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Is laparoscopic hysterectomy feasible for uteri larger than 1000 g?
European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Is laparoscopic hysterectomy feasible for uteri larger than 1000 g? William Kondo *, Nicolas Bourdel, Francesca Marengo, Revaz Botchorishvili, Jean Luc Pouly, Kris Jardon, Benoit Rabischong, Ge´rard Mage, Michel Canis Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie Aubrac, 63003 Clermont-Ferrand, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 October 2010 Received in revised form 4 January 2011 Accepted 28 March 2011
Objective: To evaluate the feasibility of laparoscopic hysterectomy for uteri weighing more than 1000 g. Study design: A retrospective study was conducted in a tertiary center of laparoscopic surgery including 38 women submitted to hysterectomy for uteri weighing more than 1000 g. Patients submitted to open hysterectomy were compared to those submitted to laparoscopic hysterectomy. The primary statistical endpoint was the complication rate. Secondary endpoints were operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy. Results: The patients’ mean age was 49.4 years and mean BMI was 25.2 kg/m2. The surgical intent was laparoscopic hysterectomy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%). Conversion to open surgery was required in 4 patients (17.4%) due to inaccessibility of the pelvis at the beginning of surgery (n = 2), technical difficulties during surgery (n = 1), and intraoperative bleeding (n = 1). One patient in the laparotomy group had an intraoperative ureteral injury. Despite longer operative time (130 vs. 80 min, p = 0.002), laparoscopic surgery was associated with reduced length of hospital stay (3 vs. 6 days, p < 0.001). Intraoperative bleeding was evaluated by the difference of pre- and post-operative hemoglobin and was equivalent in both groups (2.2 vs. 1.6 g/dL; p = 0.84). There was a tendency for more postoperative complications in the laparotomic group (33.4% vs. 8.7%; p = 0.05). Conclusion: Laparoscopic hysterectomy is feasible for selected patients with uteri weighing more than 1000 g. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Hysterectomy Laparoscopy Enlarged uteri
1. Introduction Hysterectomy is the most common major gynecological operation performed in the world. Benign diseases including menorrhagia, fibroids, pelvic pain, and uterine prolapse are responsible for more than 70% of indications for hysterectomy [1]. Traditionally, it is performed by laparotomy or vaginal approach [2]; however, laparoscopy has been increasingly employed since its initial report in 1989 [3]. Advantages of the laparoscopic approach compared to its open counterpart include lower intraoperative blood loss, shorter duration of hospital stay, faster convalescence, and fewer wound or abdominal wall infections, at the cost of longer operating times and more urinary tract injuries [4]. Large uteri determine technical challenges for laparoscopic surgery. Some authors have demonstrated that there is an increased risk of intraoperative bleeding and postoperative complications as well as a longer time of hospitalization when laparoscopic hysterectomy is performed for uteri weighing more
* Corresponding author. Tel.: +33 4 750 138. E-mail address: [email protected] (W. Kondo). URL: http://www.drwilliamkondo.site.med.br/ 0301-2115/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2011.03.027
than 500 g [5]. Others [6] report a high rate (93%) of successful laparoscopic-assisted vaginal hysterectomy for uteri larger than 1000 g. The aim of this article is to assess the feasibility of laparoscopic hysterectomy for uteri weighting more than 1000 g and to compare the surgical outcomes to those observed after standard open surgery. 2. Materials and methods We retrospectively reviewed 2618 hysterectomies performed at the CHU Estaing, Clermont-Ferrand, France, from January 1995 to December 2008. Patients with uteri larger than 1000 g on pathological examination were selected for the study. The study was approved by the Inter-regional Ethics Committee of the Rhoˆne-Alpes-Auvergne Clinical Investigation Center, Grenoble, France, on April 29, 2010 (IRB number 5044). Data collected from the charts and from the hospital database included age, body mass index (BMI), parity, previous surgical history, menopausal status, preoperative symptoms, indications for hysterectomy, preoperative therapy with gonadotrophin releasing hormone agonists, surgical time, difference between pre and postoperative hemoglobin, length of hospital stay, complications, uterine weight on pathological examination, and follow-up.
W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
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Fig. 1. (A) Total laparoscopic hysterectomy for a uterus weighing 1375 g. (B) Coagulation/section of the right utero-ovarian ligament and fallopian tube using Ultracision harmonic scalpel. (C) Opening the posterior leaf of the right broad ligament. (D) Coagulation/section of the right utero-sacral ligament.
The indication for primary laparotomy was the presence of an enlarged uterus with no mobility on vaginal examination associated to the absence of enough space in the abdominal wall to place the trocars cranially to the uterine fundus. In the absence of these findings on physical examination, laparoscopy was always the initial surgical approach. Laparoscopic hysterectomy was performed as previously reported [7], but placing the trocars higher than usual in the
abdominal wall. Briefly, the patient was positioned in the lithotomy position with legs in stirrups. The table was placed in Trendelenburg position (at least 30 degrees). A Foley catheter was placed to empty the bladder and to control the urine output and a Clermont-Ferrand uterine manipulator (Karl Storz) with a longer screwed tip was placed through the cervix. Pneumoperitoneum was insufflated at the Palmer’s point (left upper quadrant) and 4 trocars were placed: 10 mm at the epigastrium (or the left
Fig. 2. Coagulation/section of the left utero-ovarian ligament using Ultracision harmonic scalpel. (B and C) Opening the posterior leaf of the left broad ligament. (D) Coagulation/section of the left utero-sacral ligament.
