Total Laparoscopic Hysterectomy
A total laparoscopic hysterectomy requires a vaginal seal to prevent a gas leak. Two 4 × 4 inch wet sponges in the gloves can be used to insert into the vagina to prevent loss of pneumoperitoneum. By applying contralateral retraction to the uterus, the vaginal wall surrounding the cervix is outlined, coagulated with the unipolar scissors or bipolar forceps and cut circumferentially until the cervix is separated. The specimen is pulled to the mid vagina but not removed to preserve pneumoperitoneum. Vaginal vault is irrigated and inspected for any active bleeding. Once hemostasis is achieved, vaginal angles are sutured to the adjacent cardinal and uterosacral ligaments. Care is taken to avoid the ureter. The rest of the vaginal cuff is closed using intracorporeal knotting. Bipolar is used cautiously at the vaginal cuff to prevent tissue necrosis and subsequent wound breakdown if the sutures replaced in non-viable tissue.
Total Laparoscopic Hysterectomy
The hysterectomy can be performed laparoscopically up to the uterine size of 26 weeks. These patients must have adequate hemoglobin and hematocrit. The GnRH analog should be given if the uterus is more than 18 weeks gestational size. According to the baseball diamond concept, the telescopic port should be placed between umbilicus and xiphoid in the patient whose uterus is more than 18 weeks size. The secondary ports should also be placed higher than usual. Big uterus with multiple myomas is difficult to manipulate. Sometimes, 4 to 5 port may be necessary to handle this uterus. Anatomy is distorted and ureteral dissection may be necessary in these cases.
Subtotal Hysterectomy
Supracervical hysterectomy is performed to preserve the libido of the patient. The procedure is performed fully laparoscopically. After desiccating and cutting the uterine vessels at the level of cardinal ligaments above the uterosacral ligament, the uterus is retracted and its lower segment is amputated with the scissors and unipolar cutting current. After transecting the uterus from the cervix, the uterine manipulator is removed vaginally, the cervical stump is irrigated and hemostasis is achieved. The endocervical epithelium, lining the cervical canal is vaporized or coagulated with laser or electrosurgery. The rest of the endocervical canal is ablated vaginally to reduce the risk of intraepithelial cervical neoplasia. The cervical stump is closed with interrupted absorbable sutures and covered with peritoneum, which is stitched transversely with interrupted sutures. The dissected uterus is morcellated and removes through a 10 mm cannula. Mini-laparotomy or posterior colpotomy can also be performed to remove the uterus in the case of subtotal hysterectomy. These patients are advised to annual examination for Pap smear.
Ending the Procedure
One of the benefits of LAVH or TLH over NDVH is the inspection of pedicles at the end of surgery. The vaginal cuff can be closed from below or above but after that pneumoperitoneum is again restored to see the pelvic and abdominal cavity. Irrigation and suction should be performed. In case of any residual bleeding, it can be controlled laparoscopically. In the end, the pelvis is filled with 300 ml Ringer’s lactate and it should be seen for change in color. Once the inspection is satisfying the fluid is sucked and the instrument and cannula are removed after deflating the abdominal cavity. It has been demonstrated that TLH and LAVH are associated with a shorter hospital stay and patients require less pain medication compared to TAH. LAVH can replace most of the abdominal hysterectomy for the benign disease of the uterus and with the technology available today it has a definite benefit over non-descended vaginal hysterectomy.
Discussion
Vaginal hysterectomy is part of the repertoire of every trained gynecologist. It is considered as a feasible option for abdominal hysterectomy and many studies have shown that vaginal hysterectomy has fewer complications, short recovery, and hospital stay than laparotomy. A laparoscopic hysterectomy requires greater surgical expertise and has a steep learning curve. Randomized trials have shown advantages of laparoscopy versus laparotomy, including reduced postoperative pain, shorter hospitalization, rapid recovery, and substantial financial benefits to society. The objective of performing hysterectomy laparoscopically can be achieved but the question is does this offer any advantage over the vaginal route. Every mode of hysterectomy has advantages and disadvantages but the indications for each remain controversial. Good surgical practice is when the indication for hysterectomy is considered as the primary criterion for selecting the route of hysterectomy and not factors such as the surgeon’s choice and experience. A major determinant of the route of hysterectomy is not the clinical situation but the attitude of the surgeon. There is no need for extra training and special skills or complicated equipment for vaginal hysterectomy.
