Chapter 8.2 Conventional Laparoscopic Hysterectomy Including Laparoscopic Supracervical Hysterectomy. Operative Techniques

 Chapter 8.2 Conventional Laparoscopic Hysterectomy Including Laparoscopic

Supracervical Hysterectomy

GENERAL PRINCIPLES

Definition

Hysterectomy is the most common nonobstetric operation performed in the

United States with 602,457 procedures performed in 2003 alone.1 It is also

the most common surgical procedure performed on women in Western

countries, with 23.3% of women aged 18 years or older undergoing the

procedure.2 The primary indication listed for hysterectomy are fibroids

(31%), uterine prolapse (14.5%), endometriosis (11%), abnormal uterine

bleeding (14%), and cancers of the genital tract (10%).3 Cohen revisited this

using the 2009 United States Nationwide Inpatient Sample and found a

decrease in the total number of hysterectomies performed, 479,814, in

women 18 years of age or greater,4 with 86.6% performed for benign

indications. Note that the decrease in numbers does not necessarily reflect a

drop in the actual number of hysterectomies performed as this and the

previous studies looked primarily at inpatient statistics and does not reflect

the shift to the outpatient performance of these procedures. In fact, Loring et

al.,5 looking at a large retrospective review of hysterectomies performed

between 2004 and 2012, noting that, in 2004, 2 of 194 laparoscopic

hysterectomies were performed in an outpatient setting, whereas, by 2012,

85% (293/344) were performed as outpatient procedures. Still, the study is

instructive in that 56% were completed abdominally, 20.4% were performed

laparoscopically, 18.8% done vaginally, and 4.5% performed with robot

assistance. Furthermore, Wright et al.6 documented a change in the

performance of hysterectomy for benign indications with the introduction of

the robot between 2007 and 2010. In his study, there were 40% abdominal,

30.5% laparoscopic, 9.5% robot-assisted, and 19.9% vaginal showing that

robotic and conventional laparoscopic approaches continue to decrease the

numbers of abdominal procedures, although 40% or more are still done as an

open laparotomy.

The access to laparoscopic minimally invasive hysterectomy also appears to

be related to patient socioeconomic status and geographic location. Patel et

al.7 studied a retrospective cohort of 32,436 patients from the 2010

Healthcare Cost and Utilization Project and noted 32% of the patients

underwent laparoscopic hysterectomy (LH) compared to 67% abdominalhysterectomy. Stratifying this, women most likely to undergo LH were less

than 35, Caucasian, and privately insured. Geographically in the United

States, women in the Northeast were far more likely to have an LH compared

to the Midwest and South. Our urban hospitals were more likely than rural,

and teaching hospitals more likely than nonteaching, to offer LH with

government-owned hospitals least likely to offer LH.

The goal of this chapter is to give the reader the tools to advance from the

performance of hysterectomy by laparotomy to a laparoscopic, minimally

invasive approach for most procedures.

Anatomic Considerations

Minimally invasive hysterectomy includes total laparoscopic hysterectomy

(TLH), laparoscopic supracervical hysterectomy (LSH), robotic-assisted

hysterectomy (RAH), and laparoscopic-assisted vaginal hysterectomy (LAVH).

The basic technique for the laparoscopic portion of all of the subgroups is

similar and will be described below as either the TLH or LSH.

There are few contraindications for the TLH approach because this

technique can be used in both benign and malignant conditions. Additionally,

most large uteri can be efficiently addressed using conventional laparoscopic

techniques by an experienced surgical team. Kovac8 outlined three basic

technical issues to determine the route of hysterectomy for benign disease as

they are the difficulties that make most gynecologists apprehensive:

1. Adequacy of the vaginal passageway (e.g., virginity, orthopedic restrictions

to the lithotomy position, and a narrow vagina of <2 fingerbreadths,

especially at the apex of the vagina)

2. The size of the uterus (e.g., leiomyomata)

3. Potential, severe, extrauterine risk factors suggestive of serious pelvic

disease (e.g., endometriosis, adnexal pathology, and adhesions)

Though Kovac originally described an algorithm of obstacles for the

performance of vaginal hysterectomy, the use of conventional laparoscopy

circumvents these obstacles and allows for a minimally invasive solution for

each issue.

Particular consideration must also be paid to obesity in the performance of

laparoscopic surgery. This affects up to 36.5% of Europeans and more than

39.5% of American patients. Guraslan and colleagues9 completed a

retrospective review of 153 patients undergoing TLH stratified by BMI. The

rate of conversion to laparotomy (9.8%), blood loss, total complications

(5.9%), and length of stay did not vary between the groups and they

concluded that LH was safe and feasible in the obese and morbidly obese

population. This was echoed by Mathews10 though they noted potential issues

with increased abdominal pressure and Trendelenburg positioning resulting inincreased airway pressure and end-tidal CO2, in obese versus nonobese

patients. Increased BMI did not appear to be associated with differences in

blood loss, duration of surgery, length of stay, or complication rates.

Additionally, a relative contraindication to laparoscopy was thought to be

the presence of a ventriculoperitoneal shunt. Cobianchi and colleagues11

examined this in a case series and literature review. They concluded that the

current generation valves were unlikely to cause issues with gas leakage

under 80 mm Hg, which is well below that of the current standard insufflation

pressures of 10 to 15 mm Hg. A possible exception is laparoscopy

immediately following a newly implanted shunt for both adults and children.

