Original Article
Laparoscopic Supracervical Hysterectomy With Transcervical Morcellation: Our Experience Angela Graziano, MD, Giuseppe Lo Monte, MD, Herbert Hanni, MD, Johann Georg Brugger, MD, Bruno Engl, MD, and Roberto Marci, MD, PhD* From the Department of Morphology Surgery and Experimental Medicine, Section of Obstetrics and Gynaecology, University of Ferrara, Ferrara, Italy (Drs Graziano, Lo Monte, and Marci), and Department of Gynaecology and Obstetrics, Centre of Human Reproduction and Cryoconservation of Gametes, Brunico Hospital, Brunico, Italy (Drs. Hanni, Brugger, and Engl).
ABSTRACT Study Objective: To present our experience with laparoscopic supracervical hysterectomy with transcervical morcellation (LSH-TM). Design: A retrospective observational study (Canadian Task Force Classification III). Setting: Gynecologic Department at Brunico Hospital, Brunico, Italy. Patients: Three hundred sixty-five patients affected by gynecologic benign diseases who underwent LSH-TM. Interventions: A minimally invasive surgical technique for supracervical hysterectomy that involves extraction of the morcellated uterus through the cervical canal. Measurements and Main Results: We performed LSH-TM successfully in 365 patients; the mean (standard deviation) operating time was 72.24 (23.21) minutes. We registered no intraoperative complications. The main postoperative complications resulted in 2 cases of second-look laparoscopy because of internal bleeding, 5 cases of asymptomatic hematoma around the cervical stump, and 7 cases of pelvic pain. Conclusion: Our experience shows that LSH-TM is a safe and easy to perform technique and that it ensures minimal blood loss. Journal of Minimally Invasive Gynecology (2015) 22, 212–218 Ó 2015 AAGL. All rights reserved. Keywords:
DISCUSS
Adenomyosis; Gynecologic benign diseases; Laparoscopy; Myomas; Supracervical hysterectomy; Transcervical morcellation
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Laparoscopic hysterectomy was originally described by Reich in 1989 [1] and successively in 1990 by Minelli et al [2]; the endoscopic access was adopted in order to reduce the frequency of postoperative pain and complications traditionally connected with the laparotomic technique [1,2]. In particular, laparoscopic supracervical hysterectomy (LSH) is a viable choice in benign gynecologic pathologies. The authors declare no conflicts of interest. Corresponding author: Roberto Marci, MD, PhD, Department of Morphology Surgery and Experimental Medicine, Section of Obstetrics and Gynecology, University of Ferrara, Ferrara, Italy. E-mail: [email protected] Submitted July 29, 2014. Accepted for publication September 29, 2014. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.09.013
This technique is easier to perform and has reduced surgical duration and intraoperative bleeding when compared with total laparoscopic hysterectomy (TLH). Moreover, it is associated with a very low rate of complications (e.g., ureteral, bladder, or bowel damage) [3,4]. We developed a minimally invasive surgical technique for supracervical hysterectomy that ensures minimal blood loss; this procedure involves extraction of the morcellated uterus through the cervical canal. The literature reports only a few studies using a similar technique, all with small samples [4–9]. In addition to these experiences, we developed a specific uterine manipulator in order to improve the morcellating phase. The aim of this study was to describe this innovative technique in a large population, analyzing efficacy and related side effects.
