CISH-Hysterectomy Without Destruction of the Pelvic Floor Support

Dr. Hugo Verhoeven:  “My name is Hugo Verhoeven from the Center for Reproductive Medicine in Dusseldorf, Germany.  I am on the Editorial Board of the OBGYN.net, and I’m reporting from the 9^th International meeting of the Society of Laparoendoscopic Surgeons in Orlando, Florida.  It is a real pleasure for me to have the chance to talk this afternoon with Dr. John Morrison from Fayette in Alabama who is one of the leading experts in the United States in the field of laparoscopic hysterectomy.  John, thank you very much for giving me this pleasure to talk to you.  One of the biggest disadvantages of hysterectomy, independent  whether you perform the procedure by laparotomy or by laparoscopy is the destruction of the pelvic floor support.  There are some alternatives. I think you are one of the leaders in performing a technique of hysterectomy without destruction of the pelvic floor support. Please inform us about this technique.”

Dr. John Morrison:  “Hugo, the options for maintaining the pelvic floor support whether done laparoscopically or open, are to either do a supracervical hysterectomy which leaves the cervix, the support of the vagina and pelvic floor intact, and particularly the uterosacral ligaments and cardinal ligaments, or to take that procedure one step further and perform a CISH hysterectomy which has the same advantages of a supracervical hysterectomy regarding pelvic floor support but reduces or completely eliminates the possibility of cancer in the cervix because the transition zone and endocervical canal are also removed at the time of surgery." 

Dr. Hugo Verhoeven:  “What does the abbreviation CISH stand for?”

Dr. John Morrison:  “CISH stands for classic intrafascial supracervical hysterectomy.  Professor Kurt Semm in Kiel developed the procedure initially in 1991.  I’ve been performing the procedure myself since October of 1992 and continue to perform the procedure to this day." 

Dr. Hugo Verhoeven:  “It is my understanding that you are working in a very small village with only one big hospital but that you have patients from all over the United States.  This technique must have quite a lot of advantages for the patient.  Indeed, patients are going there where they expect advantages.  So what is the advantage of the technique for the patients?”

Dr. John Morrison:  “Of course, the advantages are what we talked about initially with leaving the pelvic floor intact but you’re right, I do have patients that seek out my services from other states throughout the United States.  Mainly what the patients are looking for when they come to see me is that they are very interested in having the procedure done laparoscopically so they can return to work much sooner, get back to their normal activities much sooner, they’re out of the hospital sooner, and they have less pain which goes along with most laparoscopic procedures.  Plus, we can obtain an adequate surgical procedure for the patient’s problem with, again, leaving the pelvic floor intact and doing this with very little risk to the patient and, again, them returning to their normal activities much, much sooner - that’s what the patients are looking for.”

Dr. Hugo Verhoeven:  “Describe very briefly the technique so that the patients know about what you’re doing.”

Dr. John Morrison:  “When I describe the technique to the patients I start off initially by telling them that most of the procedure regarding mobilizing or releasing the uterus from its upper support is basically the same as it is with either a normal open hysterectomy or a laparoscopic assisted vaginal hysterectomy, etc.  Once we get down to the main vascular supply to the uterus including the uterosacral ligaments and cardinal ligaments of pelvic support, that’s when the procedure varies from a standard open or vaginal hysterectomy.  I describe to the patients then that we in essence core out the center of the uterus like you would remove the core of an apple or a pear, which leaves a circular rim of muscle behind with all of the attachments to that circular rim of muscle.  Then the uterine body is removed, and I don’t get into the details with the patients of how that’s removed but I stress to them that with leaving the pelvic floor intact there is no incision at all in the vagina.  This seems to be something the patients recognize is a good concept and they’re very willing to proceed with the procedure. They accept that some little part of tissue is left behind.  I describe to them that it is usually not anything of much consequence because we do take out the transition zone and cervical canal to reduce their chances of cancer.”

Dr. Hugo Verhoeven:  “Can you perform this technique in all patients or are there some limitations?”

Dr. John Morrison:  “The only limitations that I have in my practice are either the presence of cancer, and this is not a technique to be used in the presence of cancer, or in patients that weigh over 200 kg.  I’ve attempted it; it’s very, very difficult.  The instruments are not long enough but I have several patients in the range of 100-150 kg that I’ve successfully performed the procedure on.  A previous surgery does not restrict the use of this technique and the presence of significant endometriosis does not restrict the use of this technique,  so I only use the presence of cancer or weight greater than 200 kg as a restriction.”

Dr. Hugo Verhoeven:  “How do you exclude the chance of cancer?  Are you doing a D&C or hysteroscopy before you start the procedure?  What are you doing?”

Dr. John Morrison:  “My standard approach is any patient who is forty years old or older has a D&C if they’ve not had it within the preceding six months.  Also, routine Pap smears have to be done within the preceding six months to a year to make certain that there is no sign of any cancer prior to doing the CISH hysterectomy.”

Dr. Hugo Verhoeven:  “One of my concerns is : is there a chance for post-operative bleeding?  You are cutting away 90% of the uterus and leaving maybe 5% in place.  How are you managing that there is no bleeding in this remaining 5%?”