Laparoscopic hysterectomy took a long time to perform in all studies. However, with the increasing weight of the uterus, there was a linear increase in operating time and blood loss in hysterectomy performed vaginally which was not observed in laparoscopic-assisted vaginal hysterectomy. There is no statistically significant difference in postoperative analgesia requirement, hospital stay, recovery milestones, or complication rates. The biggest drawback of the laparoscopic route over vaginal one is its cost due to expensive disposable instruments, prolonged operating and anesthesia time, and the need for a trained senior gynecologist. For laparoscopic-assisted vaginal hysterectomy to be cost-effective expensive disposable instruments have to be eliminated.
Laparoscopic surgeons argue that subtotal hysterectomy can be performed laparoscopically but most randomized trials have failed to demonstrate any benefit of subtotal hysterectomy over total hysterectomy. In women who wish to retain their cervix vaginal subtotal hysterectomy described by Doderlein Kronig technique can be performed. The disadvantage of the vaginal approach is vault hematomas. The abdominal approach to hysterectomy does ensure good hemostasis under direct vision, while during the vaginal operation, the vault is closed and subsequent bleeding from the vagina between the mucosa and the peritoneum can give rise to problems, especially if a vasoconstrictor has been given that subsequently wears off. The laparoscopic approach can help check hemostasis and reduce the incidence of vault hematomas. However; this aspect needs to be evaluated in studies.
Lack of uterine descent and nulliparity, fibroid uterus, need for oophorectomy, previous pelvic surgery is no more considered as contraindications to the vaginal route. With adequate vaginal access and technical skill, and good uterine mobility, vaginal hysterectomy can easily be achieved Multiparity, lax tissues due to poor involution following multiple deliveries and lesser tissue tensile strength afford a lot of comfort to vaginal surgeon even in the presence of significant uterine enlargement. No evidence supports the use of laparoscopic hysterectomy rather than VH if the latter can be performed safely. No outcomes are significantly worse for vaginal hysterectomy compared to LAVH. There are clinical situations where vaginal surgeries is not appropriate such as dense pelvic adhesions, severe endometriosis adnexal disease when vaginal access is reduced when laparoscopic hysterectomy is indicated as it has advantages over the abdominal approach. The laparoscopic approach may be helpful postoperatively to rule out hemorrhage in some cases. Laparoscopic assistance should not be used to supplant the inadequate skills of vaginal hysterectomy.
Lack of training in vaginal surgery is not a reason for not removing uteri vaginally. The learning curve of VH is very short compared to laparoscopic surgery, however, the current scenario in residency programs is not providing a level of surgical competency in performing difficult vaginal hysterectomies. There is a need to improve this training.
In order to compare the complication rates of different types of hysterectomies, considering an incidence of 4 to 5 percent of serious complications of hysterectomies 1460 women would be required in each arm of the study to detect 50 percent increase in the complication rate. Therefore, larger randomized controlled trials are required to compare different types of hysterectomies.
When the size of the uterus is greater than 16 weeks gestation there is an increase in the operative time and blood loss in VH compared to LAVH which is statistically significant.
Laparoscopically assisted vaginal hysterectomy is a useful adjunct to transvaginal hysterectomy for lysis of extensive adhesions and sometimes for certain concomitant adnexal surgery. Besides, LAVH can also secure almost all the main blood supplies to the uterus, i.e. the uterine vessels and the adnexal collaterals. Although a skilled surgeon can do transvaginal hysterectomy with a larger uterus by employing volume-reducing techniques, Kohler reported that laparoscopic coagulation hemostasis of the uterine vessels was associated with less blood loss. It may take time to achieve these goals, but they may make subsequent extirpation or volume reducing procedures easier and safer to perform. Therefore, the average operative time and estimated blood loss for the LAVH remained almost constant regardless of increasing uterine weight. Generally, the average operative time for LAVH is longer than that for transvaginal hysterectomy. It takes time to secure the uterine blood supply before extirpation and volume reducing procedures, but it also makes LAVH superior to transvaginal hysterectomy when dealing with a larger uterus. In our opinion, LAVH might be considered for a larger uterus in view of the relatively shorter operative time and less blood loss, whereas transvaginal hysterectomy is preferable for a small uterus, not only for the shorter operative time and minimal wound but also for much lower costs.
