Laparoscopically Assisted Vaginal Hysterectomy: A Gimmick or An Advance?

Diaa M. El-Mowafi - Zagagig University, Egypt

D. El-Mowafi and Ch. Lall
Department of Obstetrics and Gynecology, Benha Faculty of Medicine, Egypt
Hutzel Hospital, Detroit Medical Center, Wayne State University, Detroit MI, USA.

Corresponding Author: Diaa El-Mowafi, M.D. 4 Ghazza St., El-Hossania, El-Mansoura 35111, Egypt. Tel. + 2 050 363308 Fax + 2 050 332771

Abstract

Objective: To evaluate the laparoscopically assisted vaginal hysterectomy (LAVH) in terms of indications, uterine size that can be operated upon, surgical procedures and their safety, intraoperative complications and blood loss, operative time, concomitant surgical procedures, postoperative period and complications, and average total cost.

Design and setting: Retrospective study.

Subjects and Interventions: A total of 136 patients underwent LAVH between November 1996 and November 1997 at Hutzel Hospital, Detroit Medical Center, Wayne State University, Michigan, USA.

Results: The mean age of our patients was 45.8± 0.7 years (range, 30-59). Thirty-one patients (22.8%) had previous abdomino-pelvic surgery. The most common indication for LAVH and postoperative pathological finding were myoma(s). The mean length of the removed uteri was 11.8± 0.4 cm (range, 5.6-14). Their mean weight was 235± 8 gm (range, 59-560). The bipolar cautery was used in 96 cases (71%), Endo GIA alone in 4 cases (3%), and both in 36 cases (26%). There was no significant difference between these three modalities in terms of operative time, estimated blood loss, intraoperative and postoperative complications. The mean estimated blood loss was 149± 7 ml (range, 75-750). The mean operative time was 150± 4 min (range, 60-215). Interaoperative complications included one case of bladder injury due to thick adhesions, two cases of inferior epigastric vessels injuries that were easily repaired. Two cases had to be switched from laparoscopic to laparotomy procedure due to bleeding from the uterine artery in one case and from the infundibulopelvic ligament in the other. No blood transfusion was indicated in any of our patients. Postoperative complications included two cases of cystitis, four cases of ileus, one case of pelvic infection, and one case of pelvic abscess. All our patients had a hospital stay of 1-2 days. The estimated average total cost of LAVH was $ 7,500.

Conclusion: LAVH is a true advance in gynecological surgery enables the surgeon to convert most of the abdominal hysterectomies into vaginal ones and hence decreases morbidity, postoperative pain and complications.

Key Words: LAVH, laparoscopic hysterectomy.

Introduction

Hysterectomy is one of the most common gynecological surgical procedures. The advantages of vaginal hysterectomy include no visible scar, less postoperative pain, reduced postoperative complications, shorter hospitalization, and more rapid recovery.1-3 In spite of these advantages, vaginal hysterectomy accounts only for 30% of hysterectomies due to many restrictions. These restrictions are absolute or relative contraindications include significant uterine enlargement, fixation of the uterus by adhesions, previous pelvic surgery, endometriosis, restricted uterine mobility, and adnexael pathology.2,4 In fact, most of these contraindications depend upon surgeon’s experience.

The main aim of laparoscopically assisted vaginal hysterectomy (LAVH) is to enable the surgeon to overcome as many as possible from these contraindications, and hence converting most of the abdominal hysterectomies into vaginal ones.

Materials and Methods

This study included 136 patients who underwent LAVH in the period between November 1996 and November 1997 at Hutzel Hospital, Detroit Medical Center, Wayne State University, Michigan, USA.

The inclusion criteria for our patients were indications for abdominal hysterectomy such as symptomatic liomyoma(s), abnormal uterine bleeding, pelvic pain, endometriosis, endometrial hyperplasia, ovarian cyst, and/or cervical intraepithelial neoplasm. The exclusion criteria for our study were a uterine size ³ 16 weeks and patients who are candidates for vaginal hysterectomy i.e. having uterine prolapsed.

