Hysterectomy is one of the most common gynaecological procedure which involves the removal of fibroids from a woman. Laparoscopic hysterectomy is one of the minimally invasive surgical procedures used to remove the uterus. Laparoscopic hysterectomy has been termed as the procedure of choice for most women due to its safety compared to the traditional open hysterectomy. The adoption of laparoscopic hysterectomy has been growing over the years due to several advantages of minimally invasive surgery that are associated with laparoscopic hysterectomy.

Hysterectomy is an irreversible procedure after which the woman is no longer able to become pregnant. The removal of the uterus renders her infertile.

Laparoscopic hysterectomy can be categorized into three main types:

·         Laparoscopic assisted vaginal hysterectomy (LAVH). Here a small incisions are made and the surgeon is able to view the uterus on a monitor. The specialised laparoscopic surgical tools are used to detach the uterus from the surrounding tissue. Once detached the uterus is removed through the vagina.

·         Laparoscopic supracervical hysterectomy (LSH). Here small incisions are made and by use of the specialised laparoscopic surgical tools, the uterus is separated from the cervix. These incisions are usually larger than those in the vaginal assisted hysterectomy. Once separated, the uterus is removed through one of the small abdominal incisions. In this procedure the cervix remains, however, it is at a risk of getting cervical cancer, thus regular screenings are required. Usually the recovery and hospital stay is longer than in the laparoscopic assisted vaginal hysterectomy.

·         Total laparoscopic hysterectomy (TLH). This is a complete hysterectomy surgical procedure in which the uterus along with the cervix are removed. It involves the ligation of the ovarian arteries and the veins and the removal of the uterus can be done vaginally or abdominally. TLH is considered as a safe technique to remove to remove the uterus. Unlike the abdominal hysterectomy, TLH is able to reduce trauma and morbidity in a patient.

How laparoscopic hysterectomy is performed

This procedure is performed when the patient is under general anaesthesia. It is a surgical procedure that is usually performed by highly qualified gynaecologist. Small incisions are made in your abdomen just below your umbilicus. A laparoscope is inserted in order to send images of the internal organs to a monitor where the surgeon is able to view them. By use of specialised laparoscopic surgical tools the uterus and the cervix are detached and removed with or without both ovaries and fallopian tubes. The small incisions are sutured closed and carefully dressed.

Who should have laparoscopic hysterectomy surgery?

Laparoscopic hysterectomy is performed on women who have various complications in the uterus. These complications can include bleeding of the uterine and also those women who have developed fibroids. This procedure cannot be possible to perform on women who have very large uterus and those who probably have undergone several surgeries in their abdomen.

The choice to have hysterectomy done can be a tough decision to a woman especially when she’s younger. As earlier mentioned this procedure is irreversible and when it is done it simply means that the woman can no longer have children. Most of the times younger women feel like they have lost their womanliness. However, this procedure can be very beneficial to a woman who has several problems within her uterus. 

Advantages of laparoscopic hysterectomy

Laparoscopic hysterectomy has several advantages compared to the traditional abdominal hysterectomy.

These advantages are associated with the minimally invasive surgical procedure and they include:

·         Shorter recovery time. This surgical procedure involves the making of small incisions in the abdomen. These incisions take a shorter time to heal unlike the open surgical operations where large incisions are made. Patients are able to go back to their normal lives within two weeks or less.

·         Shorter hospital stay- Patients don’t have to spend days in the hospital. Some can even be released the same day several hours after the surgery.

·         Reduced bleeding. Since only small incisions are made the bleeding is greatly reduced. Blood transfusions is not necessary for the patients. This is a bit different with the abdominal hysterectomy where a large incision is made.

·         Minimal post-operative discomfort. Patients experience minimal discomfort after the surgery. Lower to no medications is involved with this procedure.

·         Improved vision. The surgeon is able to view the internal organs on a monitor which receives images from a laparoscope that is inserted through one of the ports. The surgeon is thus able to avoid inflicting injury to the internal organs and is also able to accurately cut the uterus and detach it from the other internal organs surrounding it.

