmonic shears. This kind of dissection usually achieves about 2.5 to 3 cm of vaginal cuff. Both the ureters are clipped (Figure 6.22) and cut. Lastly, both the infundibulopelvic ligaments are clamped or sealed with bipolar and then cut (Figures 6.23 and 6.24). Their cut proximal ends should always be checked for haemostasis. The myoma screw is removed under vision. The entire specimen is separated. This is then removed through the vagina and the vagina is again packed to prevent carbon dioxide leak.

Figure 6.18 The assistant retracts the bladder to the left and the peritoneal cut is extended to the anterior abdominal wall, to separate the bladder from the anterior (Figure 6.18) abdominal wall, using the harmonic shears or the monopolar hook. First filling up the bladder may facilitate this. A similar dissection is repeated on the left, the urachus is cut and the bladder is brought down completely from the roof. As the dissection precedes anteriorly, the retro-pubic space, i.e. the Cave of Retzius is entered (Figure 6.19). This area contains many veins and the use of haemostatic energy sources is recommended here (Bipolar, harmonic Ace or Ligasure. The urethra is reached anteriorly. The urethra is cut and the Foley catheter is seen (Figure 6.20). The Foley catheter is cut or is deflated and partially withdrawn into the distal end of the cut urethra. The catheter should be clamped to avoid loss of pneumoperitoneum.

LYMPH NODE DISSECTION

The lymph node dissection starts at the bifurcation of common iliac artery.

Figure 6.20

Laparoscopic Anterior Exenteration

53

Figure 6.21

Figure 6.23

Figure 6.22

Figure 6.24

The loose areolar tissue on the external iliac vein is held with the forceps and pulled medially (Figure 6.25). The vein is denuded of the tissue with the help of a suction cannula, sweeping the cannula along the vein longitudinally. All the fibro fatty tissue along the external iliac vein is then dissected. At this point the iliac bone is exposed which is the lateral limit of dissection. The nodes in the obturator fossa are visualised by stretching the peritoneum. The assistant sweeps the nodes from the pubic bone cranially. At this point the obturator nerve is exposed and all the nodes above the nerve are cleared. This dissection is done right up to the bifurcation of the iliac vein. The entire fibro fatty tissue is then dissected medially till the internal iliac artery is exposed. This is

the medial limit of dissection. The entire internal iliac artery is cleared off the fibro fatty tissue. At the end of dissection, the external iliac artery, vein and the obturator fossa should be devoid of any fibro fatty tissue (Figure 6.26). The psoas muscle along with the ilioinguinal nerve is the lateral limit of dissection. During this dissection, minor blood vessels are likely to be torn and simply packing the fossa with gauze pieces can stop the oozing. The same dissection is done on the right side (Figures 6.27 and 6.28). In case of bleeding, the fossa is packed. This usually controls it. The specimen of nodes removed is placed in the vagina. The entire nodal tissue is removed through the vagina. This avoids any port metastasis. Haemostasis is achieved and the wound is irrigated.

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Manual of New Hysterectomy Techniques

Figure 6.25

Figure 6.27

Figure 6.26

Figure 6.28 interrupted sutures. An infant feeding tube is placed through the ureteral anastomosis (Figure 6.31) and is brought out from the open end of the conduit. They act as stents and directly drain urine from the ureters into urine bag. The end of the conduit is then brought out through the lateral aspect of the rectus abdominis muscle and anchored to the fascia and the stoma is formed. The stoma should protrude, without tension, approximately 1.5 cm above the skin surface (Figure 6.32).

ILEAL CONDUIT
The ileal conduit is prepared extra-corporeally. A 5 cm transverse incision is taken on the abdominal wall at Mac-Burneys point (Figure 6.29). A segment of ileum approximately 15-20 cm proximal to the ileocaecal valve is brought out from the wound. The proximal and distal mesenteric blood vessels are ligated and the bowel is divided, thus isolating the segment selected for conduit construction. The base of the conduit is closed and the two ends of the intestine are sutured and put back into the abdomen to maintain bowel continuity. The two ureters are brought out from the abdominal wound and are implanted into the conduit (Figure 6.30), each one being implanted separately into the ileum. The uretero ileal anastamosis is done with 2-0 vicryl using

URETERO-SIGMOIDOSTOMY
The right ureter is transfixed to the sigmoid colon, anteriorly over the taenia coli. The assistant pushes the stay suture to the pelvis and holds it up, for better visualisation. The ureter is cut partially and the cut on the ureter is fashioned into a fish mouth. A cut is also

Laparoscopic Anterior Exenteration

55

Figure 6.29

Figure 6.31

Figure 6.30 made on the sigmoid, anteriorly, overlying the taenia coli. A proximal full thickness stitch taken; outside in on colon, and is continued inside- out on ureter (Figure 6.33). A 5 or 6 no. infant feeding tube is inserted, to act as a stent across the anastomosis. It is proximally put into the ureter, upto the renal pelvis. A note is made of the presence of flowing urine in the tube, to confirm proper placement. It is distally inserted into the opening made in the sigmoid colon. Once the stent is in place, the ureter edges are sutured with a 3:0 vicryl continuous suture. A full thickness continuous suture is taken on one side of the anastomosis, going from proximal to distal. The same suture is taken around and continued from distal to proximal end on the opposite side of the anastomosis. The suture is brought around from below the ureter; to be tied to its tail on the left side (Figure 6.34).

Figure 6.32 An additional transfixation suture (hypnotic) is also taken. A similar hypnotic suture may be taken on the other side of the anastomosis (This is usually, just to keep the surgeon at ease psychologically, during the postoperative period!). The sutures are cut and the excess tip of ureter is trimmed. The left ureter is brought under the colon and then to the right side. It is then similarly anastamosed at a site slightly proximal to the first anastomosis.

THE SPECIMEN
The vaginal margin is usually 3.5 to 4 cm. The vagina is then sutured with 2:0 vicryl continuous suture. The operative site is given a wash with distilled water to lyse any cancer cells. It is also checked for haemostasis. An abdominal drain is placed through the right iliac fossa lower port. The ports are then removed under vision.

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Manual of New Hysterectomy Techniques

Figure 6.33

Figure 6.34
7. Meng-Yeh Lin, Eric W Fan, Allen W Chiu, et al. Laparoscopy-Assisted Transvaginal Total Exenteration for Locally Advanced Cervical Cancer with Bladder Invasion after Radiotherapy. Journal of Endourology 2004;18:9, 86770. 8. Puntambekar SP, Kudchadkar RJ, Chaudhari YP et al. Role of Pelvic Exenteration in Advanced and Recurrent Pelvic Tumours. Journal of Pelvic Surgery. 2002;8:5,241-45. 9. Pomel C, Rouzier R, Pocard M, Thoury A, Sideris L, Morice P, et al. Laparoscopic total pelvic exenteration for cervical cancer relapse.Gynecol Oncol 2003;91(3):616-18. 10. Puntambekar SP, Kudchadkar RJ, et al. Laparoscopic pelvic exenteration for advanced pelvic cancers: A review of 16 cases. Gynecol Oncol 2006 102(3):513-16

REFERENCES
1. Brunswig A. Complete excision of pelvic viscera for advanced carcinoma.Cancer 1948;1:177. 2. Deckers PJ, Ketcham AS, Sugarbaker EV, et al. Pelvic exenteration for primary carcinoma of uterine cervix. Obstet Gynaecol 1971;37:647. 3. Bricker EM. Pelvic exenteration . Adv Surg 1970;220:241. 4. Morley GW. Pelvic exenterative therapy and treatment of recurrent carcinoma of cervix. Sem Oncol 1982;9:331. 5. Monagan JM. Surgical management of advanced and recurrent cervical carcinoma: the place of pelvic exenteration. Clin Obstet Gynecol 1985;12:169. 6. Sevin B, Koechli OR. Pelvic exenteration. Surgical clinics of North America. Gynaecologic Oncology. 2001;81:771.

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INTRODUCTION

Robotic Laparoscopic Radical Hysterectomy for Cervical Cancer

Of the five types of hysterectomy summarised above, Types II and III are the types that are most commonly utilised. Bilateral pelvic lymph node dissection is usually performed in cancer patients at the time of radical hysterectomy. Removal of the ovaries is not always required, though it can be performed at the time of radical hysterectomy if clinically indicated. Transposition of the ovaries out of the radiation field in the pelvis can be performed as well in women desiring preservation of ovarian function. Open radical hysterectomy has been the gold standard of care for treatment of early stage cervical cancer for decades. However, recent advances in laparoscopic instrumentation have made it possible to safely perform radical hysterectomy laparoscopically. Laparoscopic hysterectomy is not a new procedure, but rather is a modified version of the traditional open surgery, where by the same procedure is performed with laparoscopic equipment. Since the original reports by Nezhat et al2,3 in 1992, total laparoscopic radical hysterectomy with pelvic and/or para-aortic lymph node dissection has been gaining acceptance as a feasible alternative to an open radical hysterectomy. Multiple publications have now established both its safety and feasibility.4 The advantages of laparoscopic radical hysterectomy echo those seen with laparoscopy in general, such as shorter hospitalisation, faster bowel function recovery, less postoperative pain, and decreased overall cost. One of the major benefits of the laparoscopic approach is superior visualisation due to pneumodistension and optical magnification. This enhanced visualisation allows for improved small blood vessel access and identification, which results in less blood loss, as well as unparalleled precision during the ureteric dissection. Though there have not been any randomized

Konstantin Zakashansky, Farr R Nezhat

Radical hysterectomy is performed as the primary treatment for a number of gynacologic cancers. Specifically, radical hysterectomy is a recommended treatment for stage IA1 carcinoma of the cervix with lymph-vascular space involvement, as well as stages IA2, IB or IIA. The radical hysterectomy procedure is also performed in select patients with stage II adenocarcinoma of the endometrium, upper vaginal carcinoma, uterine or cervical sarcomas, recurrent cervical carcinoma, and other rare malignancies confined to the area of the cervix, uterus, and/or upper vagina. Piver et al described five different types of hysterectomies:1 1. Type I is an extrafascial hysterectomy, in which the fascia of the cervix and lower uterine segment is removed with the uterus. 2. Type II is an extrafascial hysterectomy that includes removal of the parametrium medial to the ureter. In the case of the type II hysterectomy, the uterine artery is ligated where it crosses over the ureter and 50% of the uterosacral and cardinal ligaments are removed and the upper one-third of the vagina is resected. 3. Type III refers to the traditional radical procedure of excision of the uterus en bloc with the parametrium. Before the excision, the uterine artery is ligated at its origin from the internal iliac artery. Uterosacral and cardinal ligaments are subsequently resected at their attachments to the sacrum and pelvic sidewall. The upper one-half of the vagina is resected in this procedure. 4. A Type IV hysterectomy is similar to the type III procedure, but involves a complete ureteral dissection, a more extensive resection of iliac vessels, and removal of three-fourths of the vagina. The superior vesical artery is sacrificed with this procedure. 5. Type V involves excision of the uterus en bloc with the parametrium as well as partial resection of the ureter or a portion of the bladder, or both.

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Manual of New Hysterectomy Techniques for deep venous thrombosis prophylaxis. Betadine solution is applied topically and drapes are placed in the usual sterile fashion. A Foley catheter is placed into the bladder prior to starting the procedure; the catheter is left open to gravity for the duration of the surgery. An intrauterine manipulator is placed, if possible. Traditional diagnostic laparoscopy is performed first to assess for feasibility of the intended procedure, as well as to evaluate for the presence of intra-abdominal metastatic disease. A multipuncture operative video laparoscopy technique is employed. Any lesions that appear suspicious for malignancy are evaluated and biopsied. The procedure should be terminated if metastatic disease is detected, and confirmed by frozen section, outside of the pelvis (i.e. in the omentum, bladder, liver, or bowel), in the adnexae, or if the tumour has broken through the uterus into the peritoneal cavity. In the absence of the above mentioned findings the laparoscopic equipment is removed. A standard 12 mm trocar placed at the umbilicus is used for camera placement, two working robotic arms are attached to 8 mm reusable trocars placed at the lower quadrants bilaterally, and ancillary 5 to 10 mm trocars are placed in the suprapubic region and the left upper quadrant, The robotic ports are placed one hands breadth apart from one another, so as to enable optimal movement of the robotic arm and to minimise the risk of collision (Figure 7.1). The daVinci robot is an integrated computer based system, which consists of two interactive robotic arms, a camera arm and a remote control consol with three dimensional vision capabilities. The motions of the surgeon at the consol unit are replicated by the robotic arms placed within the patient. During robotic surgery, an assistant is available at the operating table. The assistant performs a variety of important robot-related tasks, including alignment and exchange of instruments on the robotic arms, and operative manoeuvres with conventional instruments such as organ manipulation, tissue countertraction, suction, and irrigation. The presence of the scrubbed assistant is crucial, in the event that an emergent conversion to laparotomy is required. The whole procedure is performed using the robotic monopolar cautery scissor placed through the right port, and the bipolar fenestrated forceps placed through the left. Conventional instruments that are available are Nezhat Dorsey SmokEvac suction irrigator pump and probe (Bard, Inc.), grasping forceps, bipolar forceps and needle holder as needed, as well as harmonic shears (Ethicon EndoSurgery, Inc.) or a Ligasure vessel sealant device (ValleyLab, Boulder, CO).

trials reported, published peer reviewed studies suggest that the cure rate for laproscopic radical hysterectomy is similar to that for the open procedure. For example, the 5 years overall survival for patients with stage IA2 or IB1 cancer following laparoscopic radical hysterectomy is reported to be close to 96%.5 Despite the improvement in quality of life outcomes and complication profile, conventional laparoscopy is not without its technical drawbacks; including use of nonarticulated instruments with an ergonomically inadequate handle design, inefficient handle-to-tip force transmission, an awkward and uncomfortable position for the surgeon at the operating table, and a flat, twodimensional image.6,7 In the last few years, telerobotic surgery has been introduced into laparoscopic gynaecologic oncology practice. The advantages offered by this new technology include a three dimensional magnified field, tremor filtration, and five or six degrees of instrument mobility inside the body, thus significantly reducing the ergonomic problems associated with conventional laparoscopic equipment. Clinical use of robotic assisted procedures has evolved rapidly, and is now widely used in various surgical fields. Comparative studies of robotic assisted vs laparoscopic prostatectomies, colon resections or Nissen fundoplications have consistently shown that the robotic technique is feasible, safe and provides the surgeon with superior dexterity and flexibility.8-10 Though survival data for oncology patients is not yet available, there have been no observed differences in radicality of the procedure performed based on specimen size, specimen lengths or number of lymph nodes removed when comparing open, laparoscopic or robotic approaches. To date there has only been a single case report published on robotic assisted laparoscopic radical hysterectomy with pelvic lymphadenectomy.11 Following is the technique used for type III robotic assisted radical hysterectomy with pelvic lymphadenectomy, as developed and performed at our institution over the last five years.

ROBOTIC LAPAROSCOPIC RADICAL HYSTERECTOMY SURGICAL TECHNIQUE

After patients have received appropriate preoperative counselling and given their written informed consent, a standard outpatient mechanical bowel preparation is prescribed. Perioperative prophylactic antibiotics are given. The procedure is performed under general endotracheal anaesthesia in the dorsal lithotomy position with adjustable Allen stirrups and lower extremity compression devices

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Figure 7.1: Trocar placement for robotic radical hysterectomy and bilateral pelvic lymphadenectomy. The arrows mark the locations of the trocars. A 12 mm camera trocar is placed at the umbilicus, two working robotic arms are attached to 8 mm reusable trocars placed bilaterally, additional ancillary 5 to10 mm trocars are placed in the suprapubic region and the left upper quadrant, The camera port and each working robotic ports are placed in a way that allows for optimal robot arm movement and minimises risk of collisions. This is achieved by placing the ports at least one hand-breadth apart from each other Adhesions are lysed first to restore normal anatomy and the undersurfaces of the diaphragm, liver, gallbladder, stomach, omentum, large and small bowel, and kidneys are visualised, if possible. The para-aortic lymph nodes are inspected, followed by the pelvic lymph nodes. If gross para-aortic metastatic disease is present radical hysterectomy is usually abandoned. Laparoscopic paraaortic lymph node dissection is performed in selected cases if microscopic disease is suspected and if frozen section biopsy can be performed. Management of patients with malignant pelvic lymph nodes is controversial. We usually proceed with the radical hysterectomy in cases where the pelvic lymph nodes can be completely resected. Proceeding with a radical hysterectomy requires that six avascular pelvic spaces be developed and that the bladder and rectum be mobilized. Traditionally we start out by dissecting the rectovaginal space. The uterus is sharply anteverted using uterine manipulation and the peritoneum between the uterosacral ligaments is incised using the monopolar scissors; the rectum can then be gently brought down away from the vagina. A moistened sponge on a sponge-forceps is placed in the posterior vaginal fornix to facilitate visualisation and development of this surgical plane (Figure 7.2). The surgeon subsequently begins the pelvic wall dissection. After round ligaments on either side of the

Figure 7.2: Development of the rectovaginal space (A). The posterior vaginal fornix is placed on tension (marked by the arrow) and a moistened sponge on sponge-forceps is placed in the vagina to facilitate delineation of the tissue planes uterus are coagulated and cut using monopolar scissor, the anterior leaf of the broad ligament is opened bilaterally. The bladder flap is developed using both blunt and sharp dissection. The bladder is gradually dissected away from the cervix and vagina and once again a moistened sponge on a sponge-forceps is placed in the anterior vaginal fornix to facilitate development of the vesicovaginal space (Figure 7.3). The posterior leaf of the broad ligament is opened using the scissors and forceps and the paravaginal and pararectal spaces are developed using gentle blunt dissection. If ovarian preservation is indicated or desired, the utero-ovarian ligament and the proximal portion of the fallopian tube are coagulated and divided. If the adnexa are to be removed, the infundibulopelvic ligament is isolated, desiccated and divided using bipolar forceps and

Figure 7.3: Development of the vesicovaginal space (A). The uterus (B) is pushed cephalad into the abdominal cavity to facilitate visualisation

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scissors. The paravesical space is developed by placing tension on the umbilical ligaments with blunt and sharp dissection performed with the scissors, forceps and suction irrigator. The dissection is continued inferiorly to the iliac vessels, after which the obturator space is developed. The structures surrounding the obturator space, including the obturator internus muscle and pubic bone, are visualised and care is taken to avoid injury to the obturator nerve and vessels that traverse this area. After development of the paravesical and pararectal spaces, the pelvic lymphadenectomy can be performed. Pelvic lymphadenectomy involves removal of the lymph node packets from the common iliac vessels and external iliac vessels down to the level of the deep circumflex veins (Figure 7.4). The obturator nerve is identified and the obturator fossa nodes and the hypogastric nodes are completely removed and sent for pathological examination. At this point, the medial umbilical ligament is suspended with upward tension and the origin of the uterine artery from the hypogastric artery is identified (Figure 7.5). The uterine artery is desiccated and divided at its origin using bipolar forceps and monopolar scissors as shown in Figure 7.6. In a similar fashion, the uterine vein is also identified, desiccated and cut. The uterine vessels are placed on medial tension and the ureter is unroofed using the tip of the curved tip of the monopolar scissor out of the tunnel (Figure 7.7), and then the parametria are coagulated and divided laterally (Figure 7.8); in this manner, the ureter is completely unroofed. The uterosacral ligaments, cardinal ligaments, and a portion of the paracolpos are then divided bipolar forceps and scissor, enabling complete mobilization of the uterus. Upon complete mobilisation of the uterus circumferential

Figure 7.5: The let uterine artery (A) is identified and dissected from the point of its origin at hypogastric artery (B) traversing over the ureter (C)

Figure 7.6: The right uterine artery (A) is isolated, coagulated, and divided at its origin using bipolar forceps and monopolar scissors. The right pararectal (B) and paravesical (C) spaces have been fully developed; and the right ureter (D), right umbilical (E) and right external iliac artery (F) are visible incision is made into the vagina assuring adequate margin using monopolar scissors (Figure 7.9). The specimen is completely separated from vagina and removed while it is attached to the uterine manipulator. The vaginal cuff is closed with interrupted 0 vicryl suture tied intracorporeallly (Figure 7.10). After removal of the specimen and closure of the vaginal cuff, the pelvic cavity is thoroughly evaluated. Pelvic and abdominal cavities are copiously irrigated with normal saline (Figure 7.11). Once the surgeon has ensured hemostasis Indigo carmine is administered intravenously to assess for ureteral and the bladder injury. The rectum is insufflated with air and is evaluated intrabdominally

Figure 7.4: Left pelvic lymphadenectomy. Lymph node packets. (F) are removed from the left common external iliac artery (A) and vien (B). The left obturator nerve (C), the left obliterated umbilical artery (D) and the left ureter (E) are identified. The obturator fossa nodes and the hypogastric nodes are completely removed

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Figure 7.7: Unroofing of the right ureter (A) using monopolar scissors. The paravesical space (B) and right obliterated umbilical artery (C) are identified

Figure 7.10: Vaginal cuff closure with intracorporial tying

Figure 7.8: Resection of the right parametrium (A). The ureter (B), right obliterated umbilical (C) and right external iliac arteries (D) are seen

Figure 7.11: Panoramic view of the pelvis after removal of the specimen. Both ureters (A and C) have been dissected to the level of the bladder, and the rectosigmoid colon (B) can be seen in the center of the figure under saline to rule out injury to the bowel. The bladder is then distended with saline to further ensure its integrity. Upon completion, the daVinci system is undocked, all instruments are removed and all of the trocar sites are closed using a figure-of-eight 0 vicryl suture and 4-0 vicryl in a subcuticular fashion. Postoperatively, early ambulation and oral intake are encouraged. We routinely use subcutaneous heparin, low molecular weight heparin or pneumatic compression devices until the patients are fully ambulatory. The patients are usually discharged home on the second or third postoperative day with a Foley catheter in place. The catheter is removed 7 to 10 days after the surgery in the office.

Figure 7.9: Circumferential incision is made into the vagina assuring adequate margin using monopolar scissors

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COMPLICATIONS

Manual of New Hysterectomy Techniques gists is still in its early stages. We feel that the substantial magnification, dexterity, and flexibility offered by the robotic system can significantly simplify the performance of the most difficult stages of radical hysterectomy and pelvic lymphadenectomy, enabling a greater number of surgeons to perform this procedure laparoscopically.

Complications following robotic assisted laparoscopic hysterectomy can generally be divided in three groups: surgery-related, robot assisted laparoscopy-related, or procedure-specific complications. Surgery-related complications refer to general surgical complications, such as pulmonary emboli, deep vein thrombosis, transfusion, fever, ileus and small bowel obstruction. Robot assisted laparoscopy-related complications refer to conditions arising from the laparoscopy procedure, such as open conversion, incisional hernia, pneumomediastinum, and subcutaneous emphysema. Radical hysterectomy procedure-specific complications include ureteral injury, cystotomy, hydronephrosis, ureterovaginal and vesicovaginal fistula.

REFERENCES
1. Piver MS, Rutledge F, Smith JP. Five classes of extended hysterectomy for women with cervical cancer. Obstet Gynecol 1974;44(2):265-72. 2. Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE. Laparoscopic radical hysterectomy with para-aortic and pelvic node dissection. Am J Obstet Gynecol 1992;166(3):864-65. 3. Nezhat CR, Nezhat FR, Burrell MO, et al. Laparoscopic radical hysterectomy and laparoscopically assisted vaginal radical hysterectomy with pelvic and para-aortic node dissection. J Gynecol Surg 1993;9(2):105-20. 4. Zakashansky K, Chuang L, Gretz H, Nagarsheth NP, Rahaman J, Nezhat FR. A case-controlled study of total laparoscopic radical hysterectomy with pelvic lymphadenectomy versus radical abdominal hysterectomy in a fellowship training program. Int J Gynecol Cancer 2007. 5. Spirtos NM, Eisenkop SM, Schlaerth JB, Ballon SC. Laparoscopic radical hysterectomy (type III) with aortic and pelvic lymphadenectomy in patients with stage I cervical cancer: surgical morbidity and intermediate follow-up. Am J Obstet Gynecol 2002;187(2):340-48. 6. Berguer R. Surgery and ergonomics. Arch Surg 1999;134(9):1011-16. 7. Dakin GF, Gagner M. Comparison of laparoscopic skills performance between standard instruments and two surgical robotic systems. Surg Endosc 2003;17(4):574-79. 8. DAnnibale A, Morpurgo E, Fiscon V, et al. Robotic and laparoscopic surgery for treatment of colorectal diseases. Dis Colon Rectum 2004;47(12):2162-68. 9. Patel VR, Thaly R, Shah K. Robotic radical prostatectomy: Outcomes of 500 cases. BJU Int 2007;99(5):1109-12. 10. Heemskerk J, van Gemert WG, Greve JW, Bouvy ND. Robot-assisted versus conventional laparoscopic Nissen fundoplication: A comparative retrospective study on costs and time consumption. Surg Laparosc Endosc Percutan Tech 2007;17(1):1-4. 11. Sert BM, Abeler VM. Robotic-assisted laparoscopic radical hysterectomy (Piver type III) with pelvic node dissection case report. Eur J Gynaecol Oncol 2006;27(5):531-33. 12. Burgess SV, Atug F, Castle EP, Davis R, Thomas R. Cost analysis of radical retropubic, perineal, and robotic prostatectomy. J Endourol 2006;20(10):827-30.

CONTRAINDICATIONS
Absolute contraindications to the robotic assisted laparoscopic approach are any medical conditions that prevent appropriate anaesthesia administration, positioning of the patient for surgery, or prolonged pneumoperitoneum, such as a severe restrictive lung disease, hip disease, or a ventriculoperitoneal shunt. Relative contraindications would be the same as for laparoscopic hysterectomy, and should be considered on a case by case basis: A history of multiple prior abdominal surgeries with extensive dense intestinal adhesions, a uterus larger than 14 cm, the presence of a large ventral hernia, pregnancy, and a body mass index greater than 35. The robotic system is not without a number of drawbacks. The cost of the equipment is nearly prohibitive for the majority. The machine is bulky and complex, requiring dedicated both rooms and staff experienced with the set up. The current generation of daVinci machines lacks tensile feedback. Robotic technology is, however, developing rapidly new instruments, smaller arms, addition of a forth arm and tactile feedback are innovations due to enter clinical practice shortly. Operative cost is very high at this time; the hope is, however, that widespread use of this technology in the future and a shortening of hospital stay may lead to a substantial decrease in costs.12 In conclusion, though robotic technology has revolutionised urologists treatment of prostate cancer, its use in the treatment of cervical cancer by gynaecologic oncolo-

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Masaaki Andou INTRODUCTION

Extraperitoneal Hysterectomy: Total Pelvic Peritonectomy Combined with the Segmental Resection of the Rectosigmoid
also works as optimal cytoreductive surgery for selected stage III patients who have massive residual pelvic disease after previous surgery or neoadjuvant chemotherapy where upper abdominal tumours have been completely controlled. The extraperitoneal hysterectomy begins with a peritoneal incision starting from the pelvic sidewall triangle at the level of the pelvic brim (Figure 8.1). The incision is extended anteriorly, curving along the upper edge of the pubic bone and finally arriving at the same

Surgery for ovarian cancer is originally very invasive because of possible extensive spread of tumour. Advanced or recurrent disease requires even more superradical surgery. To maintain surgical clearance, much more extensive resection is required in which an extensive defect has to be compensated for using reconstructive techniques. In advanced or recurrent malignancy cases, even if complete resection is thought to have been achieved, usually adjuvant therapy is required. Superradical procedures are directly related to delayed recovery and more seriously, the delay of postoperative therapy. Laparoscopic surgery is well known to be a less invasive strategy. However feasibility and efficacy for very complicated laparoscopic procedures is yet to be demonstrated. Our purpose is to expand the radicality for more complete resection while keeping the procedure less invasive by introducing reconstructive techniques.

THE EXTRAPERITONEAL HYSTERECTOMY

Theoretically, total removal of the pelvic peritoneum is the most beneficial tactic for disease restricted to the pelvis. With the total removal of the pelvic peritoneum in mind, we developed our extraperitoneal hysterectomy. The goals for this kind of surgery are the complete eradication of tumour cells for stage II ovarian cancer. It

Figure 8.1: Incision line of the pelvic peritoneum

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Manual of New Hysterectomy Techniques The vagina is exposed and transected. The second stage of this procedure is the removal of the rectosigmoid. As the peritoneum of this portion cannot be detached from the organ, the procedure requires the segmental resection of this segment. The rectosigmoid is mobilised starting from the dissection of the presacral space. This dissection is proceeded until the pelvic diaphragm is reached. The mesosigmoid is divided using a harmonic scalpel. After full mobilisation of the mesosigmoid the upper portion of the segment is transected using a linear stapler (Figure 8.4). Then the caudal portion of the segment is also transected. After all of these procedures have been completed, the uterine body along with the rectosigmoid are put into a protection bag and removed through the vagina (Figure 8.5). Finally the rectum is anastomosed to the sigma using a circular stapler (Figure 8.6). To date, only 4 patients have undergone this procedure, one with stage II clear cell carcinoma, one with

Figure 8.2: Extraperitoneal resection of the parametria

Figure 8.4: Transection of the rectosigmoid

Figure 8.3: Transection of the left cardinal ligament point on the left side of the pelvis. The next step is the dissection of the bladder peritoneum from the bladder wall. The bladder peritoneum is dissected until the uterine cervix appears. The bladder is then dissected off from the cervix. After mobilisation of the peritoneum of the bladder and pelvic sidewall, the extraperitoneal transection of the parametria is started (Figure 8.2). After the ureter is detached from the posterior layer of the broad ligament, the ureter is dissected down until the entrance of the ureteral tunnel. Then the cardinal ligament is bipolar desiccated and transected (Figure 8.3).

Figure 8.5: Retrieved specimen

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Figure 8.6: Anastomosis of the rectosigmoid extensive granulosa cell tumour which involved the colorectum, one with stage II mucinous cystadenocarcinoma and the third with stage IIIC serous papillary adenocarcinoma who previously underwent 3 courses of neoadjuvant chemotherapy. All patients are still alive after an average observation period of 14 (13-15) months with no evidence of disease. No major complications occurred, the postoperative course was uneventful and recovery was very quick. Although the indications for this surgery are not broad, it is efficacious and safe for patients who require extensive pelvic resection or cytoreduction. Through this procedure, it has become possible to achieve complete tumour eradication if the tumour is located in the pelvis.