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Material and Methods
Surgical Instrumentation
In this retrospective study, we analyzed 365 patients undergoing LSH with transcervical morcellation (LSH-TM) from January 1, 2000, to February 28, 2014, in the Department of Gynaecology and Obstetrics, Brunico Hospital, Brunico, Italy (in partnership with Residency School of Obstetrics and Gynaecology, University of Ferrara, Ferrara, Italy). All these surgical procedures were performed by 3 skilled surgeons highly qualified in the field of endoscopic surgery. Indications for LSH-TM were myomas, menometrorrhagia, adenomyosis, dysmenorrhea, and chronic pelvic pain. All patients underwent accurate transabdominal and transvaginal sonographies in order to assess uterine volume, exclude renal diseases, and determine gynecologic malignancies. LSH-TM is not indicated in uteruses with an estimated volume .600 g. (Our experience showed that TM is potentially dangerous in larger uteruses for several reasons including the worse laparoscopic view and the intrinsic difficulty during the morcellating process.) The number and location of myomas were described; longitudinal, transverse, and anterior-posterior diameters were recorded. We evaluated the myometrial and myoma vessels using directional power Doppler imaging. A subjective, semiquantitative assessment of the amount of blood flow within the examined lesion was made (color score) according to published reports [10,11] and the International Ovarian Tumor Analysis consensus statement [12]. We also described the vascularity of the central and peripheral region of the lesion (moderate, mild, or not appreciable as previously reported) [10]. Myomas with marked peripheral and central vascularity detected on color power Doppler, a rapid increase in mean diameters (especially in postmenopausal women), or a diagnosis of myomas after menopause (in women without previous pathological evaluations) were considered at risk of potential malignancy and, thus, not eligible for the LSH-TM procedure. Patients with an abnormal Papanicolaou (Pap) smear or sonographic suspicion of a pathologic endometrium eventually confirmed by biopsies were not included in the analysis. In addition, the cervix was accurately evaluated to verify if the morcellation process could be applicable (i.e., not-too-soft consistency of the cervix, sonographically measured cervical length .2 cm, or cervical myomas .4 cm). All patients received a prophylactic single dose of antibiotics (ampicillin/sulbactam 1.5 g or clarithromycin 900 mg). The bowel preparation was not required before surgery. Postoperative follow-ups were performed after 1, 2, 6, 12, and 24 months by interview, a Pap smear (performed after 1 year), an ultrasound evaluation (both transvaginal and abdominal), and a gynecologic examination. After this interval, we offered the patients the opportunity to be evaluated each year, and many of them accepted (data not shown; we only presented complications).
The surgical instrumentation required included 4 trocars (one 10-mm trocar placed through the umbilicus and 3 ancillary 5-mm trocars in the suprapubic region and the right and left lower quadrants); a rigid 30 , 10-mm diameter laparoscope (Karl Storz GmbH & Co KG, Tuttlingen, Germany); a 5-mm bipolar instrument (Plasmakinetik; Gyrus Medical, Tuttlingen, Germany, until 2010; thereafter, LigaSure; Covidien-Valleylab, Boulder, CO); a 15-mm calibrated electromechanical morcellator (Gynecare Morcellex; Ethicon, Johnson & Johnson Gateway, Somerville, NJ, until 2008; thereafter, Rotocut G1; Karl Storz, Culver City, CA); a uterine manipulator (currently being patented); two 5-mm atraumatic fenestrated grasping forceps (Karl Storz GmbH & Co KG); a 5-mm hook scissor (Karl Storz GmbH & Co KG); an aspiration system for peritoneal lavage; and a 30-cm absorbable endoloop (Endoloop PDS II; Ethicon, Somerville, NJ, until 2008; thereafter, Serafit CISH-Endoloop; SeragWiessner, Naila, Germany). Surgical Procedure LSH-TM is a 3-step surgical procedure consisting of vaginal preparation, LSH, and TM; vaginal examination and suture are performed if needed. Vaginal Preparation After abdominal and vaginal disinfection, the surgeon puts our specific uterine manipulator (Fig. 1A and B) and a transurethral catheter into place. The uterine manipulator, designed by our team and currently being patented, is a 14 ! 600 mm cylinder with a conical end made of a material that is inexpensive, reusable, and easy to sterilize (TecapeeK MT; Ensinger, Washington, PA). A helical groove in the surface of the conical end allows insertion in the cervix by screwing, avoiding the trauma connected with dilation that might occur when using Hegar dilators (Fig. 1A). Our instrument makes it possible to core the cervix while keeping the core specimen as intact as possible, thus facilitating the pathologic analysis that it will undergo later. The device is designed to have a double function; its conical end works as a uterine manipulator during laparoscopic hysterectomy, whereas its blunt end can be used as a guide for the Rotocut blade when performing uterine morcellation. LSH-TM LSH is performed using a bipolar vessel sealing system (LigaSure since 2010) and involves the following steps: coagulation and transection of the round ligaments, preparation of the anterior leaflet of the broad ligament by dissection and development of the bladder flap, coagulation and transection of the utero-ovarian ligaments (or infundibulopelvic ligaments in women with bilateral adnexectomy), and
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Fig. 1 (A) Uterine manipulator. (B) Vaginal preparation.