Dr. John Morrison:  “There are several different ways to manage the cervical stump which is left behind.  Some people coagulate the stump, some use laser, and some surgeons inject the tissue with hemostatic agents.  I personally prefer to suture the stump closed.  Occasionally, patients will have some spotting or minor bleeding after the procedure but this seems to be very limited and it has been only a very, very small percentage of the patients that I’ve had to actually either cauterize a bleeder or bring them back as an outpatient to resuture the cervical stump.  It is a very rare occurrence, and I think it is a small price to pay in this procedure for the advantages of the procedure and the patients agree.”

Dr. Hugo Verhoeven:  “Postoperatively, there’s no chance of developing cancer as you are resecting the complete endometrium and the transition zone of the cervical canal.  How can you be sure that you do not miss a minimal part of the transition zone or the endometrium ?”

Dr. John Morrison:  “Prior to doing the surgery or initiating the abdominal part of the procedure, instead of doing the classic technique that Professor Semm described, I initially will perform a large conization to make certain I remove the entire transition zone but to answer your question, no, I tell patients I cannot guarantee them that they cannot develop any dysplasia or carcinoma in the remaining cervical stump.  But I encourage all my patients whether they have the CISH hysterectomy or they have a standard abdominal or vaginal hysterectomy to have follow-up Pap smears on somewhat of a routine basis because there are diseases, particularly HPV infections, which can be detected by a Pap smear.  I encourage them to do that but we’ve not done this long enough to give a good evaluation of the patient’s risk but I encourage all of them to still have follow-ups because, yes, that is still a possibility.  I think that removing the transition zone and intracervical canal greatly reduces the chance but I’m not going to go so far as to say it completely eliminates the possibility of malignancy but I think it greatly reduces it.”

Dr. Hugo Verhoeven:  “I guess the duration of the CISH procedure is not longer than the duration of a traditional laparoscopic hysterectomy, so the price is probably the same.  Is that correct?”

Dr. John Morrison:  “Yes, the time that it takes to do the procedure excluding large uteruses - 900-1600 gm - for a standard CISH hysterectomy is about one hour from beginning to end.  By the way, since I am the only surgeon in my town I do all of the procedure myself, I do not have an assistant surgeon helping me do the procedures so it’s all done by myself with nurse assistance holding the camera, etc. The operative time is certainly increased in cases of endometriosis or after multiple previous surgeries, but this is not different from open procedures. But even if the operating time is two hours or more, patients are routinely discharged from the hospital in less than twenty-four hours.”

Dr. Hugo Verhoeven:  “As you are conserving the pelvic floor support, I guess the patients will have no problems with incontinence postoperatively?”

Dr. John Morrison:  “What’s been interesting is :  as part of the procedure I usually suture the round ligament stump down to the cervical stump and that gives a little bit of extra support to the patients.  Now I’ve had some patients that had mild incontinence preoperatively that this corrected, and I understand that there is some controversy about whether round ligaments do really support the vagina pelvic floor or not but this has been my experience.  Now in patients that have significant uterine prolapse or significant incontinence, I will add other procedures, particularly vaginal sacral suspension or Burch procedure as needed, but just doing the CISH hysterectomy with suturing the round ligament down to the stump does add a little bit of extra support to the vagina and pelvic floor.  I’ve had the fortune of re-operating on some of these patients for other conditions and it’s amazing to look at the pelvic floor and see the comparison to a standard hysterectomy where there’s a lot of weakness in the pelvic floor, and the support after the CISH seems to be very close to what it is immediately after surgery.”

Dr. Hugo Verhoeven:  “The technique is perfect but I think you still have wishes for the future and you are trying to make the technique even better.  So what are your expectations for the near future with this technique?”

Dr. John Morrison:  “Initially for the future, I would like to encourage other gynecologic surgeons to consider the technique and to try to adapt the technique to their patients because this is an excellent, excellent operation for benign uterine conditions.  Initially it is technically challenging, I will admit that, and it does have a learning curve particularly involved with some of the morcellators that are used to remove the specimen but the procedure as I do it right now, I cannot see any real major changes that I would like to see in the future because I’ve had so few problems with this procedure that it is a very, very well suited operation for what it’s used for.”

Dr. Hugo Verhoeven:  “How many patients did you do surgery upon and what is your follow-up time?”

Dr. John Morrison:  “We started doing the CISH in October of 1992, up to this point, I have close to 450 CISH hysterectomies that I’ve performed successfully.  I’ve had 3 in that time that I’ve had to convert to open procedures and so our follow-up is anywhere from less than a month to eight years.  There have been an occasional mucocoele which is formed at the cervical stump, which was easily drained as an outpatient procedure but otherwise the re-operative rate or particularly the infection rate has been very impressive to me.  I’ve had no cervical stump infections or intraabdominal infections at all, and I think that is a testimony to the operation and to leaving the vascular integrity of the pelvic floor intact so that you have good healthy viable tissue that can fight off any kind of infectious process.”

Dr. Hugo Verhoeven:  “John, thank you very much for this information.”

Dr. John Morrison:  “Thank you.”