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Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique
Journal of Minimally Invasive Gynecology (2006) 13, 183–189
Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique Bernd Bojahr, MD, PhD, Detlef Raatz, MD, Georg Schonleber, MD, Christine Abri, and Ralf Ohlinger, MD From the Clinic for Minimally Invasive Surgery, Minimally Invasive Center, Berlin (Drs. Bojahr, Raatz, Schonleber, and Abri); and from the Department of Obstetrics and Gynecology, Ernst Moritz Arndt University, Greifswald (Dr. Ohlinger), Germany. KEYWORDS: Laparoscopic supracervical hysterectomy; Perioperative complications
Abstract STUDY OBJECTIVE: The aim of the study was to determine perioperative morbidity and complication rate after a standardized technique of laparoscopic supracervical hysterectomy (LASH). DESIGN: Retrospective analysis of consecutive patients (Canadian Task Force classification II-3). SETTING: Private hospital. PATIENTS: Seventeen hundred and six consecutive patients with symptomatic uterine myomata, dysfunctional uterine bleeding, dysmenorrhea, or chronic pelvic pain. INTERVENTION: Laparoscopic supracervical hysterectomy using a unipolar hook for dissection of the body of the uterus followed by electric morcellation MEASUREMENTS AND MAIN RESULTS: The main indications for LASH were uterine myomata with dysfunctional uterine bleeding (31.1%) or without (45.4%) and therapy-resistant dysfunctional uterine bleeding (21%). The mean uterine weight was 226.4 ⫾ 193.9 g (95% CI 217.1–235.6), the mean duration of surgery was 91.4 ⫾ 33.3 minutes (95% CI 89.9 –93.0), and the mean duration of hospital stay was 2.15 ⫾ 0.63 days (95% CI 2.12–2.18). Nine hundred two (52.9%) of the patients had a history of at least one laparotomy. In 14 patients (0.82%), a conversion to laparotomy was necessary. Of these, 11 were due to the size and immobility of the uterus, one was due to severe adhesions, and two because of intraoperative complications. In total, five (0.3%) intraoperative and 20 (1.2%) postoperative complications occurred. The mean weight of the uterus in the five patients with intraoperative complications (three bladder injuries, one ureter injury, and one severe intraoperative bleed) was 818.4 ⫾ 911.9 g (95% CI -313.9 –1950.7). In two patients who suffered trauma to the bladder, there was a history of cesarean sections (two and three, respectively). The most common postoperative complications were bleeding from the cervix and pain caused by adhesions or postoperative infection. CONCLUSION: Laparoscopic supracervical hysterectomy is a minimally invasive surgical method that should be regarded as an alternative to all other methods of total hysterectomy in benign conditions of the uterus (uterine myomata, dysfunctional uterine bleeding, uterine adenomyosis) as it is associated with a low perioperative morbidity and a rapid period of convalescence. Of special significance is that LASH can be performed on nulliparous patients, patients who have not previously had vaginal delivery, and patients who have had previous abdominal surgery. © 2006 AAGL. All rights reserved.
Corresponding author: Bernd Bojahr MD, PhD, Klinik für MIC, Minimally Invasive Center, am Ev. Krankenhaus Hubertus, Kurstr. 11, 14129 Berlin, Germany. E-mail: [email protected] Submitted October 7, 2005. Accepted for publication January 16, 2006.
1553-4650/$ -see front matter © 2006 AAGL. All rights reserved. doi:10.1016/j.jmig.2006.01.010
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Because of rapid development of surgical laparoscopy over the past 25 years, there have been enormous changes in hysterectomy methods. In the 1990s, the number of abdominal hysterectomies was already declining worldwide primarily due to the introduction of the laparoscopic-assisted vaginal hysterectomy (LAVH). The significant advantages of LAVH compared with abdominal hysterectomy are reduced morbidity and speedier recovery. There is, however, increasing evidence of advantages of the laparoscopic supracervical hysterectomy (LASH) as an alternative to LAVH. It is also considered a safe procedure with few complications. It is indicated in patients with therapy-resistant dysfunctional uterine bleeding, enlarging or painful uterine myomata, or if there is a suspicion of uterine adenomyosis. Important criteria for this particular procedure are normal cervical cytology and colposcopy, and the exclusion of a malignant endometrial cause of dysfunctional uterine bleeding made by diagnostic hysteroscopy with dilation and curettage (D&C). Some studies have shown that the complication rate for LASH are lower than for LAVH and other methods of hysterectomy.1– 6 By complete preservation of the cervix, vagina, and uterosacral ligaments, the surgical procedure is significantly simplified and the risk of accidental injury to the bladder, intestine, and ureter is reduced.5–7 The aim of this retrospective study was to analyze the perioperative complication rate after LASH in relation to various other factors that may influence this rate.
Materials and methods The retrospective study was based on data collected from 1706 consecutive patients who were treated at the MIC Hospital in Berlin from June 1, 1998, through October 31, 2003. They had a diagnosis of a benign condition of the uterus and were therefore selected to undergo LASH. The indications for a LASH were: (1) uterine myomata with either pain and/or enlargement; (2) therapy-resistant dysfunctional uterine bleeding; (3) suspected uterine adenomyosis; and (4) recurrent bleeding after endometrial ablation or resection. An important prerequisite for surgery was completion of child bearing. All patients had to have evidence of a normal ectocervix both on colposcopy and cytology. Patients with abnormal bleeding or abnormal ultrasound findings had a D&C performed to exclude malignancy. Preoperative counseling of the patients included advice on the need for continued annual cervical screening and information on the possibility of continuing light menstrual cyclical bleeding. In the first 2 years, the operative technique was standardized and was carried out by three surgeons in the hospital as follows. After disinfection of the vagina and catheterization of the bladder, the patient is positioned supine with outstretched legs. Uterus manipulators are not used. Carbon
dioxide insufflation by a Veres needle placed through an incision in the inferior umbilical fossa is performed to an intraabdominal pressure of 15 mm Hg. A 5-mm trocar is then introduced through this incision. The obligatory full visual sweep is then done with the routinely used 30-degree optic. For this, the patient is brought into maximum Trendelenburg position. Then, 5-mm trocars are introduced left and right under direct vision lateral to the epigastric vessels in the region of the pubic hair border. The localization of the additional two trocars depends on uterine size: the larger the uterus, the further above the symphysis pubis the lateral trocars need to be positioned. Only reusable instruments are used during the operative procedure. In addition to the standard 5-mm instruments, a bipolar coagulation clamp, Metzenbaum scissors, three various grasping forceps, a needle holder, a monopolar hook, and a suction-irrigation system are used. The uterus is mobilized using bipolar coagulation of the round ligament, the fallopian tube, and the ovarian ligament with subsequent dissection. For this, the uterus is pulled to the contralateral side with grasping forceps. After separating the ovary and fallopian tube from the uterus and dissecting through the round ligament, a trail is placed on the bladder peritoneum using the bipolar coagulation forceps that delineates the planned direction of incision to open the bladder peritoneum. From the dissected round ligament, the bladder peritoneum is undermined using scissors. The