Surgical Techniques

Poor access and exposure are the main concerns. Seve­ral different methods have been suggested for do successful and safe LH in large uteruses. Wattiez et al.⁹ introduced several modifications to the current technique for LH for large uteri. The key modifications consisted in higher insertion of the optic cannula with consideration of open abdominal entry to minimize the risk of lacerating the uterus. The optic cannula should be placed 10 cm above the umbilicus and the 30-degree optic can ensure better visualization of ute­rine pedicles⁹. The middle cannula should be placed through the umbilicus or even higher, while the other two lateral ones should be placed according to uterine size and location of fibroids⁹. The role of the uterine manipulator is especially importat in case of very large uteri to optimize the exposure of structures (vessels and ligaments) and can significantly reduce the opera­ting time. Not all uterine manipulators are suitable in these patients⁹. However, it was suggested that in some cases adding another port and using an additional ins­trument for manipulation may be helpful⁹. Another concern is the risk of hemorrhage, which in cases of very enlarged uteri can be increased due to difficult exposure⁹. This can be overcomed through polar ins­truments as described by Wattiez et al⁹ and Fiaccavento et al¹¹. Since the uterine pedicle is enlarged as well, the surgeon should be experienced in performing ligation and suturing the uterine artery near its origin from the internal iliac artery. In selected cases, li­gation or suturing may be of help in reducing the blood supply before applying bipolar coagulation, thereby lowering the risk of hemorrhage and ureteral injury⁹. Transection of the vaginal cuff can be performed vaginally or laparoscopically; however, better visualization of pelvic anatomic structures is obtained by laparoscopy, resulting in a safer procedure⁹. Enlarged uteri required significantly more morcellation than smaller uteri. This can be performed this either vaginally or with a laparoscopic knife, which facilitated uterine extraction⁹. The laparoscopic knife has potential advantages, as it may reduce operating time and may be associated with few vaginal and rectal injuries⁹.

Tchartchian et al¹³ described the combined LH in a case of a uterus with a weight of 2480 grams using the switch-over technique, which means a number of six trocars in the anterior abdominal wall. The necessity of the switch-over technique does depend not only on the uterine weight but also on the mobility of the uterus, the uterine shape and the exibility of the abdominal wall, and thus the residual intraabdominal volume¹³. As such, it is inserted 6 trocars including 3 on the left: one trocar in the lower, one in the middle, and one in the upper abdomen, allowing access to the left narrow space¹³. The 3 trocars on the right side are placed in a mirror-like position. The upper lateral trocar is to introduce the camera and the other two located trocars to introduce forceps and coagulator or scissors¹³. The patient is slightly tilted to the opposite side to facilitate visualization and preparation of structures¹³. Next, the surgeon and his team switched sides positioning to the other side of the patient, thus accessing the narrow space between the uterine wall and abdominal wall. Again, the patient is slightly tilted to the opposite side, enabling better exposure and preparation of organ structures¹³. Tchartchian et al¹³ affirmed that this technique enables to complete hysterectomies of uteri of nearly all sizes and the use of the changeover techique is useful and advisable when a high uterine weight of more than 2.000-2.500g is expected.

Shahid et al¹⁴, performed a five port modified technique for a laparoscopic subtotal hysterectomy (LSH). The first trocar with 5mm was inserted in Palmers point. A second 5 mm port was placed on the contralateral side, in the right hypochondrium and two other ancillary (5 mm) ports were inserted laterally at the level of the umbilicus depending upon the size of the uterus, above the level of the ovarian ligaments lateral to the epigastric vessels and a 10 mm suprapubic port 4 cm above the pubic symphysis in the midline¹⁴. The right side of the procedure was carried out with the laparoscope in the right subcostal port and likewise the left side was carried out with the laparoscope in the left subcostal port. The advantages of this technique is that exposes the both pelvic side despite the size of the uterus as the camera can be placed on the left side for left sided pedicles and likewise on the right side for the right sided pedicles, avoiding the umbilical or supraumbilical port wich minimize the laceration of the uterus¹⁴. This technique has added cosmetic benefits as all the ports above the bikini line are small (5 mm) and symmetrical with shorter operation time¹⁴. However, LSH brings the risk of developing cervical cancer in the future.