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W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
hypochondrium) for the laparoscope, 5 mm at the left flank, 5 mm at the right flank, and 5 mm at the umbilicus. When available, a 30 degree laparoscope was used to improve the viewing range by rotating the scope, effectively changing the viewing direction. The round ligament was coagulated using bipolar forceps (or Ultracision harmonic scalpel, Ethicon Endo-Surgery) and sectioned. The anterior leaf of the broad ligament was dissected up to vesico-uterine cul-de-sac. The posterior leaf of the broad ligament
was opened and the infundibulo-pelvic ligament or the uteroovarian ligament/fallopian tube can be individualized (depending on the indication of ovarian conservation or not), coagulated and sectioned. The posterior leaf of the broad ligament was dissected towards the utero-sacral ligament (Figs. 1 and 2). The uterine artery was skeletonized along its length to the lateral cervix. The bladder was dissected from the cervix and the anterior vaginal wall. The utero-sacral ligament and its peritoneum were coagulat-
Fig. 3. (A) Coagulation of the left uterine artery using bipolar forceps. (B) Coagulation of the left uterine veins using bipolar forceps. (C and D) Coagulation of the right uterine vessels using Ultracision and bipolar forceps.
Fig. 4. (A and B) Dissecting the bladder from the cervix and the anterior vaginal wall. (C) Entering the intrafascial plane. (D) Vaginal cuff.
W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
ed and sectioned. The uterine artery was coagulated and sectioned. Halban’s fascia was dissected to allow the section of the vaginal cuff in an intrafascial fashion (Figs. 3 and 4). The cervicovaginal junction was opened using monopolar energy. The 5 mm umbilical trocar was replaced for a 10 mm trocar. The uterus was morcellated using either a tissue morcellator (Gynecare Morcellex, Ethicon Endo-Surgery) or a laparoscopic knife (Karl Storz) and the fragmented uterus was retrieved from the abdominal cavity through the vagina. The vagina was closed using interrupted suture (Fig. 5). The abdominal cavity was checked for eventual bleeding. Primary statistical endpoint was complication rate. Secondary endpoints included total operating time (calculated from the initial coagulation of the round ligament to the last vaginal stitch), estimated blood loss (assessed by the difference between pre and postoperative hemoglobin levels), time to first bowel movement (calculated in hours from the end of the procedure to the ability to pass feces or gas), time of bladder catheterization (calculated in hours from the end of the procedure until the removal of the Foley catheter), length of hospital stay (calculated in days from the day of the procedure until the day of discharge), and conversion to laparotomy. Analysis was based on the intention to treat. Nonparametric Mann–Whitney test and Fisher’s exact test were performed to compare groups when needed, with p < 0.05 considered statistically significant. 3. Results Thirty-eight patients were included in the analysis. Mean age was 49.4 8.5 years (ranging from 34 to 70 years) and mean BMI was 25.2 5.7 kg/m2 (ranging from 19.1 to 48 kg/m2). Mean parity of the patients was 1.4 1.4 (ranging from 0 to 6). Previous surgeries included 11 appendectomies, 3 open pelvic surgeries (2 myomectomies and one tubal sterilization), and 6 laparoscopic pelvic surgeries (2 treatments of uterine retroversion, 2 tubal sterilizations, 1 laparoscopy for infertility, and 1 myomectomy). Two women (5.3%) were postmenopausal. Indications for hysterectomy included uterine bleeding (n = 21), abdominal pain and/or pressure (n = 15), and adnexal pathology
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(n = 2). Preoperative treatment with gonadotrophin releasing hormone agonists for 2.5 0.6 months (ranging from 1 to 3 months) was performed in 44.7% of the patients. Of 38 patients, the surgical intent was laparoscopy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%) (Table 1). There was no difference in the BMI between both groups. Median uterine weight was greater in the laparotomy group, but there was no statistical difference (2166 vs. 1446 g; p = 0.11). Indication for laparotomy was the absence of uterine mobility on physical examination. The laparoscopic procedure could be successfully completed in 19 patients (82.6%), but it had to be converted to open surgery in 4 patients (17.4%). Reasons for conversion to laparotomy were inaccessibility to the pelvis already in the beginning of the surgery (n = 2), technical difficulties during surgery (n = 1), and intraoperative bleeding from the epiploon (n = 1). All but one patient underwent total hysterectomy. The sole patient submitted to supracervical hysterectomy had a uterus of 1560 g and required a minilaparotomy for extraction of the specimen because the procedure was completed by laparoscopy. One patient in the laparotomy group had an intraoperative ureteral injury. The ureter was sutured and a double J catheter was left in place for 2 months. Median operative time was longer in the laparoscopic group (130 vs. 80 min, p = 0.002). There was no difference regarding intraoperative blood loss, time to remove the urethral catheter, and time to first bowel movement between both groups. Patients submitted to laparoscopy were discharged sooner than those submitted to laparotomy (3 vs. 6 days, p < 0.001). Postoperative complications occurred in 5 patients (33.4%) in the laparotomy group and in 2 patients (8.7%) in the laparoscopic group (p = 0.05). Detailed postoperative morbidity is detailed in Table 2. The patient who had a vaginal vault hematoma underwent conversion to open surgery due to hemorrhage from epiploic vessels. In 36 patients (94.7%) the pathological diagnosis was uterine leiomyoma. The remaining two patients, both operated by laparoscopy, had the diagnosis of endometrial cancer and uterine sarcoma. The former received adjuvant radiation therapy and the latter underwent reoperation for trachelectomy because the initial procedure was a supracervical hysterectomy.
