Surgery: Is total laparoscopic hysterectomy a safe surgical procedure?
Human Reproduction
Is total laparoscopic hysterectomy a safe surgical procedure?
Charles M.Chapron 0
Jean-Bernard Dubuisson 0
Yann Ansquer 0
0 Service de Chirurgie Gynecologique (Pr Dubuisson) , Chruque Universitaire Baudelocque, CHU Cochin Port-Royal 123, Boulevard Port-Royal, 75014 Paris , France
'To whom correspondence should be addressed Total hysterectomy via laparoscopy is a recently developed technique. Assessment of a new surgical technique, once the operation has been shown to be feasible, requires an evaluation of the risks of complications. Here we report our cumulative 3 year experience with laparoscopic hysterectomy in a total of 222 patients. The overall complication rate was 10.0%. We did not observe any haemorrhage complications requiring another operation. Four patients (1.8%) were re-admitted to hospital but only two of them (0.9%) had to be operated upon again (one veslco-vaginal fistula and one vaginal cuff wound separation). These encouraging results mean that, provided the surgeons are experienced in laparoscopic surgery, total laparoscopic hysterectomy technique would appear not to have a higher rate of complications than hysterectomy via laparotomy or the vaginal route.
Introduction
Hysterectomy is the second most common major surgical
procedure in the USA (Graves, 1992). In about three-quarters
of operations the procedure is carried out via laparotomy
(Wilcox et al, 1994). The development of laparoscopic surgery
has certainly been the most important step forward in
gynaecological surgery over the past 20 years. Although the feasibility
of total hysterectomy via laparoscopy has been proved today
(Reich et al., 1989), there is still considerable debate concerning
the indications for hysterectomy (Finkel and Finkel, 1990;
Carlson et aL, 1993; Wilcox et al, 1994) and the indications
for laparoscopic surgery for hysterectomy (Dorsey et al., 1995;
Chapron and Dubuisson, 1996). Laparoscopic surgery is not
an alternative to vaginal surgery when the latter can be
carried out under good conditions (Richardson et al., 1995).
Laparoscopic surgery should only be proposed as a means of
making a difficult vaginal hysterectomy easier and/or to avoid
laparotomy for the patient (Chapron and Dubuisson, 1995).
From both the patient's and society's point of view, the
benefits to be had by avoiding laparotomy are considerable.
Nevertheless, before this technique can be proposed, the risk
of complications needs to be assessed.
Materials and methods
From 1 January 1993 to 31 December 1995, 222 pauents underwent
total laparoscopic hysterectomy (TLH). All the operations were
carried out using the same technique, which has been described
previously (Chapron et aL, 1994b). Three 5 mm suprapubic ports
were used to introduce the laparoscopic instruments. It was essential
to cannulate the uterus to obtain proper exposure. The two essential
characteristics of this technique are that all the instruments are
reusable and that all haemostasis is carried out by electrosurgery
(bipolar coagulation). Using this technique every part of the operation
was carried out via laparoscopy, from the adnexal phase (conservative
or radical) to the colpotomy included.
hi every case the operation was indicated for a benign pathology.
All the pauents presented either a contraindication or considerable
difficulty for performing an exclusively vaginal hysterectomy. No
patient presented genital prolapse, pelvic floor relaxation or associated
stress urinary incontinence.
The mean age of the patients was 47.3 ± 6.6 years (range 31-75);
45 patients (20.3%) were menopausal. The mean parity of the
patients was 1.5 ± 1.2 (range 0-5). Of the 74 (33.3%) pauents
who had had no previous vaginal delivery, 16 (21.6%) presented a
history of Caesarean section, with an average of 1.8 ± 0 8 sections
per pauent (range 1-4). In all, 70 patients (31.5%) had a history
of laparotomy (not including simple appendicectomy) The mean
number of previous laparotomies was 1.4 ± 0.7 (range 1—4). The
indications for hysterectomy, of which there was sometimes more
than one in the same patient, were as follows' abnormal uterine
bleeding (n = 175; 78.8%), enlarging uterine myomas (n = 98;
44.1%), an adnexal mass (n = 27; 12.2%); and chronic pelvic pain
(n = 63; 28.4%) A total of 100 pauents (45.0%) underwent one
or more laparoscopic surgical procedures in association wim the
hysterectomy: lysis (n = 39; 17 6%), prophylactic adnexectomy
(n = 52; 23.4%), adnexectomy for benign ovarian cyst (n = 27;
12.2%), coagulation of peritoneal endometriosis (n = 6; 2.7%);
myomectomy (n = 2; 0.9%); and appendicectomy (n = 1; 0.5%). hi
36.5% of cases (n = 81) it was necessary to use procedures to reduce
uterine volume (morcellation, enucleation, coring, bivalving, etc.)
before the uterus could be extracted.
Results
The rate of conversion to laparotomy was 5.4% (n = 12). In
one-third of the patients (n = 4) the decision for laparotomy
was taken after a simple diagnostic laparosc (...truncated)