Yavuzcan et al¹⁵, described a four port technique for LT: a 10mm trocar inserted in the Palmer Point, ano­ther 10mm port below the umbilicus inserted under direct vision, two 5mm ancillary ports in both hypocondrium lateral to the rectus abdominis muscle, inferior epigastric vessels and 1/3 outer portion of the distance between spina iliaca anterior superior and umbilicus, and the laparoscope was inserted trough intraumbilical trocar. This approach has better cosmetic results and does a total LH. However this study had a small number of patients and it’s difficult to extrapolate information about complication rates and operation outcomes.

Uccella et al¹⁶, hypothesize that the reduction in the caliber of the trocars can be associated not only with better cosmetic results, but also with reduced operative trauma and a lower rate of wound complications. In particular, it should not be neglected that, up to now, no incisional hernias have been described through 3mm incisions among adults, whereas several reports have shown that 5mm trocars are at risk of this threatening complication and that its likelihood is related to the size of the accesses¹⁶. Under direct visualization, three 5mm or 3mm ancillary trocars were inserted, one suprapubically and two laterally to the epigastric arteries, in the left and right lower abdominal quadrants, respectively¹⁶. In fact, Uccella et al¹⁶, concluded that with high-level proficiency in the field of MIS, large uteri with a size between 16 and 20 weeks of gestation can be safely and effectively managed using 3mm ins­truments with no shortcomings compared with conventional laparoscopy and with better cosmetic outcomes.

Recent concerns about the risk of iatrogenic tumors in the abdominal cavity after morcellation by implants of lost morcellated tissue fragments have been discussed in the last years. Because of potential tissue dissemination within the abdominal cavity, the Food and Drug Administration recently warned against the use of electromechanical power morcellation in hysterectomy and myomectomy.¹⁷ The steering committee on fibroid morcellation of the European Society of Gyneacological Endoscopy concluded that the prevalence of uterine sarcoma in presumed fibroids is 0.14% with a range from 0.49% to 0.014%¹⁸. The meticulous removal of all tissue particles after morcellation and a sufficient wash of the complete intrabdominal space are very important¹⁰. Uterine size, ultrasound examination, and radiologic methods cannot safely predict uterine malignancy¹⁰. Presurgical uterine biopsies have a very low sensitivity and therefore cannot help to avoid the morcellation of malignant or premalignant tissues¹⁰. In response, accessories have been innovated to minimize this risk. One example is specialized bag protection around the surgical instrument to prevent fragment dissemination into the peritoneal cavity. However the use of bags is limited to a certain uterine size¹⁰. The alternative laparoscopic-assisted vaginal hysterectomy (LAVH) with extraperitoneal vaginal morcellation or the vaginal removal of the uterine corpus was not feasible in the described cases¹⁰. A condition for the vaginal approach is the mobilization of the uterine tissue into the pelvis¹⁰. Due to their size, in the presented ca­ses the uterine bodies were cranial of the pelvis, which made the vaginal mobilization of the cervix impossible¹⁰. However, in the case of suspicious myomas growing after menopause, growing on GnRH agonists, rapidly growing over a short time frame in premenopause, exceeding 10 cm in diameter, caution should be used, maybe evaluating the option of a laparotomic approach to avoid morcellation of the uterus or myomas⁸.

Complications

Many improvements have been made in the number and location of laparoscope and trocars in an attempt to gather better results for both the patient and surgeon¹⁵. Powerful morcellators have been put in practice for morcellating large uteruses and fibroids that cannot be removed by vaginal route. In contrast to the routine practice in the last years, the idea of safely performing LH in large uteruses has been raised even in those uterus with >1000g^8-10,13,16.