peritoneum is then opened up, and the bladder is pushed slightly caudally. This procedure is repeated in an analogous way on the contralateral side. After identification and skeletonization of the uterine vessels, they are then coagulated and divided. Subsequently the bladder peritoneum is once again mobilized from the anterior surface of the cervix. It usually is not necessary to push away the bladder as done in a total hysterectomy, as now the uterine body is dissected off in the upper third, cranial to where the uterosacral ligaments leave the cervix. The uterus is separated from the cervix with a monopolar hook under constant upward pull. Following hemostasis in the region of the cervical stump, the cervical canal is coagulated. Peritoneum is used to cover the cervical stump using a continuous purse-string suture. The two uterosacral ligaments are included in this suture. To remove the uterus, the incision in the left iliac fossa is increased to between 10 to 20 mm. An electric STEINER or SAWALHE morcellator (Karl Storz, Tuttlingen, Germany) or an S*E*M*M* morcellator (WISAP, Munich, Germany), is introduced under direct vision. After morcellation is completed, the fascia underlying the left-sided incision is closed using one or two interrupted sutures, as is the skin. If the uterus is very enlarged, an additional 5- or 10-mm port may be necessary. This usually is placed centrally above the symphysis pubis. The patient’s clinical records provided information regarding age, body weight, height, body mass index, American Society of Anesthesiologists (ASA) scores, histology results, previous operations, and any necessary additional
Bojahr et al Table 1
Perioperative complications after LASH
Patient characteristics and operative parameters
Characteristic/parameter Age (yrs) Body mass index ASA Score I II III IV Duration of operation (min) Weight of corpus uteri (g) Hospital stay (days)
Mean ⫾ SD (95% CI) / No. of patients (%) 45.7 ⫾ 6.9 (45.4–46.0) 24.8 ⫾ 4.3 (24.6–25.0) 476 930 294 6 91.4 ⫾ 33.3 226.4 ⫾ 193.9 2.15 ⫾ 0.63
(27.9) (54.5) (17.2) (0.4) (89.9–93.0) (217.1–235.6) (2.12–2.18)
ASA ⫽ American Society of Anesthesiologists.
surgical interventions. The records also provided information regarding length of hospital stay, duration of surgery, and weight of uterus. Perioperative complications were also recorded and analyzed. Uterine weight was divided into four classes. Class I included uterine weight up to 100 g, class II included weight between 101 and 500 g, class III was 501 to 1000 g, and class IV included all uteri weighing more than 1000 g.
Statistical analysis The data collated from the clinical records was analyzed using the SPSS program version 11.5 (SPSS Software, Chicago, IL). Mean values were calculated and shown with their standard deviations and 95% CI. Statistical significance was demonstrated using the Mann-Whitney U test and the Wilcoxon test to compare groups. For all statements of significance the probability of error of ␣ ⫽ 0.05 (5%) was used, so that statistical significance was considered to be achieved with p ⬍.05.
Results In the study period, data were collected on 1692 patients (Table 1). Preoperatively, the indication for LASH was made in 1706 patients. The indication for surgery in 1306 patients (76.5%) was uterine myomata with or without dysfunctional uterine bleeding. In a further 358 patients (21%), the indication was solely dysfunctional uterine bleeding. In 19 patients (1.2%), suspected uterine adenomyosis was the indication; and in a further 23 (1.3%), uterine adenomyosis in combination with uterine myomata and/or dysfunctional uterine bleeding was suspected (Table 2). A total 1029 patients (60.8%) had had at least one previous operation documented in their medical history: 37.8% of the patients had had at least one surgical procedure and 23% at least one gynecologic procedure. Six hundred sixty-three patients (39.2%) had no recorded history of previous surgery.
185 Of all the patients, 902 (52.9%) had a history of at least one previous laparotomy. Eight hundred ninety-four patients (52.8%) who underwent LASH had no further surgical intervention. However, 623 patients (36.8%) required further intervention, with 167 patients (15.8%) requiring two further interventions and 8 patients (0.5%) three further interventions. The most common further interventions were: unilateral adnexal surgery in 448 patients (26.5%), bilateral adnexal surgery in 69 (4.1%), division of adhesions in 394 (23.3%), and sacropexy in 40 (2.4%). The most commonly represented uterine size was class II (64.3%); whereas only 27% were in class I, and 7.8% fell in the uterine weight class III. In only 0.8% of all cases did the uterus weigh more than 1000 g. When relating the duration of the surgery to the year it was performed, data showed a steady reduction of mean surgery duration from 159.1 ⫾ 63.5 minutes (95 % CI 126.5–191.8) in 1998 to 80.6 ⫾ 29.2 minutes (95% CI 78.1– 83.2) in 2003. When the surgical duration was related to uterine weight, however, data showed increasing duration of surgery with increasing uterine weight. Mean duration of surgery in uterine weight class I was 73.8 ⫾ 22.5 minutes (95% CI 71.7–75.9). This increased to 92.5 ⫾ 28.8 minutes (95% CI 90.9 –94.3) in uterine weight class II (p ⬍.05), and 131.3 ⫾ 42.4 minutes (95% CI 124.1–:138.5) (p ⬍.05) in uterine weight class III. The longest surgical duration was in uterine weight class IV (Figure 1) at 160.5 ⫾ 53.2 minutes (95% CI 131.3–178.4) (p ⬍.05). In 14 patients, a conversion to laparotomy was necessary. This equates to a conversion rate of 0.82%. In two patients, it was necessary to proceed to a laparotomy due to intraoperative complications: one was a bladder injury and the other severe bleeding from the uterine artery where laparoscopic hemostasis could not be achieved. The patient who suffered the bladder injury had a history of three cesarean sections. In one patient conversion was necessary due to severe adhesions; and in another, conversion was necessary because of adhesions and uterine bulk. In the other 10, laparotomy was performed solely because of the bulkiness of the uterus and its immobility. The patient who suffered the intraoperative bleed had a uterine weight of 2400 g. The mean uterine weight of the conversion group
Table 2 Indications for laparoscopic supracervical hysterectomy Indication
No. of patients (%)
Myomas Myomas and bleeding disorder Myomas and pelvic pain Myomas, bleeding disorder, and pelvic pain Bleeding disorder Bleeding disorder and pelvic pain Suspicion of adenomyosis
775 531 4 4 358 15 19
(45.4) (31.1) (0.2) (0.2) (21) (0.9) (1.2)
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Duration of surgery in minutes
500
400
300
200
100
0 N=
458
1087
132
14
1
2
3
4
Uterus weight category Figure 1 Correlation of surgical duration according to uterus weight category.
bladder injuries the patients had had three cesarean sections and an appendectomy and two cesarean sections and an appendectomy, respectively. To establish a “learning curve,” the development of surgical duration in relation to average uterine weight and the distribution of complications was analyzed. Mean surgical duration for the first 20 operations was 152.8 ⫾ 60.7 minutes (95% CI 124.3–181.2) and for the next 20 was 116.5 ⫾ 34.1 minutes (95% CI 100.5–132.4). From the 130th operation onward, surgical time decreased to under 100 minutes. In the year 2003, average surgical time was only 80.6 ⫾ 29.2 minutes (95% CI 78.1– 83.2). Specific analysis of the five serious intraoperative complications did not show that these occurred more frequently in the initial phase of this method of surgery. Three of the intraoperative complications occurred with surgeon 1 during operations number 181, 307, and 667. One complication occurred with surgeon 2 during his 171st operation. And with surgeon 3, the complication occurred during the 18th operation.
