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The total laparoscopic hysterectomy that I performed was because of chronic pelvic pain related to endometriosis in a patient that had completed her family. I generally do laparoscopic hysterectomy when a vaginal hysterectomy is not feasible to avoid doing an abdominal hysterectomy. This is based on the Cochrane systematic review done by Nieboer et al in 2009. This review showed that the benefits of Laparoscopic hysterectomy versus abdominal hysterectomy were quicker return to normal activities (MD 13.6 days, 95%CI 11.8 to 15.4 days), less intraoperative blood loss (MD 45.3 ml, 95%CI 17.9 to 72.7 mls), a smaller drop in haemoglobin (MD 0.55 g/dl, 95%CI 0.28 to 0.82g/L), shorter hospital stay (MD 2.0 days, 95%CI 1.9 to 2.2 days), and less abdominal wall or wound infections (OR 0.3, 95%CI 0.12 to 0.85). However , there was a higher incidence of urinary tract injuries (OR 2.6, 95%CI 1.22 to 5.60) as well as longer operation time (MD 10.6 minutes, 95%CI 7.4 to 13.8 minutes). The advantages of laparoscopic assisted vaginal hysterectomy versus total laparoscopic hysterectomy were a lower incidence of febrile episodes or unspecified infection as well as shorter operating time (MD 25.3 minutes, 95%CI 10.0 to 40.6 minutes). The comparison of laparoscopic hysterectomy versus vaginal hysterectomy showed that operation time (MD 41.5 minutes, 95%CI 33.7 to 49.4 minutes) and bleeding were increased in laparoscopic hysterectomy and therefore it was advised that vaginal hysterectomy should be the gold standard if possible. However, if vaginal hysterectomy cannot be conducted, laparoscopic hysterectomy should be conducted to avoid the need for abdominal hysterectomy, however both the length and extent of surgery increase in the laparoscopic route. The woman should discuss the pros and cons of the surgical approach to hysterectomy with the surgeon and make an informed decision (Neiboer et al, 2009).
The question is when is it considered not feasible to do a vaginal hysterectomy? The indications for performing an abdominal hysterectomy (laparoscopic hysterectomy or total abdominal hysterectomy) instead of a vaginal hysterectomy are the contraindications of a vaginal hysterectomy which are: the size of uterus being more than 12 weeks gestation, an abnormality of the adnexa (mass), non-specific pelvic pain, a pelvic mass, endometriosis, or having a family history of ovarian cancer, intraoperative findings of a significant adnexal mass, adhesions or pelvic inflammatory disease. Other criteria include pathological features including uterine weight > 400 gm, cancer ,pelvic inflammatory disease, haematosalpinx or pyosalpinx (Dorsey et al, 1995).
Many widely accepted contra-indications to vaginal hysterectomy are not justified in practice as far as the surgeon performing hysterectomy is experienced and well trained to the vaginal route. The remaining group of patients in which vaginal surgery has been considered contraindicated should be evaluated preoperatively to identify how many abdominal laparotomies can be really avoided by laparoscopic surgery. Laparoscopic surgery has the same limitations as vaginal surgery in cases of large uteruses. The same problem arises in cases of a narrow genital tract in nulliparas when extracting the uterus using either a laparoscopic or vaginal procedure. Severe pelvic adhesions and ovarian tumors are the best indication for laparoscopy (Meeus et al 1997). Laparoscopic hysterectomy is not advised for the diagnosis and treatment of a pelvic mass that cannot be removed intact through a culdotomy incision or that is too large to fit intact into an impermeable sack, especially in the case of postmenopausal patients. Obesity may present special problems because the use of the Trendelenburg position may not be possible because it can cause anesthesia ventilation difficulties. Stage III ovarian carcinoma requiring surgical staging through a large abdominal incision is another contraindication. Also lack of experience or training of the surgeon is an obvious contraindication to the laparoscopic approach. The other difficulty is that it is not always a simple task to properly assess patients preoperatively to make a proper decision as to which laparoscopic route is best. So the surgeon can always convert a laparoscopy to a laparotomy (Reich 2003).