Figure 8.7: Debulking lymphadenectomy

ADDITIONAL CYTOREDUCTIVE PROCEDURES

Because of the aggressive nature of ovarian cancer, many cases suffer from extensive tumour distribution or dissemination. For these cases it is necessary to find ways to manage the broad extension of the disease while considering the quality of life of the patient. We have introduced some additional procedures for laparoscopic cytoreductive surgery for advanced ovarian cancer such as a debulking lymphadenectomy, diaphragma stripping and an omentectomy. Segmental resection of the small bowel or rectosigmoid is achieved totally laparoscopically. In the case of the debulking lyphadenectomy we use the para-aortic dissection followed by the transperitoneal approach in the pelvis (Figure 8.7). We use very fine bipolar forceps to grasp the base of the adhered metastatic lymph node and then simultaneously coagulate the connected area and slice off the lymph node in a

Figure 8.8: Dissection of metastatic lymph nodes using bipolar forceps. sweeping motion (Figure 8.8). The resected lymph nodes are retrieved from the port site after being placed in a retrieval bag. As for diaphragma stripping we use gasless laparoscopy at the very end of the entire procedure (Figure 8.9). The reason for this is to prevent barotraumas like pneumothrax. We infiltrate diluted pitressin between the diaphragma fascia and the diaphragma muscle to create space (Figure 8.10). Then we use a harmonic scalpel to remove the fascia layer. We do not use electrocautery to avoid the contraction of the diaphragma (Figures 8.11A to D).

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Figure 8.9: Gasless technique for diaphragma-stripping

Figure 8.11B: Removal of dissected diaphragma (Diaphragmastripping)

Figure 8.10: Infiltration of diluted pitressin as aqua dissection (Diaphragma -stripping)

Figure 8.11C: Retrieved specimen after diaphragma-stripping

Figure 8.11A: Dissection using harmonic scalpel (Diaphragma-stripping)

Figure 8.11D: Status after diaphragma-stripping

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Figure 8.12: Omentectomy

Figure 8.14A: Dissemination to the small bowel stumps of the small bowel. Firing of the linear stapler creates side-to-side anastomosis. The open cut end of connected bowel stumps is stapled and closed using a 60 mm linear stapler. For cases of extensive peritoneal implants, we eliminate peritoneal dissemination using argon beam coagulator (Figure 8.17). Some cases underwent resection of the pancreas tail and spleen because of metastatic tumours to the splenic hilus, We used a linear stapler to transect the pancreas tail (Figures 8.18A and B). As a result of performing these additional procedures along with we can optimal cytoreduction tailored to individual patients. From November 1998 through March 2006 twentyeight cases of stage III-IV epithelial ovarian cancer underwent laparoscopic interventions. Basically, they underwent a hysterectomy, a bilateral salpingo-oophorectomy, retroperitoneal lymph node dissection, sampling of ascitic fluid, multiple peritoneal biopsy, appendectomy and omentectomy. Some selected cases underwent a cytoreductive procedure including elimination of peritoneal dissemination using an argon beam coagulator, removal of the pancreas tail and spleen because of metastatic tumours to the splenic hilus, and resection of the total pelvic peritoneum including extraperitoneal hysterectomy and segmental resection of the rectosigmoid due to dissemination to pelvic peritoneum and/or bowel wall invasion.

Figure 8.13: Omentectomy specimen The omentectomy we perform is an infragastric omentectomy with the goal of removing as much of the tumour as possible. As a first step we cut the omentum from the transverse colon (Figure 8.12) and dissect until the upper boundary- just under the gastroepiploic artery with a harmonic scalpel (Figure 8.13). For resection of the bowel we employ reconstructive techniques. Segmental resection of bowel requires a stapling technique, using both a linear and circular stapler. For the small bowel, functional end-to-end anastomosis is required with the aid of four linear staples (Figures 8.14A to 8.16). After transection of the segment of the small bowel using two 45 mm linear staples anastomosis of the residual bowel stumps start. The antimesenteric sidewall of both bowel stumps are approximated using a 3-0 stay suture. Each of the forks of a linear stapler are inserted into each of the orifices of the oral and anal

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Figure 8.14B: Functional end-to-end anastomosis

Figure 8.14C: Status after functional end-to-end anastomosis Figure 8.16: Closure of the open cut end of the connected bowel stumps using a 60 mm linear stapler

Figure 8.15: The antimesenteric sidewall of both bowel stumps are approximated and stapled (side-to-side fixation)

Figure 8.17: Elimination of peritoneal dissemination using an argon beam coagulator

Extraperitoneal Hysterectomy

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Figure 8.18A: Small bowel resection. Specimen We compared the laparoscopic group data (excluding the cases in which observation period is less than 12 months N=28) and a traditional open surgery group (historical controls from January 1995 through March 2006 N=17). The survival analysis of our laparoscopy group, when compared with the historical open laparotomy group, revealed no significant differences even when restricted to the advanced cases (stage III, IV) (P=0.63). No cases were converted to laparotomy, and no cases required a colostomy. No leak, stenosis, or infectious complications occurred postoperatively. There was 1 cases of bowel obstruction.

Figure 8.18B: Removal of the pancreas tail and spleen because of metastatic tumours to the splenic hilus Laparoscopic surgery, with its minimally invasive advantages, is vital for achieving a more patent friendly approach, even in advanced ovarian cancer. By using this kind of extensive debulking technique, optimal cytoreduction can be achieved totally laparoscopically. There is the possibility to expand the radicality for advanced and recurrent gynaecologic malignancy without increasing the invasiveness of the surgery using laparoscopic reconstructive techniques. Introducing reconstructive techniques makes it possible to reach a new stage in malignancy management. Minimally invasive surgery benefits those who must undergo the most radical procedures.

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9
Chyi-Long Lee INTRODUCTION

Laparoscopic Radical Hysterectomy

With advance of laparoscopy, gynaecologic surgeons use this technique increasingly for staging and treatment of patients with gynaecologic cancer. Among Asia countries, cervical cancer is one of the most frequent malignancies of the lower female genital tract. It has a high death rate with approximately 7800 and 970 deaths annually resulting from cervical cancer in the United States and Taiwan. Evidences have mounted that surgical management in cervical cancer not only could decrease either mortality or recurrence rate, it would also improve the qualities of life of patients; especially if the treatment results of surgery are compared to radiation therapy. Thus, surgical management is still the best treatment for cervical cancer. There are some key points that need to ponder regarding cervical cancer treatment, no matter laparotomy or laparoscopy is being utilised. First is feasibility of the surgery. Second, regarding the cost and benefit to the patient. Third, cost and benefit to the surgeon. Fourth, is there more complication afterward? How about the 5 years survival rate after the surgery compared with traditional surgery? These would be key points of cancer surgery that worthwhile for our attention.

telescope was inserted and two more 5 mm puncture sites were made in the lower abdomen at the para-median line at the level of just above the pubic hair line ; One 5 mm and one 12 mm puncture site were then made at the paramedian line at the level of the umbilicus. A total of five trocars were required. To control bleeding and cutting, Kleppinger bipolar forceps (KB)/monopolar scissors (conventional electrosurgery) or the plasmakinetic (PK) tissue management system were used.

LAPAROSCOPICALLY PELVIC LYMPHADENECTOMY

Before the operative procedures, all pelvic structure was inspected and abdomen was explored through laparoscope in clockwise fashion. If adhesions were seen around uterus and ovaries, and pelvic cavity, adhesiolysis was performed. The operation began with an incision with conventional electrosurgery or PK cutting forceps of the pelvic peritoneum between the round and infundibulopelvic ligaments. The incision was made parallel to the axis of the external iliac vessels. The paravesical space was entered, then widened by blunt dissection between the obliterated umbilical artery medially and the external iliac vessels laterally. The pelvic floor and the obturator nerve were easily reached. The cellulolymphatic tissue around the external iliac vessels, obturator nerve and the hypogastric artery was then clearly visible and safely dissected. The technique for removal was similar to that in open laparotomy. The external iliac artery was freed from inguinal area to the bifurcation of the common iliac artery, and lymphatic tissue between external iliac and internal iliac artery and above obturator nerve was removed by blunt or sharp dissection. The cellulolymphatic tissue was thus dissected en bloc thoroughly. Tissue samples were removed from the 12 mm port by using an endobag

LAPAROSCOPIC SURGICAL TECHNIQUES

Procedure was performed under general anaesthesia. The patient was placed in the Trendelenburgs position with both legs protected by elastic bandages. A skin incision was then made at the middle point between the umbilicus and xyphoid process (Lee-Huang point),1 and this site was used as the point of access for the Verres needle, the trocar and the telescope. The Verres needle (Auto-Suture, Norwalk, CT) was inserted perpendicular to the abdominal wall. After adequate pneumoperitoneum, a 10 mm

Laparoscopic Radical Hysterectomy to prevent the implantation of tumour cells at trocar site. The uterine artery was tracing back from obliterated umbilical artery and easily coagulation and dissection by PlasmaKinetic (PK) knife or conventional electrosurgery.

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COMMENTS
RATIONALES IN LAPAROSCOPIC RADICAL SURGERY FOR CERVICAL CANCER
Since the 5-year-disease free survival rate of early cervical cancer such as stage IB and early stage II after surgery could be higher than 90% for node-negative patients, surgery remains the best tool in the management of nodenegative cervical cancer nowadays. Surgeons who have training of cervical cancer surgery using vaginal approach could also utilise laparoscopy in performing lymphadenectomy, and then subsequent radical hysterectomy through vaginal approach. Of course, using laparoscopy would make the vaginal surgery even easier. Many reports have indicated that laparoscopy would decrease complications of uterine surgery comparing with laparotomy. Moreover, some reports have pointed out that laparoscopic radical hysterectomy would have fewer complications too. From these points of view, laparoscopic radical hysterectomy can be fully accomplished.2-5

LAPAROSCOPICALLY RADICAL HYSTERECTOMY

The operation began with the coagulation and dissection of the bilateral round ligaments by conventional electrosurgery or PK cutting forceps. Therefore the anterior leaves of the broad ligaments were opened and incised completely using laparoscopic scissors. The cephalic part of the vesicouterine ligament was then desiccated and divided halfway between the bladder and the uterus, and the bladder was also push down below the level of cervix. After its division, the medial stump of the uterine artery was grasped and brought medially, thus unroofing the ureter, and then the ureter was total mobilised. The pararectal space was opened by laparoscopic scissors, and the uterosacral ligaments were well exposed. After the uterosacral ligament was transected by conventional electrosurgery or PK cutting forceps. The lateral parametrium was coagulated and transected through the pelvic side wall. Dissection was carried out down to 2 centimeter below cervix. The same procedure was performed on the opposite side. Following it, the CO2 insufflator and videolaparoscopy system were temporarily turned off. The vaginal operation began as in the modified Schauta technique. The vagina was incised 2 cm from the tumour margin. The rectovaginal, vesicovaginal, pararectal and paravesical spaces were opened and developed in the previous laparoscopic approach. Anterior and posterior culdotomy were performed. Owing to the laparoscopic preparation of the ureter, the rectovaginal, vesicovaginal, pararectal and paravesical spaces, the left parametrium and paracolpium was thus identified between the paravesical and pararectal spaces and divided at the required level. Then the uterus with part of vagina and paracolpium was removed smoothly. The rectal and vesical peritoneum was approximated first, and then the vaginal cuff was closed with 1-0 vicryl by continuous sutures. The CO2 insufflator was turned on again and the entire pelvic cavity was inspected and irrigated with lactated Ringers solution. All debris and blood clot were removed. A drain catheter was inserted from 5 mm trocar site for drainage. The 12 mm and 10 mm incision wounds were closed by 3-0 vicryl with mattress sutures; the other puncture sites were approximated by sterile adhesive tape.

RADICAL HYSTERECTOMY: LAPAROSCOPY VERSUS LAPAROTOMY

There are only a few reports nowadays on the differences between laparoscopic radical hysterectomy and abdominal radical hysterectomy. The prospective study6 from Chung Gung Memorial Hospital which published on the Journal of American Endoscopic Association in 2002 regarding this comparison is the most representative one. In this study, each group had 30 patients of cervical cancer, and there were no significant differences between these patients regarding age, body weight, pathology and staging.

Operating Time
Regarding operating time, laparoscopy and laparotomy are comparable. The mean operating time of 221+42 minutes (range 150-300) for the laparoscopic group was slightly longer than that for the laparotomic group 206+36 minutes (range 145-325) (p=0.2). The major reason is the use of Lee-Huang portal to enhance four-hand manoeuvre, so faster operation can be carried out. Besides, by using Lee-Huang portal1 could achieve wider operative field, and avoid the interference from manoeuvre of the operator and the assistant. Of course, cooperation of a well-organised team work is one of the important reasons for shorter operating time. In addition, with the accumulation of surgical experience, the operative time between laparoscopy and laparotomy showed no statistical difference in this study. Usually,

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Manual of New Hysterectomy Techniques open group. There are significant increase lymph nodes yield in laparotomic group (p=0.001).However, there are more positive nodes in laparoscopic group. This result confirmed that 75-91% of nodes were resected at laparoscopy when compare with laparotomy. However, no positive nodes were missed at laparoscopy.8

laparoscopic radical hysterectomy could be done within 4 hours by experienced hands, so in terms of operating time, laparoscopic surgery is quite feasible indeed.

Blood Loss
The mean blood loss of 450+284 ml (range 10-1800) for the laparoscopic group was significant less than that for the laparotomic group 962+543 ml (range 300-3500) (p<0.001).The less blood loss in laparoscopic group were quite acceptable. It may be thank to the magnification of laparoscopy, it make complete homeostasis possible. Moreover, we used the ureteral stent as a marker. It is helpful in identifying ureter while opening the well vascular ureteral tunnel in laparoscopical procedures as well as in vaginal procedures while dissecting paracolpium and cardinal ligaments. It may reduce the possibility of unnecessary bleeding.

The Length of Hospital Stay

More patients in open surgery suffered from delay in bladder function recovery were noted. However, further evaluation is undergoing. The length of hospital stay was slightly decreased in laparoscopic group; we think that this could be reduced much as the patients were well educated.

Portal-site Metastasis
This has been one of the major reasons why laparoscopic surgery is so controversial in cancer surgery. Possible mechanisms would be discussed as follows: 1. Increased exfoliation of tumour cells of unsuspected malignancy. 2. Increased contact time between tumour-laden instruments and the port site. 3. Malignant cells contacting the wound. 4. Increased spillage of tumour cells following pneumoperitoneum. The above four points are the possible mechanisms for portal-site metastasis. Childers et al9 have shown that the incidence of abdominal implantation per puncture site was between 0.2% and 1.0% per procedure.10 None of our 150 puncture sites (30 10 mm 30 12 mm and 90 5 mm portal sites) has tumour implantation. It may be due to we removed the adipolymphatic tissue with caution. We put endobag at cul-de sac and put the lymphatic tissue into endobag immediately after the adipolymphatic tissue was dissected off. When removed, the endobag does not come into contact with the abdominal wall.

Complications
The complications of radical hysterectomy and pelvic lymphadenectomy include haemorrhage or haematomas, lymphocysts, fistulas, postoperative ileus, wound infection, and incisional hernias. There are two major complications in laparoscopic and laparotomic group respectively. One bladder injury and one vesicovaginal fistula occurred in laparoscopic group. Since the ureter and bladder were well free from the attached tissue in laparoscopical radical hysterectomy, urinary tract injury can be easily repaired through vagina.7 Another complication, vesicovaginal fistula, was repaired 3 months later post-radical hysterectomy with uneven outcome. One bladder injury and one external iliac vessel damage occurred in laparotomic group. The bladder and vessel were repaired smoothly intraoperatively. Since the complications are related mainly to the surgical technique. There are no significant different in the complication rate in two group. As long as the experience of the surgeon becomes more sophisticated, complication rate will be much less no matter it is laparotomy or laparoscopy.

CONCLUSIONS
From our prospective study showed that intraoperative complication rate from laparoscopy was comparable to laparotomy, but incidence of postoperative complications was less in laparoscopy. No difference was noted in terms of operating time or recurrence rate between these two groups. Regarding blood loss, postoperative recovery, return of bladder function, external appearance of incisions, and gastrointestinal complications during radiation therapy, laparoscopy seems to have better edge. In this aspect, laparoscopy is a rather promising way in

Numbers of Lymph Nodes Retrieved

Lymph nodes of lower para-aorta were untouched during laparoscopy in early cervical cancer, so the total numbers of lymph nodes retrieved were less than those that were done by laparotomy. In our study, the mean lymph node yield of 15.1 in laparoscopic group was less than that of in laparotomic group of 22.0 from our open approach. There are 14 positive nodes in 3 patients (3/30) of laparoscopic group and 5 positive nodes in 3 patients (3/30) of

Laparoscopic Radical Hysterectomy managing cervical cancer, as long as enough surgical experience and advance of the instruments are concerned.

73

REFERENCES
1. Lee CL, Huang KG, Wang CJ, et al. A new portal for gynaecologic laparoscopy. J Am Assoc Gynecol Laparosc 2001;8:147-50. 2. Childers JM, Surwit EA. Combined Laparoscopic and vaginal surgery for the management of two cases of stage 1 endometrial cancer. Gynecol Oncol 1992;45:45-51. 3. Childers JM, Brzechffa PR, Hatch KD, Surwit EA. Laparoscopic assisted surgical staging (LASS) of endometrial cancer. Gynecol Oncol 1993;51:33-38. 4. Spirtos NM, Schlaerth JB, Spirtos WT, Schlaerth BA, Indman PD, Kimball RE. Laparoscopic bilateral pelvic and para-aortic lymph node sampling: An evolving technique. Am J Obstet Gynecol 1995;173:105-11. 5. Melendez T, Harrigill K, Childers JM, Surwit EA. Laparoscopic management of endometrial cancer: The learning experience. J Laparoscopic Surg 1997;1:45-49.

6. Lee CL, Huang KG, Jain Smita, Lee PS, Soong YK. Comparison of Laparoscopic and Conventional Surgery in the Treatment of Early Cervical Cancer. J Am Assoc Gynecol Laparosc 2002;9(4):481-87. 7. Lee CL, Huang KG, Lai YM, Lai CH, Soong YK. Ureteral injury during laparoscopically assisted radical vaginal hysterectomy. Hum Reprod 1995;10:2047-49. 8. Fowler JM, Carter JR, Carlson JW, et al. Lymph node yield from laparoscopic lymphadenectomy in cervical cancer: a comparative study. Gynaecologic Oncology 1993;51:18792. 9. Childers J, Aqua K, Surwit E, Hallum A, Hatch K. Abdominal wall tumour implantation after laparoscopy for malignant conditions. Obsterics and Gynecology 1994;84(2):765-69. 10. Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE. Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection. Am J Obstet Gynecol 1992;166: 864-65.

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10
Ceana Nezhat INTRODUCTION

The Role of Laparoscopy and Robotics in Hysterectomy

After caesarean delivery, hysterectomy is the most frequently performed major surgery among women of reproductive age in the United States. More than 600,000 hysterectomies are performed annually. The most common indications for hysterectomy include: Uterine leiomyoma, endometriosis, uterine prolapse, and cancer of the uterus, cervix or ovaries.1 Despite general preference for minimally invasive procedures, 2 out of 3 hysterectomies are performed abdominally. However, there has been a gradual increase in the number of laparoscopic and laparoscopic assisted vaginal hysterectomies (LAVH) over the past 2 decades. The overall rate of hysterectomy has remained stable while the number of LAVH has more than doubled. Interestingly, the rate of vaginal hysterectomy (VH) has remained constant despite the known benefit of vaginal hysterectomy over other methods, including decreased

operating time, faster recovery, and lower costs.1 Notably, the 9% increase in laparoscopic hysterectomies from 1990 to 1997 corresponds to the slight decline in the rate of abdominal hysterectomies during the same period.2 The advantage of a laparoscopic approach over the open abdominal route in terms of intraoperative blood loss, short- and long-term postoperative morbidity, and recovery has been demonstrated repeatedly.3-6 However, little benefit over the vaginal approach has been seen.7 The indications for laparoscopic and laparoscopicassisted vaginal hysterectomy are generally those that would preclude a v aginal approach, i.e. similar to those for abdominal hysterectomy. In general, the considerations for a laparoscopic approach are prior surgery or pelvic inflammatory disease necessitating lysis of adhesions, endometriosis, and a coexistent pelvic mass requiring evaluation. Considerations like large uteri, adnexectomy, surgery in an obese patient and the role of

Table 10.1: Annual rates and incidence of different types of hysterectomy, 1990-1997 1990 n Abdominal hysterectomy Vaginal hysterectomy Subtotal hysterectomy Laparoscopic hysterectomy Radical hysterectomy Other unspecified hysterectomy Total Total rate 549,323 5.50 100.0 404,554 134,497 3664 1630 5978 % 73.6 24.4 0.7 0.3 1.0 n 377,647 139,629 11,815 59,353 8907 1578 598,929 5.60 1997 % 63.0 23.3 2.0 9.9 1.5 .03 100.0

Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002;99(2):229-34.

The Role of Laparoscopy and Robotics in Hysterectomy laparoscopy in gynaecologic malignancies are a matter of debate and are dependent on the surgeons experience. Moreover, as experience in vaginal surgery continues to decline with each consecutive batch of graduating residents, with rapid technological developments in the field of laparoscopy, and as data regarding various outcomes mature, increasing numbers of indications for the laparoscopic approach to hysterectomy will continue to be defined. Some of the factors that have limited the widespread adoption of the laparoscopic approach have been concerns regarding cost, complications, learning curve, operative time and the lack of well-defined indications. In terms of cost, several studies over the last decade have demonstrated that with the use of reusable instruments, shorter length of stay with laparoscopic procedures, and decreasing operative times with experience, the cost of a laparoscopic hysterectomy is comparable to the cost of a vaginal or an abdominal hysterectomy.8-10 The savings from quicker recovery and return to work and fewer postoperative visits certainly reduce the overall cost following laparoscopic hysterectomy.11 As for the complication rate and length of the procedure, these are dependent on surgeon experience and expertise in laparoscopic procedures. Nezhat et al12 in their series of 361 laparoscopic hysterectomies had no mortality, no major vessel or urinary tract injury, and one case of small bowel perforation. Wattiez et al13 in their series of over 1600 laparoscopic hysterectomies over 10 years demonstrated a significant decline in major complication rates (from 5.6 to 1.3%), conversion rates to laparotomy (from 4.7 to 1.4%), and operative time (from 115 minutes to 90 minutes) with increasing surgical experience. A large Finnish study14 attempted to define the learning curve for laparoscopic hysterectomies by demonstrating a significant drop in all major complications beyond 30 procedures. The rate of conversion to laparotomy has been described as ranging from 4 to 11%, for reasons such as large uteri, diminished uterine mobility, excessive dense abdominal adhesions, and uncontrolled haemorrhage.15 Recently, there has been a resurgence of interest in the supracervical hysterectomy for benign conditions. Proponents of this approach tout the preservation of neurovascular integrity, and as a result less bowel, bladder, and sexual dysfunction, as well as fewer complications, as reason for offering supracervical hysterectomy. However, none of the retrospective and prospective randomized studies so far has substantiated this contention.16,17 Limited data are available on the outcome

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of this procedure via laparoscopy and how it compares with total laparoscopic or assisted vaginal hysterectomy.

USE OF ROBOTICS
Advancements in the field of laparoscopy over the past 2 decades have propelled minimally invasive surgery into the norm. Laparoscopic procedures have evolved in all fields of surgery and the benefits of laparoscopy over laparotomy have been widely proven. As the field of minimally invasive surgery advances, so does the technology, providing surgeons and patients with everimproving surgical outcomes. One such advancement is the introduction of the robot into laparoscopic surgery. In the fields of urology, cardiac surgery, and general surgery many procedures are being performed with robotics. Research on the use of the robot has been best established in urology with data from robot-assisted laparoscopic radical prostatectomy showing a short learning curve and promising introductory data.18 There are also preliminary comparisons in general surgery, such as the robot-assisted Nissen fundoplication, which appears feasible and safe, but requires longer operative times and higher costs.19-21 The first use of robotics in gynaecology was by Mettler et al22 who reported positive outcomes with the use of the AESOP (Computer Motion, Goleta, California), a voice-controlled optic holder. Benefits included reduced operating times, reduced number of operating room personnel, improved visual field, and ease of use with the voice-controlled camera arm. Since this introduction of robotics into gynaecologic surgery, a large number of procedures have been performed with robotic assistance, including tubal reanastomosis, myomectomy, and sacral colpopexy. But the most reported gynaecologic procedure utilising robotics is laparoscopic hysterectomy. The first robot-assisted laparoscopic hysterectomy was performed by Cadire et al.23 They reported a nonconsecutive series of multiple laparoscopic procedures performed between March 1997 and February 2001. Key findings included physiologic tremor elimination, operating time and hospital stay within acceptable limits, and improved manoeuverability in intra-abdominal microsurgery. In 2002 Diaz-Arrastia et al.24 were the first to report a case series of robotic-assisted laparoscopic hysterectomy. Reynolds and Advincula25 reported the outcomes of 16 patients who underwent robot-assisted laparoscopic hysterectomy in 2006. All reports of robotassisted laparoscopic hysterectomy conclude that the surgeon appreciates greater manipulation and comfort, the outcomes are similar to traditional laparoscopic hysterectomy, and there is no morbidity related to the system.

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Manual of New Hysterectomy Techniques Colpotomiser (CooperSurgical, Trumbull, CT, USA), Clermont Ferrand (Karl Storz, Tuttlingen, Germany), as well as Vcare (ConMed Corporation, Utica, NY, USA). At times I have used plastic uterine dilators for identification of the anatomy and colpotomy. Regardless of the choice of manipulator, each one could be equally effective and is dependent on the surgeons preference. After completion of the hysterectomy, for suturing of the vaginal cuff, #0 polyglycolic absorbable sutures on a CT #2 needle is trimmed to approximately 8-12 inches of length and introduced to the abdomen through the 8 or 10 mm ports. There are 3 different types of robotic needle holders that could be utilised based on the surgeons preference. Vaginal cuffs could be closed similarly to an abdominal hysterectomy with interrupted sutures, figure of eight, or running interlocking, easily utilising robotic arms. In my opinion this is the most advantageous part of robotic hysterectomy. Also, if additional suturing for reconstruction of the vaginal apex and reinforcement of the support, such as Moschowitz procedure, is necessary it is performed. At the conclusion of the procedure, the robot is disassembled and using the same scope it could be manipulated with arm and lateral ports are removed. Although some reported no need for suturing of the 8 mm port site, I have routinely closed all port sites greater than 5 mm with absorbable sutures utilising suturing devices such as the Carter-Thomason CloseSure System (Inlet Medical, Trumbull, CT, USA). In my initial personal experience of more than 30 robotic-assisted laparoscopic hysterectomies there have been no major intra-or postoperative complications. There have been no lateral injuries or need for conversion to laparotomy. None of our patients have required transfusion. On 2 occasions, due to malfunction of the robotic arm, a portion of the procedure was converted to laparoscopy. The use of robotic technology in the operating room for certain cases shows great promise in further improving the laparoscopic outcome. The benefits of the robotic system begin with improved dexterity. The robot allows for a 7 range of motion versus 4 range of motion for laparoscopy or laparotomy. And it also removes hand tremor. Surgeons who normally cannot suture well laparoscopically are able to do so utilising the robot. The learning curve for laparoscopic suturing is greatly decreased with the use of the robot. Another advantage the robot provides is 3D visualisation rather than the 2D view with laparoscopy. While experienced laparoscopists have already adjusted to working in the 2D environment, surgeons new to laparoscopy could decrease their learning curve by utilising the robot. In addition, the

TECHNIQUE OF ROBOTIC-ASSISTED LAPAROSCOPIC HYSTERECTOMY

The patient is placed in modified dorsolithotomy position in Allen Universal stirrups (Allen Medical Systems, Acton, MA, USA) for laparoscopy. The arms are tucked around the patient and protected with foams. Foley catheter is placed in the bladder. Depending on the type of hysterectomy, as well as the size of the uterus, an umbilical or supraumbilical 12 mm cannula is introduced in the abdomen as with routine laparoscopic procedure. Robotic 8 mm lateral ports are placed midway between the suprapubic region and camera port. A 5 or 10 mm port is placed depending on the location of the fundus of the uterus and the planned procedure. Depending on whether two or three arms are being used, an extra 8 mm robotic port could be placed on the left side of the camera port. It is imperative to calculate the distance between ancillary ports to create adequate distance between robotic arms and avoid interference of the arms with each other. After mounting the robotic arms and camera, an assessment of the abdominopelvic cavity is made. Depending on the surgeons preference, different types of bipolar desiccating forceps are available. Recently, harmonic forceps as well PK (Gyrus Medical, Minneapolis, MN, USA) forceps have been introduced. The disadvantage of harmonic forceps is lack of tip articulation. Other energy sources include monopolar scissors, as well as hook and monopolar spatula. Depending on the surgeons preference, any of the above instruments could be used. After identification of the anatomy and points of question, such as major vessels and ureters, similar to any other procedure, first other pelvic pathology such as endometriosis and adhesions are addressed with restoration of the anatomy. I have utilised daVinci Maryland bipolar forceps (Aesculap, Inc., Tuttlingen, Germany) for electrodessication of the round, infundibulopelvic or utero-ovarian ligament depending on the patients desire to preserve or remove of the adnexa. Robotic scissors could be utilised with and without electrosurgery for sharp dissection of the vesicouterine fold and rectovaginal septum. Uterine vessels are skeletonised, electrodesiccated, and cut similar to the laparoscopic hysterectomy. Due to the size and location of the robotic arms, a modification needs to be made on the type of uterine manipulator to assist dissection of uterosacral-cardinal ligaments. This would also facilitate colpotomy. There are different type uterine manipulators and colpotomisers available. I have had experience with Koh

The Role of Laparoscopy and Robotics in Hysterectomy

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Figures 10.1A and B: (A) Port placement, (B) Patient positioning

Figure 10.2: Mounting robotic arm and port relation

Figure 10.3: Maryland bipolar and robotic scissors with identification of the vesicouterine fold

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Figure 10.4: Vesicouterine fold dissection

Figure 10.5: PK for IP

The Role of Laparoscopy and Robotics in Hysterectomy

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Figure 10.6: Posterior colpotomyInitial step

Figure 10.7: Anterior colpotomy

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Figure 10.8: Completion of hysterectomy

Figure 10.9: Vaginal cuff suturing

Figure 10.10: Final outcome with complete cuff closure and uterosacral ligament vaginal vault support as high as 1.4 million dollars. Robotic devices also have a limited life-span of a maximum of 10 uses, which results in additional costs. There is also the lost revenue for the facility in the training of OR personnel. Another disadvantage is the size of the equipment. The bulkiness of the robotic arm can prove challenging to the OR staff who have to manoeuvre around the robot to change instruments or equipment. However, despite the size of the robotic arm, it does not take a great deal of time to

robotic console provides an ergonomic and intuitive environment for the surgeon thereby reducing fatigue and eliminating physical discomfort. This not only benefits the surgeon, but also the patient by enabling the surgeon to perform better in a more accommodating environment. As with all new technology, there are drawbacks to the robot. The first is cost. An enormous outlaying of money is required, with the cost of the equipment being

The Role of Laparoscopy and Robotics in Hysterectomy disassemble the robotic arm and remove it from the immediate area. This is very important in emergency situations where potential conversion to laparoscopy or laparotomy exists.26 The drawbacks of the instrumentation will likely diminish as microrobotics are developed. And with increased demand and supply the costs should decrease. Lastly, while the setup is a drawback in the beginning, with appropriate staff training this should decrease as well.

