A new approach to hysterectomy without colpotomy: pelviscopic intrafascial hysterectomy

Outpatient Laparoscopic Hysterectomy in a Rural Ambulatory Surgery Center

STUDY OBJECTIVE

To evaluate a cost-optimized operative technique for outpatient laparoscopic hysterectomy in a rural ambulatory surgery center focusing on shortening hospital stay and substitution of expensive disposable laparoscopic instruments with standard surgical techniques.

DESIGN

Prospective feasibility and observational study (Canadian Task Force classification II-3).

SETTING

Rural ambulatory surgery center in Lamar, Alabama.

PATIENTS

Fifty-two women.

INTERVENTION

Outpatient laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

From September 2001 through September 2003, 52 consecutive procedures with a modified classical intrafascial supracervical hysterectomy (CISH) technique without disposable instruments have been performed on patients with an average age of 42.2 years (range 25-62 years) and a follow-up of 12.5 months (range 0.4-23.6 months). Mean postoperative length of stay was 6 hours, 79 minutes (range 3 hours, 10 minutes-17 hours, 30 minutes), and overall length of stay was 11 hours, 37 minutes (range 6 hours, 45 minutes-22 hours, 50 minutes). Five patients (9.6%) stayed overnight, three for medical and two for social reasons. With an average of 2 hours, 14 minutes, the operating room time was about 1 hour longer than with disposable instruments. Health insurance reimbursement for the ambulatory surgery center was on average $1814.11. No complications occurred, and no readmission to the hospital was necessary.

CONCLUSION

Outpatient laparoscopic hysterectomy is feasible and safe and can be performed cost effectively in ambulatory surgery centers, even in rural areas. Development of a protocol with patient selection, preoperative and postoperative patient teaching, caring family environment, and round-the-clock medical telephone backup is necessary.

437 classic intrafascial supracervical hysterectomies in 8 years

STUDY OBJECTIVE

To report technical aspects and practical long-term experience with classic intrafascial supracervical hysterectomy (CISH).

DESIGN

Retrospective evaluation (Canadian Task Force Classification II-2).

SETTING

Local community hospital in rural northwest Alabama.

PATIENTS

Four hundred thirty-seven women.

INTERVENTION

The procedure was performed as described originally but with slight modifications (vaginal manipulator, ETS stapler).

MEASUREMENTS AND MAIN RESULTS

Follow-up was 44.7 months (range 3-97 mo). Average operating time was 1 hour 10 minutes (range 46 min-6 hrs, 10 min), average blood loss was 68 ml (range 10-765 ml), average length of hospital stay was 22 hours (range 10 hrs-5 days), and average return to work was 14 days (range 3-28 days). Complications were 11 bleeding cervices (7 occurring within 21 days after surgery, and 4 between 2 and 4 yrs after surgery), 1 case of uterine artery bleeding, 1 ileus, 1 pelvic hematoma, and 5 mucoceles between 2 and 27 months postoperatively. There were three conversions, one because of morbid obesity (185 kg) and two because of large uterus:pelvis ratio.

CONCLUSION

CISH leaves the pelvic floor intact, has short recuperation and high patient satisfaction, and is cost effective at a low complication rate. It is an advanced laparoscopic procedure, is initially technically challenging, and has a learning curve.

Laparoscopic supracervical hysterectomy

Laparoscopic supracervical hysterectomy (LSH) provides an efficient, effective method of uterine extirpation for individuals with appropriate indications for the procedure. This article gives a rationale for the procedures and provides a step-by-step methodology for performing LSH. Data from existing literature are discussed, and suggestions for improving morbidity and mortality are presented.

Comparison of classic intrafascial supracervical hysterectomy with total laparoscopic and laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE

To evaluate the efficacy of laparoscopic hysterectomy and compare classic intrafascial supracervical hysterectomy (CISH) with total laparoscopic hysterectomy (TLH) and laparoscopic-assisted vaginal hysterectomy (LAVH).

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Six hundred fifty women who underwent laparoscopic hysterectomy from August 1993 to August 1996.

INTERVENTIONS

Charts of 231 women undergoing CISH, 102 TLH, and 317 LAVH were reviewed regarding patient characteristics, indications, uterine weight, associated procedures, estimated blood loss, operating time, and complications.

MEASUREMENTS AND MAIN RESULTS

Among the three groups, despite having the largest specimen weight and highest number of associated procedures, women undergoing CISH had the lowest complication rate and smallest amount of estimated blood loss (p <0.05). The next lowest was the TLH group (p <0.05). Although LAVH was associated with shortest operating time, there were no statistically significant differences among groups (p >0.05). The CISH group had relatively shorter operating times when compared with similar average specimen weights. Patients who underwent total hysterectomy by either TLH or LAVH had more postoperative visits than those having CISH (p <0.05, Fisher's exact test); the LAVH group had the highest number of postoperative visits. The overall complication rate appeared to be highest in the LAVH group (p <0.05, Fisher's exact test).

CONCLUSION

Among the three groups, CISH resulted in lowest blood loss and fewest complications; these values were also lower for TLH than for LAVH. If the cervix is removed along with the uterus, TLH is recommended. In our opinion, CISH is preferred in cases of benign uterine diseases because it lowers major operative complications, especially in women who have large masses with no pathologic lesions of the cervix.

Laparoscopic trachelectomy for persistent pelvic pain and endometriosis after supracervical hysterectomy

OBJECTIVES

To discuss the safety of laparoscopic removal of the cervical stump after supracervical hysterectomy.

DESIGN

Retrospective review of six cases.

SETTING

Center for Special Pelvic Surgery, a tertiary referral center.