Fig. 5. (A) Opening the vagina using monopolar energy. (B and C) Uterine morcellation using tissue morcellator and laparoscopic knife. (D) Suturing the vagina.
W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
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Table 1 Intraoperative data and postoperative course of 38 patients submitted to hysterectomy for uteri larger than 1000 g. Variables are expressed as median (range).
2
BMI (kg/m ) Uterine weight (g) Surgical time (min) Difference between pre and postoperative hemoglobin (g/dL) Time to first bowel movement (h) Maintenance of Foley catheter (h) Length of hospital stay (days)
Laparotomy (n = 15)
Laparoscopy (n = 23)
27.8 (19.1–48.1) 2166 (1000–6900) 80 (40–140) 2.2 (0.5–5.1)
23.7 (19.5–29) 1446 (1000–4660) 130 (75–250) 1.6 (1–7.2)
48 (12–76) 48 (2–144) 6 (5–10)
24 (20–72) 24 (20–96) 3 (2–7)
p value 0.13 0.11 0.002 0.84 0.05 0.08 <0.001
Table 2 Postoperative morbidity (percent refers to intention to treat).
Intra-abdominal bleeding requiring reintervention Abdominal wall hematoma Unexplained fever Urinary incontinence Urinary retention Vaginal vault hematoma
Laparotomy (n = 15)
Laparoscopy (n = 23)
p value
1 2 1 1 0 0
0 0 0 0 1 (4.3%) 1 (4.3%)
0.21 0.07 0.21 0.21 0.41 0.41
(6.7%) (13.3%) (6.7%) (6.7%)
4. Comments The route of hysterectomy for enlarged uteri is still controversial [8]. The uterus is usually considered large when its size exceeds 12 weeks of gestation (280 g on average) [9]. Despite the fact that a very big uterus can be removed vaginally or laparoscopically, most gynecologists predominantly perform abdominal hysterectomies for enlarged uteri. Randomized trials comparing open and laparoscopic hysterectomy for enlarged uteri have demonstrated the benefits of the minimally invasive technique regarding blood loss, time of hospitalization, and postoperative pain [10–13]. However, disadvantages include longer operating times [4,11] and the need for a learning curve, which is directly related to the occurrence of major complications [14]. According to the EVALUATE hysterectomy trial, laparoscopic hysterectomy is associated with a significantly higher risk of major complications and longer operating times when compared to the open hysterectomy. However, its benefits include less pain, quicker recovery and better short-term quality of life [15]. A total of 10,110 hysterectomies were analysed in Finland [14] during 1996, including 5875 abdominal, 1801 vaginal and 2434 laparoscopic operations, and the overall complication rate (including major and minor complications) was 17.2%, 23.3% and 19%, respectively. Ureteral injuries were predominant in the laparoscopic group whereas bowel injuries were more frequent in the vaginal group. Nevertheless, Donnez et al. [16] demonstrated in their series of 3190 laparoscopic hysterectomies that there is no increase in the major complications rate when laparoscopy is performed by experienced surgeons. They found no difference in the rate of ureteral lesions after vaginal hysterectomy (0.33%) and laparoscopic procedures (0.25%). Bladder injuries were observed in 0.44% of women after vaginal hysterectomy and 0.31% of women after laparoscopic procedures. In this article we retrospectively evaluated 38 patients submitted to hysterectomy for uteri weighting more than 1000 g. The procedure was successfully performed by laparoscopy in 82.6% (19 out of 23) of selected cases. Conversion to open surgery was required in cases of difficulty of exposition and intraoperative bleeding. No urinary tract injury occurred in the laparoscopic group whereas one ureteral lesion (6.7%) was observed in the laparotomic group. Despite longer operating time (130 vs. 80 min, p = 0.002), laparoscopic surgery was associated
with reduced length of hospital stay (3 vs. 6 days, p < 0.001). Intraoperative bleeding was equivalent for both groups (2.2 vs. 1.6 g/dL; p = 0.84). There was a tendency of more postoperative complications in the laparotomic group (33.4% vs. 8.7%; p = 0.05). Major complications occurred in 2 patients of the laparotomic group (one ureteral injury and one reoperation for postoperative bleeding; 13.3%) and in 1 patient of the laparoscopic group (one conversion due to intraoperative bleeding, without the need of transfusion; 4.3%). There are few articles in the literature addressing laparoscopic hysterectomy for uteri bigger than 1000 g [6,17–19]. Daraı¨ et al. [9] and Pelosi and Kadar [20] reported 2 and 1 case, respectively, which required conversion to open surgery. Nimaroff et al. [21] completed the laparoscopic procedure successfully, but one patient required blood transfusion. The only series available in the literature is that one from Fanning et al. [6] who were able to perform laparoscopic-assisted vaginal hysterectomy in 93% of their patients. The size of the uterus seems to be an important factor for the occurrence of intraoperative hemorrhage and postoperative complications during laparoscopic hysterectomy, especially when performed for uteri with more than 500 g [5]. Some authors suggest the use of the selective coagulation of the uretine artery at its origin during laparoscopic procedure in enlarged uteri in order to avoid unexpected intraoperative bleeding [22]. In our opinion, the key for the success of the laparoscopic approach to uteri larger than 1000 g seems to be the preoperative and the initial intraoperative evaluations. Two out of 4 patients in our series underwent conversion just after the inspection