81

11.

12. 13. 14. 15.

CONCLUSIONS
Vaginal hysterectomy remains the preferred method of hysterectomy. As an alternative to abdominal hysterectomy, laparoscopic hysterectomy and LAVH remain preferred methods. However, for individual surgeons who lack laparoscopic suturing experience and who would perform an abdominal hysterectomy, robotics may bridge the gap and be an enabler for conversion of abdominal hysterectomy to a minimally invasive procedure with the advantage of laparoscopy.

16. 17.

REFERENCES
1. Keshavarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillance United States, 1994-1999. MMWR 2002;51(SS05):1-8. 2. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol 2002;99(2):229-34. 3. Nezhat C, Currell MO, Nezhat F, et al. Laparoscopic radical hysterectomy with para-aortic and pelvic node dissection. Am J Obstet Gynecol 1992;166:864-65. 4. Nezhat C, Nezhat F, Gordon S, et al. Laparoscopic versus abdominal hysterectomy. J Repro Med 1992;37:247-50. 5. Garry R, Fountain J, Mason S, et al. The evaluate study: two parallel randomized trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004;328 (7432):129-36. 6. Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano G. Laparoscopically assisted vaginal hysterectomy versus total hysterectomy: A prospective, randomized, multicenter study. Am J Obstet Gynecol 1999;180:270-75. 7. Olsson J, Ellstrom M, Hahlin M. A randomized prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynecol 1996;103:345-50. 8. Nezhat C, Bess O, Admon D, Nezhat CH, Nezhat F. Hospital cost comparison between abdominal, vaginal, and laparoscopic-assisted vaginal hysterectomies. Obstet Gynecol 1994;83(5pt1):713-16. 9. Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomized trial. BMJ 2004;328:134-40. 10. Johns A, Carrera B, Jones J, DeLeon F, Vincent R, Safely C. The medical and economic impact of laparoscopically

18. 19.

20.

21.

22.

23.

24. 25. 26.

assited vaginal hystectomy in a large, metropolitan, not-forprofit hospital. Am J Obstet Gynecol 1995;172:1709-19. Ellstrom M, Ferraz-Nunes J, Hahlin M, Olsson JH. A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol 1998;91(1):30-34. Nezhat CH, Nezhat C, Admon D, Seidman D, Nezhat F. Complications of 361 laparoscopic hysterectomies. J Am Assoc Gynecol Laparosc 1994;1(4pt2):S25. Wattiez A, Soriano D, Cohen SB, et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparsc 2002;9(3):339-45. Makinen J, Johansson J, Tomas C, et al. Morbidity of 10,110 hysterectomies by type of approach. Hum Reprod 2001;16:1473-78. Cristoforoni PM, Palmieri A, Gerbaldo D, Montz FJ. Frequency and cause of aborted laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 1995;3(1):33-37. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total and subtotal abdominal hysterectomy. N Engl J Med. 2002;347:1318-25. Learman LA, Summitt RL Jr, Varner RE, et al. A randomized comparison of total or supracervical hysterectomy: Surgical complications and clinical outcomes. Obstet Gynecol 2003;102(3):453-62. Ficarra V, Cavalleri S, Novara G, Aragona M, Artibani W. Evidence form Robot-Assisted Laparoscopic Radical Prostatectomy: A Systematic Review. Eur Urol 2007;51:45-56. Heemskerk J, van Gemert WG, Greve JW, Bouyy ND. Robotassisted versus conventional laparoscopic Nissen fundoplication: a comparative retrospective study on costs and time consumption. Surg Laparosc Endosc Percutan Tech. 2007 Feb;17(1):1-4. Nakadi IE, Melot C, Closset J, De Moor V, Betroune K, Feron P, Lingier P, Gelin M. Evaluation of daVinci Nissen Fundoplication Clinical Results and Cost Minimization. World J Surg 2006 May 10; [Epub ahead of print]. Morino M, Pellegrino L, Giaccone C, Garrone C, Rebecchi F. Randomized clinical trial of robotassisted versus laparoscopic Nissen fundoplication. Br J Surg 2006 May;93(5):553. Mettler L, Ibrahim M, Jonat W. One year of experience working with the aid of a robotic assistant (the voicecontrolled optic holder AESOP) in gynaecologic endoscopic surgery. Hum Reprod. 1998;13:2748-50. Cadire G, Himpens J, Germany O, Izizaw R, Degueldre M, Vandromme J, Capelluto E, Bruyns J. Feasibility of robotic laparoscopic surgery: 146 cases. World Journal of Surgery. 2001;25(11):1467-77. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend Jr. C. Laparoscopic hysterectomy using a computer-enhanced surgical robot. Surgical Endoscopy 2002;16(9);1271-73. Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: Technique and initial experience. Am J Surg. 2006;191(4):555-60. Nezhat C, Saberi B, Shahmohamady B, Nezhat F. Roboticassisted laparoscopy in gynaecological surgery. JSLS. 2006; 10:317-20.

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Bruno J van Herendael INTRODUCTION

Strategies to Prevent Vaginal Vault Descent during Hysterectomy

The problem of uterine descent is of all ages. The likelihood that a female will be operated for a pelvic floor related problem is high. The prevalence and the prediction we do take from the Federal Interagency Forum in age related statistics Older Americans 2000. In the year 2000 there were 34.8 million females over the age of 65 years or 12.7% of the female population in the United States. In 2030 there will be 70.3 (20%) million females over the age of 65 years accounting for 20% of the female population. Over the next thirty years, the growth in demand for services to care for female pelvic floor disorders will increase at twice the rate of growth of the same population in the US of America. Prolaps surgery therefore will increase with 45%.1 If we look at the patients that have had a hysterectomy, be it by the abdominal or the vaginal route, literature survey indicates that vaginal vault prolaps occurs between 2 and 45%. If we are diligent to use simple precautions like attaching the sacrouterine ligaments to the vaginal vault at the time of hysterectomy literature shows a reduction in vaginal vault prolaps over three years between six to thirty-five percent.2,3 One of the main problems is that some of the structures we use classically as a suspension or as structures related to the suspension of the vagina, the bladder and the posterior aspect of the vagina (Cavity of Douglas and the rectum adjacent to this structure) are at times difficult to find or in some instances do not exist. The Arcus Tendineus Fascia Pubocervicale (Fascia White Line) Does not exist in 40% of postmortems. The Arcus Tendineus Levator Ani (Muscular White Line) is often difficult to see and large anatomical variety is the rule. The obturator fascia is very subtle and cannot guarantee a long lasting support. Technically the part of the white line most often

involved in paravaginal defect is the part close to the Ischiadic Spine and hence a dangerous site because of the Pudendal vessels and nerves.4 It is therefore extremely important to observe a strict technique at the time of hysterectomy to close the vaginal vault and to adhere to a standardised method. The author describes two possible rather simple laparoscopic techniques to suspend the vagina at the time of the closure at hysterectomy. Because laparoscopy allows an enlargement from two and up to twenty times the suspension is best done through means of laparoscopy.

TECHNIQUE
When considering that laparoscopy is a way of access not a technique (quote by Harry Reich) we ought to transpose the classical technique of closing to laparoscopy. Two techniques are considered to close the vagina, the modified Te Linde5 suture from abdominal surgery and the High McCall Modified suture from vaginal surgery.6

TE LINDE MODIFIED
Bruno J van Herendael adapted the original Te Linde suture to be able to use it through the laparoscope. A vicryl one suture on a CT plus needle (Johnson & Johnson International) is very suitable for this purpose. The suture is brought into the operating field through the skin incision of a five mm trocar and the trocar containing the needle holder is slipped back into the abdomen after the treat is deposited in the operating field. I (BvH) however prefer a twelve mm trocar with reduction to five mm (Apple Med Corp Marlboro MS USA). The suture is grasped some three cm behind its insertion into the needle by a classical needle holder of five mm diameter and brought into the abdomen.

Strategies to Prevent Vaginal Vault Descent during Hysterectomy The needle is brought through the sacrouterine ligament and through the posterior part of the endovaginal fascia and the vaginal wall, at a right angle of the cut posterior vaginal epithelium, into the lumen of the opened vagina at one cm of the posterior edge. The needle is re-grasped and passed from the vaginal lumen through the vaginal wall, still at a right angle with the cut vaginal epithelium, and the endopelvic fascia under the uterine artery in the medial part of the broad ligament (Cardinal ligament). The needle passes medial and under the uterine artery between the uterine artery and the vaginal wall parallel with the ureter at a distance of some two cm, closing all the small vessels in the broad ligament. The vaginal wall is passed and the needle now reappears in the vaginal lumen. The final step is grasping the needle and bring it back trough the vaginal wall and the endo pelvic fascia, this time on the anterior side. Care is taken to judge the distance between the emerging needle point and the bladder and assure oneself that enough anterior endopelvic fascia is enclosed in the bite. The suture is now tied. This can be done with an extracorporeal or with the intra-abdominal knotting technique. I (BvH) prefer the intra-abdominal. The intra-abdominal technique does allow for a constant monitoring of the movements by the endocamera. This is less tiring for the eyes of the operator as these do not need to switch from camera vision to outside vision and vice versa. It is very a safe technique: As the suture runs parallel to the ureter there is no danger of kinking the ureter as long as the needle stays between the stump of the uterine artery and the vagina in the median part of the pelvis alongside the anteroposterior axis of the vagina. As the suture compresses the vessels between the uterine artery and the vaginal wall, in the central part of the broad ligament, vaginal artery included, there is very little danger for postoperative bleeding. The inconvenience is that as the suture necessarily perforates the vaginal wall to obtain its effect it shortens the vagina with one cm or one and a half cm. After the securing the other angle the vault itself is closed with the same vicryl suture with a figure of eight stidge or an anteroposterior one. In most cases two stidges are sufficient. It is not necessary to close the vault hermetically. Be very aware, however, not to leave drainage material as a connection between the vagina and the abdominal cavity not to cause peritonitis.

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THE MODIFIED HIGH MCCALL SUTURE

The McCall suture we need in descent prevention is only the highest suture in the sequence that was originally thought off by McCall. It is a suture in delayed resorbable material (BvH uses vicryl 1 with the CT plus needle) that is brought through from the lateral edge of the transsected sacrouterine ligament. Its direction is from lateral towards central taking the lateral edge of the opened vagina. Care is taken to include the endopelvic fascia. The suture is then refed through the posterior wall of the vagina. The needle leaves the vagina at the other side to include the opposite lateral edge of the vagina and to finish on the lateral side of the opposite sacrouterine ligament.6 The vagina is closed by bringing the sacrouterine ligaments on the posterior border of the vagina. The end result is a relative stricture of the top end of the closed vagina. When the end result is an open Douglas cavity or when before the hysterectomy the Douglas cavity was already wide open a second and a third or even forth suture can be placed making the McCall culdoplasty complete. It has to be reminded that the original McCall culeplasty is a vaginal technique. Harry Reich did modify the original technique to be able to use it the laparoscopic way. The reason Reich wanted to modify the technique is because the original McCall failed to address the frequently occurring high cystocele in the anterior wall.7 Reich uses the technique in a prophylactic way to prevent prolaps at the time of hysterectomy.8 The way Harry Reich uses the suture in patients with minimal or no prolapse with no urinary complaints is described. The right sacrouterine ligament is identified. The vicryl 1 suture is placed through it. The suture is then placed through the right cardinal ligament, just below the uterine vessel pedicle, through the rectovaginal fascia and the posterior peritoneum parallel to the cut edge of the posterior vaginal epithelium. Then the suture is brought through the left posterolateral vagina and cardinal ligament to the right sacrouterine ligament. When the suture is tied it provides excellent support to the vaginal apex. The apex is elevated superiorly and posteriorly towards the hollow of the sacrum. The rest of the vagina is closed anteroposterior with the same vicryl 1 suture in a figure of eight. As this suture tend to bring both lateral edges of the vagina together in the midline the end result is a relative narrowing of the top of the newly formed vagina.

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Figure 11.1: Opened vagina after laparoscopic hysterectomy. On the left the uterine vessels, artery and vein are clearly visible. A glove with a goose is visible deep in the vagina to prevent leakage of the CO2 gas

Figure 11.4: The sacrouterine ligament is transfixed and the needle passes into the vaginal lumen some 1 cm below the cephalad edge of the vaginal epithelium

Figure 11.2: A vicryl 1 suture armed with a CT plus needle (Johnson and Johnson International) is used to close the vagina

Figure 11.5: The suture is re grasped and pushed from the vaginal lumen towards the uterine artery through the vaginal wall. The angle with the cut vaginal epithelium is perpendicular and the distance of one cm from the cephalad edge is maintained The suture is relatively less safe that the modified Te Linde as it could, by anchoring the structures towards the midline of the pelvis kink the ureters when the sacrouterine ligaments are fixed to the vaginal wall. Care therefore has to be taken to look out for the ureters and when in doubt to be prepared to perform a cystoscopy and to bring a guiding catheter in the ureter under laparoscopic vision.

REFERENCES
Figure 11.3: The sacrouterine ligament at the right is identified before the suture is allowed to pass through
1. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: Current observations. Am J Obstet Gynecol 2001 Jun;184(7): 1496-501.

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Figure 11.6: The suture is regrasped and passed between the uterine artery and the vagina from posterior to anterior. Remark that the point of the needle stays away from the plane of the ureter end the body of the needle will be parallel with the course of the ureter. The median part of the broad ligament is now re-attached to the vaginal wall

Figure 11.8: The Te Linde modified is nearly finished. The needle is re grasped and passes through the vaginal and the endopelvic fascia under the bladder

Figure 11.7: The point of the needle is seen in the lumen of the opened vagina after the passage of the suture under the uterine artery and through the medial part of the broad ligament
2. Flynn BJ, Webster GD. Surgical management of apical vaginal defects. Current Opin Urol 2002; 12(4):353-58. 3. Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999;180(4):859-65. 4. Ersoy M, Sagsoz N, Bozkurt MC, Apaydin N, Elhan A, Tekdemir I. Important anatomical structures used in paravaginal defect repair: Cadaveric study. Eur J Obstet Gynecol Reprod Biol 2004; 10;112(2):206-13. 5. Thompson JD, Warshaw J. Hysterectomy. In: Rock JA, Thompson JD (Eds): Te Lindes Operative Gynecology,

Figure 11.9: At the left side the suture is closed using the endocorporeal technique. Note that a forceps is holding the suture end at the right for stabilisation of the operating field
9th edn. Lippincott Raven Philadelphia-New York;1996: 771-854. 6. Wall LL Urinary Stress Incontinence. In: Rock JA, Thompson JD (Eds): Te Lindes Operative Genecology, 9th edn, Lippincott and Raven Philadelphia-New York 1996;1087-1134. 7. Reich H,Orbuch IK,Tamer S. Laparoscopic pelvic floor reconstruction. In: van Herendael BJ, Gomel V, (Eds):, Pelvic Floor Disorders Diagnosis and treatment, Decker New York in press. 8. Reich H, McGlynn F, Sekel L, Total Laparoscopic Hysterectomy. Gynecol Endosc 1993;2:59-63.

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12
A Salfelder INTRODUCTION

Hysterectomies in a Day Clinic

The first total laparoscopic hysterectomy (TLH) was performed in 1989.1 Still today laparoscopic hysterectomies have not been included into medical educational training programmes. Surgeons seem extremely reluctant to introduce changes concerning their own educational standards.2 For the time being outpatient laparoscopic hysterectomy marks the latest stage in the history of hysterectomy. It has taken many years of experience and daring surgeons to overcome old ways of thinking. When our day surgery unit (DSU) was founded in 1984 outpatient laparoscopic sterilisation was considered highly irresponsible. Nowadays the laparoscopic sterilisation is an accepted outpatient procedure. A similar change of attitude is developing concerning laparoscopic hysterectomy. In the early nineties senior partners at our DSU performed laparoscopic assisted vaginal hysterectomies keeping the patients hospitalised for at least three days. This seemed quite revolutionary considering that at that time total abdominal hysterectomies (TAH) in community hospitals were usually discharged only after 10-14 days. As laparoscopic supracervical hysterectomy (LASH) became an option in the nineties most gynaecologists were opposed to it. This opposition was probably due to the fact that during their medical course the removal of the cervix was classed as essential. After comparing the current literarature regarding the role of the cervix and the development of the minimal invasive surgical techniques,3-9 it appears that the prejudice against supracervical hysterectomy has resolved. LASH is now considered the best choice of procedure when dealing with benign uterus conditions that are unresponsive to previous conservative treatment.

When LASH was first performed in our DSU in 1998 patients were hospitalised for three days with a Foley catheter left in place. The uterine vessels were secured using sutures and duration of the operation took more than two hours. After years of experience and with the help of younger innovative surgeons, standardised and faster operative steps have been introduced. The uterine arteries are secured by coagulation and the Foley catheter is removed immediately after the operation. This not only has shortened the time of surgery, but also lead to the well-being and quick recovery of the patients as well as very few complications. As a result of this development LASH suddenly has become an outpatient procedure.10,11 The problem being at this stage was that hysterectomies were not listed in the German Health Care System as outpatient procedures and were consequently not being reimbursed sufficiently. At the time of the calculation of fees the general medical opinion was that hysterectomies could not be performed safely as an outpatient procedure. As a result outpatient hysterectomies were not lucrative in day surgery units in Germany and could therefore only be performed in small numbers. After some changes have taken place in Germanys Health Care System (2004) outpatient surgery has now become possible on a larger scale. From 1998 to 2006 a total number of 650 laparoscopic supracervical hysterectomies have been performed in our DSU (Figure 12.1). 90% of them are performed as outpatient procedures and are paid for by specific payment agreements with health insurance companies (so called integrated medical care). Outpatient hysterectomy is still not practicable for all patients. Some patients need a 4 day hospital stay in order for the institution to be allowed to reimburse complete DRG amounts (Figure 12.2).

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Figure 12.1: Number of LASH in our DSU 1998-2006

Figure 12.2: Distribution of reimbursement for in-/outpatient laparoscopic hysterectomy Since 2006 we have performed 25 outpatient total laparoscopic hysterectomies in our DSU. The first outpatient total laparoscopic hysterectomy in our day clinic was once again performed by a younger and experienced surgeon willing to break the tradition of hospitalising patients after total hysterectomy. From the beginning all but three patients (due to agreements with their health insurance company) after TLH have been discharged 6 hours after the operation and no major complications have occurred. The main indications for the procedure have been cervical and endometrial pathology. The duration of the operation is comparable to a LASH (X= 70 min.). Although there is no necessity for morcellation to be performed the vaginal cuff must be sutured. Operative steps for a total laparoscopic hysterectomy are similar to those for a LASH. The vaginal fornices are safely identified by the uterus manipulator and entered using a monopolar hook (Figure 12.3). Using standardised operative techniques and specially designed uterine manipulators total laparoscopic hysterectomy has become an extremely safe and straight forward procedure. Patients suitable for outpatient surgery must be carefully selected (Table 12.1).

Figure 12.3: TheHohl uterine manipulator and the monopolar hook for TLH They need to be monitored carefully after the operation in the recovery room at the DSU. Phone contact with the surgical team in the evening after the operation is mandatory and home care support must be available. When discharged patients receive an emergency phone number.

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Manual of New Hysterectomy Techniques Progress comes slowly and takes time to prevail. Laparoscopic hysterectomies can be safely performed in day surgery units and help to reduce health care costs. Strict inclusion criteria for patients must apply and careful monitoring after the operation must be warranted. Outpatient laparoscopic hysterectomy has become not a question of practicability and safety but of health care policy.

Table 12.1: Inclusion criteria for outpatient hysterectomies Age Weight Laboratory values < 65 years BMI < 40 (35) Hematology values Creatinine Liver transaminases Cholinesterase Sodium Potassium Chloride

ECG Spirometries X-ray of the lung, if necessary Hemoglobin limit > 11,0 g% ASA I + II Home care support

REFERENCES
1. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213-16. 2. Mettler L, Ahmed-Ebbiary, Schollmeyer Th. Laparoscopic hysterectomy: Challenges and limitations. Minim Invasive Ther Allied Technol 2005;14(3):145-59. 3. Kilkku P. Supravaginal uterine amputation vs. hysterectomy. Effects on coital frequency and dyspareunia. Acta Obstet Gynecol Scand 1983;62:141-45. 4. Kilkku P. Supravaginal uterine amputation versus. Hysterectomy with reference to subjective bladder symptoms and incontinence. Acta Obstet Gynecol Scand 1985;64:375-79. 5. Kilkku P, Grnroos M, Taina E, Soderstrom O. Colposcopic, cytological and histological evaluation of the cervical stump 3 years after supravaginal uterine amputation. Acta Obstet Gynecol Scand 1985;64:235-36. 6. Semm K. Hysterektomy via laparotomy or pelviscopy: A new CASH method without colpotomy. Geburtsh Frauenheilk 1991;51(12):996-1003. 7. Semm K. Endoscopic subtotal hysterectomy without colpotomy: Classic intrafascial SEMM hysterectomy. A new method of hysterectomy by pelviscopy, laparotomy, per vaginum or functionally by total uterine mucosal ablation. Int Surg 1996;81(4):362-70. 8. Mettler L, Semm K, Lehmann-Willenbrock L, Shah A, Shah P, Sharma R. Comparative evaluation of classical intrafascial-supracervical hysterectomy (CISH) with transuterine mucosal resection as performed by pelviscopy and laparotomy-our first 200 cases. Surg Endosc 1995;9 (4):418-23. 9. Hasson HM Cervical removal at hysterectomy for benign disease. J Reprod Med 1993;38:781-90. 10. Salfelder A, Lueken RP, Bormann C, et al. Die suprazervikale Hysterektomie in neuem Licht. Frauenarzt 2003; 44:1071-75. 11. Salfelder A, Lueken RP, Bormann C, et al. Laparoscopic supracervical hysterectomy. A prospective multicenter study by the VAAO. Geburtsh Frauenheilk 2005;65:396403. 12. Meyer MA, Lalich RA, Meyer MM, Widener J. Outpatient vaginal hysterectomy in a community hospital. Wis Med J. 1994;93(8):422-25. 13. Bran DF, Spellman JR, Summitt RL Jr. Outpatient vaginal hysterectomy as a new trend in gynecology. AORN J 1995; 62(5):810-14. 14. Levy BS, Luciano DE, Emery LL. Outpatient vaginal hysterectomy is safe for patients and reduces institutional cost. J Minim Invasive Gynecol 2005;12(6):494-501.

There are more data in the literature concerning outpatient vaginal and laparoscopic hysterectomies. Outpatient vaginal hysterectomies were performed safely in the early nineties.12-14 Outpatient LASH10,11,15,16 and TLH17-20 have been reported in the late nineties. The main issue concerning outpatient vaginal and laparoscopic hysterectomy today is therefore not whether it can be completed safely but whether it is reimbursed adequately by the Health Care Systems. Reducing hospitalisation and the number of disposable instruments for outpatient hysterectomies are just two ways to minimise health costs.20-22 In our free standing DSU outpatient laparoscopic hysterectomies are performed safely using reusable instruments only like specially assembled monopolar scissors and the Kleppinger bipolar forceps only (Figure 12.4).

Figure 12.4: The Kleppinger bipolar forceps and monopolar scissors with a disposable Metzenbaum tip

Hysterectomies in a Day Clinic

15. Sarmini OR, Lefholz K, Froeschke HP A comparison of laparoscopic supracervical hysterectomy and total abdominal hysterectomy outcomes. J Minim Invasive Gynecol 2005;12(2):121-24. 16. Lieng M, Istre O, Langebrekke A, Jungersen M, Busund B. Outpatient laparoscopic supracervical hysterectomy with assistance of a lap loop. J Minim Invasive Gynecol 2005;12(3):290-94. 17. Chou DC, Rosen DM, Cario GM, et al. Home within 24 hours of laparoscopic hysterectomy. Aust N Z J Obstet Gynaecol 1999;39(2):234-38. 18. Thiel J, Gamelin, A. Outpatient total laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 2003;10(4):481-83.

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19. Hoffmann CP, Kennedy J, Borschel L, Burchette R, Kidd A. Laparoscopic hysterectomy: The Kaiser Permanente San Diego experience. J Minim Invasive Gynecol 2005;12(1):1624. 20. Thiel JA, Kamencic H. Assesment of costs associated with outpatient total laparoscopic hysterectomy. J Obstet Gynaecol Can 2006;28(9):794-98. 21. Morrison JE Jr, JacobsVR. Replacement of expensive, disposable instruments with old-fashioned surgical techniques for improved cost-effectiveness in laparoscopic hysterectomy. JSLS 2004;8(2):201-06. 22. Morrison JE Jr, Jacobs VR Outpatient laparoscopic hysterectomy in a rural ambulatory surgery center. J Am Assoc Gynecol Laparosc 2004;11(3):359-64.

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13
Rakesh Sinha, Yogesh A Nikam

Bladder Dissection Modalities in Total Laparoscopic Hysterectomy

Ultrasonic energy. In cases of large uteri the use of a Myoma screw to mobilise the uterus is of immense help to expose the uterovesical fold of peritoneum.1 With the help of scissors the vesicouterine peritoneal fold is divided starting at the left side and continuing across the midline to the right round ligament. The upper junction of the vesicouterine fold is identified as a white line firmly attached to the uterus, with 2-3 cm between it and the bladder dome. The bladder peritoneum is lifted with grasping forceps in the midline at the uterovesical peritoneal fold. Dissection is continued in the midline and the initial incision is made below the white line while lifting the peritoneum covering the bladder. While we follow and recommend the lateral window approach discussed later in this chapter in all our cases, few still follow the above method. The bladder is mobilised off the uterus and upper vagina using sharp dissection with scissors or blunt dissection with the same bipolar forceps or a suction-irrigator until the anterior vagina is identified. This dissection is aided by the carbon dioxide which enters through the previous openings of the anterior leaf of the broad ligament. Similarly the cavitation effect caused by the ultrasonic dissector can be used here to ease out dissection. If it does not occur, one can try to undermine the bladder peritoneum by carefully incising the peritoneal fold and then carefully dissecting the loose connective tissue off the cervix with scissors and bipolar coagulation forceps.2 Many instruments have been devised to reduce the incidence of bladder injury; uterine manipulators with attachments which serve to present the vaginal fornices thus easing out the bladder dissection.3 The instillation of methylene blue into the bladder is helpful in early recognising bladder injuries but does not avoid them. Filling up the bladder with saline thereby giving

SURGICAL ANATOMY OF THE BLADDER

The pelvis is always delineated anteriorly with a prominent peritoneal fold overlying the uterus and called the transverse peritoneal fold. This lies over the dome of the bladder and runs horizontally across the anterior pelvis from one superior pubic ramus to the other, crossing each obliterated hypogastric artery approximately an inch above where they are crossed by round ligaments. The base of the bladder is related to the cervix, with only a thin layer of connective tissue intervening. It is separated from the anterior vaginal wall below by the pubocervical fascia, which stretches from the pubis to the cervix. Mobilisation of the bladder of the cervix is an important step in total laparoscopic hysterectomy. This step is always performed before taking the uterine pedicle.

APPROACH TO BLADDER
1. We recommend the use of a 30 telescope. It greatly improves the access to the bladder in cases with bladder adhesions, large uteri, and anterior fibroids; in this way a simple change of the angle of vision allows to clearly expose the vesicocervical fold of the visceral peritoneum anteriorly. 2. Enucleation of anterior fibroids may be sometimes essential to approach the bladder.

BLADDER DISSECTION TECHNIQUES

UNSCARRED UTERUS
In an unscarred uterus. This is the regular approach to patients with no previous caesarean section or myomectomies. The opening of the vesicovaginal space is accomplished in the usual manner; the round ligaments are divided at their midportion using bipolar desiccation/

Bladder Dissection Modalities in Total Laparoscopic Hysterectomy prominence to the bladder wall is sometimes useful to demarcate the bladder boundaries.

