Gynaecological Endoscopy, 1996 5, 271-276

Ex'iraperitoneal laparoscopic hysterectomy for the large uterus Nicholas Kadar Accepted for publication 11 June 1996

Abstract

allows all vital structures to be reliably identified and the uter ine arteries to be ligated .1, 2 The

Objective To determine the feasibility of dividing the uterine arteries laparoscopically during extra­ peritoneal laparoscopic hysterectomy (ELH) for an enlarged uterus. Method Retrospective review of ELHs over a 12­ month period .

dissection is carried out in a precise series of opera­ tive steps that involves identification of the ureter, development of the retroperitonel spaces and divi­ sion of the uterine artery before any attachments of the uterus are divided. The technique has been extremely effective, especially in obese women, but the feasibility of the retroperitoneal dissection in the presence of

Results A total of 28 women underwent ELH for a fibroid uterus. Additional procedures were performed in seven cases: pelvic lymphadenectomy (PLN) in three, pelvic and aortic lymphadenectomy (PALN) in three, and colposuspension in one. In 13 of the 28 cases the uterus weighed 2': 500g (mean 874 g); four weighed 750-1000 g, and three weighed > 1000 g. Considering the 13 patients where the uterus weighed > 500 g, two patients had PLN, and one had PALN in addition to a hysterectomy; the patients' mean age was 50 years; mean anaesthetic time was 3.25 h; mean blood loss was 565 ml ; mean hospital stay was 1.5 days, and two (15%) women were transfused . With respect to the uterine arteries 23/26 (88% ) were divided laparoscopically; both arteries in 11 patients, one artery in one patient and neither artery in another patient. None of the women in whom both uterine arteries were divided laparoscopically was transfused , whereas both women in whom one or both uterine arteries were divided vaginally were transfused . Conclusion Both uterine arteries can be divided laparoscopically in most patients undergoing ELH for an enlarged uterus, and laparoscopic division of the uterine arteries may reduce blood loss during morcellation. Keywords: fib roid uterus, laparoscopic hyster­ ectomy.

Introduction An N, Kadar MD Seton Hall University and The New Margaret Hague Women's Health Institute New Jersey, USA

extraperitoneal

technique

for

laparoscopic

hysterectomy has been developed, based on a systematic dissection of the retroperitoneum that Correspondence: N. Kadar, The New Margaret Hague Women 's Health Institute , 1 Harmon Plaza, Secaucus, NJ

07094, USA.

an enlarged uterus remains largely untested. The purpose of this article is to report the author's experience with extra peritoneal laparoscopic hys­ terectomy (ELH) for removing fibroid uteri weighing more than 500 g. Subjects and methods The hospital records of all patients who had a hys­ terectomy, performed by or under the supervision of the author, for a fibroid uterus at Englewood and Meadowlands Medical Centers over a 12-month period were reviewed. The following information was abstracted for all patients whose uterus weighed over 500 g. The patient's age, height and weight; previous abdominal surgery and medical ill­ nesses; the operation performed and operative find­ ings ; anaesthetic time; estimated blood loss and postoperative change in haemoglobin; postopera­ tive complications and duration of hospitalization and weight of the uterus. Particular attention was paid in the operative report to whether the uterine arteries had been divided and the posterior dissection (division of uterosacral ligament and incision of posterior vaginal wall) carried out laparoscopically. The body mass index was calculated from the patient's height and weight. Our technique has been described in detail else­ where, but, briefly, consists of the following steps . Step 1. The retroperitoneum is entered without dividing the round or the infundibulopelvic liga­ ments, by incising the peritoneum of the pelvic side wall triangle, and the broad ligament is opened (Figs 1 and 2). Step 2. The infundibulopelvic ligaments are mobil­ ized and displaced medially to expose the ureter

272 N. Kadar

Figure 1 The peritoneum of the pelvic sidewall triangle is incised and the broad ligament is opened . Reproduced with permission from Atlas of Laparoscopic Pelvic Surgery (N. Kadar; Boston: Blackwell Science, 1995).

Figure 2 See legend for Fig. 1.

Step 7. The hysterectomy is completed vaginally.

at the pelvic brim, by extending the peritoneal

Results

incision to above the pelvic brim lateral to the infun­ dibulopelvic ligament (Fig. 3).

