Indications of laparoscopic hysterectomy

Total laparoscopic hysterectomy: Preoperative risk factors for conversion to laparotomy

STUDY OBJECTIVE

To identify the preoperative factors affecting the risk of conversion to laparotomy during total laparoscopic hysterectomy (TLH) indicated for benign conditions (surgery performed in cases of genital prolapse and/or urinary stress incontinence was excluded).

DESIGN

Retrospective comparative study (Canadian Task Force classification II-2).

SETTING

University tertiary referral center for gynecologic endoscopic surgery.

PATIENTS

Four hundred sixteen consecutive patients who underwent TLH during the first 5 years of our experience performing TLH.

INTERVENTION

Total laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

The rate of conversion to laparotomy was 7% (29 patients). Factors that were found to be independently related to the risk of conversion to laparotomy are the following: body mass index (adjusted OR 1.09; 95% CI 1.01-1.18); uterine width on transvaginal ultrasonography (US) between 8 and 10 cm (adjusted OR 4.01; 95% CI 1.54-10.45); uterine width on US greater than 10 cm (adjusted OR 9.17; 95% CI 2.74-30.63); lateral myoma measuring greater than 5 cm on US (adjusted OR 3.57; 95% CI 0.97-13.17); history of adhesion-causing abdominopelvic surgery (adjusted OR 2.92; 95% CI 1.23-6.94).

CONCLUSION

Transvaginal US evaluation is essential before performing TLH. Awareness of the risk factors for conversion to laparotomy is essential for proper patient information and better selection of patients.

Facteurs du choix de la voie d’abord des hystérectomies pour lésions utérines bénignes (prolapsus et indications obstétricales exclus)

OBJECTIVES

We searched for the factors determining the type of hysterectomy (vaginal, laparoscopy or laparotomy) performed in women with supposedly benign uterine disease.

MATERIAL AND METHOD

We conducted a retrospective study of 101 consecutive hysterectomies performed on voluminous uteruses, prolapsus and obstetrical indications excluded. The following factors likely to have influenced the decisions were examined: patient age, nulliparity, menopausal status, history of laparotomy, uterus weight, narrow vagina, nature of uterus lesions, associated unilateral or bilateral annexectomy, complications.

RESULTS

The frequencies were: vaginal route 58.4% (average uterine weight 249.4 g, range 93-1149 g), laparoscopic preparation 37.6% (average uterine weight 348 g, range 92-818 g), and laparotomy 4% (average uterine weight 586.2 g, range 112-1216 g). Factors determining type of hysterectomy were uterine weight (and therefore volume) (p < 0.05), nulliparity (p < 0.04), narrow vagina probed by compulsory Schuchardt incision (p < 0.02), associated annexectomy (p < 0.01). No other factors were significantly determinant. The vaginal route appears to be highly preferred.

CONCLUSION

Vaginal hysterectomy is clearly the most preferred and practiced. Laparoscopy may be helpful for vaginal hysterectomy and laparotomy is exceptional.

Les hystérectomies chez les patientes n'ayant jamais accouché par voie basse. Une étude de 243 cas

OBJECTIVE

The object of this study was to audit the policy of hysterectomy in nulliparous women in a university hospital.

PATIENTS AND METHODS

A retrospective medical records analysis of all hysterectomies performed during an 8-year period. Patients with no history of vaginal delivery were stratified into three groups: group 1, patients who underwent abdominal hysterectomies; group 2, patients undergoing vaginal hysterectomy (2a) or laparoscopy-assisted vaginal hysterectomy (2b). The groups were compared as to demographic data, surgical complications and outcomes.

RESULTS

During the study period, there were 243 hysterectomies in patients with no history of vaginal delivery. Among these, vaginal hysterectomies (group 2) were undertaken in 75% (182 patients) and successfully performed in all but 13 patients (7.1%). Mean uterine weight was 943 grams in group 1 and 370 grams in group 2. Abdominal route (group 1) was associated with longer operative time (average: 105 min) than vaginal route (group 2a; 81 min) but shorter operative time that laparoscopy-assisted vaginal route (group 2b; 173 min). There was no significant difference in mean estimated blood loss and complications rates between groups 1 and 2. Hospital stay was shorter in group 2. Laparoscopic assistance was not associated with bigger uteri, neither with fewer complications.

DISCUSSION AND CONCLUSION

Nulliparity should no longer be considered a contraindication to vaginal hysterectomy. In such patients, many more hysterectomies should be carried out vaginally and laparoscopic assistance does not offer obvious advantages over the standard vaginal approach.

A simplified method to decrease operative blood loss in laparoscopic-assisted vaginal hysterectomy for the large uterus

STUDY OBJECTIVE. To evaluate the role of oxytocin in decreasing operative blood loss in laparoscopic-assisted vaginal hysterectomy (LAVH) for the large uterus (weight > or = 500 g).

DESIGN

Prospective clinical study (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

Eighty-eight women scheduled for a hysterectomy for large benign uterine tumors.

INTERVENTION

Two ampules of oxytocin (10 u/mL/amp) were added to 1000 mL of saline solution running at the rate of 40 mU/min during the course of LAVH.

MEASUREMENTS AND MAIN RESULTS

Blood loss and blood transfusion rate were significantly greater in the group without oxytocin infusion (group B) than in the group with oxytocin infusion (group A), with 485.7 +/- 321.6 mL versus 364.1 +/- 173.2 mL (p <.05) and 26.7% versus 6. 1% (p <.05), respectively. There was no significant difference in average age, body weight, and number of vaginal deliveries and cesarean sections between the two groups. There also was no significant difference in mean uterine weight, postoperative stay, and complications between the two groups.