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SCARRED UTERUS
It is a well known fact that previous caesarean section is indeed a significant risk factor for damage to the lower urinary tract at the time of hysterectomy (odds ratio [OR] 2.04; 95%CI 1.2-3.5).4 Similarly, repeated previous caesarean sections and an enlarged uterine size appeared to be the associated factors.5 Usually, in cases of previous LSCS the bladder is adherent to the lower uterine segment where the transverse Kerr incision is taken to open the uterine cavity during LSCS. As the bladder is pulled up on to the lower segment, it poses a problem when these patients undergo total laparoscopic hysterectomy later for other indications. Most of the un-intentional bladder injuries during TLH occur when the bladder is attempted to be pushed down on the cervix, as most of the dense fibrosis and adhesions are encountered anteriorly in the midline at the level of the vesicouterine fold. A safer approach is from the lateral part of the cervix. In this area the adhesions are less dense and firm and the bladder is not in direct contact with the cervix. This space was firstly described by Dr S Sheth (1995-1999) as the uterocervical broad ligament space for the vaginal approach to hysterectomy in uteri with previous caesarean sections. This anatomic space was described by S Sheth as follows: The anterior wall consists medially of the under surface of the bladder and laterally of the anterior leaf of the broad ligament. The posterior wall consists of the uterocervical surface as it slopes toward the uterocervical border. Laterally, this space is bounded by a tangential line joining the maximally bulging point on the uterine body and cervix. Medially the space ends where the bladder comes in close contact with the uterocervical surface thickening at the level of the bladder pillars. This anatomical space has been demonstrated by Magnetic Resonance Imaging slices taken at the isthmic level, through different planes show a distinct vacant space medial to the line joining the maximally bulging uterus above and the cervix below with its continuity medially between the uterocervical surface and the bladder until they come intimately close to each other in the midline.6 In abdominal and total laparoscopic hysterectomy this space is reached by dissection, from lateral to medial and from above downwards, which is exactly the opposite direction to that done in vaginal hysterectomy. Surgery is commenced similarly, with the round ligament being desiccated and cut using an energy source;

Figure 13.1: Schematic diagram 1

Figure 13.2: Lateral dissection of bladder showing the cervix and dissected bladder the anterior leaf of the broad ligament is dissected to reach the lateral border of the bladder. Here exists the potential space (Figure 13.1) between the cervix and the bladder which is utilised to achieve safe mobilisation of bladder from cervix. This lateral approach, (Figure 13.2) now creates a surgical window which allows a safe sharp dissection via laparoscopy. It essentially consists of exposing the uterine vessels and then proceeding medially along the adjacent pericervical fascia. It is unlikely that the scar of a previous caesarean section would extend laterally with the same thickness as in the medial portion (Figure 13.3). Once the fascia is exposed and the bladder is mobilised from both the sides, the medial part of the scar tissue may easily be approached. Then the dissection can be progressed towards the medial portion of the vesicouterine space where the adhesions between the bladder

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Manual of New Hysterectomy Techniques 1. Simple act of catheterizing the patient before the introduction of Verres, primary or secondary trocar goes a long way in preventing penetrating injuries to bladder. 2. Safe and meticulous dissection of the bladder from the cervix, keeping the pressure on the cervix during TLH. 3. Use of the lateral window approach in cases with a previous LSCS. 4. Filling up the bladder with 100-150cc of saline or methylene blue to define the borders of the bladder in cases of difficult dissection.

DIAGNOSIS OF UROLOGICAL INJURIES

Figure 13.3: Schematic diagram 2 Early diagnosis of urological injuries is vital to allow prompt repair and limit postoperative morbidity.

Intraoperative Recognition
Intraoperative recognition of bladder injury is important to prevent longterm sequelae. The important signs to note in case of a bladder injury are as follows: 1. Inadvertent lesions of the bladder will be immediately recognised because the catheter bag will be filled with the gas of pneumoperitoneum. Unintentional bladder injury can be easily repaired by laparoscopy. 2. Blood in the urine. 3. Filling the bladder with saline or methylene blue is of no utility as it cannot prevent bladder injury though it may be helpful in diagnosing one. Intraoperative cystoscopy with IV injection of indigo carmine is a good and simple method to rule out gross ureteral and bladder perforations. These methods, however, can still provide a false negative result in cases of urological injures secondary to thermal damage. Councell recommended routine cystoscopy at the end of the procedure to verify ureteral patency and bladder integrity.8,9

Figure 13.4: Anterior adhesions of balder with cervix being dissected and the cervix are dense in case of previous cesarean section. The bladder now only attached to the uterus at the uppermost part of the lower segment can then be dissected gradually to completely separate the bladder form the cervix using sharp dissection or ultrasonic dissector (Figure 13.4). In case of adhesions so thick that the dissection could be too difficult, it is possible to perform firstly a supracervical hysterectomy and later the cervix is removed starting the dissection from the posterior fornix.7

Postoperative Recognition
1. Postoperative drainage of urine form accessory trocar site 2. Postoperative urinary retention. 3. Postoperative peritonitis. 4. In patients with unexplained haematuria, fever, abdominal or flank pain and poor urine output, the possibility of urological injuries should be investigated into. Prompt assessment with sonogram, intravenous pyelogram or cystoscopy with retrograde dye study can be diagnostic and treatment delay prevented.

MANAGEMENT OF BLADDER INJURIES

PREVENTION
Prevention is the best modality of managing bladder injuries.

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REPAIR OF BLADDER INJURIES

Bladder injuries have occurred at a rate of 8.4/1000 in major operative laparoscopies.10 When injuries are diagnosed intraoperatively, repair with proper technique can provide near 100% success rates.11 Unfortunately, in more than two-thirds of cases, diagnosis of urological injuries is usually made postoperatively. This can be because the symptoms and signs are highly variable, depending on the location and aetiology of injury.

Intraoperatively Diagnosed Bladder Injuries

Bladder injury recognised during laparoscopy may be sutured by way of laparoscopy or rarely by laparotomy followed by bladder drainage. Small bladder injuries not recognised during laparoscopy may be managed conservatively with a Foley catheter, whereas a larger defect would require sutures.12 1. Bladder laceration may result from a primary umbilical subcutaneous trocar puncture or by Verres needle if the bladder is full. Treatment consists of placing an indwelling catheter for 7 to 10 days and prophylactic antibiotics. 2. Secondary trocar can perforate the bladder, especially in a patient who is obese and has had previous pelvic surgery if the trocar is placed too low, especially if the bladder has not been drained of urine. The incidence rate of such injuries is 0.2-1.1/1000 laparoscopies.9 A reliable diagnostic sign is the sudden appearance of gas in the Foley catheter drainage bag. Injection of indigo carmine through a Foley catheter may identify the site of the injury. When no bladder distention occurs during surgery without bladder drainage, consideration should be given to inserting a Foley catheter to observe for gas. a. The most important factor in treatment is early detection. If an injury is identified intraoperatively and is greater than 7 mm, the defect should be closed, in the majority of cases laparoscopically. Postoperatively the insertion of an in-dwelling catheter for 7-10 days and the prescribing of prophylactic antibiotic are recommended.11,12 b. If the defect is large from manipulation through the trocar sleeve during laparoscopic surgery, it should be closed with a figure of eight suture through the surrounding bladder muscularis and a second suture to close the overlying peritoneum. A watertight seal should be documented by filling the bladder with methylene blue dye solution. Postoperative complications may include bladder atony and leaking of urine in the peritoneal cavity which may also lead to peritonitis.

Figure 13.5: Bladder perforation / rent

Figure 13.6: Bladder rent repair with sutures 3. Bladder injury can occur during dissection of the bladder off the uterus and cervix or from adherent adnexa. In these cases the bladder is repaired using 3-0 vicryl usually in two layers (Figures 13.5 and 13.6).

Postoperatively Diagnosed Bladder Injuries

1. Intravesicular thermal injury can be suspected by cystoscopic visualisation of a white patch above the bladder trigone. The area should be reinforced with a laparoscopically placed suture into the bladder musculature surrounding the potential defect.2 The indwelling urinary catheter is removed after five days of free drainage. The European Association of Urology has recommends that for intraperitoneal bladder injuries the technique of surgical repair depends on the surgeons preference but a two-layer closure with absorbable sutures achieves a safe repair of the bladder wall.13

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5. Siow A, Nikam Y, Chern B. Urological complications of laparoscopic hysterectomies; A 4 years retrospective study at Minimal Invasive Surgery Unit KK Womens and Childrens Hospital, Singapore; Singapore Med J 2007; 48 (2) : 1. 6. Shirish Sheth. Vaginal hysterectomy 1996-1999, Chp. 21. 7. Wattiez A, Soriano D, Fiaccamento A, et al. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc 2002;9:125-130. 8. Councell RB, Thorp JM, Sandridge DA, et al. Assesment of laparoscopic assisted vaginal hysterectomy. J Am Assoc Gynecol Lap 1994;2:49-56. 9. Chapron C, Dubuisson JB, Ansquer Y, Fernandez B. Total hysterectomy for benign pathologies. Laparoscopic surgery does not seem to increase the risk of complications. J Gynecol Obstet Biol Reprod 1998;27:55-61. 10. Saidi et al.1996a 11. Petri E. Urological trauma in gynaecological surgery: Diagnosis and management. Curr Opin Obstet Gynecol 1999;11(5):495-98. 12. Reich H, McGlynn F, Sekel, L. Total laparoscopic hysterectomy. Gynaecological Endoscopy1993; 2: 59-63. 13. Guidelines on Urological Trauma; European Association of Urology, 2003.

2. Thermal injuries to bladder usually manifest in vesicovaginal fistula and incidence rates of 0.03/1000 in all laparoscopies and 0.3-3.1/1000 in advanced laparoscopies have been reported.9 The fistula may be repaired laparoscopically or vaginally or abdominally according to the need of the patient and technical skills of the surgeon.

REFERENCES
1. Rakesh Sinha, et al. Laparoscopic Excision of Very Large Myomas; The Journal of the American Association of Gynecologic Laparoscopists 2003;10:4. 2. Reich H. Laparoscopic hysterectomy. Surg Laparosc Endosc 1992;2(1):85-88. 3. Mettler L, Nikam YA. Survey of various uterine manipulators in operative laparoscopy; European journal of Gynecological Surgery Gynecol Surg 2006;3:239-43. 4. Rooney Christopher M. MD a; Crawford, Adam T. MD a; Vassallo, Brett J. MD; Kleeman, Steven D. MD; Karram, Mickey M. MD. American Journal of Obstetrics and Gynecology. 2005;193(6):2041-44

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14
L Mettler, T Schollmeyer, I Meinhold

Classic Intrafascial Supracervical Hysterectomy (CISH Technique)

To exclude the possible development of a cervical stump malignancy in the cervical functional tissue, the transformation zone is resected by transvaginal cylindrical coring of the cervical tissue using a 15, 20 or 24 mm CURT. This coring involves transvaginal excision of the functional cervical tissue from the muscular and connective tissue components of the uterine cervix. To ensure the safety of this excision without endangering ureters or the uterine artery, it is necessary to manipulate the uterus which normally lies in ante or retroflected position into a straight position. This is done by introducing a 5 mm perforation rod into the external cervical os and pushing it through the internal os into the cavity and finally perforating the uterus in the middle of the fundus. Even in cases of large uterine fibroids, it is possible to find the uterine cavity. The coring out of a tissue cylinder is demonstrated in Figure 14.1. Once a straight line has been established between the cervical canal and the uterine fundus, a preselected CURT may be applied over the perforation rod to cut out the appropriate cylinder leaving the cervical outer shell intact. Four steps characterise the technique, two from the vaginal side and two transabdominally.

INTRODUCTION AND SPECIFICITIES OF THE CISH TECHNIQUE SUING THE ELECTRONIC CURT (CALIBRATED UTERINE RESECTION TOOL)
The first carefully described abdominal supracervical hysterectomy was performed by Wilhelm Alexander Freund in 1878 (Freund, 1878). This was the leading technique of hysterectomy for over 80 years until Tervil (Tervil, 1936) described the danger of cervical cancer as 0.3-1.9% following supracervical hysterectomy. From 1950 onwards hysterectomy was performed almost exclusively as total hysterectomy, until Kurt Semm revived interest in supracervical hysterectomy in the 1990s by introducing the Classic Intrafascial Supracervical Hysterectomy (CISH technique) to be performed by pelviscopy and laparotomy (Semm 1991, Semm 1991, Semm 1994, Mettler et al. 1993, Mettler et al. 1993, Mettler et al. 1995, Mettler et al. 1995) with coring of the inner cervix.

MATERIALS AND METHODS

Today, the CISH technique, as one method of supracervical or subtotal hysterectomy, is performed as follows:

Figures 14.1A and B: Schematic drawing showing the transuterine-transcervical resection with the Calibrated Uterine Resection Tool (CURT) along the previously placed axial guide as 1st and 2nd vaginal steps of the Classic Intrafascial Supracervical (or Subtotal) Hysterectomy (CISH)

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FIRST VAGINAL STEP

Manual of New Hysterectomy Techniques cylinder is cored out electrically under endoscopic vision. The tenacula placed at 3 and 9 Oclock are gently pulled and the motor drive is slowly advanced. An equal pressure is applied to the cutting tube as it is rotated and advanced from the cervix through the endometrium to the fundus. As the cutting tube advances, the calibrated scale along the central cylinder slowly reveals the depth of tissue already cut. The cutting tube is rotated and slowly cores out a cylinder through the fundal serosa. It is important to ensure that each last thread of tissue has been cut; otherwise the tissue cylinder cannot be removed transvaginally. After the tissue cylinder has been completely cored out, it is carefully withdrawn and extracted through the vagina under transabdominal laparoscopic control. The endocervical wound is coagulated up to a maximum of 2.5 cm into the resection canal. After the CURT cylinder has been resected there is very little bleeding; however, as a prophylaxis against later bleeding the inner part of the remaining cervical cylinder has to be coagulated, preferably with an endocoagulator at 120C or with bipolar coagulation forceps. Figures 14.1 and 14.2 demonstrate the preparatory and two transvaginal surgical steps.

Preoperatively, the vagina is disinfected; the cervix is grasped at 3 and 9 Oclock by two tenacula. Following this, the uterus length is measured, the cervical canal is dilated up to Hegar 5 and the 50 cm long perforation rod is introduced into the uterus according to the uterine length. The perforation rod is part of the CURT set and is fixed vaginally together with two tenacula using a specifically designed clamp and screw. With large uterine fibroids this can be difficult and is sometimes more easily performed following transection of the supracervical uterus. The correct diameter of the CURT is selected based on the ultrasound measurement of the cervix and upon inspection. The proper selection of CURT is important because if the cylinder is too wide, it would cut outside the cervical fascia. A cylinder that is too narrow would not remove all of the functional cervical tissue. The centre of fixation of the uterus allows for a 3 dimensional maximal mobilisation of the uterus transvaginally (Figure 14.3). During this procedure the uterus is continually observed on the video screen.

FIRST LAPAROSCOPIC STEP

After having established a clear endoscopic view into the pelvis with no bowels adherent to the structures of the uterus, the perforation of the uterine fundus is performed under vision. The uterus can now be anteverted, retroverted and lateralised. The adnexa are separated from the pelvic side wall using ligatures, sutures, staplers, ligasure, ultrasound or whatever haemostatic technique is available. Separation of the adnexa usually causes a minimal blood loss. The round ligament is also coagulated and divided. This dissection of the adnexa and round ligament leads to an opening of the vesico-vaginal fold and to an opening of the posterior leaf of the broad ligament. The first laparoscopic part of CISH consists of the following steps: 1. Separation of adnexa and round ligament from pelvic side wall or uterus. 2. Dissection of the vesico-uterine peritoneum, opening of the paravesical space. 3. Placement of one cervical loop. After having exposed the cervix, a Roeder PDS loop is loosely placed around the cervix ready to be locked after the CURT cylinder is resected to prevent gas leakage.

SECOND LAPAROSCOPIC STEP

With a 10 mm claw forceps the uterus is grasped and pulled in the direction of the umbilicus. The prepositioned Roeder loop is placed as deep as possible and closed similar to a tourniquet around the cervix. This technique was already recommended by Rubin in 1951 as a temporary ligature around the ascending branches of the uterine artery for myoma enucleations.

The Double Cervical Ligature

A subsequent ligature is placed over the cervix to closely tie the ascending branches of the uterine artery and its collaterals. If the ligature is not set tightly enough, it is possible that after resecting the uterus, the fascial tissue could invaginate and loosen the ligatures securing the uterine arteries.

Resecting the Uterus

When the pericervical fascial tissue has been ligated using the double loop ligation technique, the uterus is regrasped with the forceps and pulled in the direction of the umbilicus. It may then be resected with a monopolar loop above the ligatures, with hook scissors, a laser or a monopolar current hook. The remaining stump should be at least 2-3 cm.

SECOND VAGINAL STEP

The fixing screw holding the axial guide rod of the CURT is removed. The cutting tube around the central cylinder is placed as a unit over the axial guide rod and the chosen

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the morcellator. We usually dilate up to the required morcellator size. The Storz Rotocut is ideal for this purpose. For further haemostasis and adhesion prevention, the remaining cervical stump is coagulated with the bipolar forceps. The second laparoscopic part of CISH consists of the following steps: 1. Closing of two ligatures around the cervix 2. Separation of cervix from uterus 3. Coagulation of cervical stump 4. Morcellation 5. Peritonealisation of stump.

Histopathology of CISH Specimens

A normal non-elongated cervix measures 2.5-3 cm in length. It is separated into an ectocervix and an endocervix. The ectocervix is covered with stratified squamous epithelium. The epithelium changes from ecto- to endocervix, from a squamous epithelium to columnar epithelium. The epithelium is quite granular and in the area of the endocervix the so-called endocervical glands may be found. The cervical sections are analysed as to whether a hyperplastic cervical mucosa is present and for remaining glandular components. The distal cervical segment, as it progresses to the isthmus, is analysed in cross sections. This is performed to demonstrate the outer circumference of the cervix and to allow the pathologist to check for possible mesonephric duct remnants. The uterine cavity segment is also sectioned in a longitudinal manner. The procedure allows for an absolutely correct and accurate histopathological assessment of all the uterine tissue. The individual steps of the laparoscopic CISH technique are summarised in Figures 14.3 to 14.6.

Figures 14.2A to D: 1st vaginal step of CISH (A) Schematic placement of the axial guide of CURT after cervical dilation to Hegar 6; (B) Schematic fixation of the axial guide of CURT with the fixation screw; (C) Grasping the cervix at 3 and 9 Oclock and measuring the length of the cervix; (D) Introduction of the axial guide of the Calibrated Uterine Resection Tool (CURT)

Sterilisation of the Intra-abdominal Cervical Stump

Disinfection is performed with iodine and the bipolar forceps are applied to coagulate the surface of the stump.

Peritonealisation
When the cervical stump clearly shows the ascending branches of the uterine artery, these may be coagulated and the tourniquet released. The two remaining PDS threads are not a hindrance. The stump may be covered by placing the vesicouterine peritoneum over the tissue pedicles. The pelvis is then irrigated with 1-2 litres of Ringers lactate and a careful supervision of the whole abdomen is carried out.

RESULTS AND DISCUSSION

Experience with CISH now dates back to 1990. The technique is easy to perform, can be carried out on smaller and larger uteri and leaves the pelvic floor intact. It has a short rehabilitation time and high patient acceptance. It is very cost effective and has a low complication rate (Semm 1994, Mettler and Semm 1997, Kim et al. 1998, Lyons 2000, Okaro 2001, Morrison and Jacobs 2001). CISH is an advanced laparoscopic procedure which is initially technically challenging but has a quick learning curve. It can be easily performed by two surgeons with 3 hands for the surgery and 1 hand to hold the camera. Every evaluation postulates that patients undergoing laparoscopic supracervical hysterectomy compared to

Morcellation of the Uterus

The large claw forceps grasp the uterus which is then morcellated from the left lateral incision point through

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Figures 14.3A to F: Classic Intrafascial Supracervical Hysterectomy (A-F) (A) Multifibroid uterus; (B) Left adnexectomy using a stapling device; (C) Right lateral bladder dissection; (D) Medial bladder dissection; (E) Utero-vesical space well prepared; (F) Perforation of uterine fundus at resection of a 1.5 cm in diameter cylinder along the axial guide with the Calibrated Uterine Resection Tool (CURT)

Figures 14.4A and B: Schematic ligation of uterine cervix with 2 PDS Roeder loops and final cutting of the uterine body from the cervix using the Lina loop (electric-powered loop); A9 Placement of second Roeder loop; Preparation for the dissection of uterine body from cervix

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Figures 14.5A to F: Classic Intrafascial Supracervical Hysterectomy (A-F); (A) Placement of second Roeder loop after the CURT cylinder resection to tie the ascending branches of the uterine arteries; (B) Sharp dissection of uterine body from cervix using the hook scissors (C) Continuous dissection of uterine body from cervix; (D) Separated uterine body and cervix; (E) Morcellation of uterine body; (F) Final situs after CISH without adnexectomy with cervical stump and remaining adnexa total hysterectomy have shorter operation times, shorter hospital stays and less morbidity than those who underwent laparoscopic assisted vaginal hysterectomy or total laparoscopic hysterectomy (Milad et al 2001). The practice of routine cervicectomy at laparoscopic hysterectomy should be reconsidered. In 2001 Okara et al published data related to the cervical stump requiring further surgery following a laparoscopic supracervical hysterectomy. These data, however, could not be verified in our own retrospective evaluation (Mettler and Semm 1997, Mettler 2006) nor in data published by colleagues using the LASH technique (Salfelder et al 2003, Bojahr et al 2006). LASH is an easier surgical method than CISH and fulfils the same purpose. Thus, CISH can be considered a simple subtotal hysterectomy. It has all the advantages of a subtotal hysterectomy and additionally includes the coring of the inner cervix (Morrison and Jacobs 2001). This prevents the occurrence of cervical stump cancer which after CISH only appears in 1 of 5 million cases. Surgical complications and clinical outcome proved to be acceptable even in large uteri (Lyons et al 2004,

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Figures 14.6A to E: Dissection of uterine body from vagina using the LiNA loop (endoscopic monopolar loop for sectioning of uterus) ligation technique in 5 steps: (A) LiNA loop placed around the cervix; (B) LiNA loop partly cutting the cervix; (C) Cervical stump after separation from uterine body; (D) Bleeding from stump of right ascending branch of uterine artery; (E) Bipolar coagulation of bleeding Note for the publisher: Presentation 1bc.ppt contains the 5 figures for the chapter. Each ppt. picture series in Fig. 3 and Fig. 5 has corresponding TIF numbers which are listed here: Learman and Summitt 2003). In cases of large uteri, the procedure is possible via laparoscopy. Uterus and fibroids are dissected and morcellated in situ. In a random evaluation of 253 non-selective cases, the entire excoriated tissue cylinder specimens obtained at hysterectomy in our department were histologically reexamined. In all cases the transitional zone, from the ectocervix to the endocervix (from squamous to columnar epithelium) was completely removed. In only six cases could endocervical glands be found at the cutting margins (2.3% = 0.02% coincidence). If cervical carcinoma were to develop in all of these cases, the incidence rate of cervical carcinoma post CISH would be 0.02 cases per 100,000 which is a frequency of 1:5,000,000.

CONCLUSIONS
Even in the case of uterine fibroids, larger than the 24th gestational week in size, a laparoscopic CISH procedure is possible and a total hysterectomy not indicated. Taking into account the remaining cervical concept, a laparotomic CISH is an alternative procedure for larger fibroids. In these cases the classic supracervial hysterectomy is first performed by laparotomy, followed by coring of the cervix. The transformation zone is cored out transvaginally using the CURT after the uterus has been sub-totally resected. The advantages of the CISH method using CURT can be summarised as follows (Mettler 2006):

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SURGICAL BENEFITS
1. Secure transvaginal coring out of the cervical mucosa including the glandular component 2. Preservation of the cardinal ligament 3. Preservation of the pericervical network of nerves 4. Protection of the ureters, uterine artery, bladder and rectum, etc. 5. No colpotomy 6. The vagina is not shortened 7. No danger of abdominal infection through contamination from vaginal bacteria 8. Elimination of the method associated secondary healing of the vaginal cuff 9. Minimal traumatisation and little blood loss 10. Elective suspension of the ligaments on the cervical fascial stump as opposed to the vaginal cuff.

MEDICAL BENEFITS
1. Prophylaxis against cervical stump carcinoma 2. Complete preservation of the pelvic floor anatomy through preservation of the support function of the cardinal ligament 3. Reduced physical stress for the patient 4. Reduction in the time for reconvalescence 5. Complete preservation of sexual function with regard to subjective vaginal and cervical components 6. Complete preservation of the functionability of the vagina as regards partner contact 7. Earlier return to sexual activity 8. No change in the perception of sexual contact by the partner.

PSYCHOLOGICAL BENEFITS
1. Better quality of life through CISH despite hysterectomy 2. Very low incidence of cervical stump carcinoma compared to sub-total hysterectomy via laparoscopy without coring of the inner cervix and total hysterectomy.

BIBLIOGRAPHY
1. Freund WA. Bemerkungen zu meiner Methode der Utuerusextirpation. Zbl Gynkol, 1878;2:497-500. 2. Tervil I. Carcinoma of the cervical stump. Acta Obstet Gynecol Scand, 1963;42:200. 3. Semm, K. Hysterektomie per laparotomiam oder per pelviscopiam. Geburtsh Frauenheilk, 1991;51:996-1003. 4. Semm K. Morzellieren und Nhen per pelviskopiam kein Problem mehr. Geburtsh Frauenheilk, 1991;51:843-46.

5. Semm K. Prophylaxe der Sterilitt durch minimal invasive Chirurgie. Der Frauenarzt, 1994;35:944-54. 6. Mettler L, Semm K, Shah A, Shah P. Intrafascial supracervical hysterectomy without colpotomy and transuterine mucosal resection by pelviscopy and laparotomy our first 200 cases. Curr Invest in Gynecol Obstet, 1993;9:359-62. 7. Mettler L, Semm K, Lttges J, Panadicar D. Pelviskopische intrafasciale Hysterectomie ohne Kolpotomie (CISH). Gynkol Prax, 1993;17:509-26. 8. Mettler L, Alvarez-Rodas E, Lehmann-Willenbrock E, Lttges J, Semm K. Intrafascial supracervical hysterectomy without colpotomy and transuterine mucosal resection by pelviscopy and laparotomy. Diagn Therap Endosco, 1995;1:201-07. 9. Mettler L, Semm K, Lehmann Willenbrock E, Shah A, Shah P, Sharma R. Comparative evaluation of classical intrafascial supracervical hysterectomy (CISH) with transuterine mucosal resection as performed by pelviscopy and laparotomy our first 200 cases. Surg Endosc, 1995;9:418-23. 10. Mettler L, Semm K. Subtotal versus total laparoscopic hysterectomy. Acta Obstet Gynecol Scand, 1997;164(Suppl):88-93. 11. Kim DH, Bae DH, Hur M, Kim SH. Comparison of classic intrafascial supracervical hysterectomy with total laparoscopic and laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc, 1998;5:25360. 12. Lyons TL. Laparoscopic supracervical hysterectomy. Obstet Gynecol Clin North Am, 2000;27:441-50. 13. Okaro EO, Jones KD, Sutton C. Long term outcome following laparoscopic supracervical hysterectomy. BJOG, 2001;10:1017-20. 14. Morrison JE Jr, Jacobs VR. 437 Classic intrafascial supracervical hysterectomies in 8 years. J Am Assoc Gynecol Laparosc, 2001;8(4):558-67. 15. Milad MP, Morrison K, Sokol A, Miller D, Kirkpatrick L. A comparison of laparoscopic supracervical hysterectomy vs laparoscopically assisted vaginal hysterectomy. Surg Endosc, 2001;3:286-8. 16. Mettler L. Manual for Laparoscopic and Hysteroscopic Gynecological Surgery. Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, 2006. 17. Salfelder A, Lueken RP, Bormann C, et al. Die suprazervikale Hysterektomie in neuem Licht. Wiederentdeckung als minimalinvasive Methode. Frauenarzt, 2003;44:1071-75. 18. Bojahr B, Raatz D, Schonleber G, Abri C, Ohlinger R. Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique. Journal of Minimally Invasive Gynecology, 2006;13(3):183-89. 19. Lyons TL, Adolph AJ, Winer WK. Laparoscopic supracervical hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc, 2004;11:170-74. 20. Learman LA, Summitt RLL; Varner RE. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcome. Obstet Gynecol, 2003;102:453-462, 2003.

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John Morrison Jr INTRODUCTION

CISH Hysterectomy
(15 Years Experience in Rural US)

TECHNIQUE
LIMITATION
The indications for CISH hysterectomy are similar to those for any patient who is a candidate for hysterectomy. Prior to beginning utilisation of CISH technique at any institution, it is important to discuss the technique and resulting operative specimens with the pathologists so adequate evaluation of the tissue is performed. The only exclusion criteria at our institution, that are specific for this procedure include the presence of carcinoma or weight greater than 180 kg. Previous surgery or uterine size is not considered exclusion criteria.

CISH hysterectomy was conceived and developed by Prof. Kurt Semm at the Department of Obstetrics and Gynaecology of the Christian-Albrechts-University in Kiel, Germany in September 1991. The procedure was developed as an alternative to abdominal or vaginal hysterectomy in order to maintain the integrity and the support of the vagina, while completing the objectives of a hysterectomy. Technical differences between hysterectomy choices are listed in Table 15.1 comparing support of the vagina, potential amputation of the vagina during surgery, maintenance of the integrity of the vascular and nerve supply to the vagina and cervix, and potential for cervical carcinoma reduction. The CISH procedure was adopted at our institution in November 1992. Our facility is located in the rural southern United States and CISH has been performed continuously there until the present time. The procedure was performed at either an acute care 50 bed hospital with outpatient surgical facility or ambulatory surgical centre by a single surgeon. Description of the technique, report of results and follow-up will be discussed.

Carcinoma
The technique is not appropriate for carcinoma, as it involves leaving some of the cervical myometrium behind, and morcellation of the uterine body is performed thus creating the potential for seeding or dissemination of malignant cells intraperitoneally during morcellation. Two patients were discovered to have a previousely unknown Stage I endometrial carcinoma after the CISH

Table 15.1: Technical differences of hysterectomy choices Hysterectomy Vaginal Abdominal Supracervical CISH Support of vagina intact No No Yes Yes Vaginal amputation 2+ 1+ 0 0 Vascular supply + innervation intact No No Yes Yes Cervical carcinoma reduction Yes Yes No Yes

CISH Hysterectomy (15 Years Experience in Rural US) hysterectomy was performed, however, the malignancy was confined to the endometrial surface of the specimen and was removed entirely by coring out of the endocervival canal and endometrial cavity. Both patients were free of recurrence from their cancer 10 years after surgery. Both patients interestingly also refused any further surgery and still had their cervical remnant intact at ten years. We continue to preoperatively evaluate all patients that have either an abnormal pelvic ultrasound or age greater than 40 years by utilising endometrial biopsy or Dilatation and Curettage to detect those that have carcinoma.

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The vagina is prepped, a Foley catheter is inserted into the bladder and the abdomen is then prepped. Step 1: The cervical os including the transition zone is removed in a conisation fashion using electrocautery and a uterine manipulator is inserted into the endometrial canal (Figure 15.2).

Weight Limitation
Regarding weight limitations, patients >180 kg present several problems. First, is the limitation of the surgical bed itself. Steep Trendelenburg is used in this technique (Figure 15.1) and the devices available to hold the patient on the table are limited and can result in a transient brachial plexus injury or slippage of the patient on the table.