of the abdominal cavity and the finding of a limited working space. Another one required conversion because of inaccessibility to the uterine vessels after performing the initial steps of the procedure. We had only one patient who required conversion due to an intraoperative complication. The placement of all trocars higher than usual is essential during hysterectomies for enlarged uteri to provide a better working space inside the abdominal cavity, as well as the standardization of the surgical technique. The availability of a 30-degree laparoscope plays an important role when there is difficulty in exposition once it can improve the viewing range. The use of a uterine manipulator with a longer tip is also crucial to allow better mobilization of the whole uterus. Potential weaknesses of the current study include the small number of patients and the retrospective nature of the study.
W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
However, laparoscopic hysterectomy for uteri weighting more than 1000 g is not a common situation and a well-designed prospective randomized study including a large number of patients could only be performed in a multicentric trial. In conclusion, laparoscopic hysterectomy is feasible for selected patients with uteri weighting more than 1000 g and presents a postoperative course better than or equal to the laparotomic approach. Difficulty of exposition and access to the uterine vessels is the main reason of conversion to open surgery. The keys for the success are the pre and intraoperative evaluations of the uterine mobility and the presence of enough space to place all the trocars higher than the uterine fundus. Standardization of the technique of laparoscopic hysterectomy also plays an important role. Larger prospective studies are necessary to confirm our initial findings. Acknowledgement None. References [1] Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol 2008;198:1–7. [2] Clayton RD. Hysterectomy. Best Pract Res Clin Obstet Gynaecol 2006;20:73– 87. [3] Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213–6. [4] Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2006;2:CD003677. [5] Bonilla DJ, Mains L, Whitaker R, et al. Uterine weight as a predictor of morbidity after a benign abdominal and total laparoscopic hysterectomy. J Reprod Med 2007;52:490–8. [6] Fanning J, Fenton B, Switzer M, et al. Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more. JSLS 2008;12:376–9. [7] Velemir L, Azuar AS, Botchorishvili R, et al. Optimizing the role of surgeons assistants during a laparoscopic hysterectomy. Gynecol Obstet Fertil 2009;37:74–80.
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[8] Claerhout F, Deprest J. Laparoscopic hysterectomy for benign diseases. Best Pract Res Clin Obstet Gynaecol 2005;19:357–75. [9] Daraı¨ E, Soriano D, Kimata P, et al. Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study. Obstet Gynecol 2001;97:712–6. [10] Marana R, Busacca M, Zupi E, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective randomized multicenter study. Am J Obstet Gynecol 1999;180:270–5. [11] Ferrari MM, Berlanda N, Mezzopane R, et al. Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids. BJOG 2000;107:620–5. [12] Schu¨tz K, Possover M, Merker A, et al. Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200 g. Surg Endosc 2002;16:121–5. [13] Sesti F, Calonzi F, Ruggeri V, et al. A comparison of vaginal, laparoscopicassisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri. Int J Gynaecol Obstet 2008;103:227–31. [14] Ma¨kinen J, Johansson J, Toma´s C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 2001;16:1473–8. [15] Garry R, Fountain J, Brown J, et al. EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy. Health Technol Assess 2004;8:1–154. [16] Donnez O, Jadoul P, Squifflet J, et al. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2009;116:492– 500. [17] Wang CJ, Yuen LT, Yen CF, et al. A simplified method to decrease operative blood loss in laparoscopic-assisted vaginal hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc 2004;11:370–3. [18] Lyons TL, Adolph AJ, Winer WK. Laparoscopic supracervical hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc 2004;11:170–4. [19] Wattiez A, Soriano D, Fiaccavento A, et al. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc 2002;9:125–30. [20] Pelosi MA, Kadar N. Laparoscopically assisted hysterectomy for uteri weighing 500 g or more. J Am Assoc Gynecol Laparosc 1994;1:405–9. [21] Nimaroff ML, Dimino M, Maloney S. Laparoscopic-assisted vaginal hysterectomy of large myomatous uteri with supracervical amputation followed by trachelectomy. J Am Assoc Gynecol Laparosc 1996;3: 585–7. [22] Roman H, Zanati J, Friederich L, et al. Laparoscopic hysterectomy of large uteri with uterine artery coagulation at its origin. JSLS 2008;12:25–9.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Is laparoscopic hysterectomy feasible for uteri larger than 1000 g? William Kondo *, Nicolas Bourdel, Francesca Marengo, Revaz Botchorishvili, Jean Luc Pouly, Kris Jardon, Benoit Rabischong, Ge´rard Mage, Michel Canis Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie Aubrac, 63003 Clermont-Ferrand, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 October 2010 Received in revised form 4 January 2011 Accepted 28 March 2011