Some surgical strategies can be use to avoid complications. The identification of the ureteral trajectory is imperative before applying an energy source to seal the uterine vessels¹⁸. The uterine vessels are pushed late­rally by the expanding lower uterine segment and are in closer proximity than usual to the ureters¹⁸. In addition, the anatomy can be significantly distorted and the ureter(s) pushed cephalad by the uterus as it grows out of the pelvis¹⁸. Sometimes it is easier to seal the uterine vessels at their origin from the anterior division of the hypogastric artery¹⁸. Some authors have advocated the practice of universal cystoscopy during major gynecologic cases to improve injury detection¹⁸. It has also been suggested that intraoperative markers such as peristalsis and visualization of ureteral caliber may be unreliable to detect injury.¹⁸ The prophylactic placement of ureteral stents is used in select cases to facilitate intraoperative ureter identification. Lighted urete­ral stents have also been used, especially in laparoscopy, in which the haptic feedback is lacking¹⁸.

The uterine artery ligation can be done by four ways: conventional, anterior, posterior and lateral approach⁶. The anterior approach consists in the ligation of the ascending branch of the uterine artery without opening the posterior broad ligament⁶. This is useful for the uterus with large fibroids with poor access to the cul sac and posterior broad ligament or when they are not maneuverable by the manipulator⁶. This way isn’t so useful for patients with fibrosis in the parametrium from endometriosis or dense bladder adhesions from caesarean⁶. The posterior approach resides in ligation of ascending branch of uterine artery without developping bladder flap⁶. This method is excellent in patients with extensive and dense uterine adhesions to the bladder and anterior abdominal wall⁶. The lateral approach is commonly done in radical hysterectomy for cervical cancer⁶. It’s helpful for retroperitoneal fibrosis in the parametrium seen in severe endometriosis and large fibroids which can be difficult to visualize without angled scope in broad fibroid uterus⁶.

Wattiez et al⁹, concluded that if given adequate training in laparoscopic surgery and with the proper technique, LH can be performed successfully in most wo­men with very enlarged uteri, with no increase in complication rates and short-term recovery comparable with women that have moderately enlarged uteri. They ana­lysed a series of LH performed in women with enlarged uteri (>500g Vs ≤300g). No difference was seen in complication rates, day 1 haemoglobin level drop and hospital stay between groups. Operative time was significantly longer (p<0,001) in the group with greater uteri. No was conversion to laparotomy required in either group.

Fiaccavento et al.¹¹, compared 149 patients with a uterus weighting less than 350 g with 100 patients with a uterus weighting more than 500 g. There was a statistically significant increase in terms of operative time and post-operative hospital stay length in the se­cond group without differences in time to recovery between groups. There were no differences in terms of major complications.

The duration of the surgical procedure shouldn’t be understimated. In turn, this increases the risk for thrombosis and neurological complaints¹³. Prophylatic measures to avoid should be done, such as, mobilization of patient legs and occasional change of the position after 2 hours to avoid nerve lesion and other complications like compartment syndrome¹⁰.

Uccella et al¹⁶ reported that LH enables a marked reduction in the need for AH and it’s safe perform minilaparoscopic approach in patients with enlarged uterus. Hospital stay and rate of intraoperative and postoperative complications are independent of ute­rine weight¹⁵. Bonilla et al.¹⁹ investigated if an enlarged uterus is associated with an increased rate of intra­operative and postoperative complications and prolonged hospital length of stay after AH or LH. They indicated that LH is an excellent choice for enlarged uteri and it is strongly associated with decreased morbidity, shorter hospital stay, and reduced mean estimated blood loss and blood transfusion rate.

Comparing to other approachs

The primary surgical approaches through which hysterectomies are performed are vaginal, abdominal, or laparoscopic (with or without robotic assistance)²⁰. Aside from personal training and experience, factors to be considered by the surgeon in selecting the hysterectomy surgical approach include: the size and shape of the uterus, pelvis, and vagina; accessibility to the uterus; extent of extra-uterine disease; the need for concurrent procedures; available hospital resources; and patient preference²⁰. Each surgical approach is associated with its own advantage regarding outcomes and complication rates²¹. When choosing the surgical approach, the surgeon should take into consideration how the procedure may be performed to optimize the patient’s health and minimize the risk of complications²⁰. While in general it is recommended to take the most MIS, the majority of the existing evidence specifi­cally supports the principle that, when feasible, VH is the safest and most cost-effective route by which to remove the uterus²⁰.