PATIENT(S)

Between August 1993 and December 1995, six patients underwent laparoscopic removal of the cervical stump. Their mean age was 43.1 years (range 32 to 56 years). All women had pelvic pain, and one had abnormal bleeding. Three patients had histories of severe endometriosis only, one had extensive endometriosis with adhesions, one had severe adhesions and leiomyomas, and one had all three conditions at hysterectomy.

INTERVENTION(S)

Laparoscopic trachelectomy.

MAIN OUTCOME MEASURE(S)

Laparoscopic findings and intraoperative and postoperative complications.

RESULT(S)

The mean blood loss was 100 mL (range 50 to 200 mL). There were no major intraoperative or postoperative complications.

CONCLUSION(S)

Cervical stump removal can be accomplished laparoscopically by an experienced surgeon.

Early complications of laparoscopic hysterectomy

Since Reich first described laparoscopic hysterectomy (LH) in 1989, a number of series have appeared in the literature detailing complications of this procedure. This review included all series obtained through a MEDLINE search from April 1989 through October 1994. Also included were series from the Journal of Gynecologic Surgery, Gynaecological Endoscopy, and the Journal of the American Association of Gynecologic Laparoscopists. Rates of various complications were calculated and compared with existing standards for abdominal and vaginal hysterectomy. Hemorrhage and injury to adjacent organs were fairly similar between traditional hysterectomy methods and LH. Infectious morbidity, however, was decreased in LH. Caution should be used in interpreting these data, as these initial reports come predominantly from leading experts in the field of endoscopic surgery. Whether these rates can be duplicated in a community hospital is debatable.

Laparoscopically assisted vaginal hysterectomy for non-malignant disease of the uterus. Report on a personal series of 126 cases

OBJECTIVE

A report is given of a series of 126 laparoscopically-assisted vaginal hysterectomies (LAVH) for benign lesions, carried out between September 1990 and December 1995.

MATERIALS AND METHOD

The mean age of the patients was 50.3 years, and the main indications for hysterectomy were metrorrhagia (88). The main reasons why LAVH was chosen from among other hysterectomy techniques were a large uterus (55), associated ovarian surgery (45), and a difficult vaginal approach (35). The surgical technique always began with a laparoscopic stage followed by a vaginal stage. The laparoscopic stage generally finished at the lower part of the broad ligament. The vagina was opened and the uterine arteries were ligatured by a vaginal approach (116). Only 10 total laparoscopic hysterectomies were performed.

RESULTS

The mean duration of the operation was 72 +/- 28 min, mean blood loss was 1.89 g/dl, and mean uterus weight was 224 g (maximum = 1093 g). Operative complications consisted of two bladder wounds and two switches to abdominal hysterectomy. Postoperative complications were urinary infections (17), hemorrhages needing second-look operations [2] and abscess of the vaginal section requiring evacuation [3].

CONCLUSION

LAVH should never be carried out instead of vaginal hysterectomy (VH), since VH is the best procedure when it is easy to perform. The authors use LAVH when VH is difficult or contraindicated (the aim being to avoid laparotomy) and actually carry out less than 5% of hysterectomies for benign lesions by laparotomy.

The classic intrafascial Semm hysterectomy as an alternative to abdominal hysterectomy

STUDY OBJECTIVE

To compare the classic intrafascial Semm hysterectomy (CISH) with abdominal hysterectomy.

DESIGN

Retrospective analysis.

SETTING

Community hospital.

PATIENTS

The first 100 women with intractable uterine bleeding, leiomyomata, and chronic pelvic pain.

INTERVENTIONS

The CISH procedure, initially with the Endo GIA stapler, but later, electrocoagulation and suture to lower costs and eliminate automatic staple complications.

MEASUREMENTS AND MAIN RESULTS

Operating time for CISH decreased and our ability to remove larger uteri increased as we became more proficient. Complications were limited to one cystotomy and four transfusions. The average hospital stay was 36 hours and most patients were back to normal activity in 3 weeks.

CONCLUSION

Our experience suggests that the CISH is organ preserving, is minimally invasive, decreases recovery time, and can be performed in women in whom an open abdominal approach once would have been the only option.

Clinical analysis of pelviscopic classic intrafascial Semm hysterectomy

STUDY OBJECTIVE

To evaluate the efficacy of pelviscopic classic intrafascial Semm hysterectomy (CISH).

DESIGN

Review of hospital records of 90 women undergoing pelviscopic CISH between April 1993 and June 1994.

SETTING

Department of Obstetrics and Gynecology at a university teaching hospital.

PATIENTS

Sequential sample of 90 women undergoing pelviscopic intrafascial hysterectomies.

INTERVENTIONS

All of the hysterectomy procedures were performed in the classic manner with grasping forceps, scissors, ligatures, and sutures. No lasers, electrocoagulation, or stapling devices were used.

MEASUREMENTS AND MAIN RESULTS

Indications, associated procedures, surgical outcomes, and complications were analyzed. The most common surgical indication was leiomyomata uteri. No major complications occurred even in patients who had extremely large leiomyomata. The mean uterine weight was 207.49 +/- 104.9 g. The average operating time (169.89 +/- 56.19 min) was consistent with that of other methods. Blood loss (160 +/- 182 ml) was lower than during conventional abdominal hysterectomy. No procedure was converted to laparotomy.

CONCLUSIONS

Pelviscopic CISH is truly a minimally invasive and organ-preserving surgery, and in our study was associated with significantly low morbidity and no major complications. Pelvic floor support is maintained and the ureters are not in danger. Coring out the cervix with the calibrated uterine resection tool may prevent the development of cervical cancer. Therefore, we think that CISH may be an acceptable technique for benign uterine disease.