Keywords: laparoscopic supracervical hysterectomy, minimally invasive surgery, hysterectomy, total vaginal hysterectomy, total abdominal hysterectomy, laparoscopic vaginal hysterectomy

             2671 words.

                                       Canadian Task Force Classification II-2

Precis: Comparing Laparoscopic Supracervical Hysterectomy to Total Abdominal Hysterectomy, Total Vaginal Hysterectomy and Laparoscopic Assisted Vaginal Hysterectomy showed a trend to lower morbidity with comparable operative parameters.

Laparoscopic Supracervical Hysterectomy compared with Abdominal, Vaginal and Laparoscopic Vaginal Hysterectomy in a primary-care hospital setting.

 John L. Washington, MD, FACOG

Abstract

Study Objective: This paper compares the parameters of LSH, LAVH, TVH and TAH in a small suburban medical center.

Study design: Retrospective case review.

Design Classification: II-2

Setting: 238 bed Not-for-Profit Community General Hospital.

Patients: 117charts from patients who had had the following procedures: LSH, LAVH, TVH, TAH, were reviewed; questionnaires completed by the patients were reviewed. All had hysterectomies performed by members of the Ob/Gyn department of Alamance Regional Medical Center

Interventions: Comparisons of intraoperative and postoperative events were made in those patients who consented to the study and who returned their questionnaires.

Measurements: Parameters compared are: patient age, weight, preop-diagnosis, operative time, operative complication, blood loss, uterine weight, length of stay, postoperative complication, return to hospital, return to work, resumption of intercourse, dyspareunia and bowel or bladder problems

Main Results:  LSH Technique is described. Patient demographics and outcomes are similar. Trends were found towards lower morbidity for LSH and quicker return to normal function but most did not reach statistical significance.

Conclusion: The results support the conclusion that the patients in each arm of the study are similar. The operative parameters show a longer operating times for the laparoscopic procedures than for TAH and TVH respectively. The other indicators of morbidity show slight advantages to LSH in blood loss, length of stay and resumption of normal activities.

The traditional approach to selection of the appropriate hysterectomy operation has been, that, if possible, a TVH should be done (1) . If a TVH was deemed not possible, because of problems of size, access, or intra-abdominal pathology, an abdominal hysterectomy was performed. In recent years, laparoscopic vaginal hysterectomy has been suggested as a less invasive alternative for most abdominal hysterectomies, (2) since morbidity and recovery time were lessened by this approach. More recently, with the availability of morcellators, the supracervical operation has been revived by the utilization of the laparoscopic approach. (3) The purpose of this study is to compare the intra and post-operative parameters of the four approaches to hysterectomy. Our thesis is that Laparoscopic Supracervical Hysterectomy (LSH) is preferable to other types of hysterectomy in operating time, morbidity, hospitalization and recovery times. We feel that, in the absence of an indication to remove the cervix, it is the operation of choice.

Materials and Methods

            A total of about 400 patients were selected from the records of Alamance Regional Medical Center who had had TAH, TVH, LAVH or LSH. Alamance Regional Medical Center is a 238-bed, private, not-for-profit hospital in the piedmont of North Carolina. The Ob/Gyn department has ten members and is not served by a training program. All of the doctors are in private practice and range in age from 30 to 65 years of age.  All but one member of the ARMC Department of Ob/Gyn consented to having their patients contacted to participate in the study; the objecting physician’s patients were excluded. 

A Certified Medical Record Technician (MRT) selected the patients from a computerized database of surgical procedures.  Patients were excluded from consideration if they had any other procedure performed at the same time other than salpingo-oophorecomy or minor lysis of adhesions. The patients were then sent a consent form for examination of the medical record and a short questionnaire (reproduced below Fig 1). If a patient returned the consent and questionnaire, her chart was pulled and abstracted by the MRT, otherwise her name was discarded. The data collection form is shown in Figure 2. The data were tabulated and “de-identified” before being given to the researcher. The data were then analyzed by ANOVA and Tukey-Kramer comparisons using Graphpad Instat V 3.05 for Windows, San Diego Ca.   This project was approved by the ARMC IRB and was found to be in compliance with HIPAA requirements.

