A laparoscopic hysterectomy should always be preferred unless the uterus is more than 1 kgr. A bigger uterus can be operated by laparoscopy but this is technically more difficult. The biggest we operated was 1850 gram (in Oxford)

There is a serious problem concerning informed consent for hysterectomy. Informed consent should inform the patient also about all alternative treatments, including those not performed by the gynecologist. Yet the incidence of total laparoscopic hysterectomies (TLH) is less than 10% in Belgium and in most counties of this world. Subtotal laparoscopic hysterectomy (SLH) is performed in less than 5%. Even if LAVH (laparoscopic assisted vaginal hysterectomy ) is considered a laparoscopic hysterectomy the incidence is less than 25%.

Why is a laparoscopic hysterectomy better ?

The advantages of a TLH for the patient are less pain, less scar, faster recovery and less adhesions.
Without disadvantages. It is clear that the complication rate of a TLH is comparable or less provided the surgeon is an experienced laparoscopist. If accidents occur videoregistration is useful. Without videoregistration the technique might be blamed.
Conversions ( start by laparoscopy and end by laparotomy) are extremely rare. Personally we never did a conversion. If more than 5% conversions occur , as often indicated in the literature, there must be a problem of indication and or skills of the surgeons. Again videoregistration is necessary to prove this.
TLH cause less adhesions. Adhesions decrease further if the duration of surgery is short and associated with little bleeding. ” a better surgeon causes less adhesions” Training thus becomes a problem knowing that during training duration of surgery easily exceeds 3 hours; normally duration of surgery should be less than 1 hour.

Even better a SLH ?

Pelvic floor (muscles and support tissue) is as a trampoline with 2 openings for the uterus and the bowel. During a LSH only the part above the “trampoline” is removed leaving the pelvic floor which is attached to the cervix intact. A TLH has to make an hole which has to be repaired. Not surprising that postoperative pain is less and recovery faster following a LSH.
Some EBM fanatics state that this is not demonstrated in RCT (randomised controlled trials). This is obvious knowing that results are aminly dependent on the experience of the surgeon.
A LSH should obviously not be performed when a eal risk of cervical cancer of adenomyosis exist.

When a vaginal hysterectomy ?

Officially the results of a vaginal and a TLH are comparable, which is not true.
A vaginal hysterectomy was indicated for a prolaps. Today we can state that “the more descent the better the indication for a laparoscopic hysterectomy.
- a vaginal repair of descent has a recurrence risk of at least 30% ; and more with severe descent.
- mesh repair cannot be done during vaginal hysterectomy and repair.
- for severe descent the method of choice is a LSH and promontofixation. This is not that popular mainly becausefew surgeons have the skills to do this in less than 2.5 hours. With less experience this will rapidly take more than 5 hours. This is not good for the patient, difficult for the surgeon and expensive for the hospital. In countries with private medicine this therefore is preformed mainly in private patients whereas thos in training will perform the vaginal hysterectomy and repair.

What is the problem of informed consent ?

Informed consent means that the patient gets information concerning the surgery and the alternative treatments including those not performed by that gynecologist
It is difficult to imagine that a patient who got decent information, will chose a laparotomy or even for a vaginal hysterectomy instead of a LSH with promontofixation.

Prof em Philippe Koninckx and Drssa Anastasia Ussia
Gruppo Italo Belga of the
European group for advanced endoscopic surgery.

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