Surgery: Is total laparoscopic hysterectomy a safe surgical procedure?
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.
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.
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 laparoscopy before TLH
began. In two cases laparotomy was used because of the size
of the uterus (930 and 790 g); in the other two cases laparotomy
was used because a large uterus (810 and 470 g) was associated
with severe adhesions. In the eight other cases (66.7%) it was
© European Society for Human Reproduction and Embryology
Table IL Complications of laparoscopic hysterectomy review of the
Urinary tract system
Bladder injury 2
Vesico-vaginal fistula 1«*
Ureteral complications 0
Urinary tract infection 3
Urinary retention 0
Small and large bowel injury 0
Intestinal obstruction 0
Vagina] cuff bleeding 2
Vaginal cuff wound separation
Pelvic haematoma 1*
Transient high fever (38°Q without explanation
Between 24 and 48 h 4
After 48 h 5
Pulmonary embolism 0
Incisional hernia 0
Abdominal wall ecchymosis 1
"Complications requiring re-admission
''Complications requiring a second operative procedure
a true conversion to laparotomy because the surgeon had
indeed started TLH. Thus the real failure rate of laparoscopic
surgery was 3.7% (87218). Conversions to laparotomy were
prompted for the following reasons: utenne volume with lateral
fibroids (n = 2; 470 and 300 g), severe adhesions (n = 5),
and the combination of large uterus (465 g) and considerable
adhesions (n = 1).
For patients who underwent TLH (94.6%; n = 210), the
mean operating time was 143.6 ± 40.2 min (range 60-300).
The mean estimated blood loss was 1.3 ± 0.9 g/100 ml
haemoglobin (range 0.0-4.1), and no patient required a blood
transfusion. The mean uterine weight was 258.1 ± 152.4 g
(range 40-860). The average hospital stay was 3.3 ± 1.3 days
The overall complication rate was 10.0% (n = 21). Details
of these complications are given in Table I. There were no
cases of mortality during the hospitalization nor during the
postoperative course. There were no complications secondary
to installation of the patient on the operating table
(neuropraxia, etc.). No complications were observed when the
pneumopentoneum was created or the trocars inserted
(umbilical and suprapubic).
Only two patients (0.9%) presented a complication which
required a further operation (vesico-vaginal fistula, vaginal
cuff wound separation). Re-hospitalization was necessary in
four cases (1.8%). Apart from the two patients who were
operated upon again, another patient had gastroenteritis and
one patient presented a pain syndrome secondary to a small
3 cm pelvic haematoma. The latter two cases responded
favourably to medical treatment combining antibiotics and
Although no complications involving the ureter were
observed, there were, unfortunately, three bladder
complicaComplications of laparoscopic hysterectomy
tions: two bladder injuries and one vesico-vagmal fistula The
two bladder injuries were diagnosed during the operation by
injecting methylene blue via the bladder catheter; bladder
repair took place under the same anaesthesia. In the first case
the bladder was sutured by laparotomy; the decision to convert
to laparotomy was not prompted by the bladder injury itself
but by the size of the uterus and the existence of severe
adhesions. In the second case the bladder was sutured via
laparoscopy using extra corporeal knots. The vesico-vaginal
fistula was diagnosed 2 months after TLH, which took place
with no particular problems. Investigations prompted by a
continuous, abundant, watery vaginal discharge revealed a
small lesion located at the supratrigonal portion of the
bladder, halfway between the ureteral orifices. Installation of
a bladder catheter for 6 weeks did not permit spontaneous
healing, so the patient underwent transabdominal closure of
Regarding the postoperative period, no hernia
complications occurred at the trocar insertion sites. Just one case of
abdominal wall echymosis was observed. There were no
thrombo-embolic complications. Only 14 (6.7%) patients
presented a postoperative febrile morbidity: three urinary
infections, the gastroenteritis case, the 3 cm pelvic haematoma
case and nine cases of unexplained transient high fever
The complication rate in this series was 10.0%. Although the
laparoscopic hysterectomy techniques are not identical in all
series, our results are nevertheless comparable with those
already published (Hill et al, 1994; Liu and Reich, 1994;
Jones, 1995; Nezhat et al., 1995) (Table II). This overall
rate is lower than those reported for abdominal and vaginal
hysterectomy (Dicker et al, 1982; Gitsch et al, 1990). Even
if there are no prospective randomized controlled trials and
although comparison of the results is difficult, because
indications for hysterectomy are often different, depending on the
approach used, it would appear that laparoscopic surgery does
not involve a greater risk of complications than the vaginal
route or laparotomy. The low level of febrile morbidity, 6.7%
in this series, is characteristic of the postoperative history
when the hysterectomy is carried out via laparoscopy (Hill
et al., 1994; Liu and Reich, 1994; Nezhat et al., 1995).