IMAGING AND OTHER DIAGNOSTICS

Gynecologic diagnostic centers use pelvic ultrasound as the first-line imaging

technique for evaluation of gynecologic complaints such as pelvic pain,

abnormal uterine bleeding, and pelvic masses. This has been the primary

imaging modality of uterine evaluation, showing the number and extent of

fibroids, presence of endometrial disease, and presence and characterization

of adnexal masses. With the controversies surrounding power morcellation

and undetected malignancy, diffusion-weighted MRI and diffusion tensor

imaging have been shown to accurately diagnose preoperatively endometrial,

myometrial, and cervical malignancies with great accuracy,12 though tissue

diagnosis is the gold standard. In the absence of this, traditional MRI is a

reasonable diagnostic tool for use in larger uteri prior to hysterectomy,

particularly in the perimenopausal age range when malignancy is more

common. Blood tumor markers, most notably CA125, have been used but

with limited success. CA125 is elevated with uterine tumors, dependent on

size, adenomyosis, and other inflammatory conditions in the abdomen,

making it of limited diagnostic use. The combination of MRI and serum

fractionated LDH may have a role for planning the surgical approach in

suspicious myometrial lesions.

PREOPERATIVE PLANNING

Proper preoperative assessment will facilitate an efficient procedure. Patients

for which hysterectomy is being considered should have a recent pap smear

and an endometrial biopsy, as clinically indicated, to rule out cancerous or

precancerous processes. Imaging, as suggested above, should be performed to

document uterine and adnexal pathology.

Decisions must be made with the patients regarding hysterectomy type and

approach. The mode of surgical approach is decided between total abdominal

hysterectomy (TAH), transvaginal hysterectomy (TVH), or LH, and the type

of hysterectomy is determined between LSH and TLH. Decisions must bemade as to whether to remove or to keep the cervix in particular. Although

ACOG guidelines continue to recommend vaginal hysterectomy in most cases,

recent studies question that approach. Allam et al.13 completed a randomized

controlled trial which found that although TLH had a longer operating time,

there was less blood loss, fewer complications, and less postoperative pain

than with TAH or VH. Similarly, Pokkinen et al.14 noted reduced need for

analgesics in LH compared with vaginal hysterectomy.

Though supracervical hysterectomy has been performed as long as total

hysterectomy, there are no studies that conclusively define the optimal

procedure. Nesbitt-Hawes15 concluded that, given the currently available

evidence, all forms of hysterectomy should be offered to women requiring

hysterectomy. She noted that it could not be stated that LSH prevents longterm pelvic organ prolapse, offer improved sexual function, or reduce

operative risk, though it does provide faster return to work. In a recent study

from Italy, however, Saccardi et al.16 noted women in their LSH group

reported a greater ease of recovery of sexual function as opposed to TLH.

Complicating the decision-making on the type of hysterectomy is the effect

of TLH and LSH on ovarian reserve. Yuan and colleagues17 looked at ovarian

reserve in patients undergoing total versus supracervical hysterectomy by

assessing anti-müllerian hormone. Their data show serum AMH levels

decreased significantly at 4 months posthysterectomy in patients in their 30s

and 40s, with a much greater decrease in patients having a TLH over those

with LSH. These data suggest that LSH is better than TLH in preserving

ovarian function, and need to be considered when discussing with your

patient.

SURGICAL MANAGEMENT

Positioning and Approach

The patient is first placed in dorsal lithotomy position with laparoscopic leg

cradles such as Allen stirrups. This allows the legs to be cushioned and allows

for access to the perineum, with flexion of the knees and hips to avoid

neuromuscular injury.18 Intermittent compression devices are also placed on

the calves at this time. As basic as it sounds, having an operating room table

with ability to achieve adequate patient Trendelenburg position is of

paramount importance (Fig. 8.2.1). Trendelenburg is often 35 degrees or

greater to allow the intestine to migrate cephalad, thereby exposing the

pelvic anatomy.

Securing the patient safely on the table is often a challenge, particularly

with obese patients. We have been placing the patient directly on an egg crate

mattress secured to the operating table as described by Klauschie and

coworkers (Fig. 8.2.2).19 This allows for the use of Trendelenburg withminimal slippage and has the advantage of working even with the morbidly

obese patient without extra straps or shoulder braces that can predispose to

neurologic and other injuries in longer procedures. One particular axiom is

that the larger the patient, the greater the Trendelenburg angle that is

required for adequate visualization. Steep Trendelenburg position is not

without consequences; however, ocular complications, alopecia, as well as

nerve injury have been reported.20 Gould et al.21 reported the use of less

Trendelenburg angle in a blinded trial which lowered the angle from 40 to 28

degrees, and found no difference in the operative times for pelvic surgery

among 16 different surgeons.

Figure 8.2.1. Placement of patient in Trendelenburg position.

