Laparoscopic Supracervical Hysterectomy in a Rural Minnesota Hospital

ABSTRACT
Hysterectomy continues to be a common gynecologic operation. Approximately 600,000 patients undergo surgical removal of the uterus annually at a considerable cost to payers, patients, and society at large. Currently most hysterectomies are via the abdominal or vaginal approach but fortunately for patients laparoscopic assisted procedures are becoming more popular. Many studies have shown the laparoscopic approach as safe, effective, and a less intrusive alternative to open surgery. Laparoscopy can be far less costly, less painful, and provides a shorter hospital stay and recovery time. This paper discusses such advantages of the laparoscopic supracervical approach compared to the laparoscopic-assisted and standard hysterectomy and reviews 83laparoscopic supracervical hysterectomies (LSH) performed at a rural Minnesota hospital. Techniques, equipment, patient mix, indications and complications are reviewed. Few complications were encountered and most patients were discharged from the hospital in 48 hours.

This report demonstrates that laparoscopic supracervical hysterectomy is a beneficial alternative to standard and laparoscopic-assisted hysterectomy, allowing the patient and family to stay in their local community. The benefits of the laparoscopic approach over open surgery have been discussed in a previous paper published in Minnesota Medicine, December 1995,Volume 78. But to summarize:

• One to two day hospital stay for the laparoscopic approach versus three to four days for the abdominal hysterectomy.
• Two to three weeks out of hospital convalescence versus five to seven weeks for the abdominal hysterectomy patient.
• Less blood loss, lower infection rate, less pain, smaller incisions, more cost effective surgery, less morbidity, and a lower mortality rate as compared to abdominal hysterectomy.

LSH offers these advantages over the abdominal approach and in addition it offers three distinct advantages to the laparoscopic-assisted hysterectomy because the cervix is left intact.

• Pelvic support structures are preserved.
• Preservation of the cervix negates the potential loss of sexual satisfaction if it is removed.
• Amputation of the uterine fundus from the cervix allows a “safe zone” from potential injury to the nearby bladder and ureter.

The indications for standard, laparoscopic-assisted, and LSH are the same. Contraindications for the laparoscopic-assisted and LSH are uterine prolapse, invasive carcinoma of the cervix and uterine corpus, ovarian carcinoma, acute pelvic and abdominal infection, uterine size more than 14-16 weeks of pregnancy, other suspected intra-abdominal cancers, as well as patients with compromised heart or lung function. For LSH patients the cervix must be free of dysplasia and have a negative pap smear no less than three months prior to surgery.

This article reviews 83 laparoscopic supracervical hysterectomies at the Virginia Regional Medical Center, a 100 bed hospital in Virginia, Minnesota.

METHOD
The patients range in age from 28 to 57. Weight range from 129 to 312 pounds. All patients with abnormal uterine bleeding underwent trans-vaginal ultrasound, office hysteroscopy, and endometrial biopsy. Those patients who did not respond to medical therapy such as oral contraceptives or cyclic progesterone and opted for a surgical alternative then a choice of endometrial ablation or LSH. Those patients with uterine myomata (not submucosal) and enlargement were pre-treated with Depo Lupron to decrease uterine size 40-50% over 3-6months. Pelvic pain, endometriosis, bleeding, fibroids, adenomyosis and adnexal masses were indications for LSH (see table 1).

Table 1 Cases

All patients with pelvic pain were previously laparoscoped prior to LSH. About 40-50% of the patients had a previous abdominal scar (see table 2).

Table 2

LSH was performed under general anesthesia in all cases in a fully equipped operating room with capability of immediate laparotomy should the need arise. Preoperative counseling of all patients included discussions related to other than surgical alternatives, potential laparotomy, specific complications related to hemorrhage, infection, urinary tract and bowel injury. Cardiovascular and pulmonary issues were discussed by anesthesia.

Thigh high Ted Sox were used in all cases prior to placing the legs in flexible-padded adjustable leg stirrups. A foley catheter was placed in the bladder. The cervix was grasped with a tenaculum and a bilateral paracervical injection of dilute pitressin(1/2cc in 100cc of saline), about 5cc on each side. A uterine manipulator was inserted into the uterine cavity (Valcheff Retractor). After establishing an adequate pneumoperitoneum with a Verres needle, I inserted a 10mm non-disposable) trocar, a 5mm right and left lower quadrant trocar (non-disposable) inserted lateral to the epigastric vessels, and a 12mm midline disposable trocar. A laparoscope, with attached video camera was inserted through the umbilical port; suction irrigator and grasping forceps through the 5mm ports and a 10mm bipolar cutting device (Everest Medical) through the 12mm site.