Figure 15.2: Uterine manipulator Step 2: The abdomen is entered using the open technique, a Hasson cannula is inserted and either a 30 or 45 laparoscope is used for visualisation. The use of an angled laparoscope is felt to be very important for adequate visualisation of the pelvic side walls for ureter identification and very useful in cases of large uteri. The patient is placed in extreme Trendelenburg position and a 5 mm operative cannula is placed in each lower quadrant. A 12 mm cannula is placed in the midline above the symphysis pubis (Figure 15.3).

Figure 15.1: Steep Trendelenburg Instrumentation until recently had been inadequate to reach the pelvis in morbidly obese patients once the abdomen is insufflated. This issue may be less of a problem since gastric bypass has become more popular, and longer instruments have become more available now. So the weight limitation issue may become less of a factor in the future.

SURGICAL PROCEDURE
The patient is placed on the operative table in lithotomy position with arms tucked to the sides and shoulder restraints placed to accommodate the steep Trendelenburg position used during surgery.

Figure 15.3: Port placement

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The round ligaments, and broad ligaments are divided using either, bipolar or monopolar cautery. Harmonic scalpel has also been used, but the linear cutting stapling device is our preferred method as it is quick and leaves healthy viable tissue behind, however, it is expensive as compared to other sources available for mobilisation of these structures. The uterus is elevated out of the pelvis using the manipulator and the peritoneum over the cervical isthmus is incised and a loop of absorbable suture is placed around the cervical isthmus (Figure 15.4).

Figure 15.5: Morcellation instruments

Figure 15.4: Loop around cervical isthmus Step 3: The endocervical canal and endometrial cavity are removed utilising a morcellation system which was developed to stay within the fascia of the uterine body during morcellation. A guide rod is first inserted into the endocervical canal then advanced until it perforates the fundus of the uterus. Next a morcellator placed over a guiding/stabilizing instrument is fed onto the guide rod and the endocervical canal and endometrium is cored out. As the specimen is removed, the previously placed loop is secured, controlling bleeding and the escape of insufflation gas. The specimen (endocervical canal and endometrial cavity) with the previously removed cervical cone is sent to pathology (Figures 15.5 to 15.7). Step 4: The remaining cervical stump may be left open, coagulated, cauterised or sutured, (which is our preference), with absorbable suture (Figure 15.8). Step 5: Two more loops are placed around the uterine body at the cervical isthmus and the uterine body is transected using hook scissors from the cervical stump (Figure 15.9). Step 6: The 12 mm cannula is replaced with either a 15 mm or 20 mm cannula and the uterine body is morcellated through this cannula. The specimens are sent for histologic evaluation (Figure 15.10). An alternative method to

Figure 15.6: Guide rod in endocervical canal with morcellator

Figure 15.7: Endocervical canal with endometrium on guide rod intraperitoneal morcellation, is to place the uterine body in a specimen bag and remove it through the Hasson site.

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Step 7: Both round ligaments are then sewn to the remaining cervival stump with nonabsorbable suture to provide extra support for the vaginal vault. The peritoneum is then closed over the cervical stump to reduce the potential for adhesion formation (Figure 15.11).

Figure 15.8: Closed cervical stump

Figure 15.11: Reperitonealisation

RESULTS
A total of 786 patients were operated on between November 1992, and March 2007, all procedures with the exception of three were completed successfully laparoscopically. Two of the patients had large uteri which filled the entire pelvis and visualisation was very poor. The third patient weighed 400+ lbs. and the instruments could not reach the pelvis for adequate access. This instrument limitation problem has been addressed earlier. All three were converted to open procedure and no other problems were encountered. There were no instances of ureter, bladder, vascular or bowel injury during surgery.

Figure 15.9: Transection of uterine body from cervical stump

OPERATIVE DATA
Average operative time was 1hour 26 minutes with a range of 46 minutes to 6 hours 10 minutes (62% of the patients had more than one procedure performed). Average blood loss was 72 ml with a range of 10 ml to 765 ml. Average length of stay was 22 hours with a range of 3 hours to 5 days. Average return to work was 14 days with a range of 3 days to 4 weeks.

Figure 15.10: Morcellation of uterine body

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Manual of New Hysterectomy Techniques that of a well defined cystic structure in the cervical stump remnant. The pathologic finding in these cases is that of Nabothian cyst histology. Most patients request marsupialisation of the cystic cavity and this appears to result in good long-term resolution. Fourteen of 786 patients, for an incidence of 1.8%, were seen with a mucocele. Eleven underwent marsupialisation of the lesion as an outpatient procedure without subsequent recurrence. Three did not request anything be done about the structure. The time to diagnosis ranged from 2 to 72 months after CISH, with no particular risk factors or pattern noted.

All patients were seen in follow-up at one week and three weeks post discharge.

COMPLICATIONS
SHORT-TERM (OPERATIVE)
One patient had laparotomy for bleeding from the cervical stump as a result of dislodged endoloops from the cervical stump. One patient developed a pelvic haematoma at postoperative day 5 which resolved spontaneousely with conservative treatment. One patient developed an ileus postoperative which required only nasogastric suction. One patient underwent laparoscopy at postoperative day 3 for unusually excessive postoperative pain and no abnormality was seen. One patient developed DVT at postoperative day 10, requiring anticoagulation.

Long-term Bleeding
Bleeding >30 days postoperatively was encountered in 5 of 786 patients for an incidence of 0.6%. This is a frequently discussed problem in the literature after standard supracervical hysterectomies as a result of retention of endometrial tissue. Two patients were seen at 2 years postoperatively, 1 at 2.5 years, 1 at 4 years and 1 at 5 years. Treatment consisted of 2 having a wider conisation of the cervical stump with retention of some of the cervical myometrium, 2 had excision of the entire cervical stump and one did not want any further treatment. Pathological examination of the excised stump failed to demonstrate any remaining endometrial tissue or other histologic abnormality accounting for the bleeding. Of the patients who underwent conisation or excision, no further bleeding was noted.

SHORT-TERM (CERVICAL)
Most patients experience some bleeding from the cervical stump for up to 21 days postoperative. A total of 12 out of 786 patients or 1.5% experienced bleeding to the point that required intervention: 3 were seen and treated in the Emergency Department with topical haemostatics and packing. 4 required suturing in the operating room 5 were treated with packing as an outpatient. The cause of this early bleeding is felt to be multifactoral as there was not any specific pattern or commonly identifiable cause recognised. Maintenance of the blood supply to the cervical stump, combined with early resumption of activity, including sexual intercourse and use of absorbable suture probably accounts for these occurrences. On examination of patients three weeks after surgery approximately one-half of the sutures are gone from the cervical stump suture line indicating that the sutures are dissolving prior to complete healing of the cervical stump.

Pain Long-term
Chronic pain was noted in 5 patients for an incidence of 0.6%. All 5 patients underwent excision of their cervical stump remnant. The length of time from hysterectomy to excision of the stump for pain was: 1 year, 2 years, 5 years, 8 years and 9 years. All had resolution of their symptoms after removal of the remaining cervical stump. No significant histological abnormality was identified accounting for the pain in the specimens removed.

Leiomyoma and Endometrioma

One patient had a leiomyoma develop in the cervical stump at 6.5 years postoperative and had only the leiomyoma excised. This was discovered on routine physical examination and pelvic ultrasound where the patient had not related any particular symptoms or problems. One patient had an endometrioma develop in the pelvis 4 years postoperative which was excised. One concern for morcellation of the uterine body intraperi-

LONG-TERM (CERVICAL) Mucocoele

The majority of long-term problems deal with the cervical stump remnant. The most common problem seen is mucocele formation. This usually presents either as a finding on routine physical examination or as a finding on workup for pressure or pain in the pelvis postoperatively. Ultrasound findings in these instances are

CISH Hysterectomy (15 Years Experience in Rural US) toneally was the potential for production of endometriosis by seeding. Thus far this is the only patient that we are aware of in our practice that has had documented endometriosis post-CISH that has required excision. Whether there is sub clinical endometriosis present or not in post-CISH patients is difficult to say, however, there have been numerous opportunities to examine the pelvis in CISH patients who were operated on for other problems and no evidence of endometriosis was seen.

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DISCUSSION
CISH hysterectomy has become the procedure of choice at our institution for benign uterine disease. The majority of patients were very satisfied with the procedure, citing minimal postoperative pain, good cosmetic results and quick return to normal activities being important factors in their decision to have this procedure. Many patients are referred to our facility for the procedure by previous patients. When the procedure was explained to them, the patients like the idea of leaving the support, blood supply and innervation to the vagina and cervical stump intact. Because of internet and information access, patients are becoming more informed regarding the different techniques available to them and are seeking out surgeons who perform this type of hysterectomy. The procedure can be done in a small rural community or other setting which has limited resources as well as in large academic centres. The basic principles of the technique, i.e. leaving the support structures, blood supply and cervical innervation intact can be accomplished by utilising instruments as described, designed specifically

for this procedure or with slight modification of technique, instruments readily available to any surgical centre that currently performs laparoscopic surgery are adequate. This makes the procedure available in most areas where cost is a major driving force and resources are limited. CISH hysterectomy is a technique which is being performed in many countries across the globe, Germany, China, Korea, Italy, Mexico, the US Austria, Argentina, Chile, to name a few, by a variety of surgeons with good results. The questions regarding the safety and efficacy of this procedure are no longer unanswered, making it a good choice for hysterectomy for benign disease at any institution where laparoscopic surgery is being performed for gynaecologic disease.

BIBLIOGRAPHY
1. Morrison JE Jr, Jacobs VR. 437 Classic Supracervical Intrafascial Hysterectomies in 8 Years. J Am Assoc Gynecol Laparosc 2001; 8(4):558-67. 2. Morrison JE Jr., Jacobs VR. Classic intrafascial supracervical hysterectomy. J Am Assoc Gynecol Laparosc 2002; 9(3):397-98. 3. Morrison JE Jr., Jacobs VR: Replacement of Expensive, Disposable Instruments With Cheap, Old-fashioned Surgical Techniques for Improved Cost-effectiveness in Laparoscopic Hysterectomy. JSLS 2004; 8(2):201-06. 4. Morrison JE Jr, Jacobs VR. Outpatient Laparoscopic Hysterectomy in a Rural Ambulatory Surgery Center. J Am Assoc Gynecol Laparosc 2004; 11(3):359-64 5. Morrison JE Jr, Jacobs VR. Classic Intrafascial Supracervical Hysterectomy (CISH): 10-Year Experience. JSLS 2006;10(1):26-29.

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ABSTRACT STUDY OBJECTIVE DESIGN

Laparoscopic Supracervical Hysterectomy

A Standardised Safe Minimal Invasive Technique (Experience of 3,920 Operations)

B Bojahr, D Raatz, G Schnleber

history of caesarean sections (2 and 3 respectively). The most common postoperative complications were bleeding from the cervix and pain caused by adhesions or postoperative infection. CONCLUSION Our standardised LASH-technique represents a minimally invasive approach for the treatment of uterine myomas and menorrhagia with a low perioperative complication rate, short hospital stay a rapid period of convalescence. Special significance of the LASH is that it can be performed on nulliparous patients, patients who have not previously had a vaginal delivery and patients who have had previous abdominal surgery. It provides a minimally invasive alternative to all other methods of total hysterectomy in benign conditions, and has a low perioperative morbidity.

The aim of the study was to determine perioperative morbidity and complication rate following a standardised technique of laparoscopic supracervical hysterectomy (LASH).

Retrospective analysis of consecutive patients. SETTING Private Hospital. PATIENTS 2334 consecutive patients with symptomatic uterine myomata, dysfunctional uterine bleeding, dysmenorrhoea, or chronic pelvic pain. INTERVENTION LASH using a unipolar hook for dissection of the body of the uterus followed by electric morcellation. RESULTS The main indications for the LASH were uterine myomata with dysfunctional uterine bleeding or without (83.4%), therapy resistant dysfunctional uterine bleeding (10.7%) and suspected uterine adenomyosis (5.2%) . The mean uterine weight was 226.8 gm, the mean duration of surgery was 87 minutes. More than half of the patients (52.9%) had a history of at least one previous laparotomy. In 17 patients (0.7%) a conversion to laparotomy was necessary. Of these 14 were due to the size and immobility of the uterus, one case was due to severe adhesions and in two cases because intraoperative complications arose. In total five (0.2%) intraoperative complications occurred. The mean uterine weight in 5 intraoperative complications (3 bladder injuries, 1 ureter injury, and 1 severe intraoperative bleed) was 818 gm. In two of the patients who suffered trauma to the bladder there was a

INTRODUCTION
At the Hospital for Minimally Invasive Surgery in Berlin, the technique of laparoscopic supracervical hysterectomy (LASH) was introduced, established and standardised by Dr Raatz in 1998. In case of benign disorders of the body of the uterus, the usual procedure is still a total hysterectomy. The minimally invasive approach enables the supracervical hysterectomy to be performed with minimal complications, and in some cases even on an outpatient basis. In line with the concept of minimally invasive surgery, laparoscopic supracervical hysterectomy removes only the diseased tissuethe body of the uterus and not the cervix, which generally has nothing to do with the symptoms. From 1998 to 2006, the Hospital for MIC performed 3920 LASH. The number of operations rose steadily from 17 in 1998, 287 in 2000, 618 in 2003 to 796 in 2006. This reflects not only the level of acceptance on the part of patients, but also in attitude of gynaecologists toward this surgical technique.

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Figure 16.1: Patient positioning and OR equipment

MATERIALS AND METHODS

The retrospective study is based on data collected from 2334 consecutive patients who were treated at the MIC Hospital in Berlin between June 27, 1998 to October 31, 2004. They had a diagnosis of a benign condition of the uterus and were therefore selected to undergo LASH. The indications for a LASH were uterine myomata, therapy resistant dysfunctional uterine bleeding, and suspected uterine adenomyosis. The operative technique was standardised and was carried out by three surgeons in the hospital as follows. Following disinfection of the vagina and catheterisation of the bladder, the patient is in a horizontal with outstretched legs (Figure 16.1). The surgeon, the assistant and the surgical nurse with instrument tables stand on the left side of the patient. The monitors and endoscopy tower with the electronic equipment are located to the right of the patient (Figure 16.2). We dont use any uterus manipulators. Carbon dioxide insufflation via a Verres, needle placed through an incision in the inferior umbilical fossa will be performed to an intra-abdominal pressure of 15 mmHg. After introduction of a 5 mm trocar through this incision the obligatory full visual sweep is then done with the routinely used 30 laparoscope. For this the patient position is changed into maximum Trendelenburg position. Under direct visual guidance two 5 mm trocars are then introduced left and right lateral to the epigastric vessels in the region of the pubic hair border (in case of a normal sized uterus) (Figure 16.3). The localisation of the additional two trocars depends on uterine size. This means that the larger the uterus, the further above the symphysis pubis the lateral trocars need

Figure 16.2: The surgeon, the assistant, the scrub nurse and the instrument table are positioned on the left side of the patient to be positioned. In the case, that the uterus extended as far as the umbilicus, we therefore isufflate on the left, below the costal arch, and then introduce a trocar there or in the umbilicus (Figure 16.4). The position of additional trocars is dependent on size of the uterus and should be correspondingly higher to enable the adnexa to be dissect. For the LASH only a few re-usable instruments are used. In addition to the standard 5 mm instruments a bipolar coagulation clamp, Metzenbaum scissors, three various grasping forceps, a needle holder, a unipolar hook, and a suction-irrigation system are used. To mobilize the uterus the round ligaments, the fallopian tubes and the ovarian ligaments will be coagulated with bipolar forceps (Figure 16.5) and subsequent dissected with endoscopic Metzenbaum scissors

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Figure 16.3: Trocar placement for a LASH (normal sized uterus)

Figure 16.5: Bipolar coagulation of the round ligament, the fallopian tube and the ovarian ligament

Figure 16.4: Trocar placement in cases of enlarged uteri

Figure 16.6: Dissection of the round ligament, fallopian tube and ovarian ligament from the right side with a pair of scissors undermined using scissors. The bladder peritoneum can then be opened and the bladder will be pushed slightly caudally (Figure 16.8). Following identification and skeletonisation of the uterine vessels, they are then coagulated with the bipolar forceps and dissected using the Metzenbaum scissors (Figures 16.9 to 16.11). The bladder peritoneum then can be once again mobilised from the anterior surface of the cervix. In this situation it is not

(Figure 16.6). For this the uterus is pulled to the contralateral side with grasping forceps. After separating the ovaries and fallopian tubes from the uterus and dissecting through the round ligaments, a bipolar coagulation zone is placed on the bladder peritoneum which then delineates the planned direction of incision to open the bladder peritoneum (Figure 16.7). From the dissected round ligaments, the bladder peritoneum is

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Figure 16.7: A coagulation zone is made on the bladder peritoneum

Figure 16.10: Dissection of uterine vessels

Figure 16.8: Undermining and opening of the bladder peritoneum

Figure 16.11: Dissected uterine vessels

Figure 16.9: Identification and bipolar coagulation of uterine vessels

Figure 16.12: Transection of the corpus uteriThe body of the uterus is pulled toward cranial

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Manual of New Hysterectomy Techniques stump, bipolar coagulation of the cervical canal is performed. Sometimes it is difficult to identify the cervical canal. In this case, the cervix is held from the left with the grasping forceps and then the palpation probe or a bipolar forceps is used to search the entrance into the cervical canal. Coagulation is performed by opening and simultaneously rotating the damp in the cervical canal (Figure 16.15). To peritonealise the cervical stump, we use a vicryl thread shortened to approximately instrument length. The round needle is introduced through the 5 mm incision under vision (Figures 16.16 and 16.17). The cervix stump is covered with peritoneum by means of a continuous purse-string suture (Figure 16.18). Both uterosacral ligaments are included in the suture. After preparing a triple knot (Figure 16.19). The peritoneum is

necessary to push away the bladder as done in a total hysterectomy, as now the uterine body is dissected off in the upper third , cranial to where the uterosacral ligaments leave the cervix. For this purpose we use a unipolar hook. Starting from the left, the uterus is held against the anterior wall with grasping forceps and pulled toward cranial (Figure 16.12). From the right, dissection is carried out step by step with the unipolar hook. During the dissection, major smoke development can be prevented by actuating the suction on the hook. In this phase, clear vision is essential to avoid injuries to adjacent organs (Figure 16.13). We then begin by positioning the dissected body of the uterus in the right-hand mesogastrium to enable haemostasis to be carried out in the wound area (Figure 16.14). After efficient haemostasis in the area of the cervix

Figure 16.13: Transection of the corpus uteri with unipolar hook

Figure 16.15: Bipolar coagulation of the cervical canal

Figure 16.14: Haemostasis in the area of the cervical stump

Figure 16.16: Introduction of a round needle (view from outside)

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Figure 16.17: Introduction of a round needle (endoscopic view)

Figure 16.19: Intra-corporal suture technique

Figure 16.18: Peritonealisation of the cervical stump pulled together and the suture is secured using an additional, fourth knot (Figure 16.20). To be able to remove the uterus, we firstly widen the incision in the left-hand lower abdomen to 10-20 mm. A local anaesthetic is injected beneath the wound area of the left-hand incision. A electric morcellator (STORZ or WISAP) is introduced under direct vision (Figure 16.21) . From the left, the uterus is gripped and pulled into the morcellator, which is activated by means of a footpedal (Figure 16.22). To avoid injuries, it is particularly important that the sharp rotating blade of the morcellator is visible in the centre of laparoscopic image at all times (Figure 16.23). To remove large section of tissue in a single piece, it is helpful to assist the process of morcellation with the right-hand grasping forceps in such a way that the blade is always visible on the surface of the uterus, and

Figure 16.20: Purse-string suture (peritoneum is pulled together) morcellation is thus always performed around the exterior of the uterus (Figure 16.24). The uterus is thus effectively peeled like a potato. At the end of the operation, lavage is performed again and the cervical stump area is checked (Figure 16.25). The peritoneum in the area of 15 or 20 mm incisions will be closed from the inside by means of bipolar coagulation, and closure of the fasciae is also obligatory to avoid incision hernias. The skin is then closed using singlebutton sutures. The final situs for a normal sized uterus shows 5 mm incisions in the umbilicus and on the right in the lower abdomen, and a 15 mm incision on the left (Figure 16.26). If the uterus is very enlarged, a 5 or 10 mm additional port may be necessary. This is usually placed centrally above the symphysis pubis.

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Figure 16.21: Introduction of a 15 mm electric morcellator

Figure 16.24: Morcellation (view from outside)

Figure 16.22: Gripping the uterus from the left

Figure 16.25: Final situs after LASH (endoscopic view)

Figure 16.23: The sharp rotating blade of the morcellator is visible during morcellation

Figure 16.26: Final abdominal situs

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RESULTS
In the study period data was collected on 2334 patients. The indication for surgery in 1946 patients (83.4%) were uterine myomata, in 250 patients (10.7%) dysfunctional uterine bleeding, in 124 patients (5.2%) suspected uterine adenomyosis, and in a further 14 cases (14%) prolaps problems. A total 1428 patients (61.2%) had had at least one previous operation documented in their medical history. 37.8% of the patients had had at least one surgical procedure and 23% at least one gynaecological procedure. Nine hundred and six patients (38.8%) had no recorded history of previous surgery. Of all the patients, 1216 (53.1%) had a history of at least one previous laparotomy. When relating the duration of the surgery to the year it was performed, data shows a steady reduction of mean surgery duration from 159.1 minutes in 1998 to 80.6 minutes in 2003. In 17 cases a conversion to laparotomy was necessary. This equates to a conversion rate of 0.7%. In two patients it was necessary to proceed to a laparotomy due to intraoperative complications. Of these complications, one was a bladder injury and the other severe bleeding from the uterine artery where laparoscopic haemostasis could not be achieved. The patient who suffered the bladder injury had a past medical history of three caesarian sections. In a further patient it was necessary to proceed to laparotomy due to severe adhesions and in another a conversion was necessary because of adhesions and uterine bulk. In the other 13 cases laparotomy was performed solely because of the bulkiness of the uterus and its immobility. The patient who suffered the intra-operative bleed has a uterine weight of 2400 g. Only two of the five complications that occurred intraoperatively were immediately recognized and dealt with by converting to laparotomy. Two bladder injuries and one ureteric injury were only recognized postoperatively and subsequently treated. The two bladder injuries were treated with a bladder suture by laparotomy, and the patient with the ureteric fistula was treated by ureteric splinting following diagnosis by laparoscopy. In total further surgical intervention was necessary in 17 patients of which 14 of these had had postoperative complications. When viewing the complication rate in relation to uterine weight, this equates to a complication rate of 1.5%

in the uterine weight class I up to 100 gm, 1.4% in class II with weights between 101 and 500 gm, 1.5% in class III with weights 501 to 1000 gm, and 7.1% in class IV of more than 1000 gm. Five intraoperative complications described above, one bladder injury and one ureteric injury occurred in the uterine weight class II. Two further bladder injuries occurred in class III, and the bleed from the uterine artery occurred in class IV. Of these five complications, the mean uterine weight was 818.4 gm. It is noteworthy that in two cases of the intraoperative bladder injuries the patients had had three caesarean sections and an appendectomy and two caesarian sections and an appendectomy respectively. Specific analysis of the five serious intraoperative complications did not show that these occurred more frequently in the initial phase of this method of surgery. Three of the intraoperative complications occurred with surgeon 1 during operations number 181, 307 and 667. One complication occurred with surgeon 2 during his 171st operation, and with surgeon 3 the complication occurred during the 18th operation.

CONCLUSION
The results of this study show that the laparoscopic supracervical hysterectomy represents a minimally invasive approach for the treatment of uterine myomata, dysfunctional uterine bleeding, and uterine adenomyosis, providing pre-malignant or malignant changes of the cervix and uterus have been ruled out. The described standardised minimally invasive surgical technique is simple to learn and can be performed with a few simple, re-usable, standard surgical instruments, in comparison with other modifications of this technique described in the literature. The electric morcellator is a more cost-intensive piece of equipment. It is, however, absolutely essential for the LASH procedure, as it has a significant influence on surgery time. Special significance of the LASH is that it can be performed on nulliparous patients, patients who have not previously had a vaginal delivery and patients who have had previous abdominal surgery. It provides a minimally invasive alternative to all other methods of total hysterectomy in benign conditions, and has a low perioperative morbidity.

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Adolf Gallinat INTRODUCTION

Endometrial Ablation Contrahysterectomy: Who Takes the Decision?

The modern endometrial ablation started in 1981 after decades and several attempts1 with the description of Goldrath, Segal and Fuller about Laser photocoagulation of Endometrium for the treatment of menorrhagia in the AJOG.2 At that time the only surgical alternatives being vaginal or abdominal hysterectomy. The next revolutionary step, which would change the entire operative strategies about 15 years later, was the first laparoscopic hysterectomy in 1989 by H. Reich.3 It took an additional years till several groups started with laparoscopic assisted vaginal hysterectomy (VALH). CASH, later called CISH4 was developed and finally, after many forms of laparoscopic hysterectomies there was a renaissance of old fashioned supracervical hysterectomy, now performed on laparoscopic way (LASH).5 As most minimal invasive, not touching pelvic floor, compared to other types of hysterectomies, dissection is easiest while complication rate is very low. This kind of procedure can

be performed in day surgery6 under special circumstances. Even radical Wertheim like procedures with all kind of lymphonodectomies are nowadays being performed in special centers (see special chapters).

INDICATIONS FOR HYSTERECTOMY

In Germany there are about 150.000 hysterectomies performed each year (Figure 17.1). 10% till 15% because of malignancies (or premalignancies), because of fibroids or additional gynaecological pathology like descensus, incontinence etc. Probably the majority is performed due to sole dysfunctional uterine bleeding disorders, which is nowadays the indication for endometrial ablation.

ENDOMETRIAL ABLATION TECHNIQUES

In the last 26 years after introduction of photocoagulation of endometrium various methods (Figure 17.2) have been developed. All these different methods have been

HysterectomyPyramid 120.00015.000 pa.

Figure 17.1: Indications for hysterectomy

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most important are the late results showing how often hysterectomy or additional surgery can be avoided at all. These data are now available for the first generation of endometrial ablation techniques. Long-term follow-up result in success rate of about 80%. For the second generation these data are not yet available. But preliminary data indicate better results at lower complication rates.

NOVASURE TECHNOLOGY
Figure 17.2: Endometrial ablation techniques First generation (hysteoscopic techniques) Second generation (global techniques) demonstrated and discussed with its advantages and disadvantages at a consensus meeting in Teaside (UK) 2001. All data are published in Gynaecological Endoscopy.7 All participants agreed, that the methods, showing the lowest complication rate are preferable. Although the efficacy of different methods using the Highhams Score (PCAC)8 are proved by bleeding reduction, but finally Most effective, in my opinion, is the NovaSure system, which we introduced in our department in 1998. This new technology offers many advantages and including several safety features: This NovaSure system consists of a bipolar ablation device (Figure 17.3) and a radio-frequency controller (Figure 17.4) that enables endometrial ablation in an average of 90 seconds. No endometrial pre-treatment of any kind (mechanical, pharmarzeutical, timing) is required. Once the uterine cavity length is sounded, after intrauterine placement of the conformable gold plated porous device, cavity width is measured by the device.

Figure 17.3: NovaSure application device

Figure 17.4: NovaSure multifunctional controller

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These two values are key entered into the controller, which automatically calculates the power output necessary to ensure an optimal ablation. Continuous monitoring of tissue impedance during the procedure allows for controlled depth of ablation. Endometrium is vaporised and evacuated from the uterine cavity by continuous section. Once the myometrial layer is reached, tissue impedance increases and quickly reaches 50 Ohms (equivalent to impedance of ablated superficial myometrium) and the system automatically terminates the ablation. The device is inserted transcervically into the uterine cavity; the sheath retracted deploying the fan shaped bipolar electrode that conforms to the uterine cavity.

SAFETY FEATURES
A cavity integrity-assessment system is an integral part. This automatic safety feature allows the physician timely detection of uterine wall perforation, thus preventing energy delivery. A small amount of carbon dioxide is delivered via the device into the uterine cavity. Once proper CO2 pressure is maintained, confirming good uterine wall integrity, the controller proceeds with ablation. A constant vacuum is generated during the entire procedure, which continuously removes blood, endometrium, steam and vaporisation by products generated during the bipolar electrosurgical process, and assures an intimate apposition between electrode and endometrium. A prospective study started in Nov. 1998. A total of 107 premenopausal women with menorrhagia secondary to DUB were enrolled (Figure 17.5). Medium age was 42.2 years (Figure 17.6). Follow-up was initially performed at 6 and 12 month. The PBAC score was used to assess the amount of bleeding to correlate to the classification approved by the World Health Organisation (amenorrhoea, spotting, hypomenorrhoea, eumenorrhoea, menorrhagia).9

Figure 17.6: Prospective NovaSure study results at 12 months follow-up

RESULTS
The results of the 12 month follow-up, differ from to all others endometrial ablation systems as nearly all patients reported amenorrhoea or spotting. Even hypomenorrhoea is a rare outcome. Interesting, when comparing the 6 months with the 12 month results (Figure 17.7), a steady state is reached very late at 9 or 10 months. That means the final bleeding status after bipolar endometrial ablation is seen after about 1 year. Follow-up data after three years10 suggest strong result stability (plateau phase between 1 and 3 years follow-up). Now at the 5 years follow-up an increase of amenorrhoea, because first patients are becoming climacteric (Figure 17.8).

FAILURES
Three patients underwent hysterectomy during the five year follow-up.10 On re-ablation was performed on a patient that failed initial therapy during the first year follow-up. Therefore, five years after NovaSure ablation, hysterectomy was avoided in 97,1% and no additional intervention necessary in 96.2% respectively (Figure 17.9).

COMPLICATIONS
Treatment was performed in general anaesthesia (TIVA). There were no complications in connection with to anaesthesia or the operation itself. All patients were dismissed after 2 to 4 hours, while complete recovery took 1 till 4 days. Our NovaSure study shows an evident improvement of the second generation endometrial ablation techniques compared to the first generation.

Figure 17.5: Prospective NovaSure study pretreatment protocol of 107 patients

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Figure 17.7: Prospective NovaSure study patient data

Figure 17.8: Prospective NovaSure study Result at 3 and 5 years follow-up

Figure 17.9: Prospective NovaSure study Durable long-term success rates Failures at 5 years follow-up

ENDOMETRIAL ABLATION CONTRAHYSTERECTOMY

In conclusion in cases of bleeding disorders, according to accurate diagnose Endometrial Ablation is method

of choice for dysfunctional bleeding disorders, while in patients with organic changes an appropriate treatment is necessary (Figure 17.10). Therefore, it is now no more the question of emndometrial ablation contra-hysterectomy.