Data collected from the patient questionnaire included the patient’s time of return to intercourse and work. The patient was asked if she had had any problems or complications following her surgery, as these might not have been included in the hospital chart. The questionnaire asked for her subjective evaluation of sexual, bowel and bladder functioning since her surgery.

The hospital record was abstracted to collect: patient age and weight, length of stay, weight of uterus, pathology diagnosis, blood loss, operative time, and any intra-operative complication. We wished to first establish that the patients who had different types of hysterectomy were comparable, and then to see if there were any differences in the parameters of the surgery or the outcomes.

Techniques of TAH and TVH require no further description. LAVH (LAH) included any procedure in which the uterus was dissected free laparoscopically, down to the vaginal cuff, whether or not the uterine vessels and vaginal cuff were cut laparoscopically, if the uterus was delivered vaginally.  Instruments and technique varied from surgeon to surgeon. Most used a combination of bipolar cautery, monopolar cautery and Ultracision™.  Stapling devices were used rarely if at all. Manual morcellation was used on large uteri when needed to effect vaginal delivery. 

LSH patients all had benign preoperative diagnoses and had no abnormal pap smears or procedures for dysplasia within ten years. The LSH was performed using bipolar cautery, Ligasure ™, and Ultracision scalpel™. There was a change in instrumentation over the three years of the study depending on what was available at the hospital.  The uterus was removed with a Gynecare X-tract ™ morcellator. All of the tissue was sent to pathology.

Blood loss was the circulating nurse’s notation. Operative time is the anesthesia time, which in our institution overestimates operating time by about 15 minutes.

Results

Results are below in Tables 1-3 and Figure 1. In each the p values and 95% confidence intervals  are used to compare the LSH to the other types of hysterectomy.  Table 1 shows demographic data. The four groups of patients were compared for age and body weight. Comparison of age showed no significant difference in age (p>0.10) Body weight showed a trend for the LSH patients to be heavier but this was only significant between the LSH and LAVH patients.  Uterine weights were similar (p>0.05). The trend was for the TAH uterine weights to be heavier. Table 2 examines intraoperative parameters. Estimated blood loss showed a trend to less blood loss in laparoscopic procedures that did not reach statistical significance. Operative times were similar. Not surprisingly the trend was to shorter times for TVH. Length of stay was shorter for LSH than the other types of hysterectomy. The difference was statistically significant, though only in comparison to the TAH. There were only two intra operative complications reported, both during LAVH. Occurrences during post-hospital recuperation are in Table 3. Reports of bleeding, Pain, bowel or bladder problems, and postoperative complications are difficult to interpret and indicate only that they were significant to the patient.  Generally the trends seem to show little difference in bleeding at home, but less pain in the laparoscopic procedures, and less postoperative problems in the laparoscopic procedures. Resumption of intercourse was sooner in the laparoscopic procedures, but in this sample only reached statistical significance in comparing TVH and LSH. Return to work was quickest in LSH and was followed by LAVH TVH and TAH in that order. This trend only reached significance in the LSH-TAH comparison. Quality of intercourse (better-same – worse) is presented in graph form in Figure 3. There seems to be no significant difference. Dyspareunia was reported more frequently in TVH with LSH having the least incidence (Fig 4.).

