Laparoscopic-Assisted Vaginal Hysterectomy

Abstract

We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels. Of 81 women who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, 19 who underwent each procedure were chosen for inclusion in the study. Patients were matched in a case control manner for age, weight, diagnosis, and uterine weight. All 38 hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were performed. The average surgery time for LA VH was 144 minutes and for TAH 98 minutes, a significant difference (p <0.005). There were no significant differences between estimated blood loss and change in hemoglobin from preoperative levels to postoperative day 1 levels between the groups. Women having TAH reported significantly more pain after their release from the hospital. There was no significant difference in pain during hospitalization apparently because patients who had TAH self-medicated to maintain acceptable levels. That group in fact used an average of 436-mg meperidine during their hospital stay, significantly more than the 197mg used by the LAVH group (p <0.005). The length of stay was 2.125 days for LAVH and 3.542 days for TAH (p <0.00 1). On a scale of 1 to 10 (10 being complete normal activity) the activity level of women undergoing LAVH was 9.2 by day 14 compared with 6.4 for those having TAH (p <0.005). By the sixth postoperative week, the latter group reported an activity level of only 8.5, indicating that the ability to function is much more severely limited after TAH than LAVH.

Dr. Carter is Assistant Clinical Professor, Department of Obstetrics and Gynecology. University of California College of Medicine, Irvine, California. Dr. Ryoo is Chairman of the Department of Obstetrics and Gynecology, and Ms. Katz is a member of the nursing staff of Kaiser Permanente Hospital, Panorama City, California.

The Endo GIA was used successfully for laparoscopic hysterectomy in a 42-year-old woman for the treatment of pelvic pain and endometriosis in 1990. The first seven women to undergo laparoscopic-assisted vaginal hysterectomy (LAVH) in Italy experienced rapid recuperation, and the authors concluded that the procedure was a reasonable alternative to total abdominal hysterectomy (TAH). 2 We evaluated the two procedures on a case control basis for length of - operation, blood loss as estimated by the surgeon drop in hemoglobin in the 24 hours after surgery, drug use to control postoperative pain, length of hospital stay, and pain and activity levels in the immediate postoperative period to week 6.

Materials and Methods

Of the 81 women (32 TAH, 49 LAVH) who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, at the two study sites (Kaiser Foundation Hospital, Panorama City, CA; Mission Hospital Regional Medical Center, Mission Viejo, CA), 38 were selected for inclusion in this study, 19 undergoing each operation. Inclusion criteria were that patients be matched in a case control manner for age, weight, diagnosis, and uterine weight, and that they be candidates for TAH.

All 19 LAVHs were performed by one surgeon to ensure uniformity and familiarity with the procedure. Abdominal hysterectomies were performed in the standard manner using similar techniques.

Patients with fibroid uterus in the LAVH group underwent therapy with a gonadotropin-releasing hormone analog (depot leuprolide; TAP Pharmaceuticals. Deerfield, IL), resulting in a 40% to 60% reduction in uterine volume from initiation of therapy to surgery. The LAVH was performed by placing one 10-mm cannula infraumbilically and two 12-mm cannulas in the lower quadrant approximately 6 cm above the pubic rami, lateral to the inferior epigastric arteries. A 5-mm cannula was placed 4 cm above the pubis in the midline. A ZUMI catheter (Zinnanti Surgical Instruments, Chatsworth, CA) was placed in the uterus for uterine manipulation.

In each case, the round ligaments were treated with bipolar coagulation and transected with the contact-tip neodymium:yttrium-aluminum-gEtrnet (Nd:YAG ) laser (Surgical Laser Technology, Oak Ridge, PA) with a GRP6 sapphire-tip scalpel. The anterior leaf of the broad ligament was similarly transected. The bladder flap was then developed by placing 4 x 8-cm gauze on a ring forceps into the vagina and elevating the vaginal apex so that the bladder could be taken down over the apex by sharp and blunt dissection. The bladder pillars were coagulated with bipolar electrocoagulation and transected with a GRP6 probe. The perivesicle and perivaginal spaces were then developed. Windows were created using a right-angle dissector. The Endo-GIA linear stapler was used to transect the infundibulopelvic or utero-ovarian ligaments according to an earlier decision to remove or preserve the ovaries.

Using contralateral placement of the linear stapler, a very close approximation of the uterine body and cervix and vagina was obtained, and the ascending branch of the uterine artery was transected. The anterior and posterior colpotomy incisions were opened with the laser. The cardinal ligaments were cross-clamped, divided, and suture ligated from below, with the final vaginal cuff closure also being accomplished from below. Once the vaginal cuff was closed, the peritoneal cavity was insufflated, inspected laparoscopically for hemostasis, and irrigated with warm lactated Ringer's solution. Throughout the procedure and at the final look, bleeders were coagulated with the argon beam coagulator (Birtcher Medical Systems, Irvine, CA). The bladder was drained with a Foley catheter, and no vaginal packing was used postoperatively.