Objective: To evaluate the feasibility of laparoscopic hysterectomy for uteri weighing more than 1000 g. Study design: A retrospective study was conducted in a tertiary center of laparoscopic surgery including 38 women submitted to hysterectomy for uteri weighing more than 1000 g. Patients submitted to open hysterectomy were compared to those submitted to laparoscopic hysterectomy. The primary statistical endpoint was the complication rate. Secondary endpoints were operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy. Results: The patients’ mean age was 49.4 years and mean BMI was 25.2 kg/m2. The surgical intent was laparoscopic hysterectomy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%). Conversion to open surgery was required in 4 patients (17.4%) due to inaccessibility of the pelvis at the beginning of surgery (n = 2), technical difficulties during surgery (n = 1), and intraoperative bleeding (n = 1). One patient in the laparotomy group had an intraoperative ureteral injury. Despite longer operative time (130 vs. 80 min, p = 0.002), laparoscopic surgery was associated with reduced length of hospital stay (3 vs. 6 days, p < 0.001). Intraoperative bleeding was evaluated by the difference of pre- and post-operative hemoglobin and was equivalent in both groups (2.2 vs. 1.6 g/dL; p = 0.84). There was a tendency for more postoperative complications in the laparotomic group (33.4% vs. 8.7%; p = 0.05). Conclusion: Laparoscopic hysterectomy is feasible for selected patients with uteri weighing more than 1000 g. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Hysterectomy Laparoscopy Enlarged uteri
1. Introduction Hysterectomy is the most common major gynecological operation performed in the world. Benign diseases including menorrhagia, fibroids, pelvic pain, and uterine prolapse are responsible for more than 70% of indications for hysterectomy [1]. Traditionally, it is performed by laparotomy or vaginal approach [2]; however, laparoscopy has been increasingly employed since its initial report in 1989 [3]. Advantages of the laparoscopic approach compared to its open counterpart include lower intraoperative blood loss, shorter duration of hospital stay, faster convalescence, and fewer wound or abdominal wall infections, at the cost of longer operating times and more urinary tract injuries [4]. Large uteri determine technical challenges for laparoscopic surgery. Some authors have demonstrated that there is an increased risk of intraoperative bleeding and postoperative complications as well as a longer time of hospitalization when laparoscopic hysterectomy is performed for uteri weighing more
* Corresponding author. Tel.: +33 4 750 138. E-mail address: [email protected] (W. Kondo). URL: http://www.drwilliamkondo.site.med.br/ 0301-2115/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2011.03.027
than 500 g [5]. Others [6] report a high rate (93%) of successful laparoscopic-assisted vaginal hysterectomy for uteri larger than 1000 g. The aim of this article is to assess the feasibility of laparoscopic hysterectomy for uteri weighting more than 1000 g and to compare the surgical outcomes to those observed after standard open surgery. 2. Materials and methods We retrospectively reviewed 2618 hysterectomies performed at the CHU Estaing, Clermont-Ferrand, France, from January 1995 to December 2008. Patients with uteri larger than 1000 g on pathological examination were selected for the study. The study was approved by the Inter-regional Ethics Committee of the Rhoˆne-Alpes-Auvergne Clinical Investigation Center, Grenoble, France, on April 29, 2010 (IRB number 5044). Data collected from the charts and from the hospital database included age, body mass index (BMI), parity, previous surgical history, menopausal status, preoperative symptoms, indications for hysterectomy, preoperative therapy with gonadotrophin releasing hormone agonists, surgical time, difference between pre and postoperative hemoglobin, length of hospital stay, complications, uterine weight on pathological examination, and follow-up.
W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
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Fig. 1. (A) Total laparoscopic hysterectomy for a uterus weighing 1375 g. (B) Coagulation/section of the right utero-ovarian ligament and fallopian tube using Ultracision harmonic scalpel. (C) Opening the posterior leaf of the right broad ligament. (D) Coagulation/section of the right utero-sacral ligament.
The indication for primary laparotomy was the presence of an enlarged uterus with no mobility on vaginal examination associated to the absence of enough space in the abdominal wall to place the trocars cranially to the uterine fundus. In the absence of these findings on physical examination, laparoscopy was always the initial surgical approach. Laparoscopic hysterectomy was performed as previously reported [7], but placing the trocars higher than usual in the
abdominal wall. Briefly, the patient was positioned in the lithotomy position with legs in stirrups. The table was placed in Trendelenburg position (at least 30 degrees). A Foley catheter was placed to empty the bladder and to control the urine output and a Clermont-Ferrand uterine manipulator (Karl Storz) with a longer screwed tip was placed through the cervix. Pneumoperitoneum was insufflated at the Palmer’s point (left upper quadrant) and 4 trocars were placed: 10 mm at the epigastrium (or the left
Fig. 2. Coagulation/section of the left utero-ovarian ligament using Ultracision harmonic scalpel. (B and C) Opening the posterior leaf of the left broad ligament. (D) Coagulation/section of the left utero-sacral ligament.