Guidelines on laparoscopic hysterectomy
i. NICE Guideline on laparoscopic techniques for hysterectomy (NICE 2007):
NICE have issued guidelines on the laparoscopic route of hysterectomy. The following is a summary of the recommendations:
The patients should be advised of the higher risk of severe bleeding and urinary tract injury associated with these laparoscopic procedures, in comparison to having open surgery.
In comparing laparoscopic to abdominal hysterectomy:
the average length of hospital stay was 2 days less in laparoscopic hysterectomy.
Women returned to work 13.6 days earlier in the laparoscopic hysterectomy group.
There was a significantly higher risk of urinary tract injuries in patients undergoing laparoscopic hysterectomy.
There was no difference in bowel injury or vascular injury.
Comparing laparoscopic hysterectomy to vaginal hysterectomy, there was no significant difference in conversion to laparotomy. There was a higher risk of injury to the urinary bladder and ureter, but similar incidence of bowel injury. There was a higher incidence of visceral damage in the laparoscopic group however this difference was not significant.
There was no evidence that there is any difference in haemorrhage between laparoscopic hysterectomy, vaginal hysterectomy and abdominal hysterectomy
ii. ACOG guideline on choice of route of hysterectomy(ACOG 2009):
Whenever possible, vaginal hysterectomy should be the route of choice. The decision to perform a prophylactic oophorectomy at the time depends on patientâ€™s age, risk factors, and informed wishes, but not the route of hysterectomy. Laparoscopic hysterectomy can be an alternative to abdominal hysterectomy for those patients in which an abdominal hysterectomy is not indicated or feasible. Experience with robot assisted hysterectomy is limited. More data are necessary to determine its role in the performance of hysterectomy.
Total laparoscopic hysterectomy technique
The technique I use for doing total laparoscopic hysterectomy involves using the bipolar diathermy alternating with the harmonic scalpel. A retrospective study by Demirturk et al in 2007 compared the use of electrothermal bipolar vessel sealer (EBVS) with harmonic scalpel (HS) during total laparoscopic hysterectomy . The HS arm had significantly less mean procedure time and estimated blood loss compared to the HS arm(59.57 +/- 3.71 vs 90.95 +/- 5.73 min, P < 0.001; 87.76 +/- 25.48 vs 152.63 +/- 60.90 mL; P < 0.001, respectively). The HS group has a more significant change in haemoglobin and haematocrit levels. The conclusion was that EBVS took less time and caused less bleeding in comparison to HS (Demirturk et al 2007). It is unclear how many surgeons performed these procedures in this study. The cohorts compared in the study were only compared for age and uterine weight. Other factors such as BMI or indication where not mentioned or accounted for in multivariate analysis which can lead to confounding influencing the validity of the results. The study was also underpowered to detect differences in complication. It has however produced significant results in favour of EBVS. It is therefore certainly worth considering trying the EBVS device, however it is currently not available at my local hospital. Further randomized controlled trials comparing the use of different instruments in laparoscopic hysterectomy is advisable.
During the TLH procedure, once the uterus has been separated, I remove it through the vagina then suture the vagina laparoscopically .Vaginal cuff closure via laparoscopic suturing results in much better hemostasis and pelvic support than blindly placed sutures vaginally. With the laparoscopic approach, vaginl cuff bleeding can be stopped directly with bipolar forceps prior to closing the cuff. Laparoscopic cuff closure with suture from above also allows the uterosacral and cardinal ligaments and endopelvic fascia to complete a This also allows a high McCall vaginal cuff suspension yp yjr uterosacral and cardinal ligaments and endopelvic fascia. This results in no postoperative bleeding into the peritoneal cavity as well as less omental and bowel adhesions which could eventually lead to bowel obstruction. The vaginal approach involves doing bulk sutures vaginally without laparoscopic observation during the procedure (Reich 2003).
Subtotal laparoscopic hysterectomy technique
The next case I described was a laparoscopic subtotal hysterectomy. This is indicated in patients with enlarging or painful uterine myomata, therapy-resistant dysfunctional uterine bleeding or if there is any suspicion of uterine adenomyosis (Bojahr et al, 2006). The patients having Laparoscopic supracervical hysterectomy should have a recent normal Papanicolaou smear without a recent history of any abnormal cervical cytology. They should also be committed to obtaining cervical cytologic evaluation at the interval that has been recommended. The patients should also not have pre-existing pelvic pain or endometriosis. This is because of the high incidence of persistent pelvic pain (Jenkins 2004).