Figure 8.2.2. Securing the egg crate mattress to operating table.Procedures and Techniques

Total laparoscopic hysterectomy

Step 1: Placement of uterine manipulator and bladder catheter

Before instrumentation of the patient, standard prophylactic antibiotics and DVT

prophylaxis are administered. The Caprini (ACCP) score guidelines account for the

type of surgery, obesity, previous VTE, and other complicating factors such as

malignancy to determine need and dosing.22 Antibiotic prophylaxis and VTE

prophylaxis should be based on BMI (and volume of distribution), not ideal weight.

A standard Foley catheter is placed to drain the bladder during the procedure.

One can consider the use of a dual port (three-way) catheter to allow filling and

draining of the bladder when significant lower uterine segment and bladder

adhesions are anticipated or when encountered. This allows for rapid installation of

saline to delineate the borders of the bladder and prevent incidental cystectomy.

The surgeon can use blue dye if a cystotomy is encountered to assess the water

tightness of closure.

A uterine manipulator with a pericervical cup is placed to allow for greater

movement of the uterus with fewer ports to achieve the desired angles at which to

operate. For both TLH and LSH, we use the V-Care uterine manipulator (ConMed

Endosurgery, Utica, NY) (Tech Fig. 8.2.1). Other manipulators are available and may

work equally well for these procedures. The cervix is grasped with a single-tooth

tenaculum and dilated to 21 French. The manipulator is introduced and the balloon

inflated. For the TLH, the cup of the manipulator is sewn onto the cervix to assist in

tissue removal. For the supracervical procedures, the manipulator is placed without

suturing.

Tech Figure 8.2.1. V-Care uterine manipulator.

Van den Haak and colleagues23 recently reviewed 25 articles covering 10 uterine

manipulators. Interestingly, they found that though convenient, definitive

documentation of efficacy and safety was scant. Their review did not find the

“optimal” manipulator. There has also been speculation that dilatation of the cervix

and placement of any manipulator may upstage an undiagnosed uterine

endometrial carcinoma. Iavazzo and Gkegkes24 recently reported “the assumption

that uterine manipulators can induce intra-operative dissemination of tumor cells is

suggested to be a derivative of common sense. The existence of cases with

positive peritoneal cytology after uterine manipulation cannot be determined with

certainty, and whether manipulators result in metastasis at peritoneum or disease

recurrence.” In cases where it is impossible to place a manipulator, use of a

standard infant nasal suction bulb or bulb top of an Asepto syringe in the vagina will

often delineate the vaginal edges (Tech Fig. 8.2.2).

Tech Figure 8.2.2. Use of the bulb top of an Asepto bulb syringe. The bulb portion

goes in the vagina first up against the cervix.

Step 2: Placement of primary trocar

Our approach to initial trocar placement is predicated on factors including uterine

size and type of previous abdominal surgery. For uteri 16 weeks pregnancy size or

less, we place the camera port at the umbilicus (Tech Fig. 8.2.3). This is a 5-mm port

for most patients, though 10-mm ports should be considered in more obese

patients to prevent damage to the instruments and camera from torque. The angle

of port insertion at the umbilicus should be 45 degrees for normal BMI patients and

more toward a 90-degree angle with increasing obesity due to the position of the

umbilicus in relation to the aortic bifurcation. We employ the direct optical insertion

technique under direct vision rather than a blind Veress needle insertion. Tinelli et

al.25 reported no statistically significant difference in complications between direct

insertion and Veress needle, suggesting that the visual entry systems offer

statistical advantage in terms of time savings and reduced minor vascular and

bowel injuries. The key concept is not to be “wed to the umbilicus” or Veress

needle.

Tech Figure 8.2.3. Standard camera port placement for uteri 16 weeks or less.

When the uterus is greater than 16 weeks size, then the camera port is placed

above the umbilicus in the midline up to a level several centimeters below the lower

costal margin (Tech Fig. 8.2.4). These should be placed at 90-degree angle to the

abdominal wall to avoid tunneling and will give greater visualization of the pelvis.

When there is a history of previous mid-abdominal or umbilical surgery such as

hernia repair with mesh or colorectal surgery, the use of Palmer’s point in the left

upper quadrant is preferable to avoid potential bowel injury on insertion.

Tech Figure 8.2.4. Port placement for larger uteri with camera above the umbilicus in

the midline.Step 3: Placement of secondary trocars

Once the patient is placed in Trendelenburg position, the abdomen is insufflated

with CO2 to a final pressure of 12 to 15 mm Hg, and the secondary ports are placed

under direct vision. If the operating surgeon is on the patient’s right side, then a 10-

mm trocar is placed in the right lower quadrant above the anterior superior iliac

spine (ASIS). The safe distances from the midline to avoid internal epigastric artery

injury are 6 cm from the midline at the level of the ASIS and 9 cm off the midline at

the level of the umbilicus.26 The exact placement depends on the size of the uterus

as this port will migrate cephalad as the uterus enlarges. The second 5-mm trocar

will be placed on the right side approximately 10 cm above the 10-mm trocar. The

third 5-mm trocar is placed on the patient’s left side at approximately the same level

as the right-sided port. If the surgeon is operating from the patient’s left side, then

the port locations are reversed. For morbidly obese patients, consideration should

be given to using all 10-mm ports to allow use of instruments with greater diameter

and avoid damage to instruments due to torque.

