Laparoscopic supracervical hysterectomy for the larger uterus (>500 g): a case series and literature review

Association of maximum uterine diameter with postoperative complications in laparoscopic supracervical hysterectomy: A retrospective cohort study

OBJECTIVE

To determine the maximum uterine diameter threshold associated with an elevated risk of complications following laparoscopic supracervical hysterectomy (LSH).

METHODS

This was a retrospective cohort study from a single tertiary referral center. We enrolled patients who underwent LSH for benign indications at our hospital between January 2013 and June 2023. The primary outcome was the occurrence of surgical complications within the 30-day timeframe of hysterectomy. The covariate included the year of the procedure, patient age, body mass index, parity, American Society of Anesthesiologists classification, comorbidities, history of previous abdominal and pelvic surgery, and preoperative anemia, blood loss, surgical time, hospital stay and pathology. The exclusion criteria comprised those who underwent hysterectomy for malignancy, individuals who underwent total vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy, and those with missing data on uterine maximum diameter, study outcomes, or covariates.

RESULTS

We included a final sample of 120 patients, revealing a median uterine diameter of 9.12 cm, with 9.2% experiencing complications. The median uterine weight among 40 patients was 275 g. Receiver operating characteristic (ROC) curve analysis suggested a potential cutoff of 11.55 cm for predicting complications, with an area under the ROC curve of 0.67. Multivariate logistic regression confirmed a significant association between uterine diameter exceeding the cutoff and increased complication risk (OR 33.925, 95% CI: 2.294-501.690, P = 0.0103). A correlation (r = 0.762, P < 0.001) between uterine weight and diameter indicated the latter's suitability for preoperative assessment of uterine weight.

CONCLUSION

The maximum uterine diameter with an optimal cutoff of 11.55 cm was associated with increased complication risk.

Facilitating method for removal of the large uterus after laparoscopic hysterectomy: Vaginal vault vertical incision

BACKGROUND

In patients with a large uterus, an important part of the laparoscopic hysterectomy operation time is the phase of removing the uterus from the abdomen.The development of techniques that will shorten the morcellation time is the key to reducing the total operation time.

AIM

To evaluate the effect of vaginal cuff vertical incision in accelerating removal of the large uterus in laparoscopic hysterectomy.

METHODS

This study was performed with patients who underwent total laparoscopic hysterectomy. In the study group, a vertical incision was performed in the middle of the posterior vaginal stump before the vaginal removal of the larger uterus (weighing more than 500 g). The control group consisted of patients who underwent vaginal morcellation after conventional colpotomy. Patients in both groups were matched in terms of uterine weights +/-50 g and the same vaginal morcellation technique was applied to all patients.

RESULTS

In patients who underwent a vertical incision procedure, the time to remove the uterus from the abdomen (17.55±2.53 min vs 26.62±4.72 min, p<0.001) and the total operation time (130.81±12.83 min vs.143.29±13, 15 min, p = 0.001) was statistically significantly less than the patients without vertical incision. There was no difference between the groups in terms of intraoperative complications, drop in hemoglobin levels, time to flatus, postoperative 6th,24th hour visual analog score and length of hospital stay.

CONCLUSIONS

The vertical incision procedure reduces the time to remove the large uterus from the abdomen after laparoscopic hysterectomy and, accordingly, the total operation time. This procedure may be the preferred method before vaginal morcellation, especially in large uterus.

Evaluation of complications, conversion rate, malignancy rate, and, surgeon's experience in laparoscopic assisted supracervical hysterectomy (LASH) of 1274 large uteri: A retrospective study

INTRODUCTION

Hysterectomy now belongs to standard gynecological procedures. Moreover, a shift towards laparoscopic techniques is ever more apparent as they provide many advantages such as less traumatization and shorter convalescence. Large uteri are still mentioned as contraindications for laparoscopic hysterectomy even though those patients might benefit from the lower morbidity associated with minimal invasive techniques. In this study, the largest reported so far, we analyzed intraoperative and postoperative complications as well as the surgeon's experience of laparoscopic assisted supracervical hysterectomy (LASH) in patients with a uterus weight over 500 g.