If the patient opted for adnexal removal the infundibulopelvic ligaments bilaterally were coagulated until the current ammeter displayed no current flow and then the pedicle was divided with the cutting blade of the same device. Sorbital solution was bathed the coagulation site to prevent lateral thermal burn and ureteral damage. If the adnexa were preserved then the round ligaments bilaterally were coagulated and divided along with the ovarian ligaments and fallopian tubes. If the adnexa were removed they were separated from the fundus a secured with an endoloop and stored in the cul-de-sac. The upper portion of the broad ligament on each side were coagulated and divided. Then the 5mm bipolar-cutting device was used to elevate, coagulate and divide the bladder-flap peritoneal reflection. A tonsil sponge was inserted through the 12mm port and the bladder-flap pushed off the lower uterine segment and upper cervix; methylene blue dye had been inserted into the catheter prior to this. The 5mm bipolar-cutting device was used to coagulate and divide the ascending branch of the uterine artery bilaterally thus rendering the uterine corpus cyanotic. Dilute pritressin was injected into the fundus and the cervical uterine junction, then a 5mm needle electrode (Everest Medical) was inserted through the left 5mm port and a circumferential incision was made starting posterior using the force 2 generator (Valley Lab) set at 18watts bipolar cutting current. The uterine manipulator was then removed and the incision was completed anteriorally till the fundus was separated from the cervix. The 12mm trocar was removed and replaced by a 15mm trocar, through which the power driven morcellator (Wisapp) was inserted. The uterine fundus with or without the adnexa were then morcellated and removed from the abdomen. The cervical stump was then cauterized as well as the endocervical canal both from the abdominal and vaginal sides with the 5mm bipolar device to prevent future bleeding. The bladder was filled with methylene blue to check bladder integrity. The abdominal cavity was rinsed out with copious amounts of saline-antibiotic solution. Nuknit (Johnson&Johnson), an adhesion/coagulation barrier, was put over the cervical stump. The 15mm trocar was replaced by a 12mm plug through which a Carter-Thomason suturing device was used to close the facial defect. After inspecting for any bleeding the trocars were all removed. 

Most patients were discharged in 48 hours, a few in 24 hours and 3 in 72 hours. Patients were instructed to report immediately fever of more than 100 degrees F, excessive bleeding, or any vomiting or unusual abdominal pain.

RESULTS 
The results of this series of LSH’S are outlined in Tables 1 to 7. Two failures occurred. “Failures” are defined as laparoscopic procedures that turned into laparotomies. Both of these cases were large uteri pretreated with 6 months of depo lupron and anticipated degree of shrinkage did not occur. These patients were scoped and it was deemed unsafe to proceed laparoscopically. I had warned both patients pre-operatively that I felt there was only a 50-50 chance of success laparoscopically.

One patient was found to have a microscopic focus of adenocarcinoma of the endometrium by the pathologist. The patient was a non-hypertensive, non-diabetic, petite 52 year old referred patient who had been on Prempro5 for 2 years. She had some spotting; an endometrial biopsy was negative and an ultrasound showed a 5cm uterine fundal fibroid. She opted for LSH because of bloating and pelvic pressure. I sent the slides to Gyn. Oncology at the University of Minnesota. They recommended 2 options: follow the patient frequently with endocervial sampling or trachelectomy. The patient chose the latter. The cervical stump was free of carcinoma. She will be followed per the University Gyn. Oncology protocol.

Table 3

Table 4

Table 5

Table 6

Total number of patients from June, 1998 to June, 2000: 83

Table 7

Operating Time

DISCUSSION 
Hysterectomy is an emotionally charged issue. Patients should always obtain a second opinion when surgery is advised. LSH is a very “patient friendly procedure”. In my opinion it is even superior to laparoscopic-assisted hysterectomy in terms of technique and patient satisfaction in all aspects. This procedure should only be performed by gynecologists who are skilled laparoscopists. Patients should inquire as to the number of cases the physician has done. These procedures should only be done in hospitals equipped with competent anesthesia departments, operating room staff, labs and blood banks. Good pre and post op nursing care is mandatory. This does not mean, however, that this procedure cannot be performed in a rural hospital as long as strict criteria for patient selection and physician skill and experience are adhered to.

Gynecologic laparoscopic surgery patient friendly, doctor friendly, and cost conscious. Most important it that LSH to this date, I believe, the best surgical approach for those patients who choose hysterectomy to solve their problem because it really minimizes the post operative pain and recovery and return to a better life as soon as possible.