Step 4: Instrumentation for optimal visualization

The insufflation tubing is placed on one of the lateral ports to decrease lens

fogging. Efficient evacuation of smoke and water vapor from lysed tissue is

essential for good visualization. We employ the AirSeal (Tech Fig. 8.2.5) insufflator

(Surgiquest, Millford, CT, USA) which allows heated insufflation with CO2 and

smoke evacuation from a single port (either 5 to 10 mm). Additionally, the device is

calibrated to maintain a steady, preset pneumoperitoneum, even when the vaginal

cuff is open, which is an advantage in TLH and obese patients.

Tech Figure 8.2.5. AirSeal insufflation device.The general instrumentation used is in the standard laparoscopy sets available in

most operating rooms. Soft bowel graspers, Maryland graspers, and single- and

double-toothed tenaculums are the primary instruments for manipulation of tissue

and bowel. Electrosurgical devices are used to coagulate blood vessels and cut

tissue. We commonly use an ultrasonic device for dissection, vessel sealing, and

tissue division, as one instrument can be used for most steps (Tech Fig. 8.2.6).

Advanced bipolar devices (such as LigaSure [Covidien, Boulder, CO, USA], EnSeal

[Ethicon Endo Surgery, Somerville, NJ, USA], PlasmaKinetic, and others) can also

be used.

Tech Figure 8.2.6. Ultrasonic energy device.

Standard irrigation sets with power irrigation and suction are used to keep the

surgical field clean for dissection. In patients where there is extensive pelvic

adhesion or endometriosis, the use of lighted ureteral stents should be considered.

Placed at the beginning of the procedure, they offer a way to avoid complications

by “lighting the path” (Tech Fig. 8.2.7).

Tech Figure 8.2.7. Use of lighted ureteral stents to help with visualization of the ureters

in complex cases.

Step 5: Divide the round ligament, tube, and utero-ovarian ligament

If the ovary is to be removed, the infundibulopelvic ligament is skeletonized,

desiccated with bipolar radiofrequency device, and divided (Tech Fig. 8.2.8). The

Sonicision ultrasonic device is then used to transect the fallopian tube, round

ligament, and utero-ovarian ligament as the first step of the procedure (Tech Fig.

8.2.9).

Tech Figure 8.2.8. Inspect the pelvic structures, desiccate and divide the

infundibulopelvic ligament.

Tech Figure 8.2.9. Transect the fallopian tube, round ligament, and utero-ovarian

ligament.

Step 6: Divide the superior portion of the broad ligament

The upper portion of the broad ligament is then incised (Tech Fig. 8.2.10) and the

bladder flap is developed by opening the anterior leaf and deflecting the bladdercaudally. The insufflated CO2 will help open the leaves of the broad ligament by

filling and expanding areolar tissue and sharp dissection will expose the uterine

vessels.

Tech Figure 8.2.10. Divide superior portion of broad ligament.

Step 7: Isolate, divide, and lateralize cardinal ligaments

Once isolated, the uterine artery and veins are desiccated with bipolar

radiofrequency device and divided (Tech Fig. 8.2.11). Technically, the ultrasonic

devices should handle up to 7-mm-diameter vessels which include most uterine

arteries encountered, but our experience has been that bipolar cautery is often

needed for reliable bleeding control. The vessels are then “lateralized” in a series

of “V” motions to move the vessels laterally and over the manipulator cup (Tech Fig.

8.2.12). This also moves the ureter laterally and out of the surgical field.

The bladder flap is then further developed over the manipulator cup by sharp and

blunt dissection (Tech Fig. 8.2.13). This moves the bladder out of the way for the

colpotomy. Adhesions in this area are common and sharp dissection is used to

remove the bladder from the lower uterine segment and cervix. Injury to the bladder

is most common in this location. If it does occur, complete the dissection of the

bladder from the cervix with adequate margins prior to repairing the bladder. Use a

simple, two-layer closure with 3-0 polydioxanone (PDS-like) or polyglactin (Vicryllike) suture. Cystoscopy postprocedure is mandatory if this occurs to ensure

satisfactory watertight repair.

Tech Figure 8.2.11. Desiccate and divide the uterine artery and vein. A shows

desiccation of the uterine artery and vein with bipolar cautery. B shows division of the

uterine artery and vein using ultrasonic energy.

Tech Figure 8.2.12. Lateralize the uterine vessels over the manipulator cup with a “V”

technique. A: Artist rendition of placement of energy device to lateralize the vessels

over the manipulator cup with a “V” Technique. B: “v” technique lateralizing over the

lower uterine segment.

Tech Figure 8.2.13. Expose the vagina over the manipulator cup by deflecting the

bladder caudally.

Step 8: Repeat procedure on the contralateral side

Step 9: Colpotomy

Colpotomy proceeds along the manipulator cup from the vaginal attachments over

the manipulator cup using ultrasonic energy, or monopolar radiofrequency

instrument (Tech Figs. 8.2.14 and 8.2.15). The dissection is occurring over the V-Care

cup, Rumi-type manipulator, McCartney Tube, sponge on a sponge-stick, or other

device that is being used in the vagina to delineate the fornices. The uterus is

pulled into the vagina and the fundus can be used to occlude the vagina and

maintain pneumoperitoneum (Tech Fig. 8.2.16). Alternatively, the uterus can be

removed completely and a wet lap pad, wet lap placed in a glove, or similar device

can be used to occlude the vagina.