CONCLUSION

Oxytocin infusion can cause uterine contractions that decrease uterine perfusion. It is a safe and inexpensive method to help decrease operative blood loss during LAVH for the large uterus.

Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study

BACKGROUND

The purpose of this study was to compare peri-operative morbidity, preoperative sonographic estimation of uterine weight and postoperative outcomes of women with uterine fibroids larger than 6 cm in diameter or uteri estimated to weigh at least 450 g, undergoing either vaginal, laparoscopically assisted vaginal or abdominal hysterectomies.

METHOD

Ninety patients who met the criteria of uterine fibroids larger than 6 cm by ultrasonographic examination were included in our prospective study. Patients were randomized into laparoscopic-assisted vaginal hysterectomy (30 patients), vaginal hysterectomy (30 patients) and abdominal hysterectomy (30 patients) groups.

RESULTS

The laparoscopically assisted vaginal hysterectomy group had significantly longer operative times than the abdominal and vaginal hysterectomy groups (109 +/- 22 min, 98 +/- 16 min, and 74 +/- 22 min, respectively, p < 0.001). Blood loss for vaginal hysterectomy was significantly lower than for either abdominal or laparoscopically assisted vaginal hysterectomies (215 +/- 134 ml, 293 +/- 182 ml, and 343 +/- 218 ml, respectively, p = 0.04). Vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy groups had shorter hospital stays, lower postoperative pain scores, more rapid bowel recovery and lower postoperative antibiotic use than the abdominal hysterectomy group. Uterine weight in the abdominal hysterectomy group was significantly heavier than in the vaginal and laparoscopically assisted vaginal hysterectomy groups (1020 +/- 383 g, 835 +/- 330 g, and 748 +/- 255 g, respectively, p = 0.02). We estimated that when a myoma measured between 8 and 10 cm, the uterus weighed approximately 450 g, and the sensitivity of this prediction was 57.5%. For a myoma larger than 13 cm, the estimated uterine weight was more than 900 g and the sensitivity of this prediction was 71%.

CONCLUSION

The study shows vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy can be performed in women with uterine weight of at least 450 g. Preoperative ultrasonographic examination can provide the surgeon with valuable information on the size of the fibroid and the estimated weight of the enlarged uterus before implementing a suitable surgical method.

Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus

STUDY OBJECTIVE

To evaluate in a prospective series whether, even in presence of a large uterus, total laparoscopic hysterectomy is feasible and safe, and may be substituted for abdominal hysterectomy.

DESIGN

Randomized comparison (Canadian Task Force classification I). Setting. Center for Reconstructive Pelvic Endosurgery, Bologna, Italy.

PATIENTS

One hundred twenty-two women with large uterus (>14 wks' gestation) caused by myomas.

INTERVENTION

Total laparoscopic hysterectomy and total abdominal hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Sixty women underwent laparoscopic hysterectomy (group 1) and 62 abdominal hysterectomy (group 2). Mean longitudinal diameter of the uterus, mean number and diameter of myomas, operating time, and average drop in hemoglobin were similar in the groups. One conversion to laparotomy was necessary because of a bowel injury in a patient with severe pelvic adhesions. Cystotomy occurred in one woman in group 2 and was immediately repaired. Febrile morbidity was statistically more frequent in group 2 than in group 1. Postoperative hospitalization and convalescence were statistically shorter in group 1.

CONCLUSION

Laparoscopic hysterectomy is safe and feasible even in the presence of large uterus, and is a valid alternative to abdominal hysterectomy when the vaginal route is contraindicated.

Comparison of two procedures for laparovaginal hysterectomy: a randomized trial

OBJECTIVE

To compare peroperative parameters of two variants of a laparovaginal hysterectomy in surgical management of gynecological conditions.

METHODS

A prospective randomized study of 70 laparovaginal hysterectomies performed by the same two surgeons for disease of female pelvic organs. The following criteria were studied: indication for surgery, previous surgery, duration of the procedure, recovery, hospital stay, blood loss, tissue damage markers, hysterectomy proportions and complication incidence. Statistical analysis was performed using the non-parametric chi(2)-test and non-parametric Fischer's exact probability test when appropriate, with a level of significance P=0.05.

RESULTS

Totals of 38 (54.3%) laparoscopy-assisted vaginal and 31 (45.7%) vaginally assisted laparoscopic hysterectomies were performed for fibroma as the main indication. Conversion to laparotomy was applied in only one patient. The VALH group (P=0.01) showed both fewer procedures and shorter hospital stay with insignificant blood loss.

CONCLUSION

The two variants of a laparovaginal hysterectomy appear to be safe and appropriate, effective procedures for women with gynecological conditions. Furthermore, vaginally assisted laparoscopic hysterectomy has been shown to be superior to laparoscopy-assisted vaginal hysterectomy in terms of shorter operating time and greater palliative effect upon the complex of uterosacral ligaments. Laparoscopic surgery can alter the relationship between vaginal and abdominal hysterectomy.

Laparoscopically assisted vaginal hysterectomy

The LAVH revolution beginning in the late 1980s is far from over. The overwhelming growth and, at times, overuse of the laparoscopic approach have waned somewhat as physicians reevaluate LAVH, adopt new techniques such as arterial embolization and myolysis, and rediscover old techniques such as uterine morcellation at vaginal hysterectomy. In addition, the cost of new procedures and instrumentation has come under intense scrutiny. As analysis of patient care moves from cost containment to improved outcomes, there will be renewed interest in minimally invasive approaches. The challenge to accumulate data, critically analyze each approach, and select the most appropriate procedure for each patient holds the greatest promise for improved patient satisfaction and outcomes.