A total laparoscopic hysterectomy requires a vaginal seal to prevent a gas leak. Two 4 × 4 inch wet sponges in the gloves can be used to insert into the vagina to prevent loss of pneumoperitoneum. By applying contralateral retraction to the uterus, the vaginal wall surrounding the cervix is outlined, coagulated with the unipolar scissors or bipolar forceps and cut circumferentially until the cervix is separated. The specimen is pulled to the mid vagina but not removed to preserve pneumoperitoneum. Vaginal vault is irrigated and inspected for any active bleeding. Once hemostasis is achieved, vaginal angles are sutured to the adjacent cardinal and uterosacral ligaments. Care is taken to avoid the ureter. The rest of the vaginal cuff is closed using intracorporeal knotting. Bipolar is used cautiously at the vaginal cuff to prevent tissue necrosis and subsequent wound breakdown if the sutures replaced in non-viable tissue.
Total Laparoscopic Hysterectomy
The hysterectomy can be performed laparoscopically up to the uterine size of 26 weeks. These patients must have adequate hemoglobin and hematocrit. The GnRH analog should be given if the uterus is more than 18 weeks gestational size. According to the baseball diamond concept, the telescopic port should be placed between umbilicus and xiphoid in the patient whose uterus is more than 18 weeks size. The secondary ports should also be placed higher than usual. Big uterus with multiple myomas is difficult to manipulate. Sometimes, 4 to 5 port may be necessary to handle this uterus. Anatomy is distorted and ureteral dissection may be necessary in these cases.
Subtotal Hysterectomy
Supracervical hysterectomy is performed to preserve the libido of the patient. The procedure is performed fully laparoscopically. After desiccating and cutting the uterine vessels at the level of cardinal ligaments above the uterosacral ligament, the uterus is retracted and its lower segment is amputated with the scissors and unipolar cutting current. After transecting the uterus from the cervix, the uterine manipulator is removed vaginally, the cervical stump is irrigated and hemostasis is achieved. The endocervical epithelium, lining the cervical canal is vaporized or coagulated with laser or electrosurgery. The rest of the endocervical canal is ablated vaginally to reduce the risk of intraepithelial cervical neoplasia. The cervical stump is closed with interrupted absorbable sutures and covered with peritoneum, which is stitched transversely with interrupted sutures. The dissected uterus is morcellated and removes through a 10 mm cannula. Mini-laparotomy or posterior colpotomy can also be performed to remove the uterus in the case of subtotal hysterectomy. These patients are advised to annual examination for Pap smear.
Ending the Procedure
One of the benefits of LAVH or TLH over NDVH is the inspection of pedicles at the end of surgery. The vaginal cuff can be closed from below or above but after that pneumoperitoneum is again restored to see the pelvic and abdominal cavity. Irrigation and suction should be performed. In case of any residual bleeding, it can be controlled laparoscopically. In the end, the pelvis is filled with 300 ml Ringer’s lactate and it should be seen for change in color. Once the inspection is satisfying the fluid is sucked and the instrument and cannula are removed after deflating the abdominal cavity. It has been demonstrated that TLH and LAVH are associated with a shorter hospital stay and patients require less pain medication compared to TAH. LAVH can replace most of the abdominal hysterectomy for the benign disease of the uterus and with the technology available today it has a definite benefit over non-descended vaginal hysterectomy.
Discussion
Vaginal hysterectomy is part of the repertoire of every trained gynecologist. It is considered as a feasible option for abdominal hysterectomy and many studies have shown that vaginal hysterectomy has fewer complications, short recovery, and hospital stay than laparotomy. A laparoscopic hysterectomy requires greater surgical expertise and has a steep learning curve. Randomized trials have shown advantages of laparoscopy versus laparotomy, including reduced postoperative pain, shorter hospitalization, rapid recovery, and substantial financial benefits to society. The objective of performing hysterectomy laparoscopically can be achieved but the question is does this offer any advantage over the vaginal route. Every mode of hysterectomy has advantages and disadvantages but the indications for each remain controversial. Good surgical practice is when the indication for hysterectomy is considered as the primary criterion for selecting the route of hysterectomy and not factors such as the surgeon’s choice and experience. A major determinant of the route of hysterectomy is not the clinical situation but the attitude of the surgeon. There is no need for extra training and special skills or complicated equipment for vaginal hysterectomy.