In the TAH group, 25 procedures were performed: 14 women had bilateral and 1 unilateral salpingo-oophorectomies. 1 had an appendectomy. 2 had lysis of pelvic adhesions, and 7 were treated for endometriosis. In the LAVH group. 24 procedures were performed: 7 patients had bilateral and 5 unilateral salpingo- oophorectomies. 7 had lysis of adhesions, 1 had a repair of bilateral hernia, and 4 were treated for endometriosis.

After a brief stay in the recovery room, the patients were transferred to the wards. They were discharged when they were able to void, pass flatus and tolerate oral agents to control pain. Discharge criteria were the same for both groups.

Operating time, blood loss as estimated by the surgeon, and intraoperative complications were recorded. Hemoglobin levels in blood drawn the morning after the procedure were compared with preoperative levels. Pain control was assessed by aggregate intramuscular narcotic use on all hospital days.

Pain levels were assessed by patient interviews 1, 3, 7, 14, and 21 days, and 6 weeks postoperatively. The women rated their pain on a 10-point scale from 1 -no pain to 10 unbearable pain. Their activity levels were assessed by interviews 1, 3, 7, 14, 21 days, and 6 weeks postoperatively, with 1 extremely limited activity and 10 no limits on activity. The data on pain and activity were analyzed by Wilcoxon's signed rank test. The rest of the data were analyzed by two-tailed Student's t test.


Results

All patients were operated on for a primary diagnosis of severe, disabling pelvic pain. As shown in Table 1, demographics and pathologic diagnoses in the two groups were closely matched.

TABLE 1. Patient Demographics and Pathologic Diagnoses

a Two-tailed Student t test.
b The primary diagnosis for all patients was pelvic pain
NS = not significant at p <0.1

Surgeries were successfully completed in the proposed manner in all patients. The mean operating time for LAVH was 46 minutes longer than for TAH, a significant difference (p <0.005). The estimated blood loss for those who underwent LAVH was not significantly different than that for women having TAH.

The drug requirement to control pain during hospitalization after TAH was almost double that after LAVH (p <0.001). The mean length of hospital stay was significantly shorter after LAVH (2.135 days) than after TAH (3.54 days) (p <0.005) (Table 2).

Table 2. Length of Time in Surgery, Blood Loss, Hemoglobin Drop, Meperidine Use,
and Length of Stay.

a Two-tailed Student's t test.
b As estimated by the surgeon.
S= significant at p < 0.005; NS = not significant at p< 0.1

Postoperative complications in the TAH group were one woman with mild fever and atelectasis, three with hemoglobin below 10g/dl, and two with urinary tract infections. In the LAVH group. one woman had mild fever with atelectasis and two had anemia with hemoglobin below 10g/dl; no patients were affected by urinary tract infections. No patients required transfusions of nonautologous blood.

Pain levels are shown in Table 3 and Figure 1. Patients undergoing LAVH reported a significantly lower level of pain than those having TAH on days 7,14, and 21 (p <0.05). The difference in postoperative activity level achieved statistical significance on day 7. This difference became more pronounced at day 14, when it was 9.2 for LAVH and only 6.4 for TAH (p <0.005) (Table 4, Figure 2). By day 21 women in the LAVH group reported an activity level of 9.6, where-as those in the TAH group reported only 7.9 (p <0.005). At 6 weeks, the levels were 9.95 and 8.5, respectively (p <0.005). Another way of comparing this is to note that the former women felt more fully recovered at 2 weeks than the latter did at 6 weeks.

TABLE 3 Postoperative Pain Levels

a Wilcoxon's signed rank test.
Ten-point activity scale: 1 = no pain, 10 = unbearable pain.
S = significant at p < 0.005; NS = not significant at p <0.01

TABLE 4 Postoperative Activity Levels

a Wilcoxon's signed rank test.
Ten-point activity scale: 1 = extremely limited activity, 10 = no limits on activity
S = significant at p < 0.005; NS = not significant at p <0.01

Figures 1 & 2 match data points in Tables 3 & 4

Literature Review

In 1992, a minimum complication rate, less postoperative analgesia, faster recovery, and shorter hospital stay were reported for the first 75 consecutive cases of LAVH than for abdominal or vaginal hysterectomy.

³

A very short hospitalization was reported for 72 patients in 1992,~ and 215 subsequent laparoscopic hysterectomies required an average operating time of 114 minutes and a mean hospital stay of 1.21 days.

⁵

At 1 week after surgery the majority of these women were permitted to drive and resume normal, non-strenuous physical activity.

In a comparison of LAVH with standard vaginal hysterectomy in a prospective study of 56 patients,

⁶

the LAVH group had a longer operating time (120 vs 65 mm). The clinical outcomes were similar for both groups, including a 12-hour hospital stay. The mean hospital charge for LAVH was $3000 more than for vaginal hysterectomy.

Perioperative and postoperative courses of hysterectomy with or without bilateral salpingo-oophorectomies were compared in 10 women undergoing LAVH and 10 undergoing TAH.

⁷

Surgery time was 160 versus 102 minutes, length of hospital stay 2.4 versus 4.4 days, and recovery time 3 versus 5 weeks, respectively. The laparoscopic Doderlein hysterectomy compared favorably with standard abdominal hysterectomy in 167 procedures.