78
W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
hypochondrium) for the laparoscope, 5 mm at the left flank, 5 mm at the right flank, and 5 mm at the umbilicus. When available, a 30 degree laparoscope was used to improve the viewing range by rotating the scope, effectively changing the viewing direction. The round ligament was coagulated using bipolar forceps (or Ultracision harmonic scalpel, Ethicon Endo-Surgery) and sectioned. The anterior leaf of the broad ligament was dissected up to vesico-uterine cul-de-sac. The posterior leaf of the broad ligament
was opened and the infundibulo-pelvic ligament or the uteroovarian ligament/fallopian tube can be individualized (depending on the indication of ovarian conservation or not), coagulated and sectioned. The posterior leaf of the broad ligament was dissected towards the utero-sacral ligament (Figs. 1 and 2). The uterine artery was skeletonized along its length to the lateral cervix. The bladder was dissected from the cervix and the anterior vaginal wall. The utero-sacral ligament and its peritoneum were coagulat-
Fig. 3. (A) Coagulation of the left uterine artery using bipolar forceps. (B) Coagulation of the left uterine veins using bipolar forceps. (C and D) Coagulation of the right uterine vessels using Ultracision and bipolar forceps.
Fig. 4. (A and B) Dissecting the bladder from the cervix and the anterior vaginal wall. (C) Entering the intrafascial plane. (D) Vaginal cuff.
W. Kondo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 76–81
ed and sectioned. The uterine artery was coagulated and sectioned. Halban’s fascia was dissected to allow the section of the vaginal cuff in an intrafascial fashion (Figs. 3 and 4). The cervicovaginal junction was opened using monopolar energy. The 5 mm umbilical trocar was replaced for a 10 mm trocar. The uterus was morcellated using either a tissue morcellator (Gynecare Morcellex, Ethicon Endo-Surgery) or a laparoscopic knife (Karl Storz) and the fragmented uterus was retrieved from the abdominal cavity through the vagina. The vagina was closed using interrupted suture (Fig. 5). The abdominal cavity was checked for eventual bleeding. Primary statistical endpoint was complication rate. Secondary endpoints included total operating time (calculated from the initial coagulation of the round ligament to the last vaginal stitch), estimated blood loss (assessed by the difference between pre and postoperative hemoglobin levels), time to first bowel movement (calculated in hours from the end of the procedure to the ability to pass feces or gas), time of bladder catheterization (calculated in hours from the end of the procedure until the removal of the Foley catheter), length of hospital stay (calculated in days from the day of the procedure until the day of discharge), and conversion to laparotomy. Analysis was based on the intention to treat. Nonparametric Mann–Whitney test and Fisher’s exact test were performed to compare groups when needed, with p < 0.05 considered statistically significant. 3. Results Thirty-eight patients were included in the analysis. Mean age was 49.4 8.5 years (ranging from 34 to 70 years) and mean BMI was 25.2 5.7 kg/m2 (ranging from 19.1 to 48 kg/m2). Mean parity of the patients was 1.4 1.4 (ranging from 0 to 6). Previous surgeries included 11 appendectomies, 3 open pelvic surgeries (2 myomectomies and one tubal sterilization), and 6 laparoscopic pelvic surgeries (2 treatments of uterine retroversion, 2 tubal sterilizations, 1 laparoscopy for infertility, and 1 myomectomy). Two women (5.3%) were postmenopausal. Indications for hysterectomy included uterine bleeding (n = 21), abdominal pain and/or pressure (n = 15), and adnexal pathology
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(n = 2). Preoperative treatment with gonadotrophin releasing hormone agonists for 2.5 0.6 months (ranging from 1 to 3 months) was performed in 44.7% of the patients. Of 38 patients, the surgical intent was laparoscopy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%) (Table 1). There was no difference in the BMI between both groups. Median uterine weight was greater in the laparotomy group, but there was no statistical difference (2166 vs. 1446 g; p = 0.11). Indication for laparotomy was the absence of uterine mobility on physical examination. The laparoscopic procedure could be successfully completed in 19 patients (82.6%), but it had to be converted to open surgery in 4 patients (17.4%). Reasons for conversion to laparotomy were inaccessibility to the pelvis already in the beginning of the surgery (n = 2), technical difficulties during surgery (n = 1), and intraoperative bleeding from the epiploon (n = 1). All but one patient underwent total hysterectomy. The sole patient submitted to supracervical hysterectomy had a uterus of 1560 g and required a minilaparotomy for extraction of the specimen because the procedure was completed by laparoscopy. One patient in the laparotomy group had an intraoperative ureteral injury. The ureter was sutured and a double J catheter was left in place for 2 months. Median operative time was longer in the laparoscopic group (130 vs. 80 min, p = 0.002). There was no difference regarding intraoperative blood loss, time to remove the urethral catheter, and time to first bowel movement between both groups. Patients submitted to laparoscopy were discharged sooner than those submitted to laparotomy (3 vs. 6 days, p < 0.001). Postoperative complications occurred in 5 patients (33.4%) in the laparotomy group and in 2 patients (8.7%) in the laparoscopic group (p = 0.05). Detailed postoperative morbidity is detailed in Table 2. The patient who had a vaginal vault hematoma underwent conversion to open surgery due to hemorrhage from epiploic vessels. In 36 patients (94.7%) the pathological diagnosis was uterine leiomyoma. The remaining two patients, both operated by laparoscopy, had the diagnosis of endometrial cancer and uterine sarcoma. The former received adjuvant radiation therapy and the latter underwent reoperation for trachelectomy because the initial procedure was a supracervical hysterectomy.