Laparoscopic hysterectomy took a long time to perform in all studies. However, with the increasing weight of the uterus, there was a linear increase in operating time and blood loss in hysterectomy performed vaginally which was not observed in laparoscopic-assisted vaginal hysterectomy. There is no statistically significant difference in postoperative analgesia requirement, hospital stay, recovery milestones, or complication rates. The biggest drawback of the laparoscopic route over vaginal one is its cost due to expensive disposable instruments, prolonged operating and anesthesia time, and the need for a trained senior gynecologist. For laparoscopic-assisted vaginal hysterectomy to be cost-effective expensive disposable instruments have to be eliminated.
Laparoscopic surgeons argue that subtotal hysterectomy can be performed laparoscopically but most randomized trials have failed to demonstrate any benefit of subtotal hysterectomy over total hysterectomy. In women who wish to retain their cervix vaginal subtotal hysterectomy described by Doderlein Kronig technique can be performed. The disadvantage of the vaginal approach is vault hematomas. The abdominal approach to hysterectomy does ensure good hemostasis under direct vision, while during the vaginal operation, the vault is closed and subsequent bleeding from the vagina between the mucosa and the peritoneum can give rise to problems, especially if a vasoconstrictor has been given that subsequently wears off. The laparoscopic approach can help check hemostasis and reduce the incidence of vault hematomas. However; this aspect needs to be evaluated in studies.
Lack of uterine descent and nulliparity, fibroid uterus, need for oophorectomy, previous pelvic surgery is no more considered as contraindications to the vaginal route. With adequate vaginal access and technical skill, and good uterine mobility, vaginal hysterectomy can easily be achieved Multiparity, lax tissues due to poor involution following multiple deliveries and lesser tissue tensile strength afford a lot of comfort to vaginal surgeon even in the presence of significant uterine enlargement. No evidence supports the use of laparoscopic hysterectomy rather than VH if the latter can be performed safely. No outcomes are significantly worse for vaginal hysterectomy compared to LAVH. There are clinical situations where vaginal surgeries is not appropriate such as dense pelvic adhesions, severe endometriosis adnexal disease when vaginal access is reduced when laparoscopic hysterectomy is indicated as it has advantages over the abdominal approach. The laparoscopic approach may be helpful postoperatively to rule out hemorrhage in some cases. Laparoscopic assistance should not be used to supplant the inadequate skills of vaginal hysterectomy.
Lack of training in vaginal surgery is not a reason for not removing uteri vaginally. The learning curve of VH is very short compared to laparoscopic surgery, however, the current scenario in residency programs is not providing a level of surgical competency in performing difficult vaginal hysterectomies. There is a need to improve this training.
In order to compare the complication rates of different types of hysterectomies, considering an incidence of 4 to 5 percent of serious complications of hysterectomies 1460 women would be required in each arm of the study to detect 50 percent increase in the complication rate. Therefore, larger randomized controlled trials are required to compare different types of hysterectomies.
When the size of the uterus is greater than 16 weeks gestation there is an increase in the operative time and blood loss in VH compared to LAVH which is statistically significant.
Laparoscopically assisted vaginal hysterectomy is a useful adjunct to transvaginal hysterectomy for lysis of extensive adhesions and sometimes for certain concomitant adnexal surgery. Besides, LAVH can also secure almost all the main blood supplies to the uterus, i.e. the uterine vessels and the adnexal collaterals. Although a skilled surgeon can do transvaginal hysterectomy with a larger uterus by employing volume-reducing techniques, Kohler reported that laparoscopic coagulation hemostasis of the uterine vessels was associated with less blood loss. It may take time to achieve these goals, but they may make subsequent extirpation or volume reducing procedures easier and safer to perform. Therefore, the average operative time and estimated blood loss for the LAVH remained almost constant regardless of increasing uterine weight. Generally, the average operative time for LAVH is longer than that for transvaginal hysterectomy. It takes time to secure the uterine blood supply before extirpation and volume reducing procedures, but it also makes LAVH superior to transvaginal hysterectomy when dealing with a larger uterus. In our opinion, LAVH might be considered for a larger uterus in view of the relatively shorter operative time and less blood loss, whereas transvaginal hysterectomy is preferable for a small uterus, not only for the shorter operative time and minimal wound but also for much lower costs.