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the cervical stump (Fig. 2C). At this point, the blade can be retracted further, and the uterine manipulator is extracted completely. Finally, transcervical morcellation is performed through the cervical canal by means of a 10-mm tenaculum (Fig. 2D). The surgeon hands the uterus just near the Rotocut blade in order to minimize the dispersion of fragments into the pelvic cavity; the different position of the morcellator allows the operator to store the residues in the pouch of Douglas. Direct laparoscopic visualization of the pelvis during the coring procedure aids in avoiding injuries to the abdominal and pelvic organs. After morcellation, the surgeon checks the peritoneal cavity for uterine tissue residues, which, if found, are extracted transcervically. The blade is then extracted, and, at the same time, the endoloop gets tightened in its final position. Then, the surgeon assesses for hemostasis and performs repeated washings (Fig. 3A). Vaginal Examination and Suture (if Needed) The second assistant examines the cervical-vaginal region (Fig. 3B) and, if needed, applies absorbable sutures (2-0 absorbable suture, Vicryl Rapid, Ethicon) in the cervical stump. Results
preparation of the posterior leaflet of the broad ligament by dissection until the level of uterosacral ligaments. Both uterine arteries are skeletonized and then coagulated with LigaSure without dissecting them. An endoloop (Serafit CISH-Endo-loop since 2008) is inserted through the left trocar and is then placed around the corpus uteri at the level of the uterosacral ligaments and tightened, only after the surgeon makes sure that neither the bladder nor the bowel got caught in the loop (Fig. 2A). At this point, the second assistant (positioned between the legs of the patient) starts with the cervical coring. The coring of the cervix/uterus is then performed by removing the transformation zone in the endocervical canal by means of a 15-mm calibrated electromechanical morcellator (Rotocut G1 since 2008). The uterine manipulator is used as a guide until the morcellator blade comes out of the uterus and protrudes into the peritoneal cavity (Fig. 2B). Then, the cored cervical/uterine tissue is extracted and set aside for histology. The uterine manipulator is extracted and rotated 180 along its major axis so that its blunt end can be reinserted into the uterine cavity. The surgeon then slices the uterus right above the cervix until the morcellator’s blade becomes visible and, subsequently, retracts both the blade and the manipulator until they protrude from the cervical canal. He then cuts the rest of the corpus uteri using a 5-mm hook scissor, detaching it from
In our sample, the mean (standard deviation [SD) age was 49 (5.6) years. The mean (SD) body mass index was 27.4 (3.2) kg/m2. Most of the patients were premenopausal (85.48% of the sample, 312 patients). The primary indication for LSH-TM is reported in Table 1. All patients with abnormal uterine bleeding underwent hysteroscopy and endometrial biopsies to exclude malignant diseases. LSHTM was combined with other surgical procedures in 35.07% cases (128 patients). Table 2 shows the distribution of concomitant procedures. The mean (SD) time for LSH-TM was 72.24 (23.21) minutes; it was longer (92.35 [25.88] minutes) when other surgical procedures were performed. All patients did not develop intraoperative complications. Patients were discharged 3.0 (1.5) days after surgery. The average loss of hemoglobin (defined as the difference between preoperative and third-day postsurgery hemoglobin levels) was 1.39 (1.02) g/dL. The corpus uteri weighed 277 (252) g. In all cases analyzed, the surgeon was able to perform the cervical coring. Moreover, the pathologist was able to describe both cervical and endometrial tissue derived from the coring in all samples. The complications that occurred in our series are shown in Table 3. All women were evaluated 1 month after surgery; 301 patients (82.47%) presented at 6 months, 287 (78.63%) at 12 months, and 231 (63.29%) at 24 months. A laparoscopic revision of the cervical stump was performed in 2 women the first day after surgery because of clinically and sonographically suspected intraperitoneal hemorrhage. In both cases, these minimal bleedings were
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Fig. 2 (A) Insertion of the endoloop, (B) protrusion into the peritoneal cavity of morcellator blade, (C) separation by section of the corpus uteri from the cervix at the uterosacral level, and (D) morcellation of the corpus uteri.