Discussion was 1202.8 ⫾ 779.7 g (95% CI 752.7–1653.1). Of the 14 procedures that were converted to laparotomy, five were uterine weight class III and eight were class IV. A total of 25 complications were recorded (1.48%), divided into intraoperative (0.3%) and postoperative complications (1.18%) (Table 3). In five patients, the cervical stump was coagulated due to troublesome vaginal bleeding. Due to continuing pain, seven patients again underwent laparoscopy. In five patients, division of adhesions was necessary. One patient underwent laparoscopic repair of an incisional hernia, and in another an incision and drainage of an abdominal wall abscess in the region of the 15-mm incision site was necessary. Only two of the five complications that occurred intraoperatively were immediately recognized and dealt with by converting to laparotomy. Two bladder injuries and one ureteric injury were only recognized postoperatively and subsequently treated. The two bladder injuries were treated with a bladder suture by laparotomy, and the patient with the ureteric fistula was treated by ureteric splinting after diagnosis by laparoscopy. In total, further surgical intervention was necessary in 17 patients (1.0%), 14 of whom had had postoperative complications. When viewing the complication rate in relation to uterine weight, this equates to a complication rate of 1.5% in uterine weight class I, 1.4% in class II, 1.5% in class III, and 7.1% in class IV. Of the five intraoperative complications described above, one bladder injury and one ureteric injury occurred in uterine weight class II. Two further bladder injuries occurred in class III, and the bleed from the uterine artery occurred in class IV. Of these five complications, the mean uterine weight was 818.4 ⫾ 911.9 g (95% CI -13.9 – 1950.7). Six patients with complications (24%) had a history of previous open gynecologic and/or abdominal surgery. It is noteworthy that in the two cases of intraoperative
The indications for surgery made in the MIC Hospital are comparable to the indications described in the literature. One study describes that the most common indications for supracervical hysterectomy are symptomatic uterine myomata with pain or bleeding 51.3%, menorrhagia or metrorrhagia (33.0%), and chronic pelvic pain (6.6%).8 In our series, the most common indications were enlarging and/or symptomatic uterine myomata, therapy-resistant dysfunctional uterine bleeding, and uterine adenomyosis. As described by other authors, LASH should be viewed as an alternative to abdominal hysterectomy, which is reflected in the caseload of patients, many of whom had undergone previous surgery (60.8%), and many required additional intervention (30.6%). Length of hospital stay of the traditional 10 days and postoperative sick leave of 6 weeks to 3 months are not
Table 3
Intraoperative and postoperative complications
Complication Intraoperative Abnormal uterine bleeding Bladder injury Ureter injury Postoperative Adhesions Incisional hernia Abdominal wound infection Pouch of Douglas abscess Bleeding disorder Cervical stump infection Pelvic pain Total
No. 1 3 1 5 1 3 1 5 4 1 25
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Perioperative complications after LASH
typical only in England.9 Consequently, LAVH and total laparoscopic hysterectomy (TLH) were established primarily to reduce hospital stay and length of convalescence, as well as perioperative morbidity. Because of these particular aspects, LASH is increasingly seen as an alternative to total hysterectomy, provided the cervix is normal.9 –13 All three gynecologists operating in the hospital had had previous endoscopic experience before introduction of the LASH method. The analysis of the learning curve shows that it took approximately 120 operations to reduce the surgical time to fewer than 100 minutes. In the literature, reduction of surgery time to fewer than 90 minutes by an experienced surgeon after 80 operations has been reported; however uterine weights were between only 70 and 470 g. The complication rate did not decrease with increasing surgical experience, especially for complications such as bleeding or infection.14 A multicenter study from Belgium reported a reduction in average operating time to 80 minutes after only 40 procedures with eight surgeons experienced in endoscopy. After that, surgical time did not decrease further, as average uterine size increased simultaneously. The complication rate and conversion rate to laparotomy did not show any correlation with surgical experience in this study.15 Comparisons made among LASH, LAVH, and TLH have shown that operating time is shortest for LASH.1,7,16,17 Surgery time for the classic intrafascial supracervical hysterectomy (CISH) technique is reported to have a duration mostly of greater than 2 hours.1,8,18 The TLH16,18,19 and the LAVH1,16,18,20 procedures also are reported to have surgical time of greater than 2 hours. Reduction in surgical time appears to be linked to the use of costly disposable instruments, such as forceps and instruments for suturing.2,10,11 No complications have been reported during the morcellation of the uterus, even though this is considered to be technically the most difficult part of the operation. To separate the uterine body a monopolar hook was used. If applied correctly, it provides a safe and cost-effective alternative to the Nd-YAG laser application,9 as here no complications were observed. In this retrospective study, 25 complications in the intraoperative or early postoperative period were recorded. This translates to a complication rate of 1.42%. In the literature, the complication rates for LASH vary between zero and 4.35%.2,3,10,21,22 Compared with this, however, complication rates for abdominal hysterectomy are between 13.1% and 48%,14,23,24 for vaginal hysterectomy between 2% and 27.7%,3,21,23–25 for LAVH between zero and 37.5%,24 –30 and for TLH between 2.7% and 9.7%.15,29 According to one study,23 the total complication rate in the United States after total abdominal hysterectomy is 24.5%. Another study 21 from Sweden reports complication rates of greater than 13.1% for abdominal hysterectomy and 4.9% for vaginal hysterectomy. It appears complications are reduced using endoscopic techniques. Two studies2,19 reported no intraoperative complications performing LASH. Another study31
187 also reports no intraoperative or perioperative complications in 117 supracervical hysterectomies performed. One study16 reports a complication rate of 4.9% performing supracervical hysterectomies. Another describes a complication rate of 17.1%, but it must be noted that this breaks down into 0.8% serious complications and 16.7% minor complications. Multicenter comparative studies among abdominal, vaginal, and laparoscopic hysterectomies have shown that major complications are more common after laparoscopic hysterectomies (11.1%) compared with abdominal hysterectomy (6.2%). The length of surgery for laparoscopic techniques also does comparatively worse.32 Mild complications occurred in 27.9% of vaginal hysterectomies, 25.2% of abdominal hysterectomies, and 23.2% of laparoscopic hysterectomies.33 The question arises of whether uterine weight increases the risk of complications. Uterine weight classes I, II, and III showed equal average risk rates of 1.4% to 1.5%. Uterine weight class IV, however, showed an increased complication rate of 7.1%. Uterine size and weight are clearly a limiting factor in the ability to perform the LASH method. Looking at the conversion