A total of 28 women had an ELH for a fibroid uterus, and two had bilateral pelvic masses in addition to

peritoneally by blunt dissection under the round ligament (Fig. 4), and freed by developing the para­ vesical spaces on either side of the ligament (Figs 5 and 6).

the fibroids. Six women had a pelvic (n = 3) or a pel­ vic plus aortic (n = 3) lymphadenectomy in addition to the hysterectomy for endometrial or ovarian car­ cinoma carcinoma, and one had a Burch procedure for stress urinary incontinence. An additional 31 hysterectomies were performed during the same time period with or without additional procedures,

Step 4. The umbilical ligament is traced proximally to the uterine artery, and the pararectal space opened by blunt dissection proximal and medial to

four of which were vaginal and none abdominal. The distribution of uterine weights is shown in

Step 3. The umbilical ligament is identified extra­

the artery, which is then clipped and divided (Fig. 7). Step. 5. The distal stump of the uterine artery is freed from the underlying ureter, the proximal attachments of the uterus coagulated or clipped

and divided, and the uterovesical peritoneal fold is incised , but the bladder is not dissected caudally off the cervix (Fig. 8). Step 6. The uterosacral ligaments are divided and the posterior vaginal fornix is incised (Fig. 9).

a'. 1999 Blackwell Science Ltd,

Figure 3 The infundibula-pelvic ligament is displaced medially to expose the ureter at the pelvic brim. Repro­

Gynaecological Endoscopy, 5,271-276

duced with permission from Atlas of Laparoscopic Pelvic Surgery (N. Kadar; Boston: Blackwell Science, 1995).

Table 1. The characteristics of each of the 13 patients who had a uterus 2: 500 g grams is shown in Table 2, and summary statistics for these 13 are given in Table 3. The mean anaesthetic time was 3.25 h, mean uterine weight 874 , mean blood loss 565 ml and mean hospital stay 1.5 days. Laparoscopic hysterectomy was successfully completed in all cases and there were no significant intra- or postoperative complications although two women required transfusion. Both uterine arteries were divided laparoscopically in all patients except the two who required blood transfusions. In one of

Figure 4 The umbilical ligament is identified extraperito­ neally by blunt dissection under the round ligament. Repro­ duced with permission from Atlas of Laparoscopic Pelvic Surgery (N. Kadar; Boston: Blackwell Science, 1995).

273 Extraperitonea/ /aparo­ scopic hyerectomy

Figure 5 The paravesical spaces are developed (opened) by blunt dissection on either side of the umbilicalligamenl. Reproduced with permission from Atlas of Laparoscopic Pelvic Surgery (N. Kadar; Boston : Blackwell Science, 1995).

these women neither uterine artery was divided laparoscopically, although access was obscured more by bleeding from resection of fixed , positive lymph nodes rather than by the large uterus. In the other patient the left uterine artery was divided laparoscopically but the right one was not easily accessible. In both cases the uterus had to be par­ tially bivalved before the uterine arteries could be clamped. The posterior dissection was carried out laparoscopically in only one patient.

Discussion

Laparoscopic hysterectomy continues to be a con­ troversial operation because there is little agree­ ment over what is the therapeutic purpose of laparoscopy during a hysterectomy and what surgi­ cal goal it is meant to accomplish. The diagnostic role of laparoscopy in cases of pelvic pain, endo­ metriosis or an adnexal mass is not in dispute, but many refuse to concede that it has any therapeutic role in a hysterectomy apart from adhesiolysis, and even that has been questioned. 3 The belief

Figure 6 See legend for Fig. 5.

that most hysterectomies in which laparoscopic assistance is used could have been carried out entirely vaginally seems to be based on the tacit assumption that because the operative steps exe­ cuted laparoscopically can be carried out vaginally (under some circumstances) the entire operation could have been carried out per vaginam. Some credence has been given to this viewpoint by the successful vaginal removal of a uterus 4 weighing 1100 g by Magos et a/ in a series of 14 vaginal hysterectomies for fibroid uteri with a mean weight of 637 g. However, this series was both small and exceptional. 3 , 5 For example, among 37 selected women with fibroid uteri weighing 300-1000 g (mean 459 g) Mazdisnian et a/. 3 were able to remove the uterus in only 85% of cases. Moreover, the mean uterine weight and the weight of the largest uterus removed by Magos et a/. were 30 and 40% less, respectively, than in the pre­ sent series, and their cases, although consecutive, appear to have been selected, whereas ours were unselected. Nonetheless, it must be admitted that the argu­ ment against a therapeutic role for laparoscopy in hysterectomies is, on the face of it, most compelling

W--I--Ureler

1995 Blackwell Science Ltd, Gynaecological Endoscopy, 5, 271-276 !;;

Figure 7 The pararectal space opened by blunt dissection proximal and medial to the uterine artery. Reproduced

with permission from Alias of Laparoscopic Pelvic Surgery (N. Kadar; Boston: Blackwell Science, 1995) .

