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Laparoscopic supracervical hysterectomy: a procedure whose time has come.

Captivated by the promise of cutting-edge technology and ever-more-complex techniques, we sometimes become so enamored with what is new that we fail to appreciate the old and abandon techniques or principles that could still serve our patients well. This may be the case with hysterectomy, one of the most common operations performed in the United States each year.

In its infancy more than 100 years ago, subtotal or supracervical hysterectomy was the norm, performed to relieve catastrophic uterine bleeding and/or massive tumors of the uterus, most of them leiomyomas. Morbidity and mortality were high in those early surgical wards, but advatices in anesthesia and surgical technique, antibiotic therapy, and blood banking eventually led to reassuringly low complication rates. The procedure gained acceptance for benign, albeit painful and/or distressing, indications.

Alarm over rising mortality from cervical cancer led to the virtual abandonment of the supracervical approach between the early 1940s, when this method constituted 85%-95% of hysterectomies, and the mid-1950s, when it represented fewer than 5%.

But progress marched on.

Today, we have myriad tools to detect and treat cervical cancer, from Pap smears to colposcopies, and from directed biopsy to laser and electrosurgical therapies to cold knife conization. Women well understand the risk of cervical cancer and are remarkably compliant with screening programs. All these factors have led to a continuing decline in mortality from cervical cancer, almost eliminating this disease as a risk for today's woman.

The historic need for routine extirpation of the cervix in hysterectomy has passed, regardless of the surgical approach, except in patients with invasive carcinoma of the cervix or carcinoma of the endometrium.

With the return to the preservation of the cervix and utilization of the most current laparoscopic methods, laparoscopic supracervical hysterectomy (LSH) stands as a fusion of the best of past and present techniques in gynecologic surgery. Much safer and less invasive than total abdominal hysterectomy, LSH is easier to perform than laparoscopic hysterectomy, laparoscopically assisted vaginal hysterectomy (LAVH), or vaginal hysterectomy.

Impressive Results

Simplicity is key to the procedure's success and versatility.

Laparoscopic supracervical hysterectomy avoids the necessity of performing a challenging vaginal procedure at the end of a difficult laparoscopic procedure (as in LAVH). A single surgeon can perform the surgery in a standard operating suite using basic equipment.

In 1993, I published a comparison of 50 LAVH and 50 well-matched LSH patients with similar indications, including abnormal uterine bleeding, uterine leiomyomata, pelvic/abdominal pain, endometriosis, adnexal masses, pelvic inflammatory disease, adhesive disease, and endometrial cancer (the latter diagnosis treated in the LAVH group only) (J. Reprod. Med. 38[10]:763-767, 1993).

Operating times, estimated blood loss, length of hospital stay, return to work, and return to normal activity were all significantly better in patients who had LSH. Patients who underwent LAVH had increased postoperative symptoms that included vaginal discharge, postoperative bladder and bowel symptomatology, increased back pain, and decreased libido and coital frequency.

In the next 8 years, I performed approximately 550 more LSH procedures--this time including patients with stage IV endometriosis, severe pelvic inflammatory disease, ovarian cancer, leiomyosarcoma, uteri weighing as much as 2,400 g, and total pelvic floor prolapse--with excellent outcomes and a low rate of complications.

Patients recover quickly from the procedure and infrequently suffer the bladder, bowel, and sexual complications found more commonly with total abdominal hysterectomy or LAVH. The supracervical approach avoids several anatomical minefields, reducing the chance of injuring adjacent structures such as the ureter or bladder. Leaving an intact paracervical ring and neurovascular supply offers improved pelvic floor support. Likewise, preserving Frankenhauser's plexus and its associated nerves may explain consistently better sexual outcomes after LSH, although the mechanism for this phenomenon deserves more study.

In the largest series reported to date, accounting for 1,000 patients, the complication rates ranged between 0.6% and less than 1% (OBG. Management 11[1]:15-32, 1999; Gynaecol. Endosc. 6[2]:73-76, 1997). My own series of 294 cases included patients with uteri weighing 65-2,180 g and procedures that lasted 55-224 min; these also had a complication rate of less than 1% ("Hysterectomy" [Cambridge, Mass.: Blackwell Science], 1995). We now have extended our series to well over 1,000 patients with no change in morbidity. The patient with a large fibroid uterus is particularly well suited for this procedure, which avoids a large abdominal incision and the attendant morbidity.

A Straightforward Procedure

Patients should participate in the decision to undergo LSH as opposed to alternative procedures, and should not be considered candidates if they have endometrial cancer, invasive cervical cancer, or pelvic floor relaxation in the context of a retroverted uterus and a short (less than 7 cm) anterior wall, or if doubts exist about whether the patient will continue cytologic surveillance.

Obtain full patient consent for laparotomy. Preparation for the procedure should include bowel preparation and the delivery of preoperative intravenous antibiotics.