laparotomies, it becomes apparent that of the 14 conversions, 11 were necessary due to uterine size and bulk. Of these, four were uterine weight class III and seven were class IV. A study performed from 1989 to 1999 describes that of the 1647 laparoscopies performed, the conversion rate of the first 695 operations was 4.7%, decreasing to1.4% in the subsequent 952 operations.34 It also became apparent in our study that previous gynecologic surgery poses a significant risk for the patient. In three of the five intraoperative complications, the patients had a history of sometimes several gynecologic laparotomies. The conversion rate of 0.82% is relatively low compared with rates for LASH described in the literature. These are variously described as 0.85%29 to 22.7%15 for LAVH, and for LASH they range from zero19 to 0.3%35 to 0.69%.36 The rate of postoperative complications was 1.2%, which translates to 20 patients. In 14 of these, further surgical intervention was necessary. The indications for further intervention were made generously, as postoperative abdominal pain was a major factor. In five patients adhesions were found to be the cause, and after successful division of the adhesions the patients were symptom free. In a further patient, no correlation for the pain could be found; and in another, case a pouch of Douglas abscess was treated laparoscopically with drainage and irrigation. Of the six patients treated conservatively, four were diagnosed with an infection of the cervical stump, probably secondary to infection from the cervical canal. The other two had infection of the incision sites, which healed by secondary intention. These complications were successfully treated with antibiotics and local treatment. It is worth remembering that in cases of unclear persistent abdominal pain, a rare complication could be remnants of uterine myoma left in the abdominal cavity after morcellation.37 Further rare complications of septic shock secondary to cervical stump necrosis 38 and an ectopic pregnancy located
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in the fallopian tube 4 months post-LASH 39 have been described in the literature. It is therefore essential that there is a complete retrieval of all endometrial tissue during LASH, as there is a possibility of the development of iatrogenic symptomatic endometriosis post-LASH.40 With regards to the complication rate described in the literature, there is a very wide variation. A multicenter study conducted in Finland between 1990 and 1995 examined the complication rate of injury to the urinary tract in 62 379 hysterectomies using various surgical methods. It showed that by far the highest complication rate of 2.26% was during laparoscopic hysterectomy (LH), followed by 0.17% during total abdominal hysterectomy (TAH), 0.06% during supracervical abdominal hysterectomy, and 0.04% during vaginal hysterectomy (VH).41 In these cases, the LH was performed as a total hysterectomy rather than supracervically. A further study has shown that 75% (88/118) of major complications arising during 32 205 gynecologic laparoscopic operations occurred during LHs.42 Other authors have described urinary tract injuries ranging from zero to 6.25%4,16,43 during TLH. The complication rate of urinary tract injuries in this study collective was 0.29%. Many authors believe that by not removing the cervix the risk of ureter and bladder injury is decreased.7,41,44 – 46 Analysis of length of hospital stay shows an average of 2.5 days. In the literature, the average hospital stay after LASH varies between 1 to 3 days.5,9,47 In some centers, LASH is performed as an outpatient procedure.6,10,16,28,32,47 In contrast, the average hospital stay after vaginal hysterectomy is 4 to 5 days, and 5 to 8 days after abdominal hysterectomy.2,7,16 Many studies describe a shortened period of convalescence after LASH compared with various other described procedures, which allows an earlier return to work. Time off work on sick leave after LASH is between 5.5 to 10.1 days.3,16,28,48 In comparison, the literature reports an average number of days off sick after TAH of 22 days16 to 30 days,49 and 29 days after LAVH.50 In our study, we are unable to interpret data regarding return to work; however, the cost- and economic implication of an earlier return to work after surgery is certainly important to consider.
Conclusion The results of this study show that LASH is a simple to learn, minimally invasive surgical procedure that can be performed with a few simple, reusable, standard surgical instruments, in comparison with other modifications of this technique described in the literature. The electric morcellator is a more cost-intensive piece of equipment. It is, however, absolutely essential for the LASH procedure, as it has a significant influence on surgical time. Main indications for LASH are uterine myomata with tendency to enlargement and/or dysfunctional uterine bleeding and uterine adenomyosis, providing premalignant or
malignant changes of the cervix and uterus have been ruled out. Of special significance is that LASH can be performed on nulliparous patients, patients who have not previously had a vaginal delivery, and patients who have had previous abdominal surgery. It provides a minimally invasive alternative to all other methods of total hysterectomy in benign conditions and has a low perioperative morbidity. Furthermore, the LASH method is associated with a short hospital stay, rapid convalescence, and rapid return of the patient to the workplace.
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19. Liu CY. Laparoscopic hysterectomy: a review of 72 cases. J Reprod Med. 1992;37:351–354. 20. Park K. Endoscopic management of uterine myoma. Yonsei Med J. 1999;40:583–588. 21. Nathorst-Boos J, Fuchs T, von Schoultz B. Consumer’s attitude to hysterectomy: the experience of 678 women. Acta Obstet Gynecol Scand. 1992;71:230 –234. 22. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after abdominal versus subtotal abdominal hysterectomy. N Engl J Med. 2002;347:17. 23. Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States: The Collaborative Review of Sterilization. Am J Obstet Gynecol. 1982;144:841– 848. 24. Wang P, Lee WL, Yuan CC. Major complications of operative and diagnostic laparoscopy for gynecologic disease. J Am Assoc Gynecol Laparosc. 2001;8:68 –73. 25. Darai E, Soriano D, Kimata P, Laplace C, Lecuru F. Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study. Obstet Gynecol. 2001;97:712–716. 26. Bojahr B, Lober R, Römer T, Schwesinger G. Groes Zervixmyom bei Zustand nach suprazervikaler Hysterektomie. Zentralbl Gynakol. 1996;118:468 – 470. 27. Pelosi MA, Pelosi MA 3rd, Laparoscopically assisted colpotomy with the Pelosi illuminator and Visiport trocar system. J Reprod Med. 1996;41:548 –554. 28. Schwartz RO. Laparoscopic hysterectomy: supracervical vs. assisted vaginal. J Reprod Med. 1994;39:625– 630. 29. Shen C. Major complications associated with laparoscopic-assisted vaginal hysterectomy: ten-year experience. J Am Assoc Gynecol Laparosc. 2003;10:147–153. 30. Wu M, Lin YS, Chou CY. Major complications of operative gynecologic laparoscopy in Southern Taiwan. J Am Assoc Gynecol Laparosc. 2001;8:61– 67. 31. Salfelder A, Lueken RP, Bormann C, et al. Die suprazervikale Hysterektomie in neuem Licht. Wiederentdeckung als minimalinvasive Methode. Frauenarzt. 2003;44:1071–1075. 32. Garry R, Fountain J. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004; 328:129. 33. 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.