properly coagulated, and the patients experienced no further complications. A low-grade endometrial stromal sarcoma was diagnosed after surgery on the surgical specimen; the patient underwent laparoscopic reoperation for the removal of the adnexa, cervical stump, pelvic lymph nodes, and suspected peritoneal tissue (all specimens were negative for malignancies). The patient was re-evaluated after 1, 2, 6, 12, and 24 months; to date, she is cancer free. A case of highgrade atypical squamous cells (cannot exclude high-grade squamous intraepithelial lesion, ASC-H) and a positive
Fig. 3 Final result: (A) laparoscopic and (B) vaginal view of the cervical stump.
test for human papillomavirus was detected in a patient 5 years after LSH-TM. Colposcopy was not definitive; therefore, we performed a vaginal trachelectomy. An asymptomatic supracervical hematoma (mean diameter ,2 cm) was detected in 5 patients (1.37%) 30 days after surgery. Five women presented with persistent cervical bleeding 30 days after surgery: they underwent thermoablation, and they experienced no further complications. Seven patients complained of persistent pelvic pain; this symptom resolved after 6 months in 3 of them, and the other 4 women
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Table 1
Table 3
Main indication for laparoscopic supracervical hysterectomy with
Complications associated with laparoscopic supracervical
transcervical morcellation
hysterectomy with transcervical morcellation
Indication for surgery Uterus fibromatosis Menometrorrhagia Chronic pelvic pain Adenomyosis Endometriosis Uterine prolapse Other*
No. of patients (n) 270 38 6 27 12 10 2
No. of patients (%) 73.97 (270/365) 10.41 (38/365) 1.64 (6/365) 7.40 (27/365) 3.29 (12/365) 2.74 (10/365) 0.55 (2/365)
* Surgical completion in patient diagnosed with ovarian disease.
were successfully treated by operative laparoscopy (2 cases of adhesiolysis, 1 case of trachelectomy, and 1 case of combined adhesiolysis and trachelectomy). Discussion Coring of the cervix was first described by Semm in 1993 [1] associated with traditional supracervical hysterectomy (Classische intrafascial Supracervicale Hysterektomie with Teilerhalt des Geb€armutterhalses, supracervical hysterectomy intrafascial Classic Conservation of Cervical [CISH]). The removal of the endocervix was purposed in order to solve the problem of postoperative cyclical bleeding and the potential risk of cervical malignancies [13]. We presented a minimally invasive surgical technique for supracervical hysterectomy that involves coring of the cervical canal as in the CISH procedure and reduces the incidence of postoperative bleeding and, eventually, the development of cervical dysplasia. In the original CISH procedure, morcellation was performed through an abdominal approach, increasing the risk of herniation through the enlarged access [3]. Indeed, in Table 2 Distribution of concomitant surgical procedures Concomitant surgical procedure
No. of patients (n)
No. of patients (%)
Adhesiolysis Adnexectomy Salpingectomy Endometriosis removal* Sacrocervicopexis Othery
56 25 27 8 10 2
43.75 (56/128) 19.53 (25/128) 21.09 (27/128) 6.25 (8/128) 7.81 (10/128) 3.33 (2/128)
* Excision of a nodule in the rectovaginal septum (n 5 3), removal of endometriosis in uterosacral ligaments (2 patients), removal of endometrioma (1 patients), removal of endometriosis in the vesicouterine pouch (1 patient), and removal of endometriosis in the paraovarian fossae (1 patient). y Intracervical myoma excision.