⁸

Postoperative recovery times and pain levels were assessed in 37 patients with a primary complaint of pelvic pain and diagnoses of fibroid uterus, adenomyosis, and severe endometriosis who underwent LAVH.

⁹

Women reported an activity level of 8.7 on a scale of 1 to 10 (10 no limits on activity) by postoperative day 14. In another study those undergoing abdominal hysterectomy had a mean uterine weight of 418 g compared with 150 g for those undergoing LAVH.

¹⁰

The hospital stay after abdominal hysterectomy was 4.5 days and after LAVH 2.5 days. Hospital costs were $10,511 and $12,814, respectively, a difference of $2303.

Women who underwent vaginal hysterectomy experienced significantly fewer complications than those who had undergone TAH in one study.

¹¹

The major finding was that the overall complication rate after TAH was 70% higher than that after vaginal hysterectomy, although the morbidity associated with both procedures was appreciable.

Discussion

Women in our study who underwent LAVH had a shorter hospitalization but longer operating room time than those having TAH. They also experienced a much more rapid recuperation and much quicker return to normal activities. The primary advantage of TAH is clearly the shorter operating time; the primary advantages of LAVH are shorter hospitalization, reduced requirement for drugs to control postoperative pain, and faster return to normal activities.

An important public policy issue now confronts us. As it is currently performed, LAVH is more expensive than TAH. The issue is whether the benefits of shorter convalescence and faster return to the work force, shorter hospitalization, and less need for narcotics for postoperative pain outweigh the disadvantage of the higher cost. If total health care system costs are evaluated, the short-term disability costs of 2 weeks of recovery after laparoscopic hysterectomy should be compared with disability costs of 6 to 8 weeks of recovery after abdominal hysterectomy. The woman who returns to work 4 to 6 weeks earlier is producing.

For LAVH to be, economically viable compared with TAH, savings in disability costs and the increased contribution to the gross domestic product must offset the increased health care costs. In the current system, insurance companies and hospitals do not share in these benefits, only the costs. The economic impact of laparoscopic surgery must take into account both the cost to the hospital and insurance payors and these productivity and social issues. Insurance is based on a risk pool whereby the cost of a premium is based on the cost of treatment, not the ability of the subscriber to return to work. An economic and social cost-benefit analysis must be performed before decisions are made to modify or judge a procedure that provides substantial benefits to the patient.

Laparoscopic versus open cholecystectomy was discussed in 1991 by the medical director of Blue Cross/Blue Shield of South Carolina.

¹²

He stated that hospital charges for the former were 14% higher, surgeon fees were 25% higher, and the anesthesia professional charges were 34% higher than for the latter, resulting in a 25% average higher cost for laparoscopy despite a 63% reduction in hospital days. These matters must be addressed, together with the development of methods to improve efficiency, to shorten the length of surgery time by using partial vaginal approaches, and to reduce the cost of instruments required for the procedure. Without a resolution to these problems, LAVH may not be a viable option for the health care consumer of the future.

Conclusion

In this case control study LAVH resulted in a significantly shorter hospital stay, with a much more rapid return to normal activities, than TAH. The drug requirement to control pain and the level of pain patients experienced were also significantly less. Blood loss was not different for the two procedures.

Although LAVH took on average 46 minutes longer to perform, women in that group were able to leave the hospital in an average of 2.1 days and return to normal activity by 2 weeks, thus demonstrating significant advantages over TAH for both patients and the health care system. If 80% of patients scheduled for abdominal hysterectomy undergo LAVH, the average reduction of hospital stay of 1.5 days would save more than half a million hospital days over 1 year.

The impact on the workforce is equally important. Allowing women to return to employment in 2 weeks rather than 8 weeks will result in more than 16 million more days spent in productive work. This translates into equally important savings in disability insurance.

Since its introduction in 1989, continued improvement of techniques will likely progress rapidly so that LAVH will be performed on an outpatient basis for many women, and will result in shorter recovery time.

¹³

Thus the increased operating room time of approximately 46 minutes is significantly outweighed by the benefits available with widespread application of this procedure.

References:

References:

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2. Minelli L, Angiolillo M, Caione C, et al: Laparoscopically assisted vaginal hysterectomy. Endoscopy 23:64-66, 1991

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10. Boike GM: Laparoscopic-assisted vaginal hysterectomy in a university hospital: A report of 82 cases in comparison with abdominal and vaginal hysterectomy. Am J Obstet Gynecol 168(6 Pt 1):1690-1701, 1993

11. Dicker RC, Greenspan JR, Strauss LT, et al: Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 144:841, 1982

12. Jordan AB: Hospital charges for laparoscopic and open cholecystectomy [letter}. JAMA 226(24):3425, 1991

13. Reich H, DeCaprio J, McGlynn F: Laparoscopic hysterectomy. I Gynecol Surg 5:213-214, 1989

Reprinted with permission of the author. For original publication, please see:Carter JE, Ryoo J, Katz A: Laparoscopic -assisted vaginal hysterectomy: A case controlled comparative study with total abdominal hysterectomy. J Amer Assoc Gynecol Laparosc 1 (2): 116-21, 1994