Hysterectom

1
Hysterectomy

• Robert D. Auerbach, M.D.
• Senior Vice President Chief Medical Officer
• CooperSurgical, Inc.
• Associate Clinical Professor
• Yale University School of Medicine

2
Introduction

• Hysterectomy is the most commonly performed
  gynecological surgical procedure
• 600,000 hysterectomies are performed yearly (US)
• 90 done for benign conditions
• Abdominal hysterectomy was more common than
  vaginal hysterectomy
• (65 vs. 35)
• Proportion of vaginal hysterectomies performed
  with laparoscopic assistance doubled (from 13 to
  28)

3
Indications

• Leiomyomata
• Pelvic pain
• Pelvic relaxation
• Abnormal uterine bleeding
• Malignant and premalignant disease

In the absence of a life-threatening emergency
(eg, uterine hemorrhage), the decision to proceed
with hysterectomy is made mutually by the woman
and her physician based upon her functional
impairment, childbearing plans, response to
medical therapy, discussion of alternatives, and
perception that the risks of the procedure are
outweighed by the expected benefits. UpToDate,
March 17, 2007
4
Alternatives Depend on Underlying Disorder

• Uterine artery embolization and myomectomy may be
  used to treat symptomatic leiomyoma
• Pain control services may be able to return
  patients with intractable pelvic pain to a
  functional status without surgery
• Endometrial ablation may be an effective therapy
  for menorrhagia
• GnRH analogs can help reduce discomfort
  associated with endometriosis
• Endometrial hyperplasia can sometimes be treated
  medically with progestins
• Conization may be adequate therapy for some women
  with high grade CIN/CIS

5
Hysterectomy

• Complete removal of fundus/cervix
• TAH
• TVH
• LAVH
• TLH

6
Hysterectomy

• Subtotal or supracervical hysterectomy
• Result in cyclic vaginal bleeding in 7-11 of
  patients
• May require future resection
• No difference in the rates of incontinence,
  constipation or measures of sexual function
• Length of surgery and amount of blood lost during
  surgery were reduced during subtotal hysterectomy
  compared to total hysterectomy
• No difference in transfusion rates

7
Hysterectomy

• Subtotal/supracervical hysterectomy
• There was no difference in the rates of other
  complications, recovery from surgery, or
  readmission rates
• Absolute contraindication to subtotal
  hysterectomy
• presence of a malignant or premalignant condition
  of the uterine corpus or cervix
• Extensive endometriosis is a relative
  contraindication
• persistence of dyspareunia if the cervix is
  retained

8
Abdominal vs. Vaginal Hysterectomy

• Historically, TAH has been designated as the
  appropriate route for more serious conditions
• Abdominopelvic exploration
• Procedures deemed too difficult to perform
  through the vagina
• These traditional indications for laparotomy have
  been challenged

9
Abdominal vs. Vaginal Hysterectomy

• Uterine mobility
• Prospective study
• All patients without prolapse undergoing
  hysterectomy for benign conditions were included
• There were 97 abdominal and 175 vaginal
  procedures, with no significant differences in
  patient characteristics
• The frequency of complications was low and
  similar in both groups

Varma, R, Tahseen, S, Lokugamage, AU, Kunde, D.
Vaginal route as the norm when planning
hysterectomy for benign conditions change in
practice. Obstet Gynecol 2001 97613.
10
Abdominal vs. Vaginal Hysterectomy

• Uterine size
• Prospective study evaluated vaginal hysterectomy
  outcome in 204 consecutive women with a myomatous
  uterus weighing 280 to 2000 g.
• Vaginal morcellation was performed in all cases
• no patient had uterovaginal prolapse
• Four patients underwent conversion to a
  laparoscopic procedure for the completion of the
  hysterectomy
• two of these ultimately required laparotomy
• Adnexectomy was successfully performed vaginally
  in 91 of patients in whom it was indicated
• Traditional uterine weight criteria for exclusion
  of the vaginal approach may not be valid