Complications
No. of patients (n)
No. of patients (%)
Endometrial stromal sarcoma Intraperitoneal bleeding Cervical bleeding Pelvic pain Hematoma around the cervical stump Recurrence of prolapse Dysplasia in the cervical stump Total
1 2 5 7 5 2 1 23
0.27 (1/365) 0.55 (2/365) 1.37 (5/365) 1.92 (7/365) 1.37 (5/365) 0.55 (2/365) 0.27 (1/365) 6.30 (23/365)
LSH-TM, the extraction of the morcellated uterus was performed through the cervical canal. We have used this technique for LSHs since the 1990s and have thus decided to adopt it routinely in surgical treatment of benign gynecologic diseases. The literature reports only a few studies using a similar technique, all with small samples [4–9]. The evaluation of a larger sample allowed us to conclude that LSH-TM is an easy and faster technique (mean time 5 72 minutes) that minimizes the risks connected with intraoperative bleedings. A second laparoscopy was performed in 2.1% of cases, and 1.37% of patients required outpatient treatment for persistent bleeding. However, it is mandatory to perform an adequate stratification of indications for surgery. Two cases (a diagnosis of endometrial stromal sarcoma and high-grade atypical squamous cells as shown in the Results section) should not be included in this analysis because their indication to reintervention was not a surgical complication. Two patients underwent surgery because of intraperitoneal bleeding; in accordance with Rosenblatt et al [6–8], we speculate that a reduced hemorrhagic rate (in our sample 0.55%) could be explained by the synergic action of coagulation of uterine vessels, the pressure of the uterine morcellator upon the endocervical surface, and the role of the endoloop in cervical stump suture. Thus, the endoloop has a double function; it closes the cervical stump after coring, and it enhances hemostasis in order to obtain a safer surgery (especially in enlarged uteruses complicated by myomas or adenomyosis). We observed a decrease in postoperative abdominal pain. We hypothesized that the transcervical approach could avoid the enlargement of the abdominal access required in traditional morcellation. However, 4 women underwent a second surgery because of persistent pelvic pain (preexisting diagnosis of deep endometriosis or adhesions syndrome). All of these cases were treated in 2007; 2 (or more if needed) monofilament endoloops were used to close the cervical stump. Since 2008, we started to use a single polyfilament endoloop, and we had no further complications. Thus, we had a real percentage of postoperative complications that required
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surgery with the actual instrumentation of about 0.55% in agreement with the literature [14,15]. In fact, a recent prospective analysis of 1952 patients undergoing LSH or TLH, respectively, reported a 0.6% and 4.8% rate of shortterm complications requiring reoperation (p , .001) and a 0.8% and 1.7% rate of long-term complications requiring surgery (p 5 .173) [15]. Persistent bleeding presented in 1.3% of women; all of them were treated with outpatient coagulation, with no further complications. In the literature, the incidence of bleeding after LSH amounted to 1% to 25% [16,17]; thus, cervical coring minimized the problem of postoperative bleeding. In the last decades, LSH was usually associated with lower rates of sexual dysfunction, pelvic organ prolapse (POP), and urinary tract injuries when compared with TLH [17]. To date, the improvement of endoscopy has reduced the risk of ureteral injury to less than 1%. As stated in a recent systematic review, the overall urinary tract injury rate is actually 0.73% (0.84% in TLH, 0.23% in LSH, and 0.74% in laparoscopic-assisted vaginal hysterectomies) [18]. In our series, none of the patients reported ureteral injuries; these results are lower but comparable with the latest obtained with TLH experience. Similarly, maintenance of the cervical stump for the prevention of POP in LSH is still debated. There is a growing opinion that the uterus could have a passive role in genital prolapse. Several authors stressed the role of an adequate colposuspension or cervical suspension at the time of hysterectomy in patients with POP [7,8,19,20]. Sacrocolpopexy in addition to TLH is