Tech Figure 8.2.14. Dissect the cervix over the manipulator cup.

Tech Figure 8.2.15. Remove the cervix from the vagina.

Tech Figure 8.2.16. Pull the uterus into the vagina to hold pneumoperitoneum in

smaller specimens.

Step 10: Vaginal cuff closure

Once removed from its vaginal attachments, the pedicles are inspected for

bleeding. We have been using a modified Richardson stitch at the vaginal angles,

incorporating the uterosacral ligaments as originally described for openhysterectomy by E. H. Richardson in 1929 (Tech Fig. 8.2.17).27 This involves

placement of a stitch in a figure-of-eight fashion at the vaginal angles and include

the distal portion of the uterosacral ligament, being careful not to include the vaginal

mucosa in this permanent suture material. Care must also be taken not to kink the

ureter when placing this stitch as it lies in close proximity. We generally use 0-

gauge prolene for this. The remaining portion of the vagina is approximated using

absorbable suture in interrupted or figure-of-eight fashion, using 0-gauge

polydioxanone or polyglactin (Tech Figs. 8.2.18 and 8.2.19). Alternatively, 0-gauge

barbed sutures, such as V-Lock, Quill, or Stratafix can be used for this purpose

(Tech Fig. 8.2.20). Care must be taken to get beyond the thermal damage to the cuff

in taking the closing bites of vagina. Care must also be taken not to incorporate

bladder, minimizing the possibility of postoperative fistula. The finished cuff is well

suspended as seen in Tech Figs. 8.2.21 and 8.2.22. To help with pain

management postoperatively, we have been using 5 cc of 2% lidocaine jelly

intravaginally at the end of the procedure. This can also be used postoperatively in

the form of 5 cc of Uroject (prepackaged lidocaine jelly) every 4 to 6 hours which

will help with some of the low pelvic pain that these patients often experienced

postoperatively, similar to its use for dyspareunia in breast cancer patients.28

Tech Figure 8.2.17. Modified Richardson stitch.

Tech Figure 8.2.18. Colpotomy closure using interrupted absorbable suture.

Tech Figure 8.2.19. Finished, interrupted, and suspended vaginal closure.

Tech Figure 8.2.20. Colpotomy closure using barbed suture. A securing the barbed

suture with the looped end of the suture and B 2 layer closure of the vaginal cuff using

the barbed suture.

Tech Figure 8.2.21. Prophylactic salpingectomy.

Tech Figure 8.2.22. Cystoscopy with fluorescein dye or pyridium. A shows Fluoresceindye shooting from theutereteral orifice with a distinctive yellow “highlighter”

appearance. B shows flow of Pyridium stained urine from the ureter.

Step 11: Handling of the fallopian tubes

If the ovaries are left in situ, we have been removing the fallopian tubes

prophylactically to decrease the risk of tubal or adnexal malignancy later in life as

recently reaffirmed by the National Cancer Institutes.29 This is done using the same

energy sources used for the rest of the hysterectomy, and involves dividing the

fimbriated end of the fallopian tube from the ovary and the remaining tube from its

mesentery. It is important to take all of the fimbriated ends, as that is the portion

associated with malignancy (Tech Fig. 8.2.21). It adds little time and morbidity to

the procedure and may confer benefits over our patient’s lifetimes.

Step 12: Handling of larger uterine specimens

Uterine specimens greater than 10 to 12 weeks pregnancy size will generally not fit

through the vagina without significant tearing and may be impossible to remove via

that route due to large fibroids or patient body habitus. For many specimens,

vaginal morcellation can be accomplished in the standard fashion using coring or

bivalve techniques to achieve specimen extraction. Because of concerns about

power morcellation, some practitioners are placing the uterus in a containment bag

before vaginal morcellation to theoretically decrease risk, though the efficacy of

their use vaginally has not been proven.

Alternatively, specimens can be removed through a small 4- to 5-cm mini-lap

Pfannenstiel incision, made suprapubically, or by extending the umbilical incision.

This will be described below under the section on Extracting the Uterine Corpus.

Step 13: Cystoscopy

It has been our practice to undertake cystoscopic examination in every patient after

a TLH, or complicated supracervical hysterectomy prior to leaving the operating

room. Though the literature on the value of this is not clear, we have found the

practice invaluable. A standard cystoscope setup is used with either a 30- or 70-

degree cystoscope. The bladder is usually filled with normal saline and the walls of

the bladder examined for injury or defect, specifically a through-and-through stitch

from the cuff closure or possible electrical injury. The ureters are inspected for

urine flow. Traditionally we used indigo carmine dye to aide in observing urine flow

from ureters, but this is no longer available. We have been using pyridium 200 mg,

by mouth prior to the procedure, or fluorescein dye (1 cc) at the time of the

procedure to evaluate the ureteral jets (Tech Fig. 8.2.22). Alternatively, one can fill

the bladder with 10% dextrose and observe the jets as the difference in viscosity is

readily apparent. This simple, 5-minute procedure, can, by identifying GU injuries,

decrease postoperative complications. Identification of issues at this juncture

allows for immediate repair rather than delayed recognition.In cases where cystoscopy setups are not available, the bladder can be filled

with saline from the abdominal irrigator set and the 5-mm hysteroscope placed

through the urethra for bladder evaluation. This gives the same information without

having to open a formal cystoscopy set which may be an issue in some institutions.