189 34. Wattiez A, Soriano D, Cohan S, Nervo P. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc. 2002;9:339 –345. 35. Lyons TL. Laparoscopic supracervical hysterectomy. In: Pasic RP, Levine RL, eds. A Practical Manual of Laparoscopy: A Clinical Cookbook. London: Parthenon Publishing Group; 2002:211–224. 36. Morrison JE Jr, Jacobs VR. 437 classic intrafascial supracervical hysterectomies in 8 years. J Am Assoc Gynecol Laparosc. 2001;8: 558 –567. 37. Hutchins FL Jr, Reinoehl EM. Retained myoma after laparoscopic supracervical hysterectomy with morcellation. J Am Assoc Gynecol Laparosc. 1998;5:293–295. 38. Huang JY, Ziegler C, Tulandi T. Cervical stump necrosis and septic shock after laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol. 2005;12:162–164. 39. Pasic R, Scobee J, Tolar B. Ectopic pregnancy months after laparoscopic supracervical hysterectomy. J Am Assoc Gynecol Laparosc. 2004;11:94 –95. 40. Sepilian V. Iatrogenic endometriosis caused by uterine morcellation during a supracervical hysterectomy. Obstet Gynecol. 2003;102:2. 41. Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol. 1998;9:113–118. 42. Harkki-Siren P, Sjoberg J, Kurki T. Major complications of laparoscopy: a follow-up Finnish study. Obstet Gynecol. 1999;94:94 –98. 43. Meikle SF, Nugent EW, Orleans M. Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Gynecol. 1997;89:304 –311. 44. Hasson HM. Cervical removal at hysterectomy for benign disease: risks and benefits. J Reprod Med. 1993;38:781–790. 45. Johns A. Supracervical versus total hysterectomy. Clin Obstet Gynecol. 1997;40:903–913. 46. Richards SR, Simpkins S. Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc. 1995;2:431– 435. 47. Simon NV, Laveran R, Cavanaugh S, Gerlach D, Jackson JR. Laparoscopic supracervical hysterectomy vs. abdominal hysterectomy in a community hospital: a cost comparison. J Reprod Med. 1999;44:339 – 345. 48. Lyons TL, Adolph AJ, Winer WK. Laparoscopic supracervical hysterectomy for the large uterus. J Am Assoc Gynecol Laparosc. 2004; 11:170 –174. 49. Tietz C. Laparoscopic supracervical hysterectomy in a rural Minnesota hospital. Minn Med. 2001;84:47– 49. 50. Learman LA, Summitt RLL, Varner RE. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcome. Obstet Gynecol. 2003;102:453– 462.
Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique Bernd Bojahr, MD, PhD, Detlef Raatz, MD, Georg Schonleber, MD, Christine Abri, and Ralf Ohlinger, MD From the Clinic for Minimally Invasive Surgery, Minimally Invasive Center, Berlin (Drs. Bojahr, Raatz, Schonleber, and Abri); and from the Department of Obstetrics and Gynecology, Ernst Moritz Arndt University, Greifswald (Dr. Ohlinger), Germany. KEYWORDS: Laparoscopic supracervical hysterectomy; Perioperative complications
Abstract STUDY OBJECTIVE: The aim of the study was to determine perioperative morbidity and complication rate after a standardized technique of laparoscopic supracervical hysterectomy (LASH). DESIGN: Retrospective analysis of consecutive patients (Canadian Task Force classification II-3). SETTING: Private hospital. PATIENTS: Seventeen hundred and six consecutive patients with symptomatic uterine myomata, dysfunctional uterine bleeding, dysmenorrhea, or chronic pelvic pain. INTERVENTION: Laparoscopic supracervical hysterectomy using a unipolar hook for dissection of the body of the uterus followed by electric morcellation MEASUREMENTS AND MAIN RESULTS: The main indications for LASH were uterine myomata with dysfunctional uterine bleeding (31.1%) or without (45.4%) and therapy-resistant dysfunctional uterine bleeding (21%). The mean uterine weight was 226.4 ⫾ 193.9 g (95% CI 217.1–235.6), the mean duration of surgery was 91.4 ⫾ 33.3 minutes (95% CI 89.9 –93.0), and the mean duration of hospital stay was 2.15 ⫾ 0.63 days (95% CI 2.12–2.18). Nine hundred two (52.9%) of the patients had a history of at least one laparotomy. In 14 patients (0.82%), a conversion to laparotomy was necessary. Of these, 11 were due to the size and immobility of the uterus, one was due to severe adhesions, and two because of intraoperative complications. In total, five (0.3%) intraoperative and 20 (1.2%) postoperative complications occurred. The mean weight of the uterus in the five patients with intraoperative complications (three bladder injuries, one ureter injury, and one severe intraoperative bleed) was 818.4 ⫾ 911.9 g (95% CI -313.9 –1950.7). In two patients who suffered trauma to the bladder, there was a history of cesarean sections (two and three, respectively). The most common postoperative complications were bleeding from the cervix and pain caused by adhesions or postoperative infection. CONCLUSION: Laparoscopic supracervical hysterectomy is a minimally invasive surgical method that should be regarded as an alternative to all other methods of total hysterectomy in benign conditions of the uterus (uterine myomata, dysfunctional uterine bleeding, uterine adenomyosis) as it is associated with a low perioperative morbidity and a rapid period of convalescence. Of special significance is that LASH can be performed on nulliparous patients, patients who have not previously had vaginal delivery, and patients who have had previous abdominal surgery. © 2006 AAGL. All rights reserved.
Corresponding author: Bernd Bojahr MD, PhD, Klinik für MIC, Minimally Invasive Center, am Ev. Krankenhaus Hubertus, Kurstr. 11, 14129 Berlin, Germany. E-mail: [email protected] Submitted October 7, 2005. Accepted for publication January 16, 2006.
1553-4650/$ -see front matter © 2006 AAGL. All rights reserved. doi:10.1016/j.jmig.2006.01.010
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Because of rapid development of surgical laparoscopy over the past 25 years, there have been enormous changes in hysterectomy methods. In the 1990s, the number of abdominal hysterectomies was already declining worldwide primarily due to the introduction of the laparoscopic-assisted vaginal hysterectomy (LAVH). The significant advantages of LAVH compared with abdominal hysterectomy are reduced morbidity and speedier recovery. There is, however, increasing evidence of advantages of the laparoscopic supracervical hysterectomy (LASH) as an alternative to LAVH. It is also considered a safe procedure with few complications. It is indicated in patients with therapy-resistant dysfunctional uterine bleeding, enlarging or painful uterine myomata, or if there is a suspicion of uterine adenomyosis. Important criteria for this particular procedure are normal cervical cytology and colposcopy, and the exclusion of a malignant endometrial cause of dysfunctional uterine bleeding made by diagnostic hysteroscopy with dilation and curettage (D&C). Some studies have shown that the complication rate for LASH are lower than for LAVH and other methods of hysterectomy.1– 6 By complete preservation of the cervix, vagina, and uterosacral ligaments, the surgical procedure is significantly simplified and the risk of accidental injury to the bladder, intestine, and ureter is reduced.5–7 The aim of this retrospective study was to analyze the perioperative complication rate after LASH in relation to various other factors that may influence this rate.