Another important advantage of laparoscopic surgery is reduced
peroperative blood loss None of the patients in our series
needed a transfusion. However TLH does involve a longer
operating time than abdominal or vaginal hysterectomy.
However, this should not be used as an argument against this
technique. The technique is still very new (Reich et al, 1989),
and the operating times will shorten considerably as the
operating technique and experience of the surgeons improve
(Chapron et al, 1996). In addition, an analysis of operating
time must take the indication for hysterectomy into account.
Laparoscopic surgery must only be proposed as an alternative
to laparotomy and/or to make a difficult vaginal hysterectomy
easier. In the first of these situations, the question of how long
the operation lasts takes second place to the benefits to be had
thanks to laparoscopic surgery. In the second situation it must
be said that difficult vaginal hysterectomies also take a long
time to complete and involve a greater risk of peroperative
haemorrhage complications requiring blood transfusion (Gitsch
et al., 1991).
From the purely technical point of view, we feel that several
results are important. The fact that we had no incisional hernia
following TLH is because of our operative technique. This
type of accident occurs secondary to the use of large ports
(Kadar et al, 1993; Montz et al, 1994), notably when
endoscopic linear staplers are used. By using only 5 mm
trocars we not only avoided the risk of incisional hernia, but
also those specific to the use of endoscopic linear staplers
(Nezhat et al., 1993). Furthermore, bipolar coagulation is
perfectly reliable for haemostasis, even for large important
vessels such as the uterine artery or those of the
infundibulopelvic ligament. We observed no postoperative haemorrhage
complications requiring further operations, and none of
die patients needed a blood transfusion. Hence it is
perfectly possible to use a simple, inexpensive and re-usable
set of instruments, already to be found in every laparoscopic
surgeon's possession, to carry out efficient haemostasis in all
situations required by TLH (Chapron et al, 1994a). This point
is extremely important in that one of the main arguments put
forward against laparoscopic hysterectomy is that it costs so
much more than the vaginal route or laparotomy. If laparoscopic
hysterectomy is carried out with exclusively re-usable
equipment (bipolar coagulation, trocars), the hospital cost of the
operation is comparable with that via the vaginal route or
laparotomy (Nezhat et al., 1994).
At a time when health care costs have become a major
preoccupation, these results are of prime importance because
one of die unexpected complications of laparoscopic
hysterectomy could be an increase in hospital costs. The risk of
complications with TLH appears to be no higher than wim the
other two routes, and bipolar coagulation is a reliable method
of haemostasis. Provided that disposable equipment is not used
systematically, laparoscopic surgery is a safe technique that
can be recommended as an alternative to laparotomy for
hysterectomy. The benefits of this policy could be considerable
for both the patient and society. The improved cosmetic result
and reduced postoperative discomfort are two advantages now
recognized universally for laparoscopy over laparotomy. For
society, the benefits of carrying out a major proportion of the
hysterectomies that use laparotomy at present by laparoscopy
instead are essentially economic. The shorter hospital stay and
convalescence period enable a quicker return to normal life
and significantly reduce die cost of the operation. In view of
die considerable number of hysterectomies carried out each
year, die economic benefits of such a policy would indeed be
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Received on April 1 , 1996 ; accepted on August 9, 1996