Laparoscopic supracervical hysterectomy

Step 1: See steps 1 to 8 of total laparoscopic hysterectomy in Procedure

and Techniques section

To accomplish the LSH, Steps 1 through 8 of the preceding section are

accomplished (see also Surgical Management). Once the uterine vasculature is

occluded, the uterus is amputated from the cervix at the level of the isthmus (Tech

Fig. 8.2.23). In the case of supracervical hysterectomy, we have been cauterizing the

endocervix from the vaginal side at the beginning of the procedure, prior to

placement of the uterine manipulator by using monopolar cautery as well as from

above with bipolar cautery after amputation. We then use a reusable Hulka

tenaculum or V-Care (ConMed EndoSurgery, Utica, NY) manipulator as described

above.

Tech Figure 8.2.23. Amputation of the uterus at the level of the isthmus with V-Care

manipulator in place. A shows removal of the lower uterine segment from the cervix

using ultrasonic energy. B shows the appearance of the cervix after uterine removal with

the top of the V-care manipulator visible.

Step 2: Amputation of the uterine cervix

The uterus is amputated from the cervix using an ultrasonic energy device at the

level of the internal os (see Tech Fig. 8.2.23). Alternatively, monopolar energy in theform of scissors, hook, or wire loop can be used for this purpose. Once this is

performed, the endocervix is cauterized from the abdominal side using a reusable

bipolar instrument to lessen the chance of cyclic bleeding (Tech Fig. 8.2.24). The

combination of cautery of the endocervix with monopolar cautery from the vaginal

side and this step of cautery with bipolar energy from the abdominal side has

dropped our cyclic bleeding rate to approximately 2% and will be discussed below.

Most remaining spotting postoperatively can be treated in the office by the use of

silver nitrate applied to the endocervix. The cervix is then closed abdominally using

a single stitch of 0-gauge absorbable suture such as polyglycan, a step that

prevents the leakage of peritoneal fluid from the open cervical os which can be

troublesome for the patient (Tech Fig. 8.2.25).

Tech Figure 8.2.24. Cautery of the endocervix with bipolar energy.

Tech Figure 8.2.25. Closure of the cervix with polyglycan suture.

Step 3: Extraction of the uterine corpus

Prior to the FDA Black Box warning on the use of power morcellators in 2014, all

specimens would have been handled by use of a power mechanical morcellator

placed through one of the port sites. We had been using the lower quadrant port

sites for this purpose to enhance visualization and make it easier to track loose

fragments. Though not currently available in many institutions due to the FDA

warning, some practitioners continue to use power morcellators by morcellating the

uterus in a specimen bag to minimize the spread of aerosolized tissue. Current

data is unclear as to whether or not this is efficacious.

What we have been doing to remove the retained supracervical specimen is

utilize some form of mini-laparotomy with a self-retaining wound retractor in the

suprapubic area with a 4- to 5-cm incision or use the umbilicus with a 2.5-cm

extension.

For the suprapubic incision (Tech Fig. 8.2.26), a 4- to 5-cm incision is made above

the pubis in the midline much as one would plan a Pfannenstiel incision. Bovie

monopolar cautery is then used to open the subcutaneous fat and open the fascia.

The peritoneal cavity is then entered with the insufflation gas still on to keep the

bowel out of the way and facilitates insertion of the retractor. A GelPort retractor is

placed through the incision (Tech Fig. 8.2.27). Once this is in place, the gas is turned

off, and the specimen is drawn into the incision and externally morcellated with a

series of “C” incisions which will elongate the specimen and allow it to be

systematically removed from the cavity (see Tech Figs. 8.2.28 and 8.2.29, Video

8.2.1). We have been able to remove specimens greater than 3,000 g in thismanner (Tech Fig. 8.2.30). It is unclear as of this writing whether the use of bag

actually adds safety to the procedure. The use of the GelPort allows for reinsufflation after specimen removal to affect a washout of the peritoneal cavity or

check pedicles. Closure of the mini-laparotomy is done in the standard fashion and

the incision can be injected with local analgesics or liposomal lidocaine (Experal)

which will impart analgesia to the incisions for approximately 72 hours, allowing for

performance in the outpatient setting (Tech Fig. 8.2.31). Alternatively, one can just

close the mini-Pfannenstiel in standard fashion and then re-insufflate.

Tech Figure 8.2.26. 4-cm mini-lap Pfannenstiel incision.

Tech Figure 8.2.27. Placement of GelPort self-retaining retractor.

Tech Figure 8.2.28.A: Bring specimen into retractor and start morcellating. B: Uterine

specimen removed by external morcellation.

Tech Figure 8.2.29. Uterine specimen being removed with a “C” technique of external

uterine morcellation. A: artist rendition of uterine specimen being removed with a “C”

technique of external morcellation and B: “C” technique to remove large specimens.

Tech Figure 8.2.30. Removal of large volume of tissue through mini-lap incision.