associated with an increased risk of mesh exposure at the site of the vaginal cuff (incidence between 0.8% and 9%) [19,20]. Conversely, Rosati et al [19] showed an alternative technique involving LSH and the suspension of the cervical stump to the anterior longitudinal ligament of the sacrum. This approach showed a low recurrence rate, absence of mesh erosion, and preservation of an adequate length of the vaginal canal. We prefer to perform LSH-TM in association with adequate cervicosacropexy when POP is diagnosed. Literature concerning sexual function and preservation of the cervical stump is still poor and often conflicting [6,21– 27]. The improvement of sexual outcomes in LSH could be explained with preservation in cervical-vaginal innervation, an adequate production of genital secretion, and the maintenance of the physiological length of the vaginal canal [21]. Several authors reported an improvement in sexual function in women undergoing LSH [21–23] when compared with TLH. Recently, a prospective study on a large sample detected better outcomes regarding quality of life and sexual outcomes assessed with specific questionnaires in LSH than in TLH [23]. Conversely, other studies found no differences in sexual function regarding the surgical technique [24–27]. Our study did not analyze sexual outcomes in patients undergoing LSH-TM; further prospective randomized trials are necessary to evaluate
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quality of life and sexual function, allowing the surgeon to choose the adequate intervention for each patient. In April 2014, the Food and Drug Administration discouraged the use of laparoscopic power morcellation for removal of the uterus or uterine myomas because of the potential risk of spreading undetected cancerous tissue in women with unsuspected cancer (i.e., leiomyosarcoma). Recently, laparoscopic societies (e.g., American Association of Gynecologic Laparoscopists and Advancing Minimally Invasive Gynecology Worldwide) have been critically analyzing this statement, and several concerns about the interpretation of data were found. Prospective and population-based studies are needed to develop a better understanding of morcellating techniques and eventually identify a population of women who may be at high risk of an unrecognized uterine cancer [28–30]. At the present time, a specific diagnostic tool applicable for the definitive exclusion of uterine malignancies is still missing. However, our patients undergo an accurate preoperative evaluation (comprehensive of sonographic evaluation improved with Doppler analysis) to minimize this risk. If malignancy is suspected, we perform total laparoscopic hysterectomy without morcellation. Moreover, our peculiar morcellation (through the cervical canal) allows the surgeon to accumulate morcellated chips in the pouch of Douglas. This advantage does not have a clear protective value, but we hypothesized that it could reduce the risk of morcellated tissue spreading [4–9]. Possible solutions to decrease the incidence of hidden malignancies on surgical specimens may include the detection of specific classes of risk (i.e., large myomas in postmenopausal women), preliminary assessment of the uterine cavity via office hysteroscopy, or development of specific bags for safer morcellation [28–30]. Conclusion Our experience shows that LSH-TM is a viable surgical procedure in benign gynecologic diseases in patients with a uterine estimated volume ,600 g. Sacrocervicopexy should always be adopted when POP is diagnosed. LSHTM is a safe and easy to perform technique, and it ensures minimal blood loss. In addition, it does not require enlargement of the abdominal openings, which results in minimal esthetic damage and a lower incidence of postoperative pain. The evaluation of medical history and clinical/ultrasonographic screening are mandatory in order to exclude cases at risk of malignancy. References 1. Reich H. Laparoscopic hysterectomy. Surg Laparosc Endosc. 1992;2: 85–88. 2. Minelli L, Franciolini G, Franchini MA, Mutolo F, Momoli G. Laparoscopic hysterectomy. Minerva Ginecol. 1990;42:515–518. 3. Gimbel H. Total or subtotal hysterectomy for benign uterine diseases? A meta-analysis. Acta Obstet Gynecol Scand. 2007;86:133–144.
