Hysterectomy

Robert D. Auerbach, M.D.

Senior Vice President & Chief Medical Officer
CooperSurgical, Inc.
Associate Clinical Professor
Yale University School of Medicine

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%)

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

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

Hysterectomy


Complete removal of fundus/cervix

TAH

TVH

LAVH

TLH



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


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



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

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
Abdominal vs. Vaginal Hysterectomy
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; 97:613.

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; 8:339.

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; 50:165.

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; 110:515.

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; 103:915.

**Isik-Akbay, EF, Harmanli, OH, Panganamamula, UR, et al.
Hysterectomy in obese women: a comparison of abdominal
and vaginal routes. Obstet Gynecol 2004; 104:710.

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


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

Abdominal Hysterectomy
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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; 185:1.

Post-op Abdominal Hysterectomy
Walking and stair climbing are encouraged
Tub baths or showers are OK
Avoid heavy lifting (>20 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

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

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

Vaginal Hysterectomy
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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

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; 189:1579.

Uterine Morcellation
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Uterine Morcellation
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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
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


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; 105:929.

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

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

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


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; 9:13.
** 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; 9:287.

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



RUMI device
Pneumo-occluder
KOH Cup
Articulation Point
RUMI Tip
RUMI locking
articulation handle

Delineation - Anterior Fornix

Posterior Fornix and Vaginal Cuff

Video clip of TLH using Rumi/KOH

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

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

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
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
Traditional versus Laparoscopic Hysterectomy -
Cochrane Review

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




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
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)





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; 328:134.

** 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; 1:287

***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; 190:1714.

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



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