Figure 8 The proximal attachments of the uterus are divided and the utero-vesical peritoneal fold ('bladder flap') is incised, but the bladder is not dissected caudally off the vervix. Reproduced with permission from Atlas of Laparoscopic Pelvic Surgery (N. Kadar; Boston : Blackwell Science, 1995).

attachments do not support the uterus in the long term, they do offer considerable resistance to descent in the acute setting. so to speak. Second, with the upper attachments divided. the entire uterus does not have to be morcellated to access the adnexa, and usually after about two-thirds of the uterus has been morcellated. the fundal width

274 N. Kadar

is reduced suffiCiently to allow delivery of the speci­ men . But, whatever the precise contribution of

Figure 9 The uterosacral ligaments are divided and the posterior vaginal forni x is incised. Reproduced with per­ mission from Atlas o( Laparoscopic Pelvic Surgery (N . Kadar; Boston: Blackwell SCience, 1995).

when the uterus is enlarged and the cardinal and uterosacral ligaments cannot be divided laparosco­ pically, and the specimen is morcellated vaginally. as in our patients. If the supports of the uterus are divided and the specimen morcellated vaginally. what. one may ask, is accomplished laparoscopi­ cally that could not have ben achieved via the vaginal route? We believe laparoscopy contributes in two ways to ellect removal of uteri that could not have been removed vaginally. First. by occluding the uterine blood supply laparoscopically blood loss may be reduced and may allow a laparotomy to be avoided in the minor­ ity of cases in which excessive bleeding would force the surgeon to abandon a vaginal hysterectomy.s Admittedly. in the absence of a comparative group. this series offers only meagre evidence to support this view, but the only patients requiring transfusion were those in whom the uterine arteries were not secured laparoscopically. Second , and more importantly. division of the upper uterine pedicles and the peritoneal attach­ ments of the uterus assists vaginal morcellation and extraction of the specimen in two ways. First. it permits some descent of the specimen after its girth has been reduced , because although the round and infundibulopelvic ligaments and the peritoneal

Table 1 Distribution of uterine weight among 28 women undergoing extraperitoneal laparoscopic hysterectomy for a fibroid uterus

Uterine weight, g

< 200 200-299 300-399

400-499 1000

Number of cases

2 7 4 2 6

4 3

laparoscopy, the empirical fact is that larger uteri than have been removed vaginally can be consist­ ently removed laparovaginally. Every vaginal surgeon would agree that other factors besides the size of the uterus affect the feasibility of a vaginal hysterectomy, including vaginal mobility (as distinct from descent) . the calibre of the vagina. the topography of the uterus and obesity, but with the exception of the latter these are subjective variables that dely quantifica­ tion or objective definition. That is why attention in this report was restricted to women who had very large uteri (50% > 750 g). However. vaginal hyster­ ectomy would have been at best hazardous if not impossible in several women who had smaller uteri . although there is no way to 'prove ' this opinion. For example, in one woman who weighed 3491bs, the referring physician was unable to reach the uterus to perform hysteroscopy, even after the size of the uterus had been reduced by GnRH agonist therapy to 320 g. Another, whose uterus weighed 445 g, had extensive pelvic inflammatory disease and her hysterectomy was technically one of the most difficult in the series. Several of the uteri that weighed less than 300 g were about 14 weeks in size, and the patients had received GnRH agonist therapy from their private gynaecologists. GnRH agonist therapy made morcellation much more difficult in these cases; the gelatinous quality of the myomas made them difficult to extract as grasping instruments usually cut through their substance during attempted extraction. Although Mazdisnian et al.3 had only a 5% failure rate in women undergoing vaginal hysterectomy for fibroid uteri weighing < 300 g, their cases were selected. In four of our unselected cases vaginal hysterectomy would have been straightforward and the laparoscopic approach was chosen for teaching purposes. Despite the heated debate and apparent lack of consensus that continue to surround laparoscopic hysterectomy, several conclusions appear to be warranted . First. the goal of both the laparoscopic and vaginal approach is to eliminate abdominal hysterectomies, and the meaning of surgical series cannot be assessed without a knowledge of the abdominal hysterectomy rate and the case mix. (We have not

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