218 4. Wenger JM, Dubuisson JB, D€allenbach P. Laparoendoscopic single-site supracervical hysterectomy with endocervical resection. J Minim Invasive Gynecol. 2012;19:217–219. 5. Yoon G, Kim TJ, Lee YY, et al. Single-port access subtotal hysterectomy with transcervical morcellation: a pilot study. J Minim Invasive Gynecol. 2010;17:78–81. 6. Rosenblatt P, Makai G, DiSciullo A. Laparoscopic supracervical hysterectomy with transcervical morcellation: initial experience. J Minim Invasive Gynecol. 2010;17:331–336. 7. Rosenblatt PL, Apostolis CA, Hacker MR, DiSciullo A. Laparoscopic supracervical hysterectomy with transcervical morcellation and sacrocervicopexy: initial experience with a novel surgical approach to uterovaginal prolapse. J Minim Invasive Gynecol. 2012;19:749–755. 8. Rosenblatt PL, Adams SR, Shapiro A. Microlaparoscopy in urogynecology: LSH and sacrocervicopexy. J Minim Invasive Gynecol. 2013; 20:411. 9. Estrade JP, Crochet P, Aumiphin J, Gurriet B, Marcelli M, Agostini A. Supracervical hysterectomy by laparoendoscopic single site surgery. Arch Gynecol Obstet. 2014 [Epub ahead of print]. 10. Exacoustos C, Romanini ME, Amadio A, et al. Can gray-scale and color Doppler sonography differentiate between uterine leiomyosarcoma and leiomyoma? J Clin Ultrasound. 2007;35:449–457. 11. Timmerman D, Verrelst H, Bourne TH, et al. Artificial neural network models for the preoperative discrimination between malignant and benign adnexal masses. Ultrasound Obstet Gynecol. 1999; 13:17–25. 12. Timmerman D, Valentin L, Bourne TH, et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet Gynecol. 2000;16: 500–505. 13. Semm K. CISH (pelviscopic intrafascial hysterectomy–without colpotomy), TUMA (total uterine mucosa ablation) and IVH (intrafascial vaginal hysterectomy). Gynakologe. 1993;26:378–384. 14. Grosse-Drieling D, Schlutius JC, Altgassen C, Kelling K, Theben J. Laparoscopic supracervical hysterectomy (LASH), a retrospective study of 1,584 cases regarding intra- and perioperative complications. Arch Gynecol Obstet. 2012;285:1391–1396. 15. Wallwiener M, Taran FA, Rothmund R, et al. Laparoscopic supracervical hysterectomy (LSH) versus total laparoscopic hysterectomy (TLH): an implementation study in 1,952 patients with an analysis of risk factors for conversion to laparotomy and complications, and of procedure-specific re-operations. Arch Gynecol Obstet. 2013;288: 1329–1339. 16. Ghomi A, Hantes J, Lotze EC. Incidence of cyclical bleeding after laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol. 2005; 12:201–205.