Discussion

The theoretical role for LSH is based on several possibilities. First are the advantages of the operation itself, that is, is it less morbid than other techniques of hysterectomy. Second, is the question of whether the operation has advantages of its own beyond the operative parameters. It is theorized that the LSH, because it does not involve mobilization of the bladder base may cause less bladder dysfunction. There is evidence both for and against this possibility (4-8) It is also theorized that, with less dissection of the pubovessicocervical fascia, is less likely to result in pelvic floor weakness. In training, all residents are instructed to sew the cardinal and uterosacral ligaments to the cuff and every textbook has diagrammatic pictures of this procedure. (9) Most practicing gynecologists recognize that these tissues may be illusory, damaged or may not survive the suturing process. Indeed enterocele is at least as common a sequellae of Total Hysterectomy as cervical prolapse is of Supracervical. (10) We feel that it is incumbent on the operator to ensure the stability of the uterosacral-pelvic floor complex no matter which procedure is performed.  It is also theorized that sexual function is less likely to be affected because there is no scar in the vaginal apex at the point that penile impact is greatest and also because there is no shortening of the vagina or dissection of the nerves traversing the uterosacral ligaments (11) . We do not feel that our data really address these questions in more than a very superficial way.

 Our data do show that the LSH patients were similar to the other patients in age, body weight and uterine size. The uterine size was somewhat larger in the TAH group. This is not surprising as even a confident and skilled operator may feel that a large fibroid uterus will be easier to handle through an abdominal incision than vaginally or laparoscopically. There was a curious tendency for LSH patients to be heavier than the others. It is the LSH surgeon’s belief that obesity is less of a hindrance in laparoscopic than in open or vaginal surgery.  Operative times were about as one would anticipate, LAVH> LSH>TAH>TVH. However we were surprised to see how small the differences were.  These cases were drawn from procedures done more than two years ago and we will be interested to see if the surgeon’s advancement along the learning curve has changed these relationships. Other parameters seem to show an advantage to LSH as regards blood loss, intra and postoperative complications, dyspareunia and resumption of normal activities, though these differences are generally small.  We have not looked at long-term parameters such as post-operative conversion of a normal pap smear, residual menstruation, cervical pain or late complications. We plan to address these in a later study as well as to look at the effect of the surgeon’s experience on the operative parameters.

Conclusion

In this retrospective series we have compared patients who had different operative approaches to hysterectomy. Our data suggest that the hysterectomy patients are all drawn from the same population as regards age, body weight and uterine weight. There were differences suggesting that LSH patients may be more obese and that TAH patients may have larger uteri. In other parameters examined, there are trends to favor the LSH. This study does not address long-term complications or concerns, such as residual menstruation from the cervical stump, cervical pain or conversion of a normal pap smear.  We have shown that in a small, primary care hospital LSH can be used safely and with somewhat less morbidity and shorter length of stay than TAH, TVH and LAVH. Our thesis is that in the absence of other factors, of several similar operations, the less morbid operation is preferable. In this case, we believe that these data suggest that LSH is certainly not a more morbid operation than the other types of hysterectomy and   that it may actually represent a safer operation with a shorter  length of hospitalization and a quicker return to normal activities. Further studies with larger group size will be necessary to confirm our findings.

Reference List

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     (3)   Hasson HM. Cervical removal at hysterectomy for benign disease. Risks and benefits. J Reprod Med 1993; 38(10):781-790.

     (4)   Lalos O, Bjerle P. Bladder wall mechanics and micturition before and after subtotal and total hysterectomy. Eur J Obstet Gynecol Reprod Biol 1986; 21(3):143-150.

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     (9)   Richard F.Mattingly M. Te Linde's Operative Gynecology. 5 ed. Philadelphia,Toronto: J.B.Lippincott Company, 1977.

   (10)   Pitkin RM. Commentary on: "Posterior culdeplasty: surgical correction of enterocele during vaginal hysterectomy: A preliminary report". 1957. Obstet Gynecol 2003; 101(4):625.

   (11)   Kilkku P, Gronroos M, Hirvonen T, Rauramo L. Supravaginal uterine amputation vs. hysterectomy. Effects on libido and orgasm. Acta Obstet Gynecol Scand 1983; 62(2):147-152.

Figure 1. Patient Questionnaire

Figure 2. Chart Review Form

Table 1.Demographics

Value ±SD, ns or P value. 95% CI values.

Table 2.  Operative parameters

Value ± SD, ns or p value

Table 3. Post op parameters

(Data ±SD p value of LSH vs. column if significant.)

Figure 3. Intercourse quality post op

Figure 4. Dyspareunia