The LAVH procedure, with its advantages and possible complications, was explained to the patient in the office before deciding on surgery. Videotapes were usually used to facilitate this. The other alternative procedures were also discussed with her. Patients who chose the option of LAVH were admitted on the morning of surgery and signed her informed consent. As a routine, every patient received 2gm cefotenan IV, 1-2 h before the operation or 100 mg Vibramycin if she is allergic to cefotenan. No other antibiotics were given either intra- or postoperatively unless indicated. Under general endotracheal anesthesia, the patient was prepared and draped in the normal sterile fashion in the dorsal lithotomy position. A Foley catheter was placed into the bladder. Patient was examined under anesthesia to verify the pre-recorded clinical data. Mobilization of the uterus during surgery was accomplished by one of three methods. The first method was to grasp the cervix with two single-toothed tenaculum at twelve and six o’clock and joined by sterile rubber bands to a uterine sound placed inside the uterus. The second method is by using HUMI cannula. The third method was utilizing the Rumi & Koh colpotomizer. An infraumbilical vertical skin incision or curve-linear (in patients with previous curve-linear laparoscopic incision) was made with a number 11 knife. Verres needle was inserted through this incision. Its intraperitoneal placement is verified by suction with a plastic syringe and negative suction of saline drop when instilled in its outer tip. Carbon dioxide gas was used to obtain pneumoperitoneum, after which Verres needle was removed and a 10-mm reusable or disposable trocar was inserted after enlarging the incision to accommodate it. The secondary 5-mm punctures were made as one suprapubic and the other two in both iliac fossae or in both hypochondria regions if the uterus is more than 12 weeks size. Placement of secondary trocars were done under direct visualization of the laparoscope after transabdominal illumination to guard against injury of the anterior abdominal wall vessels particularly the inferior epigastric artery. Thorough exploration was performed for the abdominal and pelvic viscera including appendix, bowel, liver, gall bladder, diaphragm, in addition to genital organs. Special attention was made to the course of the ureters before starting any surgical procedure and throughout its performance. If there were adhesions, lysis was done using unipolar scissors or bipolar coagulation followed by scissors for thick adhesions. The thin filmy avascular adhesions could be cut without electrocautery. Using Kleppinger bipolar forceps, the round ligaments were coagulated about 1-1.5 cm from the uterine cornua then cut by unipolar scissors. For cutting of the infundibulopelvic and broad ligaments either bipolar followed by unipolar cautery, Endo GIA 30 (United States Surgical Corp., Norwalk, Connecticut) or both were used. If the ovary was to be preserved, the proximal part of the ovarian ligament, fallopian tube and mesosalpinx were desiccated on both sides down to the vesicouterine space. At this point, the bladder was filled with 250 ml of sterile indigocarmine through the Foley catheter, which is then clamped. This facilitates identification and desiccation of the bladder as well as recognition of any accidental injury to it at once. The bladder was grasped and raised up during the incision of the vesicouterine peritoneum at its reflection between the bladder and uterus. The bladder pillars were coagulated by the bipolar forceps then cut by scissors. The bladder was sharply dissected away from the uterus using unipolar cautery scissors. The remainder of the broad ligament was taken down. Uterine arteries were skeletonized on both sides, cauterized and transected. If this step was found to be an inaccessible one, uterine vessels were ligated and transected during the vaginal portion of the procedure as in usual vaginal hysterectomy.

With the use of the Rumi & Koh colpotomizer, it was easy to do colpotomy during the laparoscopic portion of the procedure through the abdomen. The visualization of the blue plastic cup of the device indicated the accomplishment of the colpotomy. This step was done with unipolar scissors. This makes the use of Rumi & Koh colpotomizer preferred from the technical standpoint.

After inspecting all the pedicles and ensuring good hemostasis, the instruments except the trocars were removed from the abdomen. Attention was now made to the vaginal portion of the procedure.

A circumferential incision was made around the cervix at the reflection of the vagina with the Bovie electrocautery. The uterosacral and the remainder of the cardinal ligaments were clamped, bisected and ligated with 00 vicryl stitches that left long to be attached later into the vaginal vault. The uterus was then delivered as usual but for bigger uteri, reduction of their size was carried out by making an incision around the entire cervix and specimen was removed by morcellation. Sometimes with delivering big myomas first, the remainder of the uterus came out easily. The vagina was closed with 00 vicryl in a transverse manner with attachment of the uterosacral and cardinal ligaments stitches into it.

Attention was turned again to the laparoscopy to ensure the final view after completion of the procedure and guarantee complete hemostasis. After evacuation of the pneumoperitoneum, abdominal incisions were closed with 000-subcuticular vicryl. Incisions larger than 5 mm were closed first with Corson-Thompson fascia closure device.

Patients were receiving two doses of 10 mg morphine IV, 8 h apart as a postoperative analgesic, then continued with non-steroidal anti-inflammatory agent as Ibuprofen 400 mg t.d.s. When the patient was discharged, she was instructed to avoid sexual intercourse for 4 weeks and to come for follow up visit one week postoperative unless she develops fever, persistent or increasing pain, or vomiting. She was allowed to drive one week and to go back to work two weeks after the operation.

Results

The age range of our patients was 30-59 years, with a mean of 45.8± 0.7. Thirty-one patients (22.8%) had undergone previous abdomino-pelvic surgery. The most common indication for LAVH in our patients, according to the preoperative diagnosis, was fibroid uterus (Table 1). All specimens were sent as a routine for pathological examination. The most common pathological finding was myoma(s) (Table 2).

The mean estimated blood loss during operation as determined by the anesthesiologist was 149± 7 ml (range, 75-750). The accurate blood loss was calculated by subtracting the volume of the irrigation fluid from the total amount of the fluid in the suction apparatus. The mean operative time as estimated by the anesthesiologist was 150± 4 min ( range, 60-215 ). The time was shorter with getting more experience with the procedure. The operations were done in a teaching hospital allowing the residents and clinical fellows to observe, assisting, and actively participating in the procedure under complete supervision of the surgeon. This is, in fact, prolonged the operative time to some extent.