Materials and methods The retrospective study was based on data collected from 1706 consecutive patients who were treated at the MIC Hospital in Berlin from June 1, 1998, through October 31, 2003. They had a diagnosis of a benign condition of the uterus and were therefore selected to undergo LASH. The indications for a LASH were: (1) uterine myomata with either pain and/or enlargement; (2) therapy-resistant dysfunctional uterine bleeding; (3) suspected uterine adenomyosis; and (4) recurrent bleeding after endometrial ablation or resection. An important prerequisite for surgery was completion of child bearing. All patients had to have evidence of a normal ectocervix both on colposcopy and cytology. Patients with abnormal bleeding or abnormal ultrasound findings had a D&C performed to exclude malignancy. Preoperative counseling of the patients included advice on the need for continued annual cervical screening and information on the possibility of continuing light menstrual cyclical bleeding. In the first 2 years, the operative technique was standardized and was carried out by three surgeons in the hospital as follows. After disinfection of the vagina and catheterization of the bladder, the patient is positioned supine with outstretched legs. Uterus manipulators are not used. Carbon
dioxide insufflation by a Veres needle placed through an incision in the inferior umbilical fossa is performed to an intraabdominal pressure of 15 mm Hg. A 5-mm trocar is then introduced through this incision. The obligatory full visual sweep is then done with the routinely used 30-degree optic. For this, the patient is brought into maximum Trendelenburg position. Then, 5-mm trocars are introduced left and right under direct vision lateral to the epigastric vessels in the region of the pubic hair border. The localization of the additional two trocars depends on uterine size: the larger the uterus, the further above the symphysis pubis the lateral trocars need to be positioned. Only reusable instruments are used during the operative procedure. In addition to the standard 5-mm instruments, a bipolar coagulation clamp, Metzenbaum scissors, three various grasping forceps, a needle holder, a monopolar hook, and a suction-irrigation system are used. The uterus is mobilized using bipolar coagulation of the round ligament, the fallopian tube, and the ovarian ligament with subsequent dissection. For this, the uterus is pulled to the contralateral side with grasping forceps. After separating the ovary and fallopian tube from the uterus and dissecting through the round ligament, a trail is placed on the bladder peritoneum using the bipolar coagulation forceps that delineates the planned direction of incision to open the bladder peritoneum. From the dissected round ligament, the bladder peritoneum is undermined using scissors. The peritoneum is then opened up, and the bladder is pushed slightly caudally. This procedure is repeated in an analogous way on the contralateral side. After identification and skeletonization of the uterine vessels, they are then coagulated and divided. Subsequently the bladder peritoneum is once again mobilized from the anterior surface of the cervix. It usually is not necessary to push away the bladder as done in a total hysterectomy, as now the uterine body is dissected off in the upper third, cranial to where the uterosacral ligaments leave the cervix. The uterus is separated from the cervix with a monopolar hook under constant upward pull. Following hemostasis in the region of the cervical stump, the cervical canal is coagulated. Peritoneum is used to cover the cervical stump using a continuous purse-string suture. The two uterosacral ligaments are included in this suture. To remove the uterus, the incision in the left iliac fossa is increased to between 10 to 20 mm. An electric STEINER or SAWALHE morcellator (Karl Storz, Tuttlingen, Germany) or an S*E*M*M* morcellator (WISAP, Munich, Germany), is introduced under direct vision. After morcellation is completed, the fascia underlying the left-sided incision is closed using one or two interrupted sutures, as is the skin. If the uterus is very enlarged, an additional 5- or 10-mm port may be necessary. This usually is placed centrally above the symphysis pubis. The patient’s clinical records provided information regarding age, body weight, height, body mass index, American Society of Anesthesiologists (ASA) scores, histology results, previous operations, and any necessary additional
Bojahr et al Table 1
Perioperative complications after LASH
Patient characteristics and operative parameters
Characteristic/parameter Age (yrs) Body mass index ASA Score I II III IV Duration of operation (min) Weight of corpus uteri (g) Hospital stay (days)
Mean ⫾ SD (95% CI) / No. of patients (%) 45.7 ⫾ 6.9 (45.4–46.0) 24.8 ⫾ 4.3 (24.6–25.0) 476 930 294 6 91.4 ⫾ 33.3 226.4 ⫾ 193.9 2.15 ⫾ 0.63
(27.9) (54.5) (17.2) (0.4) (89.9–93.0) (217.1–235.6) (2.12–2.18)
ASA ⫽ American Society of Anesthesiologists.
surgical interventions. The records also provided information regarding length of hospital stay, duration of surgery, and weight of uterus. Perioperative complications were also recorded and analyzed. Uterine weight was divided into four classes. Class I included uterine weight up to 100 g, class II included weight between 101 and 500 g, class III was 501 to 1000 g, and class IV included all uteri weighing more than 1000 g.
Statistical analysis The data collated from the clinical records was analyzed using the SPSS program version 11.5 (SPSS Software, Chicago, IL). Mean values were calculated and shown with their standard deviations and 95% CI. Statistical significance was demonstrated using the Mann-Whitney U test and the Wilcoxon test to compare groups. For all statements of significance the probability of error of ␣ ⫽ 0.05 (5%) was used, so that statistical significance was considered to be achieved with p ⬍.05.
Results In the study period, data were collected on 1692 patients (Table 1). Preoperatively, the indication for LASH was made in 1706 patients. The indication for surgery in 1306 patients (76.5%) was uterine myomata with or without dysfunctional uterine bleeding. In a further 358 patients (21%), the indication was solely dysfunctional uterine bleeding. In 19 patients (1.2%), suspected uterine adenomyosis was the indication; and in a further 23 (1.3%), uterine adenomyosis in combination with uterine myomata and/or dysfunctional uterine bleeding was suspected (Table 2). A total 1029 patients (60.8%) had had at least one previous operation documented in their medical history: 37.8% of the patients had had at least one surgical procedure and 23% at least one gynecologic procedure. Six hundred sixty-three patients (39.2%) had no recorded history of previous surgery.