During surgery, a team approach is critical, with the primary surgeon on the patient's left, the scrub nurse at the patient's feet, and the assistant surgeon on the patient's right, with the patient placed in the modified dorsal lithotomy position with Allen stirrups.

The procedure is relatively adaptable to the individual surgeon's customary practice. For example, isolation and occlusion of the vascular pedicles may be accomplished using sutures, staples, clips, a Harmonic Scalpel, bipolar electrosurgery, monopolar electrosurgery, or laser.

Certain equipment choices are critical to the procedure's success, however, including an excellent uterine manipulator. I recommend the Pelosi uterine manipulator (Apple Medical Corp., Bolton, Mass.), which is placed once sterile preparation has been completed.

Disposable or reusable trocars are then introduced: a subumbilical 10- to 12-mm trocar introduced using the open or Hasson technique; a 10- to 11-mm lower-midline trocar for use in suturing and morcellation; and two 5-mm trocars placed well lateral to the rectus muscles. All trocars must be positioned above the pathologic entity--a large uterus, for example--making precise placement dependent on the patient's size and pathology. An Olympus 10-mm operating laparoscope is used to position the lower trocars under direct visualization.

The contact Nd:YAG laser scalpel (PhotoMedex, Montgomeryville, Penn.) is passed through the laparoscope, and the BiCoag bipolar dissector/grasper using PK technology (Gyrus Medical Corp., Maple Grove, Minn.) is passed through the left lower-lateral port; an atraumatic grasper is passed through the right lateral port, and the suction irrigation device is passed through the midline lower portal. (Note that any cutting device, including monopolar devices, the Harmonic Scalpel, or bipolar cutting forceps, can be substituted through one of the lower ports.)

Following an exploration of the pelvis and abdomen, an identification of the pelvic structures, and an adhesiolysis performed along the lateral pelvic wall, ureterolysis is performed. This is accomplished either by releasing the posterior peritoneum close to the uterus or by incising the peritoneum medial to the ureter on each side, down to the level of the uterosacral ligament.

The round ligaments, tubes, and uteroovarian pedicle are then desiccated on the specimen side to limit back-bleeding. These structures are divided, the anterior uterovesical fold is scored with the laser scalpel, and the bladder flap is developed.

The posterior leaf of the broad ligament is then scored along the side of the uterus. The uterine vessel is skeletonized, a procedure that serves two functions: First, skeletonization protects the ureter and bladder, which are fairly close to the site of application of the bipolar energy source to this pedicle. Second, skeletonization allows a better acquisition of the vessels and allows a more secure seal of this major vascular pedicle.

Next, if the adnexa are to be removed, the infundibulopelvic ligament is desiccated. The ureterolysis incision permits constant visualization of the ureter. Place bipolar forceps in the ipsilateral lower-lateral port to take down the vascular pedicles, applying countertraction from the contralateral port and the uterine manipulator.

The uterus becomes cyanotic once the vascular pedicles are occluded, confirming that the uterus is devascularized.

Using any cutting device (such as monopolar or bipolar cautery, laser, or Harmonic Scalpel), amputate the cervix, beginning at the level of the internal cervical os. Using upward pressure from the uterine manipulator and a slight downward angle on the cutting device, create an inverse cone with some inclusion of the endocervical canal. In most cases, this technique leaves a shell of cervical tissue that will be closed with a mattress suture (as described below).

Use monopolar or bipolar energy to ablate the remaining endocervical canal. Now close the cervical stump using a #0 Vicryl suture on a CT2 needle. Ipsilateral McCall's #0 Ethibond sutures support the vault.

Specimen removal completes the procedure. My preference is to place the mechanical morcellator from Gynecare (Ethicon, Somerville, N.J.). directly through the lower-midline port once the trocar has been removed. The specimen can be pulled into the barrel of the morcellator using equipment such as a 10-mm single-toothed tenaculum inserted through the morcellator.

Once the specimen is removed, meticulously irrigate the abdomen and remove fluid. Close the lower midline trocar site using the Carter-Thomason fascial closure device (Inlet Medical Inc., Eden Prairie, Minn.). The larger remaining sites receive subcuticular closures, and the smaller sites are closed using Steri-Strips. Inject each site with 0.25% Marcaine with epinephrine and apply dressings.

The Foley catheter is removed in the recovery room and ambulation is encouraged. Patients are discharged within 24 hours and instructed to return to normal activities as soon as they feel comfortable doing so. Patients return to work within 1-2 weeks.

To incorporate a McCall's culdoplasty/vault suspension to ensure support prophylactically or therapeutically, shorten the uterosacral ligaments using a permanent purse-string suture of each of the uterosacral ligaments. This procedure allows a physiologic support of the vault using the patient's own tissue in the appropriate anatomic axis.
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Title Annotation:The Master Class
Author:Lyons, Thomas
Publication:OB GYN News
Date:Jun 1, 2004
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