Sizzi, O, Paparella, P, Bonito, C, et al.
Laparoscopic assistance after vaginal
hysterectomy and unsuccessful access to the
ovaries or failed uterine mobilization changing
trends. JSLS 2004 8339.
11
Abdominal vs. Vaginal Hysterectomy

• Prior cesarean delivery - concerns about scarring
  
• Retrospective review compared vaginal
  hysterectomy outcome of 220 women with prior
  cesarean deliver (one or more) to 200 patients
  with no previous pelvic surgery
• Only 3 of the 220 patients had inadvertent
  urological trauma intraoperatively
• Factors favoring a successful vaginal approach
  were only one previous cesarean, a freely mobile
  uterus, previous vaginal delivery, uterus not
  exceeding 10-12 weeks size, and absence of
  adnexal pathology
• Infection following the previous cesarean was an
  unfavorable prognostic factor due to an increased
  risk of dense adhesions between the bladder and
  cervix

Sheth, SS, Malpani, AN. Vaginal hysterectomy
following previous cesarean section. Int J
Gynaecol Obstet 1995 50165.
12
Abdominal vs. Vaginal Hysterectomy

• Nulliparity
• Vaginal hysterectomy outcome in 52 nulliparous
  and 293 primiparous or multiparous women was
  compared prospectively
• The mean operative time was significantly longer
  in nulliparous patients (95 vs. 80 minutes)
• Vaginal hysterectomy was successfully performed
  in 50/52 of the nulliparous and 292/293 of the
  parous patients
• This suggests that nulliparous women can be
  considered candidates for vaginal hysterectomy

Agostini, A, Bretelle, F, Cravello, L, et al.
Vaginal hysterectomy in nulliparous women without
prolapse a prospective comparative study. BJOG
2003 110515.
13
Abdominal vs. Vaginal Hysterectomy

• Need for oophorectomy
• Multiple clinical trials have shown that as many
  as 95 of ovaries can be removed vaginally, with
  or without laparoscopic assistance
• Obesity
• Exposure of the operative field can be difficult
  in obese women, whether an abdominal or vaginal
  route is taken
• Vaginal approach is suggested for obese women
  requiring hysterectomy
• associated with lower postoperative morbidity
  than abdominal hysterectomy

Davies, A, O'Connor, H, Magos, AL. A prospective
study to evaluate oophorectomy at the time of
vaginal hysterectomy. Br J Obstet Gynaecol 1996
103915. Isik-Akbay, EF, Harmanli, OH,
Panganamamula, UR, et al. Hysterectomy in obese
women a comparison of abdominal and vaginal
routes. Obstet Gynecol 2004 104710.
14
Abdominal Hysterectomy

• Patient Preparation
• For patients at risk, thromboembolism prophylaxis
  is begun preoperatively, or pneumatic compression
  boots are applied in the OR
• Prophylactic antibiotic agent should be given as
  a single dose 30 minutes prior to the incision
• Incision choice - transverse or vertical
• Need for exploration of the upper abdomen
• Size of the uterus
• Presence of prior incisions
• Desired cosmetic results

15
Abdominal Hysterectomy - the Procedure

• The peritoneal cavity is entered and the upper
  abdomen and pelvis explored
• unexpected pathology
• confirm suspected pathological findings
• cytologic sampling of peritoneal fluid or
  peritoneal washings if indicated
• Exposure - When positioning retractors, it is
  important to avoid placing the lateral blades
  over the femoral nerves since this can lead to a
  peripheral neuropathy
• O'Connor-O'Sullivan
• Balfour
• Bookwalter

16
Abdominal Hysterectomy
UpToDate
17
Abdominal Hysterectomy
UpToDate
18
Abdominal Hysterectomy
UpToDate
19
Abdominal Hysterectomy
UpToDate
20
Abdominal Hysterectomy
UpToDate
21
Abdominal Hysterectomy
UpToDate
22
Abdominal Hysterectomy
UpToDate
23
Abdominal Hysterectomy
UpToDate
24
Abdominal Hysterectomy
UpToDate
25
Abdominal Hysterectomy - the Procedure