The umbilicus may also be a reasonable site for extraction. The umbilical incision

is made around the top or bottom of the umbilicus and extended to half way around

(or through the central portion of the umbilicus if it is large enough). The fascia is

then incised and the peritoneal cavity opened. The fascia can be extended by use

of an omega incision extending the tails out to get more space. This allows

placement of a 12-mm or 15-mm endobag to draw the uterus up to the incision and

keep it contained near the incision. Again, continuous small “C” incisions are made

in the specimen to remove it through the small incision. As with the GelPort, the

GelPOINT Mini (Applied Medical) can be used in the umbilicus (or anyplace else) to

re-insufflate and continue other parts of the procedure if necessary.

As in the section on Total Laparoscopic Hysterectomy, the fallopian tubes are

removed to lower ovarian and tubal cancer risk.

Tech Figure 8.2.31.Inject 4-cm incision with Exparel or other analgesic and close.Pearls and Pitfalls

If the uterus greater than 14 to 16 weeks size, place camera trocar above the

umbilicus or left upper quadrant.

If there are suspected adhesions, place primary camera trocar above the umbilicus

or left upper quadrant.

If the bladder is adhesed to lower uterine segment, use three-way Foley

catheter and fill the bladder with saline or methylene-blue-dyed fluid to delineate the

bladder margins.

If there is cyclic spotting/bleeding post LSH, cauterize cervix from the vaginal side

and abdominal side.

If the patient is obese, use egg crate mattress on operating table to minimize

movement and place camera above umbilicus to maximize visualization. Use of

AirSeal insufflation device to aid in visualization and maintain pneumoperitoneum.

Use lighted ureteral stents to visualize the ureters and allow for safe dissection if

there is dense low pelvic adhesion or endometriosis.

Use a bulb syringe top in the vagina or infant suction if the uterine manipulator

cannot be used to delineate the vaginal fornices.

If there is low pelvic pain postprocedure, use lidocaine jelly 2% in the vaginal

mucosa at the end of the procedure and postoperatively to help with the vaginal

pain.

If there is need for cystoscopy and equipment is not available, instill saline from

irrigator into the bladder and use 5-mm laparoscope as a cystoscope.

POSTOPERATIVE CARE

In the absence of bladder or ureteral injury, or history of previous urinary

retention with surgery, the urinary catheter is removed in the operating room

and the patient undergoes standard postoperative care. Once the patient’s

postoperative pain and nausea is controlled with PO meds, and she passes a

voiding trial, the patient is discharged from the PACU with instructions for

postoperative evaluation in 2 weeks. For patients unable to urinate, which is

an occasional issue secondary to dissection, anesthesia, or concomitant

procedures, a bladder scan is performed to confirm there is urinary retention

and that the patient is not just dry from lack of fluid. A catheter is left in for 2

days and is removed in the office after a bladder challenge to avoid

overdistention and damage. A standard hemoglobin and hematocrit are

checked prior to discharge. The patient is discharged with narcotic analgesics,

nonsteroidal analgesics, and stool softeners; and in the case of TLH, vaginal

lidocaine jelly, as previously described.A large part of successful transition from the postoperative unit to home is

predicated on management of preoperative expectations so that the patient

and her family know she is being discharged on the day of surgery and what

her limitations might be. With the patient in an outpatient setting, they are

encouraged to achieve early ambulation prior to leaving. We have also found

that the use of an abdominal binder is helpful when ambulating in the

postoperative period as this gives support to the patient’s core. Early

ambulation is key in rapid recovery and minimizing complications.

OUTCOMES

Both LSH and TLH are minimally invasive alternatives for hysterectomy. Reoperation rates are equivalent in the two procedures with no differences in

intraoperative and postoperative complications, with a trend toward lower

complications in the LSH group.30 A method-specific procedure, sometimes

necessitated after an LSH, was trachelectomy for either bleeding or

malignancy, and occurs in about 2.7% of patients, and repair of vaginal cuff

dehiscence after TLH which occurred in approximately 0.7% of patients.

Einarsson and colleagues31 did a prospective quality-of-life (QOL) evaluation

in total versus LSH patients using validated QOL questionnaires. LSH appears

to provide greater improvement in short-term QOL compared with TLH. No

significant differences were noted in postoperative pain or return to normal

daily activities. Mastering both techniques will allow for continued

conversion to minimally invasive alternatives for most gynecologic

procedures and should be in all gynecologic surgeon’s armamentarium.

COMPLICATIONS

As with any procedure, complications related to laparoscopy by itself, and

complications related to the type of surgery may occur. Bojahr et al.32

published data on 1,706 consecutive LSH patients in 2006. The mean uterine

weight was 226 g with mean operative time of 91 minutes. Fifty-two percent

had previous laparotomy. Of the 1,706 procedures, there were 14 patients

that were converted to laparotomy due to size and immobility, and one for

adhesions. There were two bladder injuries and one ureter injury in an 818-g

uterus. Overall, there was a 1.2% postoperative complication rate including

infection and bleeding. Kafy et al.33 also reported on 1,792 patients

comparing complications between abdominal, vaginal, and LH. The overall

morbidity was 6.1% with one bowel injury in the laparoscopic and abdominal

hysterectomy groups, and one ureter injury in the abdominal hysterectomy

group. Vaginal hysterectomy was associated with more urinary retention and

hematoma formation. Conversion rates were 1.7% in the laparoscopic group

and 0.4% in the vaginal hysterectomy group. Re-operation rate was 0.4% inthe abdominal group with overall morbidity being low in all groups and no

reported mortality. In a 2014 Korean study, Kim et al.34 looked at an 11-year

trend in surgical complications between abdominal hysterectomy, multi-port

LH, and single-port hysterectomy. Major complications such as bladder,

ureteral, and bowel injury were most common in multi-port hysterectomy,

with vaginal cuff dehiscence making up almost half the complications in all

groups. The total number of complications was mostly in the multi-port

hysterectomy group with the single port having the least complications.

