Surgery: Is total laparoscopic hysterectomy a safe surgical procedure?

Human Reproduction, Nov 1996

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.

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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 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 Incidence per 100 women Table IL Complications of laparoscopic hysterectomy review of the literature Urinary tract system Bladder injury 2 Vesico-vaginal fistula 1«* Ureteral complications 0 Urinary tract infection 3 Urinary retention 0 Gastrointestinal system Small and large bowel injury 0 Gastroenteritis 1" 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 Phlebitis 0 Pulmonary embolism 0 Neuropraxia 0 Incisional hernia 0 Abdominal wall ecchymosis 1 Total 21 "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 (range 2-13) 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 analgesics. Although no complications involving the ureter were observed, there were, unfortunately, three bladder complicaComplications of laparoscopic hysterectomy Laparoscopic hysterectomy n 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 her fistula. 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 (>38°C). Discussion 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 significant. Carlson , KJ. , Nichols , D H . and Schiff , I. ( 1993 ) Indications for hysterectomy N Engl J. Med. , 328 , 856 - 860 . Chapron , C and Dubuisson, J B . ( 1995 ) Laparoscopic hysterectomy Lancet , 34 , 592 Chapron , C. and Dubmsson , J.B. ( 1996 ) Total hysterectomy by laparoscopy. advantage for the patient or only a surgical gimmick ? J. Gynecol Surg , 12 , 75 - 88 Chapron , C, Dubuisson, J.B. and Aubert , V ( 1994a ) Laparoscopic hysterectomy: it is not such an expensive surgical procedure Am . J Obstet. Gynecol , 170 , 1210 Chapron , C , Dubuisson, J B ., Aubert , V. et al (1994b) Total laparoscopic hysterectomy: preliminary results . Hum. Reprod., 9 , 2084 - 2089 . Chapron , C, Dubuisson, J B and Ansquer , Y ( 1996 ) Hysterectomy for patients without previous vaginal delivery. Results and modalities of laparoscopic surgery . Hum. Reprod , 11 , 2122 - 2126 Dicker , R.C. , Greenspan , JR. , Strauss, LT. et al ( 1982 ) Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States Am . J ObsteL Gynecol , 144 , 841 - 848 Dorsey , J H , Steinberg , E.P. and Holytz , P.M. ( 1995 ) Clinical indications for hysterectomy route patient characteristics or physician preference? Am . J Obstet. Gynecol , 173 , 1452 - 1460 Finkel , M L . and Finkel , D J ( 1990 ) The effect of a second opinion program on hysterectomy performance . Med. Care , 28 , 776 - 783 . Gitsch , G , Vytiska-Binstorfer , E and Skodler, W ( 1990 ) Various effects of abdominal and vaginal hysterectomy in benign diseases Eur J Obstet BioL Reprod ., 36 , 259 - 263 . Gitsch , G , Berger , E. and Tatra , G ( 1991 ) Complications of vaginal hysterectomy under 'difficult' circumstances . Arch. Gynecol ObsteL , 249 , 209 - 212 . Graves , EJ. ( 1992 ) National Hospital Discharge Survey: Annual Summary Vital and Health Statistics , Series 13 , no. 112. National Center for Health Statistics , Hyattsville, MD, USA. Hill , D. , Maher, PJ. , Wood , C. E et al (1994) Complications of laparoscopic hysterectomy . J Am. Assoc Gynecol Laparosc , 1 , 159 - 162 Jones , R-A. ( 1995 ) Complications of laparoscopic hysterectomy 250 cases Gynecol Endosc , 4 , 95 - 99 Kadar , N. , Reich , R , Liu , C.Y. et al ( 1993 ) Incisional hernias after major laparoscopic gynecologic procedures Am . J Obstet Gynecol , 168 , 1493 - 1495 . Liu , C Y . and Reich , H ( 1994 ) Complications of total laparoscopic hysterectomy in 518 cases . Gynecol Endosc , 3 , 203 - 208 . Montz , F J , Holchneider , C.H and Muro , M G . ( 1994 ) Incisional hernia following laparoscopy: a survey of the American Association of Gynecologic Laparoscopists . Obstet. Gynecol, 84 , 881 - 884 . Nezhat , C , Nezhat, E, Bess, O. et al ( 1993 ) Injuries associated with the use of a linear stapler during operative laparoscopy . review of diagnosis, management and prevention. J Gynecol Surg , 9 , 145 - 150 . Nezhat , C , Bess, O. , Admon , D et al ( 1994 ) Hospital cost comparison between abdominal, vaginal and laparoscopy-assisted vaginal hysterectomies . Obstet. Gynecol , 83 , 713 - 716 Nezhat , F , Nezhat , C.H., Admon , D et al ( 1995 ) Complications and results of 361 hysterectomies performed at laparoscopy J . Am. Coll Surg., 180 , 307 - 316 Reich , H. , DeCaprio , J and McGlynn , F. ( 1989 ) Laparoscopic hysterectomy J . Gynecol Surg., 5 , 213 - 216 . Richardson , R E , Boumas, N and Magos , A L ( 1995 ) Is laparoscopic hysterectomy a waste of tune ? Lancet, 345 , 36 - 41 . Wilcox , L.S. , Koonin , L.M. , Porkas , R. et al ( 1994 ) Hysterectomy in the United States , 1988 - 1990 . Obstet Gynecol, 83 , 549 - 555 . Received on April 1 , 1996 ; accepted on August 9, 1996


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Charles M. Chapron, Dubuisson Jean-Bernard, Yann Ansquer. Surgery: Is total laparoscopic hysterectomy a safe surgical procedure?, Human Reproduction, 1996, 2422-2424,