185 Of all the patients, 902 (52.9%) had a history of at least one previous laparotomy. Eight hundred ninety-four patients (52.8%) who underwent LASH had no further surgical intervention. However, 623 patients (36.8%) required further intervention, with 167 patients (15.8%) requiring two further interventions and 8 patients (0.5%) three further interventions. The most common further interventions were: unilateral adnexal surgery in 448 patients (26.5%), bilateral adnexal surgery in 69 (4.1%), division of adhesions in 394 (23.3%), and sacropexy in 40 (2.4%). The most commonly represented uterine size was class II (64.3%); whereas only 27% were in class I, and 7.8% fell in the uterine weight class III. In only 0.8% of all cases did the uterus weigh more than 1000 g. When relating the duration of the surgery to the year it was performed, data showed a steady reduction of mean surgery duration from 159.1 ⫾ 63.5 minutes (95 % CI 126.5–191.8) in 1998 to 80.6 ⫾ 29.2 minutes (95% CI 78.1– 83.2) in 2003. When the surgical duration was related to uterine weight, however, data showed increasing duration of surgery with increasing uterine weight. Mean duration of surgery in uterine weight class I was 73.8 ⫾ 22.5 minutes (95% CI 71.7–75.9). This increased to 92.5 ⫾ 28.8 minutes (95% CI 90.9 –94.3) in uterine weight class II (p ⬍.05), and 131.3 ⫾ 42.4 minutes (95% CI 124.1–:138.5) (p ⬍.05) in uterine weight class III. The longest surgical duration was in uterine weight class IV (Figure 1) at 160.5 ⫾ 53.2 minutes (95% CI 131.3–178.4) (p ⬍.05). In 14 patients, a conversion to laparotomy was necessary. This equates to a conversion rate of 0.82%. In two patients, it was necessary to proceed to a laparotomy due to intraoperative complications: one was a bladder injury and the other severe bleeding from the uterine artery where laparoscopic hemostasis could not be achieved. The patient who suffered the bladder injury had a history of three cesarean sections. In one patient conversion was necessary due to severe adhesions; and in another, conversion was necessary because of adhesions and uterine bulk. In the other 10, laparotomy was performed solely because of the bulkiness of the uterus and its immobility. The patient who suffered the intraoperative bleed had a uterine weight of 2400 g. The mean uterine weight of the conversion group
Table 2 Indications for laparoscopic supracervical hysterectomy Indication
No. of patients (%)
Myomas Myomas and bleeding disorder Myomas and pelvic pain Myomas, bleeding disorder, and pelvic pain Bleeding disorder Bleeding disorder and pelvic pain Suspicion of adenomyosis
775 531 4 4 358 15 19
(45.4) (31.1) (0.2) (0.2) (21) (0.9) (1.2)
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Duration of surgery in minutes
500
400
300
200
100
0 N=
458
1087
132
14
1
2
3
4
Uterus weight category Figure 1 Correlation of surgical duration according to uterus weight category.
bladder injuries the patients had had three cesarean sections and an appendectomy and two cesarean sections and an appendectomy, respectively. To establish a “learning curve,” the development of surgical duration in relation to average uterine weight and the distribution of complications was analyzed. Mean surgical duration for the first 20 operations was 152.8 ⫾ 60.7 minutes (95% CI 124.3–181.2) and for the next 20 was 116.5 ⫾ 34.1 minutes (95% CI 100.5–132.4). From the 130th operation onward, surgical time decreased to under 100 minutes. In the year 2003, average surgical time was only 80.6 ⫾ 29.2 minutes (95% CI 78.1– 83.2). Specific analysis of the five serious intraoperative complications did not show that these occurred more frequently in the initial phase of this method of surgery. Three of the intraoperative complications occurred with surgeon 1 during operations number 181, 307, and 667. One complication occurred with surgeon 2 during his 171st operation. And with surgeon 3, the complication occurred during the 18th operation.
Discussion was 1202.8 ⫾ 779.7 g (95% CI 752.7–1653.1). Of the 14 procedures that were converted to laparotomy, five were uterine weight class III and eight were class IV. A total of 25 complications were recorded (1.48%), divided into intraoperative (0.3%) and postoperative complications (1.18%) (Table 3). In five patients, the cervical stump was coagulated due to troublesome vaginal bleeding. Due to continuing pain, seven patients again underwent laparoscopy. In five patients, division of adhesions was necessary. One patient underwent laparoscopic repair of an incisional hernia, and in another an incision and drainage of an abdominal wall abscess in the region of the 15-mm incision site was necessary. Only two of the five complications that occurred intraoperatively were immediately recognized and dealt with by converting to laparotomy. Two bladder injuries and one ureteric injury were only recognized postoperatively and subsequently treated. The two bladder injuries were treated with a bladder suture by laparotomy, and the patient with the ureteric fistula was treated by ureteric splinting after diagnosis by laparoscopy. In total, further surgical intervention was necessary in 17 patients (1.0%), 14 of whom had had postoperative complications. When viewing the complication rate in relation to uterine weight, this equates to a complication rate of 1.5% in uterine weight class I, 1.4% in class II, 1.5% in class III, and 7.1% in class IV. Of the five intraoperative complications described above, one bladder injury and one ureteric injury occurred in uterine weight class II. Two further bladder injuries occurred in class III, and the bleed from the uterine artery occurred in class IV. Of these five complications, the mean uterine weight was 818.4 ⫾ 911.9 g (95% CI -13.9 – 1950.7). Six patients with complications (24%) had a history of previous open gynecologic and/or abdominal surgery. It is noteworthy that in the two cases of intraoperative
The indications for surgery made in the MIC Hospital are comparable to the indications described in the literature. One study describes that the most common indications for supracervical hysterectomy are symptomatic uterine myomata with pain or bleeding 51.3%, menorrhagia or metrorrhagia (33.0%), and chronic pelvic pain (6.6%).8 In our series, the most common indications were enlarging and/or symptomatic uterine myomata, therapy-resistant dysfunctional uterine bleeding, and uterine adenomyosis. As described by other authors, LASH should be viewed as an alternative to abdominal hysterectomy, which is reflected in the caseload of patients, many of whom had undergone previous surgery (60.8%), and many required additional intervention (30.6%). Length of hospital stay of the traditional 10 days and postoperative sick leave of 6 weeks to 3 months are not
Table 3
Intraoperative and postoperative complications
Complication Intraoperative Abnormal uterine bleeding Bladder injury Ureter injury Postoperative Adhesions Incisional hernia Abdominal wound infection Pouch of Douglas abscess Bleeding disorder Cervical stump infection Pelvic pain Total
No. 1 3 1 5 1 3 1 5 4 1 25
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Perioperative complications after LASH
typical only in England.9 Consequently, LAVH and total laparoscopic hysterectomy (TLH) were established primarily to reduce hospital stay and length of convalescence, as well as perioperative morbidity. Because of these particular aspects, LASH is increasingly seen as an alternative to total hysterectomy, provided the cervix is normal.9 –13 All three gynecologists operating in the hospital had had previous endoscopic experience before introduction of the LASH method. The analysis of the learning curve shows that it took approximately 120 operations to reduce the surgical time to fewer than 100 minutes. In the literature, reduction of surgery time to fewer than 90 minutes by an experienced surgeon after 80 operations has been reported; however uterine weights were between only 70 and 470 g. The complication rate did not decrease with increasing surgical experience, especially for complications such as bleeding or infection.14 A multicenter study from Belgium reported a reduction in average operating time to 80 minutes after only 40 procedures with eight surgeons experienced in endoscopy. After that, surgical time did not decrease further, as average uterine size increased simultaneously. The complication rate and conversion rate to laparotomy did not show any correlation with surgical experience in this study.15 Comparisons made among