Technique and choice of total or subtotal hysterectomy ?

Total or Subtotal Hysterectomy .

During a subtotal laparoscopic hysterectomy only the uterine corpus is removed leaving the cervix. Evidence of superiority does not exist, but common sense based upon the knowledge that the cervical rim plays an important role in the pelvic floor support while containing a lot of nerve fibers. This stronly suggest that a supracervical hysterectomy has a series of advantages.
1. A decreased incidence of pelvic floor descent
2. Less pain after surgery with a faster recovery.
3. Improved sexual function, as a consequence of the mucous produced by the cervix and as a consequence of the intact innervation.

To prove this scientifically is close to impossible since the series should be prohibitvely large.

The Laparoscopic hysterectomy

Total or subtotal ? The laparoscopic hysterecomy actually is the standard of treatment which has replaced abdominal hysterectomy.
The laparoscopic hysterectomy has a series of advantages such as less pain, no scar and a faster recovery.
Provided the surgeon has the skills complication rate is the same. In this respect the literature should be regarde critically since some randomised trials demonstrating a higher incidence of complications were done by rather inexperienced surgeons only.
The only limit of laparoscopic hysterecomy is the size. For an uterus of more than 1000 grams, special expertise is necessary.

Why is laparoscopic hysterectomy still not yet that popular.

Since 1996 I stopped to do abdominal hysterectomies, and did only Total/subtotal Laparoscopic hysterectomies or vaginal hysterectomies . Many friends did the same. In 1996 we also founded the 1 kilo club demonstrating at least that already then a slmall group was able to do a uterus of more than 1 kilo by laparoscopy.  Today however, as evidenced by the 2008 AAGL review still over more than half of the hysterectomies are performed as abdominal hysterectomies in the USA – and Europe is not going to be that different. Reality is that some are doing almost all by laparoscopy, whereas some are only doing the basic endoscopy.  Laparoscopic hysterectomy being the first step in endoscopic surgery this illustrates the problems in more advanced endoscopy as pelvic floor en lymph node dissection and even more so in advanced endometriosis surgery.

For me there are 3 reasons why the introduction of laparoscopic surgery is so slow. First endoscopic surgery is not that easy and asks for additional training.  Second referral and informed consent is inadequate and incomplete.  Patients overal do not know and are not told that for hysterectomy the TLH has become the standard as they are not informed of the experience of the surgeon.

What is a normal conversion rate ?

When a laparoscopic hysterectomy is started, how frequently a laparotomy has to be done because of eg bleeding. This depends on the skills and training of the surgeon.  I personally never had to do a conversion, whereas 20% is considered normal in the literature.  This figure is probably the easiest way to judge the surgeon.

Do we need special equipment.

An uterine manipulator is essential. The most complete is the one P. Koninckx  patented back  in 1991.

What can you expect ? .

Surgery takes 60 min.  Hospitalisation of 3 days. Complication rates are normal ie
1% ureter problems, 1% bleedings and 2-3% infections. I personally had in a series of over 500 hysterectomies
3 ureter letsions (1 late stenosis and 2 coagulation lesions, all in the first 50) and 2 postoperative bleedings/haematoma’s. Alle complications -as for endometriosis-were solved laparoscopically.

Technique of laparoscopic hysterectomy .

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hysterect 5pillars Total or subtotal ?hysterect 6utartle Total or subtotal ?hysterect 8ureter Total or subtotal ?hysterect 9after Total or subtotal ?

hysterect 10ramus%20vagin Total or subtotal ?hysterect 11cuff Total or subtotal ?hysterect 11done Total or subtotal ?hysterect 12finished Total or subtotal ?

Vaginal Hysterectomy

The LAVH (laparoscopic vaginal hysterectomy) was performed in the early 90′ as a simplified technique combining laparoscopy and vaginal surgery. Some are still performing this illustrating that either they still did not make the turn lo real laparoscopic surgery or in universities to accommodate training of registrars.
Laparoscopische hysterectomy cannot be compared to a vaginal hysterectomy : it would be crazy to replace an easy vaginal hysterectomy by a more difficult laparoscopic. We always should choose what is best for the patient. Things are changing however, and for severe prolaps the subtotal laparoscopic hysterectomy together with a mesh and promontofixation is rapidly becoming the standard for the most advanced surgeons.