When I am performing a subtotal laparoscopic hysterectomy, I do the same initial steps as with total laparoscopic hysterectomy until I have coagulated and cut both uterine arteries bilaterally using bipolar diathermy alternating with the harmonic scalpel. I then use the Lap Loop to cut the cervix above the level that I diathermied the uterine arteries followed by morcellation and extraction of the specimen through the suprapubic port. The Lap Loop is a single use monopolar cutting device that uses a coagulating current of 100. The use of the Lap Loop system has shown to be both quicker and easiers in cutting the uterus in one movement as opposed to the time consuming dissection to achieve the same result. The overall complication rate in one study using the Lap Loop for laparoscopic subtotal hysterectomy was 4.8% which were only minor complications that didnâ€™t include visceral injury or returns to theatre (Erian 2007).
Bipolar vs Monopolar hysteroscopic resection of fibroids
I currently use a monopolar resectoscope for the resection of fibroids. This is the available resectoscope my local hospital. There is now evidence supporting the use of bipolar resectoscopes in preference to monopolar resectoscopes. Berg in 2009 did a randomized controlled trial to compare three types of equipment during hysteroscopic resection (monopolar, bipolar resectoscope and bipolar Versapoint) on two hundred premenopausal women with menorrhagia as a result of dysfunctional bleedings, polyps or fibroids. Hysteroscopic resection was performed by either the monopolar electrodes which used glycine 1.5% as the irrigant or with two different types of bipolar electrodes (TCRis; Olympus, Hamburg, Germany and Versapoint; Gynecare, Menlo Park, CA) which used saline as irrigant. The study demonstrated mean serum sodium had a statistically significant reduction from 138.7 mmol/L to 133.8 mmol/L in the monopolar group, in comparison to the bipolar group which showed no reduction. The amount of resected tissue in the monopolar and TCRis group was approximately 1.00 g/min, compared with 0.65 g/min in the Versapoint group indicating that you can resect more tissues using monopolar and TCRis compared to Versapoint. The two bipolar groups had significantly higher loss of fluid. The conclusion was that the Bipolar electrodes appear to have a safer profile compared with monopolar electrodes (Berg 2009). I therefore see that it is definitely worth doing a business case to try to obtain bipolar resectoscopes instead of the monopolar resectoscopes in my local hospital.
A postal questionnaire survey was done in the UK inquiring about preferences with regards doing 1st and second degree endometrial resection. One thousand, four hundred sixty consultant gynecologists in the United Kingdom responded to this survey. Although the comments were about TCRE as opposed to resection of submucous fibroids, I think they are still relevant to the latter topic because the surgeon is still using the same instrument and in the same setting. Among the comments about TCRE, a few consultants who had mastered the technique felt it was simple, effective, and easy to perform. A significant number of consultants commented on the need for newer technology in manufacturing resectoscopes to improve on the current technical difficulties encountered when removing endometrial chippings, such as a device that would instantly allow morcellation of endometrial pieces and remove the chippings without the need to remove the instrument. Other comments included developing devices that allowa more uniform depth of resection, have larger loop electrodes as well as the need for a more reliable fluid balance system. A few of the consultants were using bipolar resectoscopes and recommend its use (Deb 2008).
Technique of resection of fibroids
In my performance of submucous fibroid resection, I initially do endometrial resection of the cavity to reduce the blood supply of the fibroid and make the submucous polyp more pedunculated in the cavity. Then I resect the fibroid. Bao-Liang Lin et al in 1994 had described a technique with a similar principle with some modifications. This technique involved transforming a sessile submucous fibroid into a pedunculated fibroid. 25 patients had a hysteroscopic myomectomy done using resectoscopes of two different sizes. The indication was large submucous fibroid which had caused symptoms of severe menorrhagia and anemia. During the procedure a 7 mm resectoscope was first used to cut the pedicle to a size smaller than 10 mm. Therefore a sessile myoma had been resected into a pedunculated myoma. The body was then resected with a 9-mm resectoscope. A pair of forceps was used to remove the smaller portions. The procedure was monitored with simultaneous ultrasonography (Lin 1994).
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