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Figure 17.10: Selection of different minimal invasive methods according to diagnosis

Figure 17.11: Exact selection of endoscopic treatment according to diagnosis

DECISION
The possibility to select the appropriate minimal invasive method for the specific case leads to an optimal outcome. As a result of an exact selection of method according to the diagnostic, there is not only a very low complication rate, but also minimal trauma for the patient (Figure 17.11). It is difficult to keep pace with the fast progressing new technologies and operation methods in the field of gynaecological endoscopy. However, this is a necessity when informing the patients about their specific case and make the decision of the corresponding optimal therapy, after which the patient has to give her consent.

REFERENCES
1. Badenheuer FH: Elektrokoagulation der Uterusschleimhaut zur Behandlung klimakterischer Blutungen. Zentralblatt fr Gynkologie 1937;4:209-11.

2. Goldrath MH, Fuller TA, Segal S. Laser photova-porization of endometrium for the treatment of menorrhagia. Am J Obstet Gynecol 1981;104:14-99. 3. Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213-16. 4. Semm, K. Hysterektomie per laparotomiam oder per pelviskopiam, Ein neuer Weg ohne Kolpotomie durch C*A*S*H*. Geburtsh. Frauenheilk. 1991;51:996-1003. 5. Salfelder, A., et al. Die suprazervikale Hysterektomie in neuem Licht. Frauenarzt 2003;44:1071-75. 6. Salfelder, A, et al. Laparoscopic Supracervical Hysterectomy. Geburtsh. Frauenheilk. 2005;65:390-403. 7. Garry R. Evidence and techniques in endometrial ablation: consensus. Gynaecological Endoscopy 2002;11:5-17. 8. Higham JM, OBrien, PMS, Shaw, RW. Assessment of menstrual blood loss using a pictorial chart. British Journal of Obstetrics and Gynaecology 1990;97:734-39. 9. Gallinat A, Nugent W. NovaSure Impedance-Controlled System for Endometrial Ablation. J Am Assoc Gynecol Laparosc 2002;9:279-85. 10. Gallinat A. NovaSure Impedance Controlled System for Endometrial Ablation: Three-Year Follow-Up on 107 Patients. Am J Obstet Gynecol 2004;191:1585-89.

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INTRODUCTION

Hysterectomy for Large Uteri

Alfonso Rossetti, Ornella Sizzi, Alessandro Loddo

Hysterectomy is the most commonly performed gynaecological surgical procedure and one of the most frequently performed major surgical procedures. The recent national surveillance data from 1994 to 1999 showed that 600,000 hysterectomies were performed yearly in the United States, of which approximately 90 percent were done for benign conditions. Traditionally, hysterectomy was performed using either an abdominal or vaginal approach. More recently, laparoscopic techniques have been used. Henry Reich performed the first laparoscopic hysterectomy in 1988. There are a variety of operations where the laparoscope is used as an aid to hysterectomy:1 laparoscopic-assisted vaginal hysterectomy (LAVH) is a vaginal hysterectomy after laparoscopic adhesiolysis, endometriosis excision, or oophorectomy. This term is also used when the upper uterine ligaments (e.g. round, infundibulopelvic or utero-ovarian ligaments) of a relatively normal uterus are ligated with staples or bipolar desiccation. Laparoscopic hysterectomy (LH) denotes laparoscopic ligation of the uterine arteries either by electrosurgery desiccation, suture ligature, or staples. All surgical steps after the uterine vessels have been ligated can be done either vaginally or laparoscopically, including anterior and posterior vaginal entry, cardinal and uterosacral ligament division, uterine removal (intact or by morcellation), and vaginal closure (vertically or transversely). Laparoscopic ligation of the uterine vessels is the sine qua non for laparoscopic hysterectomy. Total laparoscopic hysterectomy (TLH) denotes that after all vascular pedicles are ligated, the laparoscopic dissection continues until the uterus lies free of all attachments in the peritoneal cavity. The uterus is then removed through the vagina, often with laparoscopic and/or vaginal morcellation. The vagina is closed with laparoscopically placed sutures. No vaginal surgery except for morcella-

tion is done. There are many surgical advantages to laparoscopy, particularly magnification of anatomy and pathology, access to the uterine vessels, vagina and rectum, and the ability to achieve complete hemostasis. Nowadays the laparoscopic hysterectomy for a uterus weighing 300 grams or less, without other pathologies that could limit its mobility or without a poor vaginal access, has to be considered a well standardized procedure, alternative to abdominal hysterectomy in case of benign uterine pathology. Recent advances in equipment, surgical techniques and training have made total laparoscopic hysterectomy a well tolerated and efficient technique. It is increasingly being adopted around the world because of the benefits to patients. However, there are some clinical conditions which can turn laparoscopic hysterectomy in a very challenging procedure. These limits are constituted by: the presence of large uterus over 300 grams (or 12 weeks) with or without a poor vaginal access; the presence of adhesions due to previous caesarean sections or previous pelvic surgeries (myomectomies); the presence of pelvic varicosities and the presence of other pathologies like endometriosis. But these are exactly the clinical conditions which represent the main indications to laparoscopic hysterectomy. In fact these are the situations considered as contraindications to vaginal hysterectomy or relative contraindications according to the surgeons experience. Vaginal hysterectomy is very difficult for uteri > 16 weeks. Moreover, a history of pelvic or abdominal operation increases the side injury rate in vaginal hysterectomy.2-4 In practice, it is right that in these conditions most hysterectomies presently performed with the abdominal approach could be done laparoscopically. In the past, the large uterus (> 16 weeks gestation) has also been listed as a relative contraindication to laparoscopic hysterectomy (Figure 18.1).5 However, because of the

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Manual of New Hysterectomy Techniques are beneficial in the correction of preoperative iron deficiency anaemia, if present, and reduce intraoperative blood loss. Although expensive and with adverse symptoms, a preoperative course of GnRH analogues in women with very enlarged uterus may facilitate (and in some case make it possible) laparoscopic hysterectomy, also improving preoperative Hb levels.11

SET-UP AND OPERATION

The operative environment must be prepared for laparoscopic hysterectomy. Equipment must be available, functional, and a backup plan in place to cover any unanticipated malfunction. Nowadays there is available a great variety of different instruments, but only few are essential for performing laparoscopic hysterectomy. Bipolar coagulation forceps, monopolar hook, scissors, grasping forceps, suction-irrigator probe, suturing set and uterine manipulator constitute our basic set for hysterectomy. All of these instruments are reusable. The new sealing vessels bipolar systems (Ligasure, Gyrus or the BiClamp ERBE reusable system) could be handy especially in case of varicosities. The surgeon is on the left side of the patient, the first assistant stands on the right side and holds the camera. All laparoscopic surgery is performed under general anaesthesia with endotracheal intubation. A nasogastric tube is used to deflate the stomach, to avoid trocar injury and to reduce bowel distension. The patient is placed in the lithotomic position with arms tucked at her side to allow free movements for the surgeons and to avoid brachial plexus injury. The legs are supported by stirrups and abducted at 90 to permit mobilization of the uterus by the second assistant. The bladder is catheterized and the uterus mobilized by a manipulator. The role of the uterine manipulator is extremely important in cases of very enlarged uteri, especially for securing uterine vessels. Many functions are required from the uterine manipulators (whether LAVH or total or supracervical laparoscopic hysterectomy is performed): to suitably mobilize the uterus; this goal is obtained by allowing three kinds of movements: anteversion and retroversion, lateral and, very important for TLH, elevation movements; to clearly identify and distend the vaginal fornices to enable a circular section of the vaginal fornices (Figures 18.2 and 18.3); to elevate and define the cervico-vaginal junction to enable a safer dissection of the vesico-uterine fold and fascia (Figure 18.4);

Figure 18.1: Large uterus improvements in laparoscopic techniques and instrumentations in the latest years, clinical feasibility and practicality of laparoscopic surgery to remove enlarged uteri has been demonstrated.6-8 Given that the rationale for the practice of TLH is to convert abdominal hysterectomies into laparoscopic procedures, it seems logic that large uteri in patients with poor vaginal access will be the main indication for laparoscopic hysterectomy. A number of pre-existing clinical conditions generally accepted as contraindications to vaginal hysterectomy will also be associated such as nulliparity or no prior vaginal delivery, previous caesarean or pelvic surgeries, adnexal pathologies, severe endometriosis or requirement of oophorectomy.9 For a skilful laparoscopist, managing a large uterus is both feasible and safe; anyway, very enlarged uteri allow limited access to uterine vascular pedicles depending on size and location of myomas, and may be associated with high risk of complications such as haemorrhage. Other concerns of laparoscopic management of large uteri are the risk of bowel and urinary injury due to poor exposure, difficulty in extracting the uterus and duration of the procedure.10 Unfortunately, TLH in case of large uteri should be modified, to overcome some obstacles. Poor access and exposure are the main concerns that can be overcome by few modifications in technique and preoperative preparation. When the uterus is over 12 weeks in size or when there are multiple large fibroids, gonadotrophin releasing hormone (GnRH) analogues may be given. The administration of analogues reduces the size of the uterus and myoma thus making surgery easier. In most of cases, the use of GnRH analogues for 3 to 4 months prior to surgery reduce both uterine volume and fibroid size. They

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Figure 18.2: Importance of uterine manipulator in fornices presentation

Figure 18.4: Importance of uterine manipulator in uterovesical dissection

Figure 18.5: First entry vision Figure 18.3: Role of uterine manipulator in colpotomy to enable the elevation of the uterus upwards in the abdomen, in order to obtain a good visualization of the uterine artery and its removal from the ureter; to maintain a regular pneumoperitoneum. If we use the closed technique, pneumoperitoneum to 18 mm Hg is obtained before primary trocar insertion and reduced to 12 mm afterwards (Figure 18.5). Everyway, trocar insertion sites should be changed and the option of open abdominal entry should be considered to minimize the risk of lacerating the uterus, if it reaches or exceeds the midline. Using the Palmer point to insert the Veress needle could be another option, especially if adhesions are suspected (Figures 18.6 and 18.7). Obviously there is a physical limit to the space of maneuver of our instruments and to the angle of vision represen-

Figure 18.6: Graphic for Palmer point entry

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Figure 18.7: Palmer point entry

Figure 18.9: Supraumbilical trocar

Figure 18.8: Supraumbilical trocar position ted by the space between the distended abdominal wall and the uterus. The goals are better exposure and handling of the instruments without the hindrance of the uterus. The optic trocar should be placed upto 10 cm above the umbilicus (Figures 18.8 to 18.10). The middle trocar should be inserted beneath the umbilicus or even higher. Lateral suprapubic trocars are inserted higher than usual. These should be placed according to uterine size and location of myomas. The higher the uterus the higher the ancillary trocars should be inserted, at umbilical line or even some centimeters further up. Therefore, instruments that are inserted in lateral trocars will approach the uterine vessels anteriorly and posteriorly to the uterus and above. With these modifications, a larger intraperitoneal manipulation space can be achieved. Or alternatively, the left ancillary trocar should be placed lower to reach better the anterior structures and

Figure 18.10: Vision after introduction of supraumbilical trocar the right ancillary trocar should be placed higher to reach the posterior structures. The uterus is deviated by the second assistant to the contralateral side to the initial operative site to allow maximum access. It is essential that the surgeons assistants are aware of the special need for performing right traction in the different steps of the procedure. When the surgeon is working on the left side, he/she uses the bipolar forceps in the left lateral port and the scissors in the midline (Figure 18.11). The assistant has a grasping forceps to mobilizing the adnexa, showing the operative field or applying traction on the uterus in the opposite direction to allow better exposure of the uterine vessels and cardinal ligaments. On the right side, the surgeon is holding the grasping forceps with the left hand, to allow exposure of the right side and the scissors in the central port. The assistant is using the bipolar forceps

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Figure 18.11: Instruments position on the left side

Figure 18.12: Instruments position on the right side (Figure 18.12). In this way, most of the time, the surgeons do not need to continuously changing instruments during the procedures and all the structures are approached from the best angle. It has to be reminded that the most dangerous times for thermal ureteral injury are during coagulation with bipolar forceps at the right uterosacral and cardinal ligaments, and dissection or coagulation of the right uterine pedicle.12 Therefore, when coagulation is applied on the right side is preferable that the assistant uses bipolar forceps and approaches the vessels at right angles to the ascending branch. As long as surgical techniques incorporate various procedures to avoid ureteric injury, routine ureteric catheterization during laparoscopic hysterectomy is not indicated and may result in unnecessary complications.13 Most patients who have stent placement experience postoperative hematuria; anuria from ureteral spasm following surgery

with a stent in place has been reported. Ureteral catheters are necessary when ureteral injury occurs during surgical dissection; in these cases the stent is left in place for at least six-eight weeks. In larger cases, very often only two of the operative instruments are really in action, the central one and the one on the side we are working at: in fact, the contralateral instrument cannot pass through the uterus. In order to solve this problem, it should be evaluated the possibility to use five operative trocars using an additional instrument for traction and manipulation so as to have the operating field always accessible with three basic instruments (monopolar scissors, bipolar coagulating forceps and grasping forceps).14 It should moreover be remarked that speaking of uterine volume is a little too simplistic: it would be better to precise the uterine shape too. When the transverse diameter of the uterus is relevant we cannot see its isthmic part even if we try to strongly push or pull the uterus by means of a uterine manipulator or by grasping forceps. So, a relatively short but large uterus (pear shaped) may be more challenging than a much bigger one but with an easy access to the main anatomical structures (inverse pear shaped). In such cases, as in case of big myomas impeding a correct vision we advise to switch from a 0 to a 30 laparoscope: in this way a simple change of the angle of vision allows to clearly expose the vesicocervical fold of the visceral peritoneum anteriorly, the uterine vessels laterally and the utero-sacral ligaments posteriorly (Figures 18.13 to 18.16). Drawing strongly the uterus towards one side and using the 30 laparoscope on the opposite side almost always solve any problem of vision, but the fluent and correct use of this endoscope needs a certain time of training. In fact, the assistant has to coordinate the usual movement of the camera with the

Figure 18.13: 0 degrees laparoscope vision

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Manual of New Hysterectomy Techniques rotation of the endoscope. Technical difficulties in the surgical procedure may be greatly increased by the presence of myomas which can encumber depending on their size and localization. In some case, if impeding myomas are encountered in the course of the intervention, it is a matter of surgical judgment to precede the hysterectomy with a myomectomy in order to reduce uterine volume and/or to allow a better vision, for example, of the peritoneal vesicocervical fold. We currently inject a vasoconstrictive agent around myomas, a practice that makes the operative field remarkably bloodless and bloodlessness during both myomectomy and hysterectomy is itself of utmost importance if we want to be highly respectful of anatomy. Use of GnRH analogues could be suggested prior of planned intervention. On other occasions, a strong traction on myomas by grasping forceps is sufficient to obtain a clear view of the operating field. In our routine practice, round ligaments and infundibulopelvic or ovarian ligaments are coagulated and dissected with bipolar scissors, after grasping with the forceps. The round ligament should be coagulated in its midportion with bipolar coagulating forceps far from the uterine horn, to avoid bleeding from the venous plexus running along the uterus. A fenestration is performed, if space allows it, in the posterior leaf of the broad ligament to move the ureter laterally and downwards before coagulation of the infundibolo-pelvic or ovarian ligament. The vesico-uterine fold , elevated and placed on stretch with endoclinch or Manhes forceps, to facilitate inspection of the operative field , is incised by endoshears starting from the round ligament and dissected close to the uterine surface: this lateral approach makes the dissection easier in cases of adhesions due to previous caesarean sections. This careful technique of bladder dissection is very important. In fact, in extreme cases, the bladder may invaginate into a caesarean section scar and be surrounded by uterine myometrium. While the second assistant pushes on the uterus, the valve of the uterine manipulator highlights the anterior fornix and allows the vesicovaginal dissection plane to be entered. Internal pillars of the bladder are coagulated and sectioned up to the uterine pedicles. This step of the procedure is potentially really bloody if the tissue plane is not correctly identified, resulting in poor visualization. Thereafter the uterus is anteverted and anteflexed to show and elevate the uterosacral ligaments. The uterus is pushed upwards into the pelvis and the valves of the uterine manipulator delineate the rectovaginal septum more clearly. The ligaments are intrafascially coagulated and transected, so

Figure 18.14: 30 degrees laparoscope vision

Figure 18.15: 0 degrees on uterine artery

Figure 18.16: 30 degrees on uterine artery

Hysterectomy for Large Uteri that lateralization of the ureter from the uterus is obtained and ureteral injuries are avoided. The uterine vessels are exposed, skeletonized, and only then coagulated and transected. Prior to coagulation, the location of the ureter is once again checked to prevent injury. Well standardized operative techniques for skeletonizing the uterine arteries should be followed, so that the ureters will fall away from the operational field as the surgery proceeds. Adequate exposure of the uterine arteries is achieved by applying traction on the uterus from the contralateral grasper placed on the round ligament. A coagulation is applied on the ascending branch of the uterine artery to avoid back blood flow. Suture-ligating uterine vessels gives the surgeon a referential lateral landmark beyond which no coagulation should occur, but it can be difficult to perform in a narrow space. The difficult exposure can increase the risk of haemorrhage. The surgeon should be experienced in performing ligation and suturing or coagulation of the uterine artery near its origin from the internal iliac artery. The approach proposed by Roman15 consists of coagulation of both uterine arteries at their origins, performed on the onset of the surgical procedure. The second operator grasps and tracks the umbilical artery upwards and the third operator carries out the uterine contralateral mobilisation. The peritoneum is opened on the anterior leaf of the broad ligament, parallel to the infundibulo-pelvic ligament, along the umbilical artery and upward of the crossing with the external iliac artery. The dissection is performed on the medial board of the umbilical artery back to the bifurcation of iliac vessels. The superior bladder artery is crossed and care should be taken in order to avoid the confusion with the uterine artery, which is situated 1-2 cm backwards. Then, uterine artery origin is identified, the pararectal space is opened and the ureter is easy to identify. The uterine artery is coagulated with bipolar current at its origin from the internal iliac artery, while the ureter is tenderly pushed medially in order to avoid electric injuries. The artery is not generally sectioned in order to avoid bleeding. Large uteri yet have the problem of back blood flow and of bleeding due to tractions on the uterus or ligaments applied to facilitate the exposure. The coagulation of the tube and utero-ovarian vessels and the coagulation of the ascending branch of the uterine artery could decrease the back blood flow. Some authors16 have recommended the use of intravenous perfusion (at a rate of 2 mL/min) of 10 Units of oxytocin added to 1000 mL of normal saline to decrease uterine blood perfusion and minimize reflux. Oxytocin infusion can cause uterine contractions that decrease uterine perfusion. Injection of diluted vasopressin around the capsule of a voluminous

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bleeding myoma can also decrease blood loss and allows a cleaner operating field. Sometimes, in cases of very large uteri difficult to mobilize or in presence of myomas encumbering the procedure, the routine steps of hysterectomy cannot be followed. In these situations, the procedure usually starts anywhere there is a better vision and the structures are approachable. Dividing one ligament, freeing an infraligamentous myoma from the surrounding peritoneum, cutting an utero-sacral ligament allows to slowly gain space and mobility. Sometimes it is impossible to completely prepare one side: the surgeon will often switch from one side to the other, from the anterior to the posterior aspect, always working where there is a good vision, step by step until a better mobilization is achieved. The laparoscopic dissection continues with an intrafascial dissection of the vagina with circular colpotomy, carried out using monopolar hook or scissors. The uterus is removed vaginally. Closure of the vaginal cuff can be done in many different ways. Both intracorporeal and extracorporeal suturing can be used to complete a laparoscopic hysterectomy; the cuff can also be closed vaginally, with a continuous suturing.

MORCELLATION
Enlarged uteri requires significantly more morcellation than smaller uteri. Morcellation can be performed either vaginally or with a laparoscopic knife. The laparoscopic knife can be of advantage in nulliparous patients or in patients with very narrow vagina. A not complete hemisection is performed, followed by further hemisection of the two halves. In any case the uterus is at the end removed vaginally. Surgeons experienced with vaginal surgery could find easier (and less time consuming) the vaginal morcellation, bearing in mind the risk of vaginal and rectal injuries (Figure 18.17). Usually a combined use of Lash intramyometrial coring,17 bisection, wedge morcellation and myomectomy18,19 is required in all patients. Whatever technique the surgeon is using, surrounding tissue (vaginal wall, rectum and bladder) should be protected with retractors throughout the procedure. It has to be stressed that vaginal morcellation after laparoscopic hysterectomy could be more difficult than after vaginal hysterectomy. In fact, an extraperitoneal dissection of the cul-de-sac of Douglas and the section of the uterosacral ligaments improves access to the enlarged uterus with poor uterine descent. On the other hand, the laparoscopic intrafascial circular colpotomy allows a narrower passage for the uterus.

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Figure 18.19: Intramyometrial coring

CORING
Figure 18.17: Uterus extraction. Starting the morcellation through the vagina Coring is performed with some of the smaller uteri. Grasping the cervix with a Museux or Collin forceps and applying a strong traction, a circumferential incision is made at the level of the uterine isthmus approximately 5 mm into the corpus of the uterus. A central core of tissue which includes the uterine cavity and the surrounding myometrium is then excised by progressively undercutting the serosal surface of the uterine corpus towards the fundus (Figure 18.19). This process is facilitated by applying strong tractions on the cervix at the beginning, by moving the grasping forceps inwards as the coring proceeds (to apply better traction and to avoid lacerations of the tissue) and elevating the serosal part of the dissection with grasping forceps. The coring allows a thinning of the uterus which is at the end inverted at the fundus and delivered through the vagina. When dealing with bigger uteri, the coring is usually limited to a deep cervical amputation (Figure 18.20).

BISECTION
The cervix is grasped with two tenaculums on both sides and a scalpel is used to bisect the uterus in an anteroposterior direction towards the fundus (Figure 18.18). The bisection usually is carried out along the posterior uterine wall: the continuous repositioning of the tenaculums close to the upper part of the incision combined with the rotation of the proximal part towards the pubic arch help the progression to the fundus. When the fundus has been reached or the further posterior bisection is difficult, the uterus is repositioned in the correct orientation and the bivalving continues anteriorly in a similar way. Sometime one half of the uterus is delivered through the vagina followed by the other half.

Figure 18.18: Bivalving

Figure 18.20: Cervical amputation

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Figure 18.21: Myomectomy

MYOMECTOMY
This is usually combined with the other techniques. Smaller myomas are simply removed, once their capsule has been opened, by applying a rotating traction with a Bernard forceps (Figure 18.21). Larger myomas are removed in smaller pieces after bisection or situ morcellation. To avoid a sudden re-ascending of the uterus which can be dangerous because of the almost blind grasping of the uterus inside the abdomen, a tenaculum is always holding the residual uterine bulk. As soon as myomectomy has been completed and further descend of the uterus can be obtained, bisection starts again.

Figure 18.22: Wedge morcellation

WEDGE MORCELLATION
Whenever, despite cervical amputation, bisection, myomectomy, no further descensus of the uterus is possible, wedge morcellation becomes handy. The uterus is firmly grasped with tenaculums or short Bernard forceps and a sharp excision with scissors or scalpel delivers pieces of the specimen (Figure 18.22). When a sufficient reduction of the uterine bulk has been gained, a further bisection allows the delivery of the uterus through the vagina (Figure 18.23).

Figure 18.23: End of morcellation 10 mm cannula site for the laparoscope from 3 to 7 cm in the bilateral subcostal regions; during the procedure this central port will be used for retraction and manipulation. On both sides, two 5 mm accessory ports are placed lateral to inferior epigastric vessels at level of the umbilicus and left suprapubic area. On each side, section of the round ligament, infundibulopelvic or ovarian ligament, dissection of the vesicouterine peritoneal fold and coagulation and division of the uterine artery are achieved. The surgeon moves to the side where is inserted the laparoscope.

HIGH EPIGASTRIC PORT PLACEMENT

In case of very large uteri (>1500 to 2400-3050 grams) especially with large central myomas impeding the view to a central 10 mm telescope, benefit was found with high epigastric port placement.20 After obtaining a pneumoperitoneum by Veress needle inserted at the umbilicus or at the Palmer point, a 10 mm cannula is placed 5 cm above the upper margin of the palpable uterus. This port is now used to insert under vision the lateral epigastic

HAND-ASSISTED LAPAROSCOPY
An alternative to this seven port technique, in rare cases of extreme uterine enlargement, could be the hand-

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Figure 18.24: Surgeon's hand through the access system assisted laparoscopy (HAL).21 It utilizes all the principles of standard transperitoneal laparoscopy. The only difference between standard laparoscopy and HAL is that the surgeons are also able to introduce their hand into the operative field (Figure 18.24). A transverse lower abdominal incision is made and an air-sealing hand access system is mounted. Performing a HAL hysterectomy in a surgeon with size 8 gloves requires a 7 cm incision. Several devices allow the hand to be introduced into an insufflated abdomen while maintaining the pneumoperitoneum (Figures 18.25 to 18.27). The first device, introduced in 1997, was the Pneumosleeve (Dexterity, Atlanta, GA). An adhesive plate is attached to the insufflated abdominal wall, an incision is created,

Figure 18.26: Adhesive plate

Figure 18.27: Disc inside the abdomen and the surgeons hand is introduced into the abdomen. The surgeon wears a sleeve with a locking mechanism that seals to the undersurface of the plate, providing an airtight seal that allows the pneumoperitoneum to be maintained. This technique has allowed the laparoscopist to maintain use of the most versatile instrument available, the surgeons hand, for exposing, retracting and maintaining hemostasis. Manual countertraction is effective in facilitating exposure and laparoscopic bipolar coagulation and division of vascular pedicles. Morcellation is carried out through the laparotomic incision.

SUPRACERVICAL HYSTERECTOMY
In other cases, it could be easier to perform first a supracervical hysterectomy, followed by laparoscopic or better vaginal trachelectomy.22

Figure 18.25: Air-sealing hand access system

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CONCLUSION
Caution must be used in evaluating data presented in literature concerning complications rate and limit to feasibility: results can be biased by the fact that most reports on laparoscopic hysterectomies include some of the most skilled and experienced laparoscopists in the world. Nevertheless, despite some authors conclusion that uterine volume limits laparoscopic hysterectomy, we believe that laparoscopic hysterectomy can be performed safely and effectively in almost any patient when the surgical team is sufficiently trained and experienced in managing complications and is able to recognize these promptly. In our opinion laparoscopic hysterectomy will become standard treatment for benign uterine diseases and it certainly can be considered substitutive to the laparotomic approach and beneficial for patients in whom vaginal surgery is contraindicated or cannot be done.

REFERENCES
1. Reich H, Rahmanie N. Laparoscopic Hysterectomy. Chapter 25. In: Prevention and Management of Laparoendoscopic Surgical Complications. First Edition 1999. 2. Doucette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol. 2001 Jun;184(7):1386-89; discussion 139091. 3. Paparella P, Sizzi O, Rossetti A, De Benedittis F, Paparella R. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet. 2004 Sep;270(2):104-09. Epub 2003 Jul 10. 4. Xie QH, Liu XC, Zheng YH, Lin YJ. Indications and contraindications of vaginal hysterectomy for nonprolapsed uterus. Zhonghua Fu Chan Ke Za Zhi. 2005 Jul;40(7):441-44. 5. De Meeus JB, Magnin G. Indications of laparoscopic hysterectomy. Eur J Obstet Gynecol Reprod Biol 1997; 74: 49-52. 6. Salmanli N, Maher P. Laparoscopically-assisted vaginal hysterectomy for fibroid uteri weighing at least 500 grams. Aus Nz J Obstet Gynecol 1999; 39: 182-84. 7. Wang CJ, Yuen LT, Yen CF, et al. A simplified method to decrease operative blood loss in laparoscopic-assisted vaginal hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc 2004; 11: 370-73.

8. Pelosi MA, Kadar N. Laparoscopically assisted hysterectomy for uteri weighing 500 g or more. J Am Assoc Gynecol Laparosc. 1994 Aug;1(4 Pt 1):405-09. 9. Unger JB. Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams. Am J Obstet Gynecol 1999; 180: 1337-44. 10. Wattiez A, Soriano D., Fiaccamento A., et al. Total laparoscopic Hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc 2002; 9: 125-30. 11. Seracchioli R, Venturoli S, Colombo FM, et al. GnRH agonist treatment before total laparoscopic hysterectomy for large uteri. J Am Assoc Gynecol Laparosc 2003; 10: 31619. 12. Wattiez A, Soriano D.,Cohen SB., et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc 2002; 9: 33945. 13. Wood EC, Maher P, Pelosi MA. Routine use of ureteric catheters at laparoscopic hysterectomy may cause unnecessary complications. J Am Assoc Gynecol Laparosc. 1996 May;3(3):393-97. 14. Minelli L, Landi S, Zaccoletti R, et al. Overcoming technical limits of laparoscopic hysterectomy. In: The Trocar.com. Articles, 2002. 15. Roman H, Zanati J, Marpeau L. How I carry out...laparoscopic hysterectomy in large uterus Gynecol Obstet Fertil. 2006 Nov;34(11):1081-82. 16. Wang CJ, Yuen LT, Yen CF, Lee CL, Soong YK. A simplified method to decrease operative blood loss in laparoscopic-assisted vaginal hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc. 2004 Aug;11(3):37073. 17. Lash AF. A method for reducing the size of the uterus in vaginal hysterectomy. Am J Obstet Gynecol 1941; 42: 45259. 18. Magos A, Bournas N, Sinha R, et al. Vaginal hysterectomy for the large uterus. Brit J Obstet Gynecol 1996; 103: 24651. 19. Reiffenstuhl G, Platzer W, Knaptein PG, et al. Vaginal operations. Surgical anatomy and technique. Baltimore, Williams and Wilkins, 1996. 20. Lee YS. Benefits of high epigastric port placement for removing very large uterus. J Am Assoc Gynecol Laparosc 2001; 8: 425-28. 21. Pelosi MA and Pelosi MA III. Hand-assisted laparoscopy for complex hysterectomy. J Am Assoc Gynecol Laparosc 1999; 6: 183-88. 22. Nimaroff ML, Dimino M, Maloney S. Laparoscopicassisted vaginal hysterectomy of large myomatous uteri with supracervical amputation followed by trachelectomy. J Am Assoc Gynecol Laparosc 1996; 3:585-87.