• Post-Op care -
• Not necessary to leave a bladder catheter in
  place postoperatively
• IV fluids for the first 24 hours to ensure that
  the patient remains well hydrated
• Early feeding of a regular diet can stimulate the
  bowel and decrease the length of hospitalization
• Deep breathing to prevent atelectasis
• Ambulation is encouraged
• Intermittent compression boots
• Adequate control of postoperative pain

Fanning, J, Andrews, S. Early postoperative
feeding after major gynecologic surgery
Evidence-based scientific medicine. Am J Obstet
Gynecol 2001 1851.
26
Post-op Abdominal Hysterectomy

• Walking and stair climbing are encouraged
• Tub baths or showers are OK
• Avoid heavy lifting (gt20 pounds of weight from
  the floor) for 4-6 weeks to minimize stress on
  the healing fascia
• Vaginal intercourse is also discouraged 4-6 weeks
  to allow the vaginal cuff to heal completely
• Driving should be avoided until full mobility
  returns and opioid analgesia is no longer
  required
• May return to work as soon as she has regained
  sufficient stamina and mobility

27
Vaginal Hysterectomy

• A prophylactic antibiotic agent should be given
  as a single dose 30 minutes prior to the first
  incision for vaginal hysterectomy
• cefazolin, cefoxitin, and cefuroxime
• Metronidazole (500 mg IV) may be used in patients
  with cephalosporin allergies
• A course of appropriate preoperative antibiotics
  in women with bacterial vaginosis can reduce the
  frequency of cuff infection

28
Vaginal Hysterectomy

• Patient positioning - dorsal lithotomy
• Bimanual pelvic examination is performed
• assess uterine mobility and descent
• confirm that no unsuspected adnexal pathology is
  found
• A bladder catheter may be inserted
• some surgeons believe that a distended bladder
  helps with recognition of a bladder injury and
  thus do not use a catheter

29
Vaginal Hysterectomy
UpToDate
30
Vaginal Hysterectomy
UpToDate
31
Vaginal Hysterectomy
UpToDate
32
Vaginal Hysterectomy
UpToDate
33
Vaginal Hysterectomy
UpToDate
34
Vaginal Hysterectomy
UpToDate
35
Vaginal Hysterectomy
UpToDate
36
Vaginal Hysterectomy
UpToDate
37
Vaginal Hysterectomy
UpToDate
38
Vaginal Hysterectomy
UpToDate
39
Vaginal Hysterectomy
UpToDate
40
Vaginal Hysterectomy
UpToDate
41
Vaginal Hysterectomy
UpToDate
42
Vaginal Hysterectomy
UpToDate
43
Vaginal Hysterectomy
UpToDate
44
Vaginal Hysterectomy
UpToDate
45
Vaginal Hysterectomy

• Uterine Morcellation
• Piecemeal removal of a large, often myomatous
  uterus
• Contraindicated in women w/uterine cancer
• Methods
• hemisection (bivalving)
• wedge/V-type incision
• intramyometrial coring
• The uterine vasculature must be ligated before
  beginning any type of morcellation

46
Morellation is Safe

• Morbidity is less than that encountered from an
  abdominal hysterectomy
• A rare problem in excision of a myoma is loss of
  the specimen into the peritoneal cavity due to
  clamp slippage
• After completing removal of the uterus, the
  patient's head can be elevated and lavage of the
  peritoneal cavity will bring the errant fibroid
  into the pelvis
• Uterine volume may be reduced preoperatively by
  administration of a GnRH

Taylor, SM, Romero, AA, Kammerer-Doak, DN, et
al. Abdominal hysterectomy for the enlarged
myomatous uterus compared with vaginal
hysterectomy with morcellation. Am J Obstet
Gynecol 2003 1891579.
47
Uterine Morcellation
UpToDate
48
Uterine Morcellation
UpToDate
49
Poor Uterine Descensus