LASH, LAVH, and TLH have shown that operating time is shortest for LASH.1,7,16,17 Surgery time for the classic intrafascial supracervical hysterectomy (CISH) technique is reported to have a duration mostly of greater than 2 hours.1,8,18 The TLH16,18,19 and the LAVH1,16,18,20 procedures also are reported to have surgical time of greater than 2 hours. Reduction in surgical time appears to be linked to the use of costly disposable instruments, such as forceps and instruments for suturing.2,10,11 No complications have been reported during the morcellation of the uterus, even though this is considered to be technically the most difficult part of the operation. To separate the uterine body a monopolar hook was used. If applied correctly, it provides a safe and cost-effective alternative to the Nd-YAG laser application,9 as here no complications were observed. In this retrospective study, 25 complications in the intraoperative or early postoperative period were recorded. This translates to a complication rate of 1.42%. In the literature, the complication rates for LASH vary between zero and 4.35%.2,3,10,21,22 Compared with this, however, complication rates for abdominal hysterectomy are between 13.1% and 48%,14,23,24 for vaginal hysterectomy between 2% and 27.7%,3,21,23–25 for LAVH between zero and 37.5%,24 –30 and for TLH between 2.7% and 9.7%.15,29 According to one study,23 the total complication rate in the United States after total abdominal hysterectomy is 24.5%. Another study 21 from Sweden reports complication rates of greater than 13.1% for abdominal hysterectomy and 4.9% for vaginal hysterectomy. It appears complications are reduced using endoscopic techniques. Two studies2,19 reported no intraoperative complications performing LASH. Another study31
187 also reports no intraoperative or perioperative complications in 117 supracervical hysterectomies performed. One study16 reports a complication rate of 4.9% performing supracervical hysterectomies. Another describes a complication rate of 17.1%, but it must be noted that this breaks down into 0.8% serious complications and 16.7% minor complications. Multicenter comparative studies among abdominal, vaginal, and laparoscopic hysterectomies have shown that major complications are more common after laparoscopic hysterectomies (11.1%) compared with abdominal hysterectomy (6.2%). The length of surgery for laparoscopic techniques also does comparatively worse.32 Mild complications occurred in 27.9% of vaginal hysterectomies, 25.2% of abdominal hysterectomies, and 23.2% of laparoscopic hysterectomies.33 The question arises of whether uterine weight increases the risk of complications. Uterine weight classes I, II, and III showed equal average risk rates of 1.4% to 1.5%. Uterine weight class IV, however, showed an increased complication rate of 7.1%. Uterine size and weight are clearly a limiting factor in the ability to perform the LASH method. Looking at the conversion laparotomies, it becomes apparent that of the 14 conversions, 11 were necessary due to uterine size and bulk. Of these, four were uterine weight class III and seven were class IV. A study performed from 1989 to 1999 describes that of the 1647 laparoscopies performed, the conversion rate of the first 695 operations was 4.7%, decreasing to1.4% in the subsequent 952 operations.34 It also became apparent in our study that previous gynecologic surgery poses a significant risk for the patient. In three of the five intraoperative complications, the patients had a history of sometimes several gynecologic laparotomies. The conversion rate of 0.82% is relatively low compared with rates for LASH described in the literature. These are variously described as 0.85%29 to 22.7%15 for LAVH, and for LASH they range from zero19 to 0.3%35 to 0.69%.36 The rate of postoperative complications was 1.2%, which translates to 20 patients. In 14 of these, further surgical intervention was necessary. The indications for further intervention were made generously, as postoperative abdominal pain was a major factor. In five patients adhesions were found to be the cause, and after successful division of the adhesions the patients were symptom free. In a further patient, no correlation for the pain could be found; and in another, case a pouch of Douglas abscess was treated laparoscopically with drainage and irrigation. Of the six patients treated conservatively, four were diagnosed with an infection of the cervical stump, probably secondary to infection from the cervical canal. The other two had infection of the incision sites, which healed by secondary intention. These complications were successfully treated with antibiotics and local treatment. It is worth remembering that in cases of unclear persistent abdominal pain, a rare complication could be remnants of uterine myoma left in the abdominal cavity after morcellation.37 Further rare complications of septic shock secondary to cervical stump necrosis 38 and an ectopic pregnancy located
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in the fallopian tube 4 months post-LASH 39 have been described in the literature. It is therefore essential that there is a complete retrieval of all endometrial tissue during LASH, as there is a possibility of the development of iatrogenic symptomatic endometriosis post-LASH.40 With regards to the complication rate described in the literature, there is a very wide variation. A multicenter study conducted in Finland between 1990 and 1995 examined the complication rate of injury to the urinary tract in 62 379 hysterectomies using various surgical methods. It showed that by far the highest complication rate of 2.26% was during laparoscopic hysterectomy (LH), followed by 0.17% during total abdominal hysterectomy (TAH), 0.06% during supracervical abdominal hysterectomy, and 0.04% during vaginal hysterectomy (VH).41 In these cases, the LH was performed as a total hysterectomy rather than supracervically. A further study has shown that 75% (88/118) of major complications arising during 32 205 gynecologic laparoscopic operations occurred during LHs.42 Other authors have described urinary tract injuries ranging from zero to 6.25%4,16,43 during TLH. The complication rate of urinary tract injuries in this study collective was 0.29%. Many authors believe that by not removing the cervix the risk of ureter and bladder injury is decreased.7,41,44 – 46 Analysis of length of hospital stay shows an average of 2.5 days. In the literature, the average hospital stay after LASH varies between 1 to 3 days.5,9,47 In some centers, LASH is performed as an outpatient procedure.6,10,16,28,32,47 In contrast, the average hospital stay after vaginal hysterectomy is 4 to 5 days, and 5 to 8 days after abdominal hysterectomy.2,7,16 Many studies describe a shortened period of convalescence after LASH compared with various other described procedures, which allows an earlier return to work. Time off work on sick leave after LASH is between 5.5 to 10.1 days.3,16,28,48 In comparison, the literature reports an average number of days off sick after TAH of 22 days16 to 30 days,49 and 29 days after LAVH.50 In our study, we are unable to interpret data regarding return to work; however, the cost- and economic implication of an earlier return to work after surgery is certainly important to consider.
Conclusion The results of this study show that LASH is a simple to learn, minimally invasive surgical procedure that can be performed with a few simple, reusable, standard surgical instruments, in comparison with other modifications of this technique described in the literature. The electric morcellator is a more cost-intensive piece of equipment. It is, however, absolutely essential for the LASH procedure, as it has a significant influence on surgical time. Main indications for LASH are uterine myomata with tendency to enlargement and/or dysfunctional uterine bleeding and uterine adenomyosis, providing premalignant or
malignant changes of the cervix and uterus have been ruled out. Of special significance is that LASH can be performed on nulliparous patients, patients who have not previously had a vaginal delivery, and patients who have had previous abdominal surgery. It provides a minimally invasive alternative to all other methods of total hysterectomy in benign conditions and has a low perioperative morbidity. Furthermore, the LASH method is associated with a short hospital stay, rapid convalescence, and rapid return of the patient to the workplace.
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