In the literature, the review of the major reports on hysterectomy for myomatous uteri demonstrates that the vaginal approach is used more frequently for small or medium sized uteri²¹. With the LAVH, the abdo­minal-pelvic exploration and the ability to perform oophorectomy safely represent the major advantages compared with VH²¹. The specific indications for each of the hysterectomy techniques remain uncertain²¹. However, the purpose of LAVH and LH is not to replace VH, but rather to increase the abilities of the gynecological surgeon to perform MIS for more extended indications, avoiding the need of an AH also in the presence of ovarian tumors, tubo-ovarian adhesions, endometriosis, or previous pelvic surgery²¹. Hatta et al²², believe that LH is a better procedure for a large uterus because the average intraoperative blood loss in the LH group was significantly lower than that in the LAVH group. Given adequate training in laparoscopic surgery and use of proper technique, LH can be performed successfully in most patients with large myoma uteri, with no increase in the complication rates, and with a short-term recovery comparable to that achieved with LAVH²⁰. Robotic hysterectomy was shown to be feasible and safe with a lower blood loss, albeit at the cost of a greater number of ports and longer operative time²³. Last but not least, compared to AH, LH has a faster return to normal activity, shorter durantion of hospital stay, fewer wound or abdominal wall infections and longer operating time. Considering the MIS, VH, LAVH, and LH and laparoscopic supracervical hysterectomy, the AH can be avoided in almost every case¹⁰.

Surgical Technique

In cases with endometriosis the procedure may need to be modified according to the extent and anatomical location of the disease. Adhesiolysis must be meticulous and most of the time is the first step²⁷. Whenever feasible, avoid lysing dense and fibrotic adhesions of bowel and bladder adhesions to the uterus until all of the uterine blood supply is secured.⁶ A retroperitoneal approach it is used to try to work in healthy tissue, surrounding the disease²⁷. As we said before, the identification of the ureter trajetory is very important to avoid complications. Particular attention should be paid during isolation of the ureter to avoid damage to its periadventitial vessels, and to ortho and parasympathetic nerves running caudally and dorsally to it²⁷.

As we see before, uterine artery ligation can be done in four ways.⁶ The posterior is excellent in patients with extensive and dense uterine adhesions to the bladder and anterior abdominal wall⁶. The lateral approach is good for retroperitoneal fibrosis in the parametrium seen in severe endometriosis⁶. The dissection shouldn’t be extended below the level of the deep uterine vein, to spare the hypogastric nerves, the pelvic splanchnic nerves and the inferior hypogastric plexus (also known as pelvic plexus), unless massive infiltration by the endometriotic process is present below this level²⁷. In addition, the recto-vaginal septum may need to be opened and developed in the case of local infiltration by the endometriotic process²⁷.

Complications

In patients with endometriosis, even in the case of deep infiltrative lesions and “frozen pelvis”, laparoscopic surgery allows not only eradication of the disease, an excellent safety profile, lower pain, and faster recovery, compared with open surgery, but it also guarantees a better visualization of the anatomical structure with the possibility (when indicated and feasible) of nerve-sparing procedures^27-29.

However, performing LH in women with endometriosis (and in particular, moderate and severe endometriosis) is not only more difficult, but it is associated with a higher incidence of complications, urinary lesions and voiding dysfunction²⁷. Nevertheless, the total risk of post-LH complications in this subset of high-risk patients appears acceptable²⁷. Another interesting consideration is to observe how the risk of voiding dysfunction is approximately 4% among wo­men with endometriosis, compared with 0% in those not affected by the disease²⁷. This is likely due to denervation at the level of the mixed orthosympathetic and parasympathetic inferior hypogastric plexus²⁷. Despite a particular attention to preserve nervous fibers running through the pelvis, it appears sometimes impossible to preserve the hypogastric nerves and/or the pelvic splanchnic nerves that run caudally and dorsally to the ureter²⁷. Nerve-sparing procedures have been proposed recently with encouraging results, as a demonstration that a thorough and comprehensive anatomical knowledge, along with a high laparosco­pic skill may reduce the incidence of some subgroups of complications²⁷.