• Decide whether to proceed with a vaginal approach
  or convert the procedure to an abdominal approach
• If the problem relates to introital narrowing
• midline or mediolateral episiotomy can be
  performed
• If the problem stems from an enlarged uterus
• morcellation can be begun after the uterine
  arteries have been ligated
• Lack of descent resulting from extensive adhesive
  disease usually requires an abdominal incision or
  packing the vagina and accessing the pelvis by
  means of laparoscopy

50
LAVH

• Laparoscopic hysterectomy was first performed in
  1989
• The impetus was to reduce the morbidity and
  mortality of abdominal hysterectomy to the level
  observed with vaginal hysterectomy
• The patient must be counseled about the risks and
  potential benefits of surgery, including those
  risks that are inherent to the laparoscopic
  approach. Consent is given for both laparoscopic
  surgery and laparotomy in case conversion to an
  open abdominal procedure becomes necessary

51
LAVH

• ACOG has listed the following as potential
  indications for laparoscopic assistance to
  facilitate hysterectomy via the vaginal approach
• Need for adhesiolysis
• Need for treatment of endometriosis
• Need for management of large leiomyoma(s) to
  facilitate uterine extraction
• Need for ligation of the infundibulopelvic
  ligaments to facilitate oophorectomy

ACOG Committee Opinion 311 Laparoscopically
Assisted Vaginal Hysterectomy. Obstet Gynecol
2005 105929.
52
LAVH

• Laparoscopically performed portion of LAVH is
  limited to adhesiolysis, excision of
  endometriosis and division of the upper vascular
  pedicles and parametria
• the remainder of the procedure is performed
  vaginally
• At the completion of the vaginal procedure the
  abdomen is reinsufflated
• helps the surgeon assess hemostasis

53
TLH

• The entire procedure is performed
  laparoscopically
• uterus is extracted vaginally, or removed
  abdominally using morcellation techniques
• After the uterus is removed, the vaginal cuff is
  closed using laparoscopic suturing techniques
• MORCELLATION IS NOT PERFORMED IF UTERINE CANCER
  IS SUSPECTED

54
LSH

• LSH is performed in an identical fashion to TLH
• after occluding the ascending uterine vascular
  pedicles
• cervix is amputated in a coring fashion
• beginning at the level of the internal os, down
  into the endocervical canal

55
Robot-assisted Lap Hyst

• Superior laparoscopic magnification of an image
  is achieved with robotic systems - surgical
  precision
• Rotational movement of the robotic hands
  facilitates manipulation of tissues and suturing
• Tasks like adhesiolysis, suturing, and knot
  tying were enhanced with the robotic suturing
  system
• Robot-assisted laparoscopic hysterectomy
  appeared to provide a tool for overcoming
  surgical limitations seen with conventional
  laparoscopy

Beste, TM, Nelson, KH, Daucher, JA. Total
laparoscopic hysterectomy utilizing a robotic
surgical system. JSLS 2005 913. Advincula,
AP, Reynolds, RK. The use of robot-assisted
laparoscopic hysterectomy in the patient with a
scarred or obliterated anterior cul-de-sac. JSLS
2005 9287.
56
Tools of the Trade for Scope Hyst

• Sutures
• Electrosurgery
• Bipolar cautery
• Laser
• Harmonic scalpel
• Argon Beam Coagulator
• Stapling device
• Vessel Sealing device
• Uterine manipulator
• Vaginal fornix delineation tool
• Pneumo-occluder

57
RUMI device
58
Delineation - Anterior Fornix
59
Posterior Fornix and Vaginal Cuff
60
Video clip of TLH using Rumi/KOH
61
Traditional versus Laparoscopic Hysterectomy -
Cochrane Review

• 27 randomized controlled trials with a total of
  3,643 participants
• No differences were found between vaginal and
  laparoscopic hysterectomy
• intraoperative visceral injury
• intraoperative bleeding
• conversion to laparotomy rates
• return to normal activities
• duration of the hospital stay

62
Traditional versus Laparoscopic Hysterectomy -
Cochrane Review

• No significant differences were found in
• occurrences of pelvic hematoma
• vaginal cuff infection
• urinary tract infection
• chest infection
• thromboembolic events
• fistula formation
• urinary dysfunction
• sexual dysfunction
• patient satisfaction