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19
Artin Ternamian INTRODUCTION

Port Creation during Laparoscopic Hysterectomy

mental core competencies required for safe performance of any laparoscopic operation. Ultimately, all surgical methods are associated with some patient risk and endoscopy is no exception. Although procedure-based analysis of serious laparoscopic entry injury is reassuringly low, 3 to 5/10,000 cases, larger aggregate surveys show them to be more sinister and commoner than reported in procedure-based studies.1,3 Four million laparoscopies are performed annually in N-America and according to Medical Data Int., volumes are to rise at a compounded annual growth rate of 4.8% (Medical Data International, Inc.1999. U.S. Markets for EndoLaparoscopic Surgery Products). Given an increasing number of laparoscopies performed, the total public health impact of these uncommon, yet potentially disastrous misadventures becomes considerable. Despite recent advances in endoscopic surgery techniques and instrumentation, inadvertent and potentially avoidable entry injury continue to occur and remains the single most important avoidable complication.4 On account of increasing laparoscopic medico-legal cases, the Physician Insurers Association of America (PIAA) and affiliate liability insurers, commissioned a laparoscopic injury study that identified trocar accidents as the most common type of laparoscopic device injury reported. More than 31% of all studied claims cite blind sharp trocar insertion as the prime injury cause (Bartholomew L. Laparoscopic Injury Study. PIAA August 2000).

Endoscopy allows optically guided procedures to be performed through surgically created temporary invariant entry points; ports (laparoscopy) or through natural conduits, without requiring an entry wound (hysteroscopy). Endoscopy is practiced in most specialties and has become the preferred method of diagnosis and treatment in several gynaecologic conditions. Compared to open laparotomy, decreased patient disability and early recovery are among the most important advantages of laparoscopic surgery. However, laparoscopy is proven to be significantly more stressful for surgeons and require supplementary concentration.

PORT CHARACTERISTICS
This chapter reviews contemporary port methods and access instruments, emphasising characteristics, and safe deployment of visual entry. Surgeons realise the importance of safe and effective port creation to facilitate successful operations. Failure of satisfactory peritoneal access or strategic port placement can abort the laparoscopic approach or render the procedure tedious and unsafe for surgeon and patient. The fulcrum effect introduces paradoxical movement, curbs excursion, limits work ergonomics, reduces haptics, and confines the surgeons body positioning relative to the surgical target. Whereas laparotomy allows surgeons hand two degrees of freedom (DOF), for each of the nine interphalangeal joint, laparoscopic instruments offer only four DOFs. The most important and potentially dangerous first step in laparoscopy remains successful creation of a primary port. This single task represents one of the funda-

LAPAROSCOPIC PORT SYSTEMS

Ports fulfill several important functions, including access to peritoneal cavity, introduction of optics and instru-

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Figure 19.1: Methods of laparoscopic entry

ments, administration of gas, maintenance of operative envelope, and preservation of port-competence. Push-through, conventional entry methods use a central spike (trocar) and outer sheath (cannula) to transect abdominal layers towards the peritoneum. This method has served laparoscopists well, however, given recent patient safety concerns, recurring serious injuries and mounting medico-legal exposure, it is necessary to reexamine the fundamentals of port creation. Primary peritoneal entry is classified as either blind or visual (Figure 19.1). By definition, visual entry requires a laparoscope mounted into the access instrument during port creation, whereas blind entry requires no laparoscope during placement. Entry is further described as Closed entry (applied after CO2 insufflation) or Direct entry (deployed without pre-insufflation).5 Most gynaecologists use the Closed method, where a Veress needle is first used to pre-insufflate the peritoneum with CO2. This mitigates unintended access injury, and compensates for inevitable entry overshoot, though complications related to their use are well documented.6,7 Alternatively, general surgeons use the Open method, where an umbilical cut-down is performed, then the Hassons trocar is inserted, secured to rectus fascia, and then peritoneum insufflated.8 Several publications indicate that serious major vessels and bowel trauma remain underreported and many of these injuries occur during Closed laparoscopy.9-11 Although Open laparoscopy is intended to avoid major vessel and bowel injury, inadvertent vessel or visceral injury is not entirely eliminated.12-14 A recent Dutch study demonstrated that incidence of complications with the Open entry, in gynecologists

hands, seemed significantly higher compared with Closed entry.15

ACCESS INSTRUMENTS
Conventional laparoscopic access instruments consist of two partsa removable central trocar and an encasing outer sheath. Trocars have a blunt proximal end to accommodate a surgeons dominant palm, while the sharp pointed distal end delivers the created Penetration Force (PF) to port-site. This considerable PF generated by the surgeons dominant trunk-arm muscles, is aligned axial at port-site and propels the trajectory across different layers towards the intended cavity. Once placed the central trocar is withdrawn to house a laparoscope or operating instruments (Figure 19.2). The distal trocar end is usually designed to have a pointed sharp conical, beveled cutting pyramidal or bladed tip as these sharp tips render trajectory propulsion require less PF, which theoretically translates into better control.16 Although extreme sharpness of disposable trocars is desirable, risk of inadvertent bowel or vessel injury cannot be denied, mostly because of uncontrolled overshoot and blind insertion. Indeed, the risk of bowel injury with shielded disposable trocars is three times that previously reported for reusable trocars and 87% of deaths from vascular injuries involve use of shielded disposable trocars.17 In addition, port site incisional hernia risk is 10 times greater when disposable cutting pyramidal trocars are used instead of reusable conical trocar (1.83 versus 0.17%).11

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Figure 19.3: Open Hasson trocar and cannula

VISUAL ENTRY SYSTEMS

Figure 19.2: Conventional push-through trocar and cannula To mitigate serious access injury, visual Primary entry methods were introduced, to offer optical redundancy and decrease incidence of inadvertent error. Three different visual entry systems are available; reusable visual Veress needle, disposable visual trocar, and reusable trocarless visual cannula system. The visual Veress (Optical Veress Entry System; Karl Storz Endoscop GMBH, Tuttlingen, Germany) and trocars (Endopath OptiView; Ethicon Endo-Surgery, Cincinnati, OH and VisiPort; Tyco-United States Surgical, Norwalk, CT) retain a conventional push through trocar design and optically display entry sequencing on the monitor (Figures 19.4 to 19.6).

According to the U.S. Food and Drug Administrations Office of Device Evaluation data, over 10 years, >40,000 trocar related serious injuries are reported. Consequently, the FDA ordered disposable-shielded trocar manufacturers and distributors to remove all claims of added safety as they have failed to decrease entry injuries. (Department of Health and Human Services FDA Division of Enforcement II, Center for Devices and Radiological Health. www.fda.gov/cdrh/mdrfile). Blunt-tipped trocars present less entry risk and conical tips have to inflict a direct hit on a vessel to cause injury as only the pointed tip is sharp, whereas a same sized bladed-cutting pyramidal trocar will exact significant injury when it encounters vessels along the entry path. Open laparoscopy trocars have a blunt tip, and peritoneal entry is achieved by thrusting blindly a small hemostat against the transversalis fascia and peritoneum.12 Conventional cannulas have a proximal valve section to allow insertion and removal of optics or instruments without losing insufflated gas. The cannulas shaft is generally smooth and ends either horizontally or in an oblique slant with a small venting window at its distal end. Threaded cannulas fasten securely to the anterior fascia at port site and discourage slippage. The Open laparoscopy cannula has a cone-shaped anchoring sleeve that secures the cannula to the rectus fascia and discourages displacement or CO2 leakage (Figure 19.3). Laparoscopic entry instruments are either intended for single, multiple, or hybrid use. Environmental concerns and spiraling health costs encourage use of reusable instruments.18 Multiple use of single-use designated instruments, especially trocars, is not recommended.

Figure 19.4: Visual Verres entry system

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Figure 19.5: ENDOPATH visual trocar and cannula

Figure 19.7: ENDOTIP Trocar less visual Cannula with telescope stopper incremental and controlled. Real-time visual port placement and retrieval without a trocar becomes possible20 [Video 1]. The axial-linear PF that dents the myofascial wall towards the abdomen is converted to spiral-radial force; ENDOTIP tents tissue layers away from the abdomen (Figure 19.8).21 Whereas conventional push-through entry instruments comprise two components; a central trocar and an encasing cannula, the ENDOTIP visual cannula comprises a hollow threaded cannula that ends in a notched blunt tip without a central trocar (Figure 19.9). The 0 laparoscope, housed in the cannula during insertion and removal, conveys realtime visually sequencing, using the Archimedes principle, while maintaining exquisite control22 [Video 2].

Figure 19.6: VISIPORT visual trocar and cannula Although risk compared with conventional blind trocar systems remains uncertain, serious entry injury is known to occur with their use. This is especially true when surgeons are unfamiliar with safe application of visual trocars, fail to interpret correctly visual access cues, and cannot recognize displayed monitor images (perceptual blindness).19 Knowledge of anatomy, recognition of navigational cues, and correct monitor image orientation, are all essential to safe deployment of all visual entry systems. The latest addition to laparoscopic ports is a reusable trocarless visual access cannula system (Endoscopic Threaded Imaging Port, ENDOTIP; Karl Storz Endoscop GMBH, Tuttlingen, Germany) (Figure 19.7). This innovative method is different from conventional push-through trocar and cannulas design. Instead of recruiting axial-linear PF, from the surgeons dominant hand-arm combination, ENDOTIP visual cannula delivers radial-spiral PF, generated by the weaker wrist muscles. This Archimedean design, avoids use of excessive PF and unintended overshoot during peritoneal entry. Entry and exit is converted from forceful and sudden to

CONSIDERATIONS DURING VISUAL PORT PLACEMENT

In laparoscopy, the Primary port is the first entry site through which a lens, camera and light are introduced; its insertion is a critical, When most serious unintended injuries occur. Although evidence-based proof is lacking, there is consensus among practitioners that Ancillary ports must be inserted under direct vision to avoid unintended injury. Some authors extend this intuitive logic to insertion of

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Figure 19.8: Entry tissue sequencing with ENDOTIP visual cannula visual port placement. These important measures develop a 3D spatial conceptualization of the anatomic relationships of abdomino-pelvic organs and determines effective port placement. Patients must remain horizontal until insufflation and successful Primary port insertion. Port-site skin incisions along Langers line must be wide enough to accommodate the cannulas outer diameter, to prevent unnecessary friction during entry that may recruit unnecessary additional PF. Recognition of tissue sequencing on the monitor is a fundamental tenet of safe visual port creation. Instead of observing port entry images off the monitor, surgeons instinctively tend to inspect the abdominal port site during trocar deployment. Successful entry gaze transference from port site to monitor is an integral part of the learning curve for all visual entry methods. The average time required to insert a visual port is 14 minutes, depending on the patient specifics and surgeons experience. This is less than time required for open entry and is certainly worth the effort, from the patient-safety perspective.

Figure 19.9: Blunt tip of ENDOTIP visual cannula Primary ports under visual control as well, inferring that visual entry may also mitigate Primary entry complications.2 In a nationwide prospective multicentre Dutch study, of 25,764 laparoscopies, five complications were ascribed to Veress needle and 68 to trocar insertion.3 However; Veress was associated with 18% of PIAA reported cases. When adhesions are suspected or known to exist, patients must be informed of the possibility of alternate entry method, (visual or open entry), alternate access site, (Palmers point) or conversion to laparotomy. 23 Careful inspection of the supine non-draped abdominal wall for previous scars and palpation of bony landmarks must precede every laparoscopy, including

PRE-INSUFFLATION FOR VISUAL ENTRY

Most visual entry manufacturers recommend pre-insufflation prior to their application. Manual abdominal palpation is the preferred method of determining degree of distention, as instilled gas volume measurement is unreliable. Once adequately insufflated, the visual access instrument is inserted. It is important to maintain the

Port Creation during Laparoscopic Hysterectomy median plane during Veress and trocar insertion and not use umbilical positioning relative to the termination of the aorta as a reliable topographic guide.24 High pressure CO insufflation 25-30 mmHg, is a variant of Closed insertion, where a higher intra-peritoneal insufflation pressure splints the abdominal wall to counter the axial PF and interposes a larger gas cushion between the advancing trajectory and the great vessels or viscera.25 Although bowel adherent to parietal port-site remains susceptible to injury irrespective of access method, visual entry methods offer varying degrees of prediction, prevention and real time injury recognition capabilities. Upon correct cannula placement, intra-peritoneal pressure is lowered to 10-15 mmHg maintenance. Additionally, a higher intraperitoneal pressure braces the

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parietal peritoneum and reduces denting of peritoneal membrane ahead of the advancing trocar. Professor K. Semm of Kiel University was first to extol benefits of visual entry; he used beveled cannulae to insert Primary ports under visual control. His teaching proscribed blind abdominal wall puncture at all costs if we are to improve entry safety (Figure 19.10). Knowledge of abdominal wall and pelvi-abdominal anatomy is essential with all entry systems, especially visual methods, as surgeons are expected to accurately interpret monitor images and correctly identify anatomical location of the visual port. All visual entry systems require 0 laparoscopes to beam a panoramic view of the tissuecannula interface. Moreover, surgeons trained to operate with 30 laparoscopes only may find this limitation restrictive.

Figure 19.10: Kiel-Semm school visual entry technique

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In addition, a high degree of hand-eye coordination, and solid sense of spatial orientation are required for successful deploy these superior access instruments. To steer safely through different tissue planes, surgeons use several visual and haptic navigational aids. By far the most critical sequencing during visual entry is recognition of the extra to intraperitoneal transition.5 Patients with previous midline laparotomy are particularly vulnerable to periumbilical adhesions. They require alternate visual entry techniques and entry sites. Irrespective of entry method, visualization and inspection of the peritoneal aspect of a Primary port, through the Ancillary port is always recommended, at the end of each laparoscopy.26 When surgeons use visual methods without a clear understanding and appropriate training, serious access errors can occur. Although they appear deceptively simple to use, successful application requires supervised mentoring through a steep learning curve.19

Figure 19.11: ENDOPATH visual trocar and cannula showing trocar and cannula with sheathed and lit zero degree laparoscope Once the illuminated Endopath enters the peritoneum, the trocar and sheathed laparoscope is withdrawn, leaving the cannula in situ. The laparoscope is then reintroduced into the retained cannula to proceed with surgery. A serious shortcoming of this system is retention of the push-through trocar design that necessitates considerable axial PF to propel the trajectory, with no mechanism to offset overshoot. The trocar tip dents tissue layers and compression renders layer recognition difficult. Often the light intensity needs to be lowered during insertion, to avoid hot spots (Figure 19.12). Furthermore, trocar progression through abdominal wall is often sudden and uncontrolled. As with all visual entry systems, surgeons using Endopath trocars must acknowledge that while exact risk measure rates is not known, their use does not avoid all serious injuries.

APPLICATIONS OF VISUAL ENTRY SYSTEMS

VISUAL TROCARS
Two disposable visual entry systems are available that retain the conventional trocar and cannula push-through design; the Endopath and Visiport trocars. These trade blind sharp trocars for a hollow trocar that accommodates a 0 laparoscope down to a distal crystal tip where entry images are transmitted in real-time.

Endopath Optiview Visual Trocar

The Endopath is a disposable visual trocar that comprises a hollowed trocar and a cannula. The serrated, purple clear cannula portion has a proximal valve housing the CO2 stopcock and a vented beveled distal section. The trocar has a purple stained pistol-grip handle, at right angle to the hollowed opaque trocar stem, and a distal clear plastic pointed tip, with two lateral wings (Figure 19.11). A 0 laparoscope is mounted into the hollow trocar to illuminate the pointed clear tip. The surgeon psalms the Endopaths handle by the dominant hand and holds it perpendicular to the supine patients insufflated abdomen. The trocar is lowered into the umbilical wound as the surgeon generates axial PF using the shoulder and upper arm muscles. Twisting the handle advances the hydrophobic, winged trocar tip through successive layers towards the abdomen. The cascade of entry images, displayed on the monitor, demonstrates level of penetration.

Visiport Visual Trocar

The Visiport Trocar, is a disposable entry instrument that comprises a hollow trocar and a cannula. The cannula portion is made of a black plastic sleeve with a vented distal section and proximal detachable self-adjusting valve section that accommodates 5-12 mm instruments and houses a 3-way stopcock (Figure 19.13). The trocar portion has a proximal white plastic pistolgrip handle, at right angle to the opaque hollowed trocar stem that ends in a distal clear plastic hemi-sphere, transected at its equator with a cutting stainless steel knife, connected to the pistol-grip trigger. Every trigger squeeze advances the sharp cutting knife 1mm to transects tissue in contact with the crystal tip and retract back into the crystal hemisphere. A 0 laparoscope is mounted into the hollow Visiport to illuminate the clear spherical trocar tip. When

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Figure 19.12: ENDOPATH visual trocar tip and image sequencing during entry insufflation is complete, the trocar is palmed by the surgeons dominant hand and held perpendicular to the supine patients insufflated abdomen. Downward axial pressure is first applied while activating the trigger, then downward pressure is relieved, trigger released, and trocar tip position verified off the monitor. This sequence is repeated until the peritoneal cavity is entered. It is important not to fire the trigger until trocars exact anatomical location is identified. Once peritoneum is entered, the index finger is released from the trigger area and downward pressure ceased. Visiport with sheathed 0 laparoscope is withdrawn, leaving the cannula in position. The laparoscope is

Figure 19.13: VISIPORT visual trocar and cannula with clear crystal sphere at trocars tip

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Manual of New Hysterectomy Techniques fatyellow, anterior rectus muscle-red, fasciawhite, and peritoneum-translucent bright. Upon peritoneal entry, CO2 gas bubbles are observed. Once the peritoneum is insufflated, organs and parietal peritoneum is displayed, and adhesions mapped. Subsequent ports are inserted under visual control in adhesion free locations. Although the view obtained through this delicate instrument is generally adequate, given its narrow caliber and very short focal distance, the minilaparoscope distal end must be kept very close to organs, in order to achieve sufficient illumination and resolution (shallow visual field). Additionally, this expensive and fragile optics is not intended to replace operative laparoscopes, as the topheavy camera end bows and can fracture easily. Their use is not entirely injury-free as the monitor images are often sub-optimal, and initial peritoneal entry remains perilous as they retain the push through trocar and cannula design. This is especially true in patients with previous laparotomy, where the risk of inadvertent bowel injury risk is three-fold increased, compared with those with no prior surgery.

reintroduced into the abdomen through the retained cannula to proceed with surgery. The most serious shortfall of this system is maintenance of the push-through entry design that requires significant perpendicular PF to drive the trajectory across tissue planes. PF axial compression by the crystal tip renders layer recognition more difficult, access sudden, and entry uncontrolled with no means to avoid trocar overshoot. Additionally, Visiport trocars comes only in one diameter to accommodate a 10 mm laparoscope. One must observe assembly penetration as failure to monitor trocar entry depth may result in serious visceral or retroperitoneal injury.19 During insertion, muscle and fascial fibers should be aligned with the long axis of the cutting trocar wire, to minimize PF required during entry.27 As with all visual systems, surgeons using Visiport trocars must accept that while exact access risk measure remains unknown, use of this visual trocar does not avoid all access injuries.

VISUAL VERRES MINI-LAPAROSCOPY

Better optics and innovative miniaturization improved narrow caliber micro-laparoscopes allowing use of miniscule entry ports with potential advantages. The reusable visual Verres entry systems utilizes a <1.2 mm semi-rigid 0 micro-laparoscope, housed into a modified Veress needle (Figure 19.14). These small caliber semi-rigid mini-laparoscopes use advanced fiberoptic technology to offer high resolution and functional images of the peritoneal cavity. They can be used in high-risk situations, where umbilical adhesions are anticipated. To explore the peritoneal cavity, they are applied through the umbilical region or left upper quadrant (Palmers point), in critical care areas, in diagnostic outpatient situations, for conscious pain mapping, and in patients with previous midline incisions.28 Use of this systems renders creation of pneumoperitoneum under visual control possible, theoretically avoiding all serious entry complications; however, its relevant predictive risk remains uncertain. Application involves a skin incision, and holding the assembled unit, (zero degree minilaparoscope with camera, mounted into modified visual Veress) with the surgeons dominant hand, like a dart, and advancing it at 45 through the abdominal layers towards the pelvis. During insertion, a cascade of monitor images observes that represents different abdominal layers; subcutaneous

VISUAL CANNULA ENDOTIP

The Endoscopic Threaded Imaging Port; ENDOTIP is a visual cannula that cushions human error, through system redesign and allows real-time interactive port creation, where port-dynamics is archived, for recall and analysis. ENDOTIP has been validated to reduce PF, offer visually controlled entry, eliminate overshoot, use no

Figure 19.14: ENDOTIP visual cannula must be held perpendicular to supine abdomen during entry and exit. The laparoscope is held with the non-dominant hand and the cannula is rotated clockwise with the dominant hand

Port Creation during Laparoscopic Hysterectomy sharp trocar, and most importantly renders port creation less error prone. In addition, it can avoid, anticipate or at the very least recognize injury. This reusable visual cannula can be applied as a Primary and ancillary port and may be used to perform intra or retroperitoneal operations. It consists of a stainless steel cannula with a proximal valve segment and distal hollow threaded cannula section (Figure 19.7). The conventional valve sector houses a stopcock and the cannulas outer surface is wrapped with a single thread, winding diagonally to end in a distal blunt tip (Figure 19.9). The cannula is available in different lengths and diameters for different surgical applications. A retaining ring, Telescope Stopper (TS), keeps the mounted laparoscope from sliding out of focus during insertion.29 The ENDOTIP visual cannula requires no trocar and has no crystal tip at tissue-cannula interface. Interpretations of observed monitor images are real-time, interactive, and easily recognizable.

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PRIMARY ENTRY WITH ENDOTIP

A generous but cosmetically acceptable umbilical skin incision is made to avoid skin dystocia. Ribbon retractors and peanut sponges are used to expose the white anterior rectus fascia, as insertion starts at the fascial level. The Veress needle is inserted and correct placement is tested, followed by insufflation to 25 mmHg intraperitoneal pressure. During insufflation, a 0 laparoscope is defogged, TS mounted and locked to hold the laparoscope 1cm short of the cannulas distal end and the camera is focused to the cannulas tip. When insufflation is complete, the laparoscope, with sheathed cannula, is held perpendicular to the patients supine abdomen, using the surgeons non-dominant hand. The unite, with the CO2 stopcock in the closed position, are then lowered into the umbilical wound. Using the surgeons dominant wrist, the cannula is rotated clockwise, while keeping the forearm horizontal to the patients abdomen (Figure 19.13). The surgeons shoulders are held comfortably in resting position, facing the monitor while downward axial pressure, towards the insufflated abdomen, is kept to a minimum during rotation. Rotation engages the blunt cannula tip onto the anterior fascia and stretches it radially to lift the abdominal wall and to transpose successive layers onto the cannulas outer thread. [Video 3]

The white anterior fascia, red rectus muscle, pearly white posterior fascia, yellowish pre-peritoneum and transparent grayish peritoneal membrane is observed in sequence (Figure 19.15). As ENDOTIP has no cutting or sharp end, tissue layers are not transected; instead they are taken up along the outer pitch. The parted tissue layers preserve port competence and results in a smaller fascial entry wound area with less muscle damage as compared to pyramidal trocar wounds.21 The laparoscopes intense light traverses the dented thin peritoneal membrane and an adhesion free, CO2 filled peritoneal cavity appears gray-blue in color.29 Further clockwise rotation parts the peritoneum radially to advance the cannula incrementally into the cavity under direct visual control while avoiding cannula overshoot. Vessels, bowel, or adhesions are readily recognized and inadvertent injury avoided. No trocar is required and perpendicular PF is minimized. The ENDOTIP visual cannula is kept strictly perpendicular to the supine patient at all times to avoid tunneling and rotation is stopped as soon as peritoneum is entered.

ANCILLARY PORT ENTRY WITH ENDOTIP

Insertion site and entry method depends on several factors, including patients anatomy, type of procedure, presenting pathology and location, available instruments, and surgeons preference. A large Canadian survey revealed that 22% of vascular and intestinal injuries occurred during insertion of ancillary trocars.10 Consequently, ancillary ports must be inserted only under visual control to minimize injury, as occasionally serious bleeding can occur.11 Knowledge and careful attention to abdominal wall anatomy is important, as injury to the deep epigastric vessels is the single most common vascular accident during laparoscopy.3 In order to avoid vascular injury, ancillary ports can be inserted lateral to the internal inguinal ring or medial to the umbilical ligaments. The triangular area between these two lines should be avoided if possible. When vessels are suspected along a cannulas path, direction and axis of entry can be altered to avoid injury. [Video 5] When using EndoTIP as ancillary port, only a skin incision along Langers lines and subcutaneous dissection is needed; an ancillary laparoscope is not necessary as entry is observed through the already placed Primary port (Figure 19.16).

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Figure 19.15: Image sequencing at port-site with ENDOTIP visual cannula during entry. White anterior rectus fascia Red rectus muscle White posterior fascia. Blue peritoneal membrane indicating no peritoneal adhesions

Figure 19.16: Vessels encountered during ENDOTIP visual cannula entry are not transected, instead they move laterally out of harms way To avoid peritoneal tunneling, EndoTIP insertion must remain perpendicular to the skin surface until abdominal entry. Vessels encountered along the cannulas path move radially out of harms way and are not transected (Figure 19.17). The cannulas thread prevents overshoot during entry and anchors port to avoid slippage during repeated insertion and removal of instruments. The urinary bladder must always be emptied before suprapubic port insertion.

ALTERNATE ENTRY SITES

Alternate entry sites are considered when umbilical placement of a Veress or Primary port is deemed risky, such as in patients known to have umbilical adhesions. Safe application of conventional or visual entry methods through Palmers point is a popular and a safe alternative, in high-risk patients (Video 6). Particular care must be exercised in patients with portal hypertension, gastropancreatic masses, splenomegaly or previous left upper abdominal surgery.

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Patients with known peritoneal adhesions, those with a history of more than one previous laparoscopy, the morbidly obese, those with a history of previous failed laparoscopy or insufflation and others with special circumstances may be candidates for alternate entry techniques, or laparotomy.

PORT REMOVAL
Increasingly, surgeons appreciate the importance of safe cannula removal to maintain port competence and avoid malignant or endometriotic cell implantation along ports. Observing port tract during insertion and removal of cannulas, helps determine integrity of different tissues that maintain port competence. When surgeons identify ports that are compromised and susceptible to herniation, appropriate preventative measures can be taken. The published incidence of port herniation is about 0.3-1.3% (Figure 19.18).11, 30 When inserting sharp pyramidal or cutting trocars, the instrument transects tissue layers along its path, disrupting the shutter mechanism at port site. Fascial defects are significantly larger when using trocars with cutting sharp tips, compared to the non-cutting tips 21,22 [Video 7].

Figure 19.17: Ancillary ENDOTIP visual cannulas must remain perpendicular to abdomen during insertion and removal of ports Visual access deployed through Palmers point allow inspection of the umbilical and lower abdominal region. Adhesions are mapped and additional ports inserted accordingly. The incidence of umbilical adhesions is < 0.03%, however, it may be as high as 68% in patients with previous laparotomy, especially those with midline surgical scars extending to or beyond the umbilical region.11

Figure 19.18: Counter clockwise rotation disengages the ENDOTIP visual cannula and reversed port sequencing is observed. White peritoneal membrane and posterior rectus fascia Red muscle. White anterior rectus fascia and Yellow subcutaneous fat

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Manual of New Hysterectomy Techniques significant, uncontrolled axial PF to thrust sharp trajectories towards the peritoneum. Visual entry is redesigned to minimize inevitable surgical mishaps and render laparoscopic entry error-tolerant. Real-time error detection allows timely recovery and prevents injury from progressing to patient harm. The literature indicates that more than one-third of bowel injuries are not immediately identified and late recognition is associated with increased mortality, especially in elderly patients Moreover, visual systems improve understanding of laparoscopic entry complications and reduce error recurrence. Tissue dynamics is visualized, port toilette feasible and port competence maintained. Although visual entry appear deceptively simple, successful and safe application requires supervised mentoring. Given the importance of access safety, surgeons must be versed in more than one entry method and practice meticulous attention to surgical technique during port creation to reduce entry injury. One must avoid ascribing entry complications to colleagues inexperience or technical carelessness; instead thrive to understand accident causation and remember that such System Failures lie in wait every moment of a practitioners career, irrespective of surgical skill or technical proficiency.

EndoTIP is designed to address port competence concerns; the radially displaced tissue layers regain their normal gridiron orientation and restore the shutter mechanism at port site upon cannula removal (Video 8). It is demonstrated that a smaller fascial wound area and less muscle damage occurs with EndoTIP when compared with other trocars of similar diameter.21 When the operation is completed, CO tubing is disconnected; laparoscope is retracted 1cm into the cannula and focused to EndoTIPs end. The laparoscope is held perpendicular to the patients abdomen with the non-dominant hand, and cannula rotated counterclockwise with the dominant hand (Video 9). As cannula removal is visual, incremental, and controlled, tissue injury or entrapment along the cannulas tract is avoided. When the fascial port site is extended to retrieve surgical specimens or cannulas tract appears incompetent during port removal; fascial sutures are applied to further secure port competence (Video 10). Generally, fascial defects created with conventional trocars 10 mm or larger are best sutured to prevent possible herniation. Although 5 mm or smaller trocar sites are considered less herniation-prone, some recommend closure of all defects when operating on children, when surgery is long, when associated with excessive port manipulation, and when tissue is retrieved. All ancillary ports, irrespective of cannula diameter and trocar shape must be removed under visual control prior to primary port retrieval so that tissue is not entrapped along the cannulas tract. Additionally, insertion of any port through a previous surgical scar may also predispose hernias and needs careful securing. Moreover, scarring discourages tissue recoil, and predisposes incision extension to coalesce with other proximal port sites during reintroduction of displaced cannulas. It is accepted that surgeons avoid forceful disinsufflation of CO2 at the end of surgery through the Primary port site and keep the trocar valve open to room air during removal, to avoid drawing omentum or intestines into the fascial defect. Closure of fascia is important when predisposing factors exist; however, fascial suturing of laparoscopic entry sites decreases but does not entirely eliminate incidence of hernias.11

REFERENCES
1. Chapron C, Fauconnier A, Goffinet F, Breart G, Dubuisson JB. Laparoscopic surgery is not inherently dangerous for patients presenting with benign gynaecologic pathology. Results of a meta-analysis. Hum Reprod. 2002;17:1334-42. 2. Harkki-Siren P, Kurki T. A nationwide analysis of laparoscopic complications. Obstet Gynecol. 1997;89:108-12. 3. Jansen FW, Kapiteynnn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: a prospective multicentre observational study. Br J Obstet Gynaecol. 1997;104:595-600. 4. Hashizume M, Sugimachi K. Needle and trocar injury during laparoscopic surgery in Japan. Study group of endoscopic surgery in Kyushu, Japan. Surg Endosc. 1997;11:1198-1201. 5. Ternamian A: In Endoskopische Abdominalchirurgie in der Gynkologie. Edited by L. Mettler. Stuttgart, Schattauer, 2002, Chapter 9, 75-80. 6. Leonard F, Lecuru F, Rizk E, et al. Perioperative morbidity of gynecological laparoscopy, a prospective monocenter observational study. Acta Obstet Gynecol Scand. 2000; 79: 129-34. 7. Hrkki-Sirn P. The incidence of entry-related laparoscopic injuries in Finland Gynecolo Endosc.1999;8:335-38. 8. Hasson MH. Open laparoscopy as a method of access in laparoscopic surgery. Gynaecol Endosco. 1999;8:353-62. 9. Vilos G Litigation of laparoscopic major vessels injuries in Canada. AAGL 2000; 7: 503-09.