Fig. 5. (A) Opening the vagina using monopolar energy. (B and C) Uterine morcellation using tissue morcellator and laparoscopic knife. (D) Suturing the vagina.
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Table 1 Intraoperative data and postoperative course of 38 patients submitted to hysterectomy for uteri larger than 1000 g. Variables are expressed as median (range).
2
BMI (kg/m ) Uterine weight (g) Surgical time (min) Difference between pre and postoperative hemoglobin (g/dL) Time to first bowel movement (h) Maintenance of Foley catheter (h) Length of hospital stay (days)
Laparotomy (n = 15)
Laparoscopy (n = 23)
27.8 (19.1–48.1) 2166 (1000–6900) 80 (40–140) 2.2 (0.5–5.1)
23.7 (19.5–29) 1446 (1000–4660) 130 (75–250) 1.6 (1–7.2)
48 (12–76) 48 (2–144) 6 (5–10)
24 (20–72) 24 (20–96) 3 (2–7)
p value 0.13 0.11 0.002 0.84 0.05 0.08 <0.001
Table 2 Postoperative morbidity (percent refers to intention to treat).
Intra-abdominal bleeding requiring reintervention Abdominal wall hematoma Unexplained fever Urinary incontinence Urinary retention Vaginal vault hematoma
Laparotomy (n = 15)
Laparoscopy (n = 23)
p value
1 2 1 1 0 0
0 0 0 0 1 (4.3%) 1 (4.3%)
0.21 0.07 0.21 0.21 0.41 0.41
(6.7%) (13.3%) (6.7%) (6.7%)
4. Comments The route of hysterectomy for enlarged uteri is still controversial [8]. The uterus is usually considered large when its size exceeds 12 weeks of gestation (280 g on average) [9]. Despite the fact that a very big uterus can be removed vaginally or laparoscopically, most gynecologists predominantly perform abdominal hysterectomies for enlarged uteri. Randomized trials comparing open and laparoscopic hysterectomy for enlarged uteri have demonstrated the benefits of the minimally invasive technique regarding blood loss, time of hospitalization, and postoperative pain [10–13]. However, disadvantages include longer operating times [4,11] and the need for a learning curve, which is directly related to the occurrence of major complications [14]. According to the EVALUATE hysterectomy trial, laparoscopic hysterectomy is associated with a significantly higher risk of major complications and longer operating times when compared to the open hysterectomy. However, its benefits include less pain, quicker recovery and better short-term quality of life [15]. A total of 10,110 hysterectomies were analysed in Finland [14] during 1996, including 5875 abdominal, 1801 vaginal and 2434 laparoscopic operations, and the overall complication rate (including major and minor complications) was 17.2%, 23.3% and 19%, respectively. Ureteral injuries were predominant in the laparoscopic group whereas bowel injuries were more frequent in the vaginal group. Nevertheless, Donnez et al. [16] demonstrated in their series of 3190 laparoscopic hysterectomies that there is no increase in the major complications rate when laparoscopy is performed by experienced surgeons. They found no difference in the rate of ureteral lesions after vaginal hysterectomy (0.33%) and laparoscopic procedures (0.25%). Bladder injuries were observed in 0.44% of women after vaginal hysterectomy and 0.31% of women after laparoscopic procedures. In this article we retrospectively evaluated 38 patients submitted to hysterectomy for uteri weighting more than 1000 g. The procedure was successfully performed by laparoscopy in 82.6% (19 out of 23) of selected cases. Conversion to open surgery was required in cases of difficulty of exposition and intraoperative bleeding. No urinary tract injury occurred in the laparoscopic group whereas one ureteral lesion (6.7%) was observed in the laparotomic group. Despite longer operating time (130 vs. 80 min, p = 0.002), laparoscopic surgery was associated
with reduced length of hospital stay (3 vs. 6 days, p < 0.001). Intraoperative bleeding was equivalent for both groups (2.2 vs. 1.6 g/dL; p = 0.84). There was a tendency of more postoperative complications in the laparotomic group (33.4% vs. 8.7%; p = 0.05). Major complications occurred in 2 patients of the laparotomic group (one ureteral injury and one reoperation for postoperative bleeding; 13.3%) and in 1 patient of the laparoscopic group (one conversion due to intraoperative bleeding, without the need of transfusion; 4.3%). There are few articles in the literature addressing laparoscopic hysterectomy for uteri bigger than 1000 g [6,17–19]. Daraı¨ et al. [9] and Pelosi and Kadar [20] reported 2 and 1 case, respectively, which required conversion to open surgery. Nimaroff et al. [21] completed the laparoscopic procedure successfully, but one patient required blood transfusion. The only series available in the literature is that one from Fanning et al. [6] who were able to perform laparoscopic-assisted vaginal hysterectomy in 93% of their patients. The size of the uterus seems to be an important factor for the occurrence of intraoperative hemorrhage and postoperative complications during laparoscopic hysterectomy, especially when performed for uteri with more than 500 g [5]. Some authors suggest the use of the selective coagulation of the uretine artery at its origin during laparoscopic procedure in enlarged uteri in