The bipolar cautery was used in 96 cases (71%), Endo GIA alone in 4 cases (3%), and both in 36 cases (26%). There was no significant difference between these three modalities in terms of the operative time, estimated blood loss, intraoperative or postoperative complications.

The mean length of the removed uteri was 11.8± 0.4 cm (range, 5.6-14). The mean weight of the removed uteri, as estimated by the pathologist, was 235± 8 gm (range, 59-560).

Intraoperative complications included one case of bladder perforation due to thick dense adhesions to the lower uterine segment after two previous cesarean sections. It was easily repaired during the vaginal part of the procedure. Two cases of accidental injury to the inferior epigastric vessels were easily repaired by Corson-Thompson fascia closure device. Two cases had to be switched from laparoscopic to laparotomy procedure due to bleeding from the uterine artery, in one case, and from the infundibulopelvic ligament in the other case. No blood transfusion was indicated in any of our patients.

The cases of cystitis and pelvic infection were treated successfully with antibiotics, while the pelvic abscess was evacuated and drained by a second laparoscopic procedure.

All our patients had a hospital stay for 1-2 days. The estimated average total cost of LAVH in our cases was $7,500. This is less than the cost of abdominal hysterectomy in the same hospital ($11,000).

Discussion

In spite of the dramatic increase of LAVH procedure since its first description in 1989,5 its value remained controversial.6, 7,8 Advocates encourage LAVH as a procedure for conversion of abdominal hysterectomy into a vaginal one. Indeed vaginal hysterectomy entails fewer complications, shortened hospital stay, more rapid recovery and return to normal activity. This is in addition to the better cosmetic appearance of the laparoscopic scar if compared to the laparotomy scar. However, critics point out that LAVH requires longer operative time and is more expensive.

Our results showed that LAVH could be done in a wide variety of indicated cases of hysterectomy. The indications were almost the same as shown by other surgeons.9,10,11 The pathological reports of the removed specimens were confirmatory to our preoperative diagnosis. Reports added other diagnoses that are difficult to be diagnosed clinically such as adenomyosis, endometriosis, endometrial hyperplasia, cervical intraepithelial neoplasm, chronic cervicitis, and the nature of the ovarian neoplasm.

The concomitant surgical procedures that were done with our LAVHs didn’t prolong the operative time except in cases of vaginal repair. The same was noticed by other surgeon.9,11 The average intraoperative blood loss of 150 ml in our cases is fairly comparable to the 135 ml that reported in other study,9 and still much lower than the 390 ml that reported by another study.12 Our mean operative time of 150 min is more than that reported by other studies (118 and 119.4 min) 13, 14 but our study entailed a teaching and training goal for the residents and clinical fellows which was not aimed in the other studies. The post operative complication rate in our study was 5.9% which is significantly lower than the 8.6% reported by one study14, and the 22% reported by another study10 ( P< 0.0001 ). The average total LAVH cost of $7,500 to our patients was significantly lower than that reported by other studies.15 This may be attributed to the limited use of disposable instruments and the use of bipolar cautery in most of our cases instead of sutures or Endo GIA that are more expensive.

Conclusion

LAVH is a true advance in gynecological surgery that decreases morbidity, postoperative pain and complications by converting most of the abdominal hysterectomies into vaginal ones. The short hospital stay, the rapid return to work and normal activity, and the decrease in the cost of treating complications, may compensate for the claimed high cost of LAVH.

References

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Table 1 Preoperative Diagnosis and Indications for Surgery

Diagnosis/Indications	No.
Symptomatic leiomyoma	96
Abnormal uterine bleeding	76
Pelvic pain	28
Endometriosis	8
Endometrial hyperplasia (simple)	16
Endometrial hyperplasia (complex without atypia)	1
Endometrial hyperplasia (complex with atypia)	3
Ovarian cyst	12
Cervical intraepithelial neoplasm	4
Total	244

The total number exceeds our patients number as most of the patients had more than one indication for surgery.

Table 2 Pathological Diagnosis for the Specimens

Pathological Diagnosis	No.
Myoma(s)	98
Adenomyosis	40
Endometriosis	12
Endometrial hyperplasia (simple)	18
(complex without atypia)	3
(complex with atypia)	4
Simple ovarian cyst	8
Inclusion cyst	3
Brenner’s tumor	1
Chronic cervicitis	71
Cervical intraepithelial neoplasm (CIN I)	4
Cervical intraepithelial neoplasm (CIN II)	2
Cervical intraepithelial neoplasm (CIN III)	1
Total	256

The total number exceeds our patients number as most of the patients had more than one pathological finding.

Table 3 Concomitant Surgical Procedures done with LAVH

Procedure	No.
Bilateral salpingo-oophorectomy	36
Unilateral salpingo-oophorectomy	2
Pelvic adhesiolysis	48
Vaginal repair	4
Fulguration of endometriosis	8
Total	98

More than one concomitant surgical procedure was done to some patients.

Table 4 The Encountered Postoperative Complications

Complication	No.
Cystitis	2
Ileus	4
Cuff cellulitis	0
Pelvic infection	1
Pelvic abscess	1
Intraperitoneal bleeding	0
Total	8