Journal of Minimally Invasive Gynecology, Vol 22, No 2, February 2015 17. Greer WJ, Richter HE, Wheeler TL, et al. Long-term outcomes of the Total or Supracervical Hysterectomy (TOSH) Trial. Female Pelvic Med Reconstr Surg. 2010;16:49–57. 18. Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic hysterectomy: a systematic review. J Minim Invasive Gynecol. 2014;21:558–566. 19. Rosati M, Bramante S, Bracale U, Pignata G, Azioni G. Efficacy of laparoscopic sacrocervicopexy for apical support of pelvic organ prolapse. JSLS. 2013;17:235–244. 20. Rosati M, Bramante S, Conti F. A review on the role of laparoscopic sacrocervicopexy. Curr Opin Obstet Gynecol. 2014;26:281–289. 21. Ellstr€om Engh MA, Jerhamre K, Junskog K. A randomized trial comparing changes in sexual health and psychological well-being after subtotal and total hysterectomies. Acta Obstet Gynecol Scand. 2010;89: 65–70. 22. Lyons T. Laparoscopic supracervical versus total hysterectomy. J Minim Invasive Gynecol. 2007;14:275–277. 23. Brucker SY, Taran FA, Bogdanyova S, et al. Patient-reported qualityof-life and sexual-function outcomes after laparoscopic supracervical hysterectomy (LSH) versus total laparoscopic hysterectomy (TLH): a prospective, questionnaire-based follow-up study in 915 patients. Arch Gynecol Obstet. June 29, 2014 [Epub ahead of print]. 24. Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev. 2012;4:CD004993. 25. Radosa JC, Meyberg-Solomayer G, Kastl C, et al. Influences of different hysterectomy techniques on patients’ postoperative sexual function and quality of life. J Sex Med. 2014;11:2342–2350. 26. Lermann J, H€aberle L, Merk S, et al. Comparison of prevalence of hypoactive sexual desire disorder (HSDD) in women after five different hysterectomy procedures. Eur J Obstet Gynecol Reprod Biol. 2013; 167:210–214. 27. American Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for laparoscopic subtotal/supracervical hysterectomy (LSH). J Minim Invasive Gynecol. 2014;21:9–16. 28. FDA. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. April 17, 2014. Available at: http://www.fda.gov/medicaldevices/safety/alertsandnotices/ ucm393576.htm. Accessed November 6, 2014. 29. FDA Executive Summary. Laparoscopic power morcellation during uterine surgery for fibroids. Prepared for the July 10-11, 2014 Meeting of the Obstetrics and Gynecology Devices Advisory Committee. http://www. fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/ MedicalDevices/MedicalDevicesAdvisoryCommittee/Obstetricsand GynecologyDevices/UCM404148.pdf. Accessed November 6, 2014. 30. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: morcellation during uterine tissue extraction. J Minim Invasive Gynecol. 2014;21:517–530.
Laparoscopic Supracervical Hysterectomy With Transcervical Morcellation: Our Experience Angela Graziano, MD, Giuseppe Lo Monte, MD, Herbert Hanni, MD, Johann Georg Brugger, MD, Bruno Engl, MD, and Roberto Marci, MD, PhD* From the Department of Morphology Surgery and Experimental Medicine, Section of Obstetrics and Gynaecology, University of Ferrara, Ferrara, Italy (Drs Graziano, Lo Monte, and Marci), and Department of Gynaecology and Obstetrics, Centre of Human Reproduction and Cryoconservation of Gametes, Brunico Hospital, Brunico, Italy (Drs. Hanni, Brugger, and Engl).
ABSTRACT Study Objective: To present our experience with laparoscopic supracervical hysterectomy with transcervical morcellation (LSH-TM). Design: A retrospective observational study (Canadian Task Force Classification III). Setting: Gynecologic Department at Brunico Hospital, Brunico, Italy. Patients: Three hundred sixty-five patients affected by gynecologic benign diseases who underwent LSH-TM. Interventions: A minimally invasive surgical technique for supracervical hysterectomy that involves extraction of the morcellated uterus through the cervical canal. Measurements and Main Results: We performed LSH-TM successfully in 365 patients; the mean (standard deviation) operating time was 72.24 (23.21) minutes. We registered no intraoperative complications. The main postoperative complications resulted in 2 cases of second-look laparoscopy because of internal bleeding, 5 cases of asymptomatic hematoma around the cervical stump, and 7 cases of pelvic pain