order to avoid unexpected intraoperative bleeding [22]. In our opinion, the key for the success of the laparoscopic approach to uteri larger than 1000 g seems to be the preoperative and the initial intraoperative evaluations. Two out of 4 patients in our series underwent conversion just after the inspection of the abdominal cavity and the finding of a limited working space. Another one required conversion because of inaccessibility to the uterine vessels after performing the initial steps of the procedure. We had only one patient who required conversion due to an intraoperative complication. The placement of all trocars higher than usual is essential during hysterectomies for enlarged uteri to provide a better working space inside the abdominal cavity, as well as the standardization of the surgical technique. The availability of a 30-degree laparoscope plays an important role when there is difficulty in exposition once it can improve the viewing range. The use of a uterine manipulator with a longer tip is also crucial to allow better mobilization of the whole uterus. Potential weaknesses of the current study include the small number of patients and the retrospective nature of the study.
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However, laparoscopic hysterectomy for uteri weighting more than 1000 g is not a common situation and a well-designed prospective randomized study including a large number of patients could only be performed in a multicentric trial. In conclusion, laparoscopic hysterectomy is feasible for selected patients with uteri weighting more than 1000 g and presents a postoperative course better than or equal to the laparotomic approach. Difficulty of exposition and access to the uterine vessels is the main reason of conversion to open surgery. The keys for the success are the pre and intraoperative evaluations of the uterine mobility and the presence of enough space to place all the trocars higher than the uterine fundus. Standardization of the technique of laparoscopic hysterectomy also plays an important role. Larger prospective studies are necessary to confirm our initial findings. Acknowledgement None. References [1] Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol 2008;198:1–7. [2] Clayton RD. Hysterectomy. Best Pract Res Clin Obstet Gynaecol 2006;20:73– 87. [3] Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213–6. [4] Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2006;2:CD003677. [5] Bonilla DJ, Mains L, Whitaker R, et al. Uterine weight as a predictor of morbidity after a benign abdominal and total laparoscopic hysterectomy. J Reprod Med 2007;52:490–8. [6] Fanning J, Fenton B, Switzer M, et al. Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more. JSLS 2008;12:376–9. [7] Velemir L, Azuar AS, Botchorishvili R, et al. Optimizing the role of surgeons assistants during a laparoscopic hysterectomy. Gynecol Obstet Fertil 2009;37:74–80.
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[8] Claerhout F, Deprest J. Laparoscopic hysterectomy for benign diseases. Best Pract Res Clin Obstet Gynaecol 2005;19:357–75. [9] Daraı¨ E, Soriano D, Kimata P, et al. Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study. Obstet Gynecol 2001;97:712–6. [10] Marana R, Busacca M, Zupi E, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective randomized multicenter study. Am J Obstet Gynecol 1999;180:270–5. [11] Ferrari MM, Berlanda N, Mezzopane R, et al. Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids. BJOG 2000;107:620–5. [12] Schu¨tz K, Possover M, Merker A, et al. Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200 g. Surg Endosc 2002;16:121–5. [13] Sesti F, Calonzi F, Ruggeri V, et al. A comparison of vaginal, laparoscopicassisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri. Int J Gynaecol Obstet 2008;103:227–31. [14] Ma¨kinen J, Johansson J, Toma´s C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 2001;16:1473–8. [15] Garry R, Fountain J, Brown J, et al. EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy. Health Technol Assess 2004;8:1–154. [16] Donnez O, Jadoul P, Squifflet J, et al. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2009;116:492– 500. [17] Wang CJ, Yuen LT, Yen CF, et al. A simplified method to decrease operative blood loss in laparoscopic-assisted vaginal hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc 2004;11:370–3. [18] Lyons TL, Adolph AJ, Winer WK. Laparoscopic supracervical hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc 2004;11:170–4. [19] Wattiez A, Soriano D, Fiaccavento A, et al. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc 2002;9:125–30. [20] Pelosi MA, Kadar N. Laparoscopically assisted hysterectomy for uteri weighing 500 g or more. J Am Assoc Gynecol Laparosc 1994;1:405–9. [21] Nimaroff ML, Dimino M, Maloney S. Laparoscopic-assisted vaginal hysterectomy of large myomatous uteri with supracervical amputation followed by trachelectomy. J Am Assoc Gynecol Laparosc 1996;3: 585–7. [22] Roman H, Zanati J, Friederich L, et al. Laparoscopic hysterectomy of large uteri with uterine artery coagulation at its origin. JSLS 2008;12:25–9.