MATERIAL AND METHODS

The present retrospective study, between June 27, 1998 and August 31, 2019, evaluates 1274 patients with a uterus weight over 500 g who were treated with LASH for benign uterine diseases at the Clinic for Minimal Invasive Surgery (Berlin, Germany). All surgeries were performed by one of four in-house surgeons with experience in LASH: they had performed at least 500 LASH procedures before the study. Patients receiving surgical treatment for malignant tumors were not included in the study. Major and minor intraoperative and postoperative complications were recorded and evaluated. Additionally, medical files were evaluated for demographic data, American Society of Anesthesiologists score (I-IV), name of the surgeon, duration and indication for surgery, history of previous gynecological procedures and concomitant surgical interventions, weight of removed uterine tissue, duration of postoperative hospitalization in patients with complications, intraoperative conversion from laparoscopy to laparotomy, and malignancy rate.

RESULTS

The mean age was 47.0 ± 7.3 years and mean body mass index was 25.6 ± 7.1 kg/m² . Average parity was 1.04 ± 1.57. Average uterus weight was 761.8 ± 317.9 g (500-4065 g). The mean duration of surgery was 96.9 ± 49.5 min; 54% of all patients were treated without concomitant intervention, conversion rate was 2.12%. The malignancy rate was 0.4% and the complication rate was 6.81% with 1.36% intraoperative complications and 5.45% postoperative complications.

CONCLUSIONS

The overall low complication and malignancy rates observed in this study allow us to present LASH as a safe and efficient alternative laparoscopic approach to remove uteri of any size in the hands of experienced surgeons.

Single-port laparoscopic hysterectomy for uteri greater than 500 grams

OBJECTIVES

To study the operative outcomes of single-port laparoscopic hysterectomy in uteri greater than 500 g, using either laparoscopic assisted vaginal hysterectomy (LAVH) or laparoscopic supracervical hysterectomy (LSH).

MATERIALS AND METHODS

78 patients were included in a single institute by a single surgeon from March, 2013 to January, 2018.

RESULTS

The median uterine weight was 686.5 g. Larger uterine weight was correlated with longer operative time and greater estimated blood loss. Two types of operations were performed: LAVH (n = 55) or LSH (n = 23). There were no differences in operative time (150.2 ± 45.1 vs. 158.6 ± 82.1, P = 0.66) and estimated blood loss (365.8 ± 298.5 vs. 356.5 ± 46.6, ml, P = 0.94) between LAVH and LSH. However, patients in LAVH had more excess blood loss (>500 mL) compared with LSH (32.7% vs. 21.7%, P = 0.42). In the later study period, the operative time was shorter and complication rates were lower. Such differences were especially significant in the LAVH group. By multiple regression analysis, operative time was independently correlated with age, body mass index, estimated blood loss and uterine weight in LAVH. The correlation between operative time and uterine weight in LSH was attenuated by estimated blood loss. Estimated blood loss was the dominant factor correlated with longer operative time in LSH.

CONCLUSIONS

Both LAVH and LSH could be feasible in uteri greater than 500 g. LSH appeared to have less complication and less blood loss than LAVH. Operative time was correlated significantly with bleeding amount. Therefore, better bleeding control and surgical experience were warrants for single-port laparoscopic hysterectomy in uteri greater than 500 g.

Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.

Large pelvic mass arising from the cervical stump: A case report

BACKGROUND

A large cervical cyst with a cervical high-grade squamous intraepithelial lesion arising from the cervical stump is rare. After supracervical hysterectomy, there is a risk of various lesions occurring in the cervical stump. We review the types and characteristics of cervical stump lesions and compare total hysterectomy with subtotal hysterectomy. Gynecologists should choose the most suitable surgical method based on both the patient’s condition and wishes. If the cervix is retained, patients require a close follow-up.

CASE SUMMARY

A 57-year-old woman was admitted to the Gynecology Department for a large pelvic mass. Her chief complaint was abdominal distention for two months. She had undergone subtotal supracervical hysterectomy for leiomyoma 14 years prior. Abdominal ultrasonography detected a 9.1 cm × 8.5 cm × 8.4 cm anechoic mass with silvery fluid in the pelvic cavity and high-risk human papilloma virus 53 (HPV53) was positive. The admission diagnosis we first considered was a pelvic mass mimicking carcinoma of the cervical stump. We performed a laparotomy and a rapid frozen biopsy was suggestive of a fibrous cyst wall coated with a high squamous intraepithelial lesion. The pelvic mass was removed, and a bilateral adnexectomy was implemented. Final pathology confirmed that the pelvic mass was a large inflammatory cyst with a cervical high-grade squamous intraepithelial lesion. After successful intervention, the patient was discharged one week after surgery and there was no recurrence of the vaginal stump at 43 mo.

