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Laparoscopic Hysterectomy

July 2007

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Hysterectomy is the second most common major surgery among women in the United States (the most common being cesarean section). Each year, more than 600,000 hysterectomies are performed. In fact, by age 60 approximately one third of women in the United States have had a hysterectomy. 

 Traditionally, hysterectomies were performed using one of three methods:

1)      Abdominal approach: requires a laparotomy (abdominal incision >5-6cm)

2)      Vaginal approach: incision at the top of the vagina, less recovery time for patient, but requires more skill and requires a small uterus.

3)      Laparoscopic-assisted vaginal approach: similar approach to vaginal hysterectomy, but with the addition of the use of the laparoscope through the abdomen to assist the procedure.

The decision as to which technique to use is often related to the patient’s anatomy and the surgeon's training and expertise, as the indications for each technique overlap.  Despite the evidence that the transvaginal approach obviates the risk and recovery compared to the abdominal approach^[i], the abdominal approach continues to be the most common when performing a hysterectomy today.  Many feel this is due to decreasing surgical skills amongst gynecologists.

 A recent Cochrane Review^[ii] using twenty-seven (27) randomized controlled trials (RCTs) including 3643 subjects, demonstrated that the transvaginal and laparoscopic approached hysterectomies were superior to the heavily relied upon abdominal hysterectomy.  They found that blood loss was lowest during laparoscopic assisted hysterectomy (LAVH) and vaginal hysterectomy (VH) was less than abdominal hysterectomy (AH).  Somewhat surprisingly, operative time was longer in the AH technique than in the LAVH.  Hospital stay was

substantially longer after the AH, but did not differ between the LAVH or VH.  Fever and wound infection were also significantly more likely after the AH.  Return to normal activity after AH was slower than VH or LAVH.  The authors concluded that whenever possible, VH is preferred to AH.  Most importantly, when VH is not possible, LAVH and its subsets are preferred to the AH. 

One of these subsets is the total laparoscopic hysterectomy (TLH), which has recently gained greater acceptance and is fast becoming the preferred method for performing hysterectomies^[iii],[iv]. The total laparoscopic approach offers a superior view of the anatomy, facilitates meticulous hemostasis, enables the surgeon to perform adnexal (ovary and tubes) surgery and pelvic reconstructive surgery, and reduces morbidity associated with abdominal or vaginal incisions.  In fact, for many gynecologic laparoscopists, the ability to successfully perform TLH is the “Holy Grail” and perceived as the most central measure of laparoscopic competency. 

The key to the LAVH or the total

laparoscopic (TLH) approach is excellent visualization and mobility of the uterus and adnexa. Visualization is dramatically improved with the use of a uterine manipulator. The ideal uterine manipulator provides effortless movement of the uterus, with minimal manipulation. In addition, the movement will produce adequate tightening of the connective tissues of the uterus (ligaments and blood vessels) so that they may be safely ligated (see below).

Hysterectomies continue to be one of the most common procedures performed in the United States.  The steady trend in surgery has been to less and less invasive procedures, thus, the number of laparoscopic assisted and total laparoscopic hysterectomies are only expected to rise.  The benefits of this less invasive approach have been detailed in the literature, but it remains the surgeon’s responsibility to gain the necessary skill and equipment to properly and safely perform these procedures.