Overall, there was a 5.3% complication rate in the abdominal group, an 8.7%

rate in the multi-port hysterectomy group, and 2.4% in the single-port group,

showing that LH is achievable with low morbidity in most groups observed.

Laparoscopic removal of large uteri represents a particular challenge,

whether total or supracervical. Alpern 35 completed a retrospective analysis of

Kaiser Permanente’s experience of 446 consecutive cases over 500 g. The

mean uterine weight was 786 g (500 to 4,500). Life-threatening complications

occurred in 0.7% of cases and required re-operation in 0.45% of cases. There

were six cystotomies, and 92.8% of the cases were discharged on

postoperative day 0 with a 1.1% re-admission rate. There was no association

between perioperative complication morbidity and patient/surgical

characteristics. Uccella, in the following year, reported on a series of 71 TLH

cases with uteri greater than 1 kg as well as a literature review.36 The median

weight was 1,120 g (1,000 to 2,860) and there was a 4.2% (three patients)

conversion rate to open surgery, two for dense adhesions, and one because of

inability to place a uterine manipulator. The median operative time was 2

hours and median blood loss was 200 mL. There were two perioperative

complications; one with vaginal bleeding 10 days postoperatively managed

conservatively and one with vaginal cuff hematoma, also managed

conservatively showing that larger uteri can indeed be handled efficiently and

safely in a minimally invasive fashion.

TLH has a unique complication in the form of vaginal cuff dehiscence

postoperatively. This can happen from several days to years after surgery and

is usually brought on by vaginal intercourse. It is a matter of debate as to

whether this is secondary to the suturing technique or use of energy to the

cuff, particularly with monopolar energy. In a 2012 Italian study, Uccella37

completed a multi-institutional analysis of 12,398 patients who underwent

hysterectomy for both benign and malignant diseases, and looked at the rate

of cuff dehiscence with the various closure types. TLH was associated with the

highest number of cuff separations 23 (0.64%) versus 6 vaginal (0.13%).

Laparoscopic suturing of the vaginal cuff had the highest separation rate at

0.86% over transvaginal suturing at 0.24%. Reducing the monopolar current

from 60 to 50 W did not alter the rates. Blikkendaal38, in a retrospective

cohort Dutch study, compared techniques of laparoscopic cuff closure; lookingat incidence of dehiscence with transvaginal interrupted, laparoscopic

interrupted, or laparoscopic running suture with conventional or bidirectional

barbed suture. Their data did not show superiority of one technique over any

other. Fuchs-Weizman and colleagues39 performed a retrospective analysis of

2,382 TLH between 2009 and 2011. She reported 23 (0.96%) cuff dehiscences

and 4 had recurrent dehiscence. The type of energy, mode of closure, and

suture material did not differ between groups. Women with more extensive

procedures were at higher risk and continuous suturing of the cuff was a

probably superior to interrupted suturing in their study.

LSH has three unique complications associated with it that are procedure

specific. The first is continued cyclic bleeding since the cervix is left in situ,

likely due to retained endometrial type tissue in the endocervical canal.

Nouri40 recently published a meta-analysis on the subject revealing that there

are varying rates of postoperative cyclic bleeding in premenopausal women,

depending on the method used to prevent bleeding. There was a 16.2% rate if

nothing was done (up to 24%). Excision of the endocervix was still associated

with high levels of bleeding (14%), and the best results came from bipolar

electrocoagulation of the endocervix which dropped the level to 2.6% on

average. All cyclic bleeding postoperatively was looked at regardless of age,

BMI, presence of endometriosis or adenomyosis, and history of previous

cesarean delivery. Similarly, we have found that monopolar cautery of the

endocervix from the vagina prior to the hysterectomy, followed by bipolar

coagulation of the endocervix after uterine amputation has decreased the rate

of cyclic postoperative bleeding at Cleveland Clinic. Much of this can be

further reduced by the use of silver nitrate in the cervical os in the office for

refractory cases with trachelectomy being necessary for very few.

Prior to 2014, power morcellation had been used to remove uterine tissue

and fibroids for LSH and larger TLH that could not be removed vaginally.

Issues associated with the power morcellators were iatrogenic spread of

endometriosis and myomatosis, as well as possible upstaging of undiagnosed

carcinoma or sarcomas of the uterus and tubes. Due to concerns about

possible spread of undiagnosed carcinoma of the endometrium or uterine

sarcoma, the FDA issued a Black Box warning on power morcellators in 2014

and we are no longer using them for tissue management. Descriptions of how

to remove larger uteri and supracervical specimens are described in detail

under Step 3 of Laparoscopic Supracervical Hysterectomy in the Procedures

and Techniques section.