Laparoscopic Hysterectomy for Large, Fibroid Uterus

Laparoscopic Hysterectomy

I have already written a post regarding laparoscopic hysterectomy. However, I recently had a patient who presented a difficult challenge. Her uterus was approximately the same size as the uterus of a 16-18 week pregnancy, just below her belly button. For most gynecologic surgeons this large of a uterus would be removed through a c-section type or a vertical incision. I was able to complete the hysterectomy through the laparoscope with only an additional small bikini type incision which was used to remove the uterus.

This particular case was challenging due to the size and shape of the uterus. The uterus was filled with numerous and large myomas, or fibroids. The position of the fibroids made access to the blood vessels supplying the uterus difficult. I had to use a knowledge of the anatomy of the pelvis to dissect out the uterine artery and vein at their origins. This is accomplished by opening the lining of the pelvis and identifying the ureter, blood vessels, and nerves in the area. Once all structures were identified, the uterine artery and vein were clipped with a laparoscopic clip device. This allowed control of the blood vessels supplying the uterus.

Typically with a large fibroid uterus, the veins can be quite distended. Traditional devices used to close the vessels and cut them may be insufficient. In this case I placed a suture into the abdomen and through laparoscopic suturing ligated or tied off the blood vessels prior to cutting them.

With the blood supply to the uterus controlled, I was then able to safely cut the uterus into smaller pieces that would allow it to be removed through the smaller incisions used in minimally invasive surgery. In the case of a supracervical hysterectomy this can be done either with a morcellator or through a mini bikini type incision. For a total hysterectomy the uterus can be removed through the vaginal opening.

Although laparoscopy for a very large uterus may take significantly more time in the operating room, the recovery is much quicker than with open surgery. Patients still usually go home in less than 24 hours as opposed to 3-4 days.

Laparoscopic Hysterectomy (Bandaid Hysterectomy)

Laparoscopic Hysterectomy, or "Band-Aid Hysterectomy", is a wonderful option for many women who need a hysterectomy. Overall, laparoscopic hysterectomy is indicated as an alternative to open or abdominal hysterectomy. In this discussion I will talk about the indications, the benefits and risks and different methods of laparoscopic hysterectomy.

The indications for laparoscopic hysterectomy are similar to those for abdominal hysterectomy. Any patient who has previous abdominal surgery such as cesarean section or surgery for ovarian cysts may not be a candidate for a vaginal hysterectomy. This is due to the risk of adhesions of the bladder or other organs with in the abdomen. Also in patients with limited uterine descent, the uterine support is still very good. Patients with a concern for other intra-abdominal problems such as infection or endometriosis. Also women with a very large uterus that is too big to be removed vaginally.

It has been shown that vaginal hysterectomy is the safest method when possible. However; when there are contraindications to vaginal hysterectomy, laparoscopy offers some significant benefits over abdominal hysterectomy. The biggest benefit is the recovery time and hospital time. A patient who has had an abdominal hysterectomy usually stays in the hospital for 3-4 days because of the invasiveness of the procedure. A bikini type incision is made on the low abdomen and the abdominal muscles are separated. Pain is more significant because of the larger incision. Laparoscopy offers a similar hysterectomy through smaller “keyhole” incisions. In performing a total hysterectomy through the laparoscope I typically place 5 incisions, the largest being approximately 1.5 cm in the belly-button.

Laparoscopy usually allows a patient to go home within 24 hours of surgery and is considered an “outpatient” surgery. Patients usually are able to perform normal activities sooner. The normal course for my patients after total laparoscopic hysterectomy has them feeling close to normal in 10-14 days.

Another benefit is the increased ability to see small disease. If there is endometriosis or other problems, the laparoscope magnifies the view inside the abdomen and allows me to see better. I can then remove any disease that I see. I can look all around the abdomen also, including visualization of the liver, gallbladder, stomach and spleen.

Adhesions, or organs sticking to each other, are more common after abdominal or open procedures. Laparoscopy decreases the likelihood of forming adhesions due to smaller incisions and increased ability to control very small bleeding.

Some of the risks of laparoscopic hysterectomy include injury to major blood vessels during entry, injury to bowel, bladder or ureters. Early studies have shown laparoscopy to be more risky than vaginal surgery. But again, laparoscopy is not an alternative for vaginal hysterectomy. I feel that laparoscopic suturing is a very important skill for anyone performing laparoscopic hysterectomy. This allows management of most complications without having to convert to laparotomy.

Laparoscopic hysterectomy can be divided into three categories. The first is laparoscopic assisted vaginal hysterectomy. This is performed in women with good uterine descent who have other abdominal concerns that need to be addressed. Some of these concerns may be an ovarian cyst, endometriosis, or adhesions. Most gynecologists can perform some portion of the surgery through the laparoscope.

The next one is laparoscopic supracervical hysterectomy or “LSH”. This is performed fully laparoscopically by removing only the upper portion or “fundus” of the uterus. The cervix is left in place. The only benefits to this are quicker recovery, limited post operative restrictions, quicker return to intercourse, and not interrupting the uterine support that is already in place. Many patients believe and are told that sexual response is better with leaving the cervix; however, many studies have shown no benefit in this regard. This type is also less risky because the uterus is “amputated” at a level above the ureters and bladder.

The next type is total laparoscopic hysterectomy, or “TLH”. This procedure performs the hysterectomy in a similar fashion to abdominal hysterectomy. The full hysterectomy removes both the fundus of the uterus and the cervix. The top of the vagina is then closed and support is re-established to supporting ligaments. This is a very good alternative for a woman who needs a hysterectomy who also needs or wants to have her cervix removed.

Concerning surgical management of gynecologic and uterine problems, a physician who can perform laparoscopic hysterectomy can offer a full line of options to each patient.