Disadvantages of laparoscopic hysterectomy

Laparoscopic hysterectomy is an advanced technology and thus it has some of demerits.

·         More expensive. This surgical procedure relies on advanced technology and hence it can be more expensive than the standard abdominal hysterectomy. Some patients may fail to afford the costs of having this procedure done on them.

·         Requires very high skills. Laparoscopic hysterectomy requires very highly skilled gynaecologists to perform the procedure successfully. Therefore, every patient has a task to identify highly skilled surgeons who can perform laparoscopic hysterectomy on them. Surgeons also have to go through a specialised training in order to perfect their skills in handling the instruments and performing the operations accurately and successfully. If the surgeon is not skilled enough there is a greater risk to the patient.

Difficulties in laparoscopic hysterectomy for large uterus

There are those women who might having very large uterus. A large uterus is deemed to be usually 15 to 16 weeks of gestation or weighs more than 500 grams. Large uterus can render the laparoscopic hysterectomy difficult to perform. Several studies have suggested that large uteri should be treated by laparotomy.

Difficulties associated with the treatment of large uterus by laparoscopic hysterectomy include:

·         Limited access to uterine vascular pedicles. This depends on the size and location of myomas. If the myomas are very large and located deep in the uterine wall, operating on the uterus becomes difficult since the surgeon has limited access to the uterus. In the case of large myomas, the uterine vessels are usually raised up almost to the level of the ovarian vessels. This becomes very hard to access the uterine vessels and if there no high accuracy the surgery can lead to injury to some of the internal organs thus leading to internal bleeding or haemorrhage.

·         Risk of bowel or urinary tract injury.  In case of lateral myomas, the ureter can be pushed outwards and almost raised onto the surface of the myoma. Also the lateral myomas can arise above the uterine vessels thus pushing the ureter outwards and downwards. Large cervical myomas can flatten the bladder and this can make it get raised up on the anterior uterine surface. These distortions involving large uterus or myomas lead to the poor exposure of the ureter, bladder and the bowel thus increasing their risk to injury.

·         Technical difficulty in extracting the uterus. Large uterus poses some greater technical difficulties in removing it using laparoscopic hysterectomy. This would require very high skills especially when it comes to suture the uterine vessels. The extraction of the uterus is often rendered a difficult task to perform since to debulk the uterus completely is limited to space and accessibility to uterosacrals.

·         Haemorrhage. Due to the poor exposure of the internal organs there is a high risk of haemorrhage due to injury.

It has been established that, in order to reduce the difficulties in the treatment of large uteri on women, some modifications should be done on the laparoscopic hysterectomy. These modifications are here to make the technique overcome the poor access and exposure of some internal organs.

First the modifications should be done in order to enhance or facilitate proper visualisation. This is done by placing the optical trocar supraumblically. The myoma spiral can be changed frequently from one location to another thus helping in the access to all pedicles of the uterus. There is also increased mobility of the uterus.

Haemorrhage is also a major concern in when treating large uteri. This is due to poor exposure. However, blood loss can be minimised by ligating the uterine pedicle as the first step in the laparoscopic hysterectomy. The uterine pedicles can be secured by adopting several options which include, harmonic ultracision, vessel-sealing device or endoscopic suturing techniques.

Conclusion

When surgeons have adequate and quality training on the laparoscopic hysterectomy it becomes easier to perform this procedure. Adopting proper techniques, it also becomes easier to perform hysterectomy even on women who have huge uteri. When laparoscopic hysterectomy is preformed successfully and effectively, the results are always pleasing. There are minimal to no complications rates, the recovery is often very short such that the patients can get back to their normal activities without any problems. There are very minimal post-operative medications associated with this procedure. However, before taking the procedure patients should really think about it since it is an irreversible one and once done on a woman, she can no longer become pregnant. Laparoscopic hysterectomy can be very effective and also the safest method for women when it is done by very qualified person and with the right techniques.