CONCLUSION
Primary entry remains a critical first step in laparoscopy, as push-through blind trocar and cannula systems apply

Port Creation during Laparoscopic Hysterectomy

10. Yuspe A. Pneumoperitoneum needle and trocar injuries in laparoscopy. J Repro Med.1990;35:485-90. 11. Munro M. Laparoscopic access: complications, technologies, and techniques. Curr Opin Obstet Gynecol. 2002;14: 365-75. 12. Hasson HM, Rotman C, Rana N, Kumari NA. Open laparoscopy: 29-year experience. Obstet Gynecol. 2000;96:763-66. 13. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, Rich M. An external audit of laparoscopic cholecystectomy in the steady state performed in a medical treatment facility of the Department of Defense. Ann Surg. 1996;224:14554. 14. Chapron C, Carvello L, Chopin N, Kreiker G, Blanc B, Dubisson JB Complications during set-up procedures for laparoscopy in gynecology: open laparoscopy does not reduce the risk of major complications. Acta Obstet Gynecol Scand. 2003;82:1125-29. 15. Jansen F, Kolkman W, Bakkum E, de Kroon C, TrimbosKemper T, Trimbos J. Complications of laparoscopy: An inquiry about closed-versus open-entry technique. Am J Ostet Gynecol. 2004;190,634-68. 16. Corson SL, Batzer FR, Gocial B, Maislin G. Measurement of the force necessary for laparoscopic trocar entry. J Reprod Med. 1989;34(4):282-284. 17. Nezhat F, Nezhat C, Levy JS. A report of laparoscopic injuries and complications over a 10-year period. Presented at the 41st annual clinical meeting of the American College of Obstetricians and Gynecologists, Washington DC, 1993. 18. Hurd WW, Diamond MP. Theres a hole in my bucket, the cost of disposable instruments. Fertil Steril. 1997;67: 13-15. 19. Sharp HT, Dobson MK, Draper ML, Watts DA, Doucette RC, Hurd WW. Complications Associated With OpticalAccess Laparoscopic Trocars Obstet Gynecol. 2002;99: 553-55.

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20. Ternamian AM. Laparoscopy without trocars Surg Endosc. 1997;11:815-18. 21. Glass KB, Tarnay CM, Munro MG. Intra-abdominal Pressure and Incision Parameters Associated with a Pyramidal Laparoscopic Trocar-Cannula System and the EndoTIP Cannula J Am Assoc Gynecol Laparosc. 2002;9(4):508-13. 22. Corson SL, Chandler JG, Way LW. Survey of Laparoscopic Entry Injuries Provoking Litigation J Am Ass Gynecol Laparosc. 2001;8:34134-37. 23. Fuller J, Ashar B, Carey-Corrado J. Trocar-associated injuries and fatalities: An analysis of 1399 reports to the FDA. J Am Assoc Gynecol Laparosc. 2005;12:302-07. 24. Phillips G, Garry R, Kumar C, Reich H. How much gas is required for initial insufflation at laparoscopy? Gynaecol Endosc. 1999;8:369-74. 25. Vilos G A. The ABCs of a safer laparoscopic entry. J Min Invas Gynecol. 2006; 13: 249-51. 26. Soderstrom RM. Injuries to major vessels during endoscopy. J Am Assoc Gynecol Laparosc. 1997;4:(1):39598. 27. Thomas MA, Rha KH, Ong AM, Pinto PA, Montgomery RA, Kavoussi LR, Jarrett TW. Optical Access Trocar Injuries In Urological Laparoscopic Surgery J Urol. 2003; 170: 61-63. 28. Audebert AJ. The role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion Fertil Steril. 2000;73:631-35. 29. Ternamian A. How to improve laparoscopic access safety: ENDOTIP. Min Invas Ther & Allied Technol. 2001;10(1): 31-39. 30. Marret H, Pierre F, Chapron C. Complications of laparoscopy caused by trocars. Preliminary study from the national registery of the French Society of Gynecologic Endoscopy. J Gynecol Obstet et Biolde la Reprod. 1997;26(4):405-12.

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20
Harry Reich

Laparoscopic Hysterectomy: Historical Perspective

tomies and lysis of adhesions procedures with TVH. Today these cases would be called LAVH.2-4 I consider 1976 -1983 to be my learning curve years. I prepared myself to be a successful laparoscopic surgeon. In 1985, I presented laparoscopic treatment of pelvic abscess at ACOG and both laparoscopic endometrioma excision and laparoscopic electrosurgical oophorectomy at AAGL. I began teaching these techniques soon thereafter and taught an advanced laparoscopic course at AAGL for the next 20 years. One year earlier Ron Levine presented laparoscopic oophorectomy using endoloop sutures after visiting Kurt Semm in Kiel, Germany. Ron then put together the first US freestanding laparoscopic surgery course in April 1986 in Louisville and invited me as part of the faculty, along with Semm, Hulka, and Hasson. Please realize that these operations were done with the operating surgeon visualizing the operative field with his right eye with minimal assistance before 1986. Throughout the rest of the 80s, I operated using my eye and with a beam splitter to the video monitor so my assistant surgical technician and my students could see.

Laparoscopic hysterectomy, defined as the laparoscopic ligation of the uterine vessels, is a substitute for abdominal hysterectomy, with more attention to ureteral identification. Laparoscopic hysterectomy (LH) is rarely indicated for the treatment of abnormal uterine bleeding (AUB) from a normal sized uterus with no other associated pathology! Most of these cases can be done vaginally without the use of a laparoscope.1

BACKGROUND
Laparoscopic hysterectomy evolved from my commitment in the early 1980s to minimize abdominal incisions in all cases usually by a combination of vaginal and laparoscopic surgery. This choice was facilitated by my discovery in 1976 that bipolar desiccation of infundibulopelvic ligaments was possible to control hemostasis from the ovarian blood supply. Since 1983, I have done less than 20 laparotomies. I started my private practice in 1976, and vaginal surgery was my major area of interest. That year, I was the consultant for an infertility clinic that had over 100 active patients who had never been laparoscoped. I was trained to do a diagnostic laparoscopy and, when indicated, laparotomy surgery for excision of ovarian endometriosis and separation of tubal adhesions usually 2 months later. Before that year was out, I realized that many of these operations could be done at the time of diagnostic laparoscopy. In 1983, I began photodocumenting all of my operations using an Olympus OM2 camera with CLEF light source system, after a visit to Bob Hunt during Boston Marathon week. I began using the laparoscope as a part of a vaginal hysterectomy (TVH) before 1983, whenever uncomfortable with an exclusively vaginal approach. Thus, by 1988, I had done many laparoscopic oophorec-

FIRST LAPAROSCOPIC HYSTERECTOMY AND DEVELOPMENT OF TOTAL LAPAROSCOPIC HYSTERECTOMY (TLH) CONCEPT
The first laparoscopic hysterectomy recorded in the literature was done in January 1988. This was called a laparoscopic hysterectomy as the major blood supply to the uterus was secured laparoscopically. The only difference between this operation and total laparoscopic hysterectomy (TLH) is that the vaginal cuff was closed vaginally.5-8 At that time, a group of residents and staff from Baystate Medical Center, Springfield Massachusetts

Laparoscopic Hysterectomy: Historical Perspective under the direction of Larry Lundy and Percy Wadman, a former president of the Massachusetts Medical Society, would visit Kingston, PA every month to learn laparoscopic surgical techniques. On their visit that week, the case involved a 14 week size symptomatic fibroid uterus. A 3 mm and a 5 mm lower quadrant trocar site was used. Rectosigmoid to left ovary adhesions were divided. I dissected, desiccated, and divided the left infundibulopelvic ligament and the right uteroovarian ligament. I exposed the ureter and uterine vessels on each side. I decided to ligate the uterine vessels using bipolar desiccation instead of completing the operation from below vaginally, as was my usual custom. The uterine artery and vein on each side had been skeletonized. Each ureter had been exposed to demonstrate their distance from the area of the bipolar desiccation energy. An ammeter was used to monitor current flow to determine the end point of the bipolar desiccation process. In that operation I opened the vagina anteriorly and posteriorly before going vaginally to complete the procedure. Operation time was 3 hours. All instruments used were reusable including the trocars. Soon thereafter in 1988, the next problem was tackled: TLH. It was cumbersome and time consuming to change from operating laparoscopically to a vaginal position and then back again. And I worried about a position change with the patient asleep. I decided that the laparoscopic view was so good that the vagina could be opened circumferentially in most cases laparoscopically. I used a CO2 laser through the operating channel of the operating laparoscope or electrical scissors to open the cervicovaginal junction posteriorly over a sponge forceps and anteriorly over a narrow Deaver in the anterior vagina and then connect the 2 incisions, usually with much lateral bleeding from ascending vaginal vessels and thick cardinal and uterosacral ligaments. The major problem, of course, was loss of pneumoperitoneum. We went through two years using wet packs, balloon catheters, and surgical gloves filled with air or fluid to maintain pneumoperitoneum during cuff suturing. It was always a struggle. In December 1990 at the first meeting of the Society for Minimally Invasive Therapy (SMITS) in London (England), I met Professor Gerhart Buess from Germany who was suturing the rectum through a large anoscope manufactured by Wolf Instruments. This instrument was what I needed to be able to maintain pneumoperitoneum during the culdotomy incision of laparoscopic hysterectomy and to suture repair the vaginal cuff afterwards. Richard Wolf Instrument Company modified it for me. The concept was simple: the instrument had to be made

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longer than an anoscope and be approximately 4 centimeters in diameter. (There was too much leakage at 3.5 cm diameter in most women.) When applied to the cervix, the surgeon could see the junction of the anterior and the posterior vagina with the cervix. The posterior rim is longer than the anterior so that the posterior fornix can be entered first. Thereafter the anterior fornix is entered and the lateral vagina on each side is pushed upward and outward away from the ureters to complete the incision on each side without losing pneumoperitoneum. I believe most of the vaginal delineators that are now available on the market are modifications of the original idea that was developed in the early 90s.7-9 I have always emphasized that laparoscopic hysterectomy is a substitute for abdominal hysterectomy and not for vaginal hysterectomy. Since 1987, no patient was denied a vaginal or laparoscopic approach to hysterectomy except when advanced cancer was suspected. Uterine size and extent of endometriosis were not considered contraindications; rather they were the reasons to do a laparoscopic approach. Less than 15% of my hysterectomy patients had surgical castration. My early results were great. Between April 1983 and September 1991, 94 women underwent either laparoscopic hysterectomy or laparoscopically-assisted vaginal hysterectomy. Their average age at time of surgery was 46, and the age range was 30 to 79 years. The most common reason for surgery was a symptomatic fibroid uterus. The average operation lasted fewer than 3 hours. The average length of hospital stay was fewer than 2 days, and recuperation was rapid. There was one conversion to laparotomy following extensive adhesiolysis with incidental enterotomies. The concept of laparoscopic hysterectomy along with the video was presented at US Surgical Corporation headquarters in Norwalk, Connecticut in January 1988, soon after it was done. Among the small group present were Victor Gomel, Ron Levine, Steve Corson, Clifford Wheeless, Camran Nezhat, and Steve Kaali. The company swiftly adopted the concept that surgeons would much rather use techniques other than electricity to ligate the uterine arteries. The development of a laparoscopic clip followed by a laparoscopic stapler were in the works in 1988 because of this presentation of laparoscopic hysterectomy to this small group in Norwalk, Connecticut. Unfortunately, big business goes into new fields for big business. Clinical trials were not necessary for the clip applier because of the huge demand for it from general surgeons using makeshift instrumentation. The same was true for the EndoGIA, a great device for general surgery but with few gynecologic applications. So LAVH was born!

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Manual of New Hysterectomy Techniques reserve. He encouraged me to learn how to suture. For that I thank him very much. I think that he was right: the ability to suture defines a laparoscopic surgeon. In the early days, 1986-1988, I used a small Keith needle and a slip knot like Kurt and Lisolotte Mettler. The persistence of Courteney Clarke led to my adopting his knot pusher to do extracorporeal ties by 1989. Soon thereafter, I developed my technique to get large curved needles into the peritoneal cavity using a 5 mm trocar, and from then on, I felt that I could operate as well or better than most laparotomy surgeons.10 Why ligate the uterine arteries with suture instead of bipolar? If suture is used, suture can be removed if a problem is suspected afterwards. Unless the surgeon is absolutely sure that the uterine arteries are a reasonable distance away from the ureters, suture is the best technique. Of course, this means that the surgeon has to have some suturing skill. Ive learned over the years that most general surgeons think its very easy to suture from their right side from 3 oclock to 6 oclock or 6 oclock to 9 oclock but have difficulty suturing from 9 oclock to 12 oclock. This makes no sense. If the surgeon grasps the suture with his left hand instead of his right hand, it should be easy to accomplish suturing from 9 Oclock to 12 Oclock by rotating the wrist in a backhand motion. So we have three events with laparoscopic hysterectomy evolution. First, the discovery that bipolar desiccation was possible for large vessel hemostasis made the operation possible. Next, industrys recognition that staples could be used. Disposable staples brought them into the ballgame. Finally, the safest technique is suture. Usually, what you see is what you get with suture with no danger of energy spread. In most cases where the vessels are isolated and separated from the ureter, bipolar desiccation works fine. Most gynecologists will not dissect the ureter. Thus, I believe that when the gynecologist sees the pulsation of the uterine artery, it is much safer to use the technique of ligation of the uterine vessels with suture and at the end of operation check the ureters by cystoscopy after indigo carmine dye IV push to be sure that dye flows out of the ureteral orifices. If it does not, it is simple to look back with the laparoscope and undo the suture to release a potential ureteral injury.11-14 As we know then and today, TLH and related procedures can be done with reusable instrumentation. In fact, most of the procedures that have been developed over the last 20 years in laparoscopic surgery can be done using reusable instrumentation available in most ORs. This knowledge really helps when teaching the technique around the world, as most countries where I introduced

LAVH is not LH. It is an expensive vaginal hysterectomy. Gynecologists were encouraged to use the EndoGIA device to do the easy upper pedicle part of a vaginal hysterectomy. Hospital administrators soon calculated that the cost of laparoscopic hysterectomy was exorbitant. Expensive disposable trocars followed by multiple firings of a stapling device cost more than the reimbursement from the managed care or other insurer at that time. Unlike cholecystectomy where the surgeon could operate using a disposable clip device with one or two firings from a single instrument, laparoscopic hysterectomy required at least four firings of a surgical stapler. The operation cost too much. And remuneration from insurance companies for laparoscopic skills was poor. This, I believe, destroyed the option of having a laparoscopic hysterectomy operation for most women in the USA. The rest of the world rarely took to staples, and laparoscopic hysterectomy is thriving there. The EndoGIA was released in late 1990 early 1991. After it received FDA permission, I used it for a laparoscopic appendectomy in the summer of 1990. On August 29, 1990, as a visiting surgeon and lecturer at Rochester General Hospital in Rochester New York, I did the first two TLHs using the EndoGIA stapler. Through much of 1991 I used the EndoGIA for laparoscopic hysterectomy, always after ureteral dissection. Ureteral dissection was done in some cases after application of the GIA, and its broad distal tip was too close to the ureter for comfort. Ok, so I went from bipolar desiccation to the EndoGIA stapler. What was next? The acceptance level of laparoscopic hysterectomy had not improved. Hospitals did not want to pay for the expensive disposable instruments used by gynecology in contrast to their attitude towards general surgery operations. At that time I felt that the best way to progress was to go back to a technique that we all knew from laparotomy, i.e. suture ligation of the uterine vessels. While I had only a 30-year experience with bipolar desiccation of large vessels, suture has been around for centuries! When one looks at the evolution of laparoscopic hysterectomy and laparoscopic surgery in general, one of the major obstacles to adoption was the perception that too much expensive gimmickry was used. The simple solution was to use sutures for ligation for the major vessels, similar to what was done during major laparotomy surgery. I believe that suture ligation of the uterine and ovarian vessels is the safest technique near the ureter. Adhesions from living tissue distal to a tie still bother me as they may be more prevalent than after bipolar desiccation. More about suturing. When I met Kurt Semm in 1986 he observed desiccation of the ovarian blood supply with

Laparoscopic Hysterectomy: Historical Perspective TLH (Chile, Spain, Australia, Italy, Russia, Ireland) had no disposable instrumentation. Finally, please realize that publication of laparoscopic gynecological operations was very difficult in the 80s as few of the pioneers were in academic positions. Laparoscopic hysterectomy was unpublishable in 1988 and before. This has been a major struggle. In fact, many papers of substance on laparoscopic surgery in the early 90s were in a journal that never got Index Medicus acceptance: Gynaecological Endoscopy. This travesty in our system prevented over a decade of great work from many pioneers in laparoscopic surgery to be rarely quoted. I remember, with bitterness, my struggles to get bipolar oophorectomy and cul-de-sac dissection for deep fibrotic endometriosis published in the 80s, despite teaching these techniques to the professors. My paper on laparoscopic treatment of ovarian cancer received harsh reaction in 1988 in the US but not in Europe.15,16 The American College of Obstetricians and Gynecology (ACOG), the committee on quality assurance released a statement in October 1995 describing the indication for LAVH as follows; to assist in the performance of a vaginal hysterectomy in situations in which an abdominal approach might otherwise be indicated. This opinion persists to this day. TLH is not yet considered a separate procedure by ACOG. I believe that most hysterectomies can be done using a laparoscopic approach. It is certain that if the problem is bleeding, especially from a large fibroid uterus, it can be solved by TLH and the woman will be very pleased. Why are there so few laparoscopic hysterectomies done today? It is a major problem! Gynecologists today are not trained to do laparoscopic surgery. Unfortunately they are not trained to do vaginal surgery, either. The truth of the matter is that the very low payments for gynecological surgery make it much more cost effective to stay in the office and to avoid surgery if possible. The major problem for LH from its birth to the present remains inappropriate reimbursement for the work and extra training involved in developing the appropriate expertise. In the United States we continue avoid LH because of lack of training and the concept that laparoscopic surgery just takes too long. In our specialty IVF took off and laparoscopic surgery didnt. Just look at the remuneration.

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electrosurgical desiccation, suture ligature, or staples. Although hysterectomy is not the most difficult laparoscopic procedure, it can be long and tedious because four very well defined vascular pedicles must be ligated. In 1988, no one was thinking about doing hysterectomy by laparoscopy. The major centers in the world doing laparoscopic surgery were in Clermont Ferrand, France and in Kiel, Germany. I acknowledge that Kurt Semm, Lilo Mettler, Maurice Bruhat, and Hubert Manhes were great influences because they also knew no boundaries. However, most of my thinking was original. It took 5 years for laparoscopic cholecystectomy to be universally adopted! Laparoscopic hysterectomy has been available for the last 20 years with sporadic acceptance. TLH has no billing code in the USA! Remuneration at a low level for laparoscopic skills in gynecology has curbed the enthusiasm for training in minimally invasive surgery in our specialty in the United States. Practitioners faced with shrinking reimbursement and rising costs appropriately spend more time in the office and less in surgery. Abdominal hysterectomy is the preferred method of treatment based on training and economics, and, this poses an ethical dilemma. Are we offering the best choices to our patients? We as specialists need to answer this question. Why would physicians take time to learn a new technique if they are going to be poorly reimbursed? Reimbursement for hysteroscopic sterilization and/ or ablation far exceed hysterectomy. Who would have thought! So, how can we train the specialists of tomorrow in minimally invasive and vaginal surgery? Unfortunately, I do not know, but the answer has a strong financial component. Laparoscopic hysterectomy is clearly beneficial for patients in whom vaginal surgery is contraindicated or cant be done. When indications for the vaginal approach are equivocal, laparoscopy can be used to determine if vaginal hysterectomy is possible. With this philosophy, patients avoid an abdominal incision with resultant decrease in length of hospital stay and recuperation time. The laparoscopic surgeon should be aware of the risks and how to minimize them and, when they occur, how to repair them laparoscopically.

REFERENCES CONCLUSION
Laparoscopic hysterectomy was first performed in January 1988. The sine qua non for laparoscopic hysterectomy is the laparoscopic ligation of the uterine vessels either by
1. Reich H. Hysterectomy as Treatment for Dysfunctional Uterine Bleeding. In: SK Smith (Ed): Baillieres Clinical Obstetrics and Gynecology. Dysfunctional Uterine Bleeding. Publisher Bailliere Tindall (Harcourt Health Sciences), London 1999;13:251-69.

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NF Gant, IR Horowitz, A Murphy (Eds): 1994;1;29-54. Mosby Year Book. Reich H, Clarke HC, Sekel L. A simple method for ligating in operative laparoscopy with straight and curved needles. Obstet Gynecol 1992;79:143-47. Ribeiro S, Reich H, Rosenberg J. The value of intraoperative cystoscopy at the time of laparoscopic hysterectomy. Hum Reprod 1999;14:1727-29. Reich H. Letters to the Editor. Ureteral injuries after laparoscopic hysterectomy. Human Reproduction 2000; 15:733-34. Wu HH, Yang PY, Yeh GP, et al. The detection of ureteral injuries after hysterectomy. J Minim Invasive Gynecol 2006;13:403-08. Sharon A, Auslander R, Brandes-Klein O, et al. Cystoscopy after total or subtotal laparoscopic hysterectomy: The value of a routine procedure. Gynecol Surg 2006;3:122-27. Reich H, McGlynn F, Wilkie W. Laparoscopic management of Stage I ovarian cancer. Journal of Reproductive Medicine 1990;35:601-05. Reich H, McGlynn F, Wilkie W. Laparoscopic management of stage I ovarian cancer: A case report. Obstetrical and Gynecological Survey 1990;45:772-74.

2. Reich H, McGlynn F. Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tuboovarian disease. Journal of Reproductive Medicine, 1986;31:609. 3. Reich H. Laparoscopic oophorectomy and salpingooophorectomy in the treatment of benign tuboovarian disease. International Journal of Fertility 1987;32:233-36. 4. Reich H. Laparoscopic oophorectomy without ligature or morcellation. Contemporary OB/GYN. September, 1989;34(3):34. 5. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg, 1989;5:213-16. 6. Reich H. Laparoscopic hysterectomy. Surgical Laparoscopy and Endoscopy. Raven Press, New York 1992;2:85-88. 7. Reich H, McGlynn F, Sekel, L. Total laparoscopic hysterectomy. Gynaecological Endoscopy 1993;2:59-63. 8. Garry and Reich: Laparoscopic Hysterectomy. Publisher: Blackwell Scientific Publications Ltd. Oxford, England. 1993 (Textbook). 9. Reich H. The role of laparoscopy in hysterectomy. Advances in Obstetrics and Gynecology. JA Rock, S Faro,

10. 11. 12. 13. 14. 15. 16.

INDEX
A
Abdominal approach to hysterectomy 37 indications and contraindications 37 cancer 37 extrauterine pelvic pathology (endometriosis, adhesive disease) 37 narrow vagina 37 need for oophorectomy 37 nulliparity with lack of uterine descent 37 obesity 37 poor uterine mobility without access to the uterine vasculature 37 previous pelvic surgery 37 uterine size greater than 12 weeks 37 Abdominal hysterectomy 3, 17 Additional cytoreductive procedures of extraperitoneal hysterectomy 65 Advantages of the CISH method using CURT 100 medical benefits 101 psychological benefits 101 surgical benefits 101 Ancillary port entry with Endotip 141 Anterior exenteration procedure 48 bladder dissection and space of Retzius 52 cutting the ligaments 51 dissection of the para-rectal space 48 ileal conduit 54 lymph node dissection 52 posterior dissection 50 uretero-sigmoidostomy 54 Applications of visual entry systems 138 visual cannula Endotip 140 visual trocars 138 Endopath optiview visual trocar 138 Visiport visual trocar 138 visual verres mini-laparoscopy 140 Aspects for vaginal hysterectomy 15 blood transfusion 16 complications 15 invasion 17 morbidity 17 quality of life and satisfaction 17 randomized studies 17 recovery 16 stay 16 time and cost 15 Conrad Langenbeck 8 Considerations during visual port placement 135 Coring 128

B
Bisection 128 Bladder dissection techniques 90 scarred uterus 91 unscarred uterus 90

D
Development of hysterectomy in the twentieth century 9 Development of laparoscopic surgery 10

C
Charles Clay 4 Charles Clay and the first abdominal hysterectomy in the world 2 Charles Clay and the first successful hysterectomy in Europe 6 CISH hysterectomy 102 complications 106 short-term (cervical) 106 short-term (operative) 106 long-term (cervical) 106 leiomyoma and endometrioma 106 long-term bleeding 106 mucocoele 106 pain long-term 106 results 105 operative data 105 surgical procedure 103 technique 102 limitation 102 CISH technique 95 materials and methods 95 first vaginal step 96 second vaginal step 96 results 97 Close the vagina 82 technique 82 McCall suture 83 Te Linde suture 82 Comments of laparoscopic radical hysterectomy 71 radical hysterectomy: laparoscopy versus laparotomy 71 blood loss 72 complications 72 numbers of lymph nodes retrieved 72 operating time 71 rationales in laparoscopic radical surgery for cervical cancer 71

E
Early vaginal hysterectomies 7 Endometrial ablation contrahysterectomy 119 Endometrial ablation techniques 116 Ephraim McDowell 1 Ether day 4 Extraperitoneal hysterectomy 63

F
First elective vaginal hysterectomies 7 First laparoscopic hysterectomy and development of total laparoscopic hysterectomy (TLH) concept 146 Future of hysterectomy 1

H
Hand-assisted laparoscopy 129 High epigastric port placement 129 Hysterectomies in a day clinic 86 Hysterectomy associated to concomitant procedures for POP with or without SUI 27 Hysterectomy for large uteri 121 set-up and operation 122

I
Indications for hysterectomy 116 Introduction of anaesthesia 3

J
Jane Todd Crawford 1 Jules Pean 6

L
Laparoscopic assisted vaginal hysterectomy 17 Laparoscopic hysterectomy 10, 41, 146 background 146 complications 41 bladder injury 41

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bowel injury 41 haemorrhage 41 infection 41 long-term complications 42 ureter complications 41 Laparoscopic port systems 132 Laparoscopic supracervical hysterectomy 108 materials and methods 109 results 115 Laparoscopic surgical techniques 70 Laparoscopically pelvic lymphadenectomy 70 Laparoscopically radical hysterectomy 71 Lawson Tait 6

Manual of New Hysterectomy Techniques

Primary entry with Endotip 141 Primary route for hysterectomy 18 contraindications 18 common 18 excuses 19 uncommon 18 indications/associated conditions 21 associated obesity 21 dysfunctional uterine bleeding (DUB)/adenomyosis 21 fibroids 21 malignancy 21 Promote VH as primary route 22 examination under anaesthesia (EUA) 22 laparoscopic evaluation 22 preoperative uterine volume 22 trial vaginal hysterectomy 22 non-stage leaving the peritoneum open 33 opening posterior peritoneum 31 opening the anterior peritoneum 32 reconstruction of the pelvic floor 33 Thomas Keith and the dawn of the new era 5 Total laparoscopic hysterectomy technique (TLH) 38 bladder mobilization 39 cystoscopy 40 division of cervicovaginal attachments and circumferential culdotomy 40 endometriosis 41 exploration 39 incisions 38 laparoscopic vaginal vault closure and suspension with McCall culdeplasty 40 morcellation (laparoscopic and vaginal) 40 preoperative preparation 38 retroperitoneal dissection 39 skin closure 41 underwater examination 40 upper uterine blood supply 39 ureteral dissection (optional) 39 uterine vessel ligation 39 vaginal preparation 39

M
Management of bladder injuries 92 diagnosis of urological injuries 92 intraoperative recognition 92 postoperative recognition 92 prevention 92 repair of bladder injuries 93 intraoperatively diagnosed bladder injuries 93 postoperatively diagnosed bladder injuries 93 Morcellation 127 Myomectomy 129

R
Robotic assisted laparoscopic hysterectomy 62 complications 62 contraindications 62 Robotic laparoscopic radical hysterectomy for cervical cancer 57 Robotic laparoscopic radical hysterectomy surgical technique 58

N
NovaSure technology 117 complications 118 failures 118 results 118 safety features 118

S
Selection of the most appropriate surgical procedure for women with concomitant POP 26 Spencer Wells 5 Supracervical hysterectomy 130 Surgical anatomy of the bladder 90 approach to bladder 90

U
Urodynamic testing before hysterectomy and POP/SUI interventions 25 Urological complications of hysterectomy 27 Use of robotics 75

O
Oliver Wendel Holmes 4

T
Technique of robotic assisted laparoscopic hysterectomy 76 The ten step vaginal hysterectomy 30 method description 30 closing the vaginal wall 33 cutting and ligating the uterine arteries 32 detaching the bladder from the uterus 31 dissection of the lower part of the uterus 32 incision of the vaginal wall 30

P
Pelvic anterior exenteration 46 anaesthesia 47 indications 46 instrumentation 47 port position 47 position of operating surgeons and monitor 47 Port characteristics 132 Port removal 143 Pre-insufflation for visual entry 136

V
Vaginal hysterectomy 17 Vaginal route and minimally invasive surgery for stress urinary incontinence without concomitant POP 26 Visual entry systems 134

W
Wedge morcellation 129