63
Traditional versus Laparoscopic Hysterectomy -
Cochrane Review

• Return to normal activities was slower after the
  abdominal hysterectomy compared to laparoscopic
  and vaginal hysterectomy
• Total laparoscopic hysterectomy was associated
  with the longest operation time, LAVH was
  comparable with abdominal hysterectomy, and
  vaginal hysterectomy was the fastest
• The laparoscopic approach was associated with
  less risk of wound or other infections and less
  blood loss then abdominal hysterectomy

64
Traditional versus Laparoscopic Hysterectomy -
Cochrane Review

• Urinary tract injuries (bladder plus ureteral
  injuries) appeared to be more likely in patients
  undergoing laparoscopic hysterectomy
• No differences were found between TLH and LAVH,
  with the exception of surgical time

65
eVALuate Study

• Multicenter randomized controlled trials that
  evaluated the relative roles of vaginal,
  abdominal and laparoscopic hysterectomy in
  routine gynecological practice
• 2 parallel multicenter randomized trials all with
  benign disease
• Arm 1 292 women assigned to abdominal
  hysterectomy and 584 women assigned to
  laparoscopic hysterectomy
• Arm 2 168 women assigned to vaginal hysterectomy
  and 336 assigned to laparoscopic hysterectomy

66
eVALuate study

• Multicenter randomized controlled trials that
  evaluated the relative roles of vaginal,
  abdominal and laparoscopic hysterectomy in
  routine gynecological practice
• Women were excluded if they had
• 2nd or 3rd degree prolapse
• uterus greater than 12 week size
• medical disorder precluding laparoscopic surgery
• required bladder or pelvic support surgery

67
eVALuate Study

• Multicenter randomized controlled trials that
  evaluated the relative roles of vaginal,
  abdominal and laparoscopic hysterectomy in
  routine gynecological practice
• Major composite surgical complications occurred
  more frequently in laparoscopic than abdominal
  hysterectomy (11 vs. 6)
• Rate of minor complications was similar (25 -
  27)
• Laparoscopic hysterectomy took longer than
  abdominal or vaginal hysterectomy (median time of
  84 vs. 50 minutes, and 72 vs. 39 minutes)

68
Cost Analysis

• Cost analysis found that laparoscopic
  hysterectomy was not cost effective relative to
  vaginal hysterectomy
• Observational studies have documented cost
  effectiveness of laparoscopic hysterectomy as
  compared to abdominal hysterectomy

Sculpher, M, Manca, A, Abbott, J, et al. Cost
effectiveness analysis of laparoscopic
hysterectomy compared with standard hysterectomy
results from a randomised trial. BMJ 2004
328134. Demco, L, Garry, R, Johns, DA, et
al. Hysterectomy. Panel discussion at the 22nd
annual meeting of the American Association of
Gynecologic Laparoscopists (AAGL), San Francisco,
November 12, 1993. J Am Assoc Gynecol Laparosc
1994 1287 Lenihan, JP Jr, Kovanda, C,
Cammarano, C. Comparison of laparoscopic-assisted
vaginal hysterectomy with traditional
hysterectomy for cost-effectiveness to employers.
Am J Obstet Gynecol 2004 1901714.
69
Summary

• Based upon review of all available data, both
  laparoscopic assisted vaginal hysterectomy and
  vaginal hysterectomy are more cost-effective than
  abdominal hysterectomy
• When vaginal hysterectomy is contraindicated or
  predicted to be difficult, the laparoscopic
  approach should be considered

70
Summary

• Laparoscopic hysterectomy was associated with
• less postoperative pain than abdominal
  hysterectomy
• shorter length of hospitalization (3 vs. 4 days)
• quicker recovery
• better quality of life at 6 weeks postoperatively
• Laparoscopic techniques are applicable to a
  larger number of pathologies and situations than
  vaginal hysterectomy
• Gynecologic surgeons need to learn and apply
  laparoscopic techniques when considering
  hysterectomy