Adding, comparatively with AH, the use of LH has fewer complications and should be the first choice of surgical treatment in patients with severe pelvic endometriosis who require a hysterectomy³⁰.

Surgical Technique

Anterior wall adherence should be anticipated in patients who have undergone CS if the uterine cervix is found be located much superior to its normal location during pelvic examination³². In general, the umbilical trocar is inserted first to create a pneumoperitoneum for surgery³². However, because midline adhesion is most common in women with anterior wall adherence, this may be difficult³². Therefore, for LH in such wo­men, it is safer and more effective to make a pneumoperitoneum by inserting the first trocar in the upper lateral part instead of the umbilical trocar³². Ancillary trocars are then inserted in sites with less adhesion. Sufficient adhesiolysis is performed to secure adequate visual field for LH³². If both the surgeon’s hands are freed as in previously described surgical method, LH can be performed successfully. The adhesion site between the uterus and anterior wall is examined closely and the lateral portion of the adhesion is dissected with a dissecting scissors with monopolar coagulation³². The use of lateral approach for adhesiolysis can reduce bleeding, allowing hysterectomy to be performed more easily³². Sometimes it can be an issue the distance from the anterior wall adherence to the trocar. If it is too close, it is easier to perform adhesiolysis of the anterior wall adherence using a 5-mm telescope in the right upper quadrant and laparoscopic instruments in the left upper quadrant and umbilical port without leading to major changes in the surgical view between the umbilical and right upper quadrant port sites³². Bladder wall adhesion is an unavoidable side effect in patients who have undergone CS³². If the boundary between the bladder and adhesion is unclear, it can be used the cystosufflation technique using carbon dioxide to distend the bladder through a Foley catheter during the laparoscopic procedure to check the border for a site to perform adhesiolysis³².

Complications

Prior CS is associated with an increased risk of complications during a subsequent hysterectomy. CS predisposed for bladder injury³¹. In a prospective study of 574 laparoscopic hysterectomies, bladder injury occurred in 5 % of the women with a former CS compared with 1.2 % of the women with no CS, moreover, major complications increased with the numbers of CS³³. This conclusion is not surprising given that previous pelvic surgery distorts normal anatomy with loss of surgical planes increasing the difficulty of surgery³³. In the presence of previous CS, VH also has an increase in complications.³³ There is evidence in patients undergoing AH with previous CS of increased complication rates, but statistically less than with VH or LH³³. An increase in urologic injury has been shown when comparing LH with AH or VH³³. Overall LH in the setting of previous CS can still be recommended, because long-term sequelae are rare³³. Should bladder injury occur, recognition and immediate repair provides a very good prognosis³³.

Barrier Agents

Laparoscopic surgical procedures have been associa­ted with fewer postoperative adhesions than open sur­geries. Meticulous surgical technique is a means of preventing adhesions³⁴. This includes minimizing tissue trauma, achieving optimal hemostasis, minimizing the risk of infection, and avoiding contaminants and the use of foreign materials when possible³⁴. However, adhesions are not always preventable despite meticulous surgical technique. Some conditions may increase the likelihood of forming adhesions, such as endometriosis or chronic pelvic inflammatory disease. When patients are at particular risk of postoperative adhesions the use of adjuvant measures of adhesion prevention could be considered³⁴. Polytetrafluoroethylene barrier is more effective than no barrier or oxidized regenerated cellulose in preventing adhesion formation³⁴. Oxidized regenerated cellulose adhesion barrier is associa­ted with a reduced incidence of pelvic adhesion formation at both laparoscopy and laparotomy when complete hemostasis is achieved. Chemically modified sodium hyaluronate/carboxymethylcellulose is effective in preventing adhesion formation, especially following myomectomies³⁴. In the Cochrane Database³⁵, there was no evidence on the effects of barrier agents used during pelvic surgery on either pain or fertility outcomes³⁵. However, low quality evidence suggested that oxidised regenerated cellulose, expanded polytetrafluoroethylene and sodium hyaluronate with carboxymethylcellulose may all be more effective than no treatment in reducing the risk of adhesions following pelvic surgery³⁵. No adverse events directly attributed to the adhesion agents were reported³⁵.