CONCLUSION

When addressing benign uterine diseases, gynecologists should pay adequate attention to retaining the cervix. If the cervix is retained, patients require a close follow-up.

Google searches and medical publication trends since the 2014 US Food and Drug Administration position on power morcellation: Do these translate into patient awareness?

OBJECTIVES

Our primary objective was to assess patient awareness by observing Google Trends comparing search terms used in relation to morcellation rather than morcellation alone. Our secondary objective was to review trends and locations of publications on leiomyosarcoma and morcellation following the US Food and Drug Administration (FDA) position statement.

STUDY DESIGN

To assess Internet trends, we obtained the relative search volume (RSV) for each month from 1 January 2004 to 1 March 2019 from Google Trends using the terms 'fibroid', 'morcellation', and 'fibroid cancer'. RSV ranges from 0 to 100 with 100 being peak popularity for the term, and all other monthly search activity relative to the peak. To assess academic trends, we performed a systematic review of published literature discussing fibroid morcellation within the same time period. We used a two-way independent t-test to compare median RSV, and chi-squared test to compare academic output. P < 0.05 was considered statistically significant.

RESULTS

Search volume for 'morcellation' peaked during the FDA statement (RSV 0.5 to 2.9, t = 17.5, p < 0.05) but was not sustained. There is an increase in 'fibroid' activity post-FDA statement (RSV 68.8 to 76.3, t = 3.9, p < 0.05). 'Fibroid cancer' remained static throughout (t = 1.5, p = 0.1 and t=-0.5, p = 0.6). Afro-Caribbean countries had the highest RSV for 'fibroid', whereas 'morcellation' RSV was highest in predominantly Western countries. There was a significant increase in the rate of papers published on the subject following the FDA statement (6.8 vs 55.6 papers per year, 95% CI -53.96 to -43.64, p < 0.0001). No academic papers on morcellation were published from countries with the highest RSV for 'fibroid'.

CONCLUSION

Our study suggests that interest in uterine fibroids has increased since the FDA statement, but the public are perhaps unaware or not concerned of the consequent potential risk of leiomyosarcoma following morcellation. Countries where fibroid interest is highest are not necessarily those that can offer power morcellation. Further studies are required to address how the Internet influences patient choice and informed consent, and how medical professionals can use it to further educate patients on the risks and benefits of laparoscopic myomectomy and power morcellation.

Single port access laparoscopic subtotal hysterectomy using contained manual morcellation: Experience from a tertiary referral center in Taiwan

OBJECTIVE

To describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure.

MATERIALS AND METHODS

Thirty patients with symptomatic leiomyoma or adenomyosis were enrolled. A 2-cm transverse incision was made at the umbilicus and single port apparatus (LagiPort) was applied. After dissection of vesicouterine peritoneum from the uterus, the uterine ligaments and vessels were secured and transected by Gyrus PK cutting forceps. Cervical amputation at the level of internal os was made by SupraLoop (Karl Storz). The uterine corpus was put into an Endobag before morcellation. The opening of Endobag was exteriorized from the umbilical incision and the uterine corpus was removed in a contained manner by manual morcellation with a scalpel.

RESULTS

This procedure was successfully performed on all patients. Neither laparotomic conversion nor additional port was needed. The mean age and mean BMI of the patients were 43.63 years and 24.02 kg/㎡. The mean operative time was 148 min and the estimated blood loss in most patients was less than 150 ml. The median weight of uterine corpus was 214 g. No intraoperative complications occurred in any patient. One patient was diagnosed with unexpected endometrioid adenocarcinoma FIGO grade 1 postoperatively. One patient reported cyclic bleeding and underwent a transvaginal trachelectomy 17 months later.

CONCLUSION

Single port access LSH using contained manual morcellation represents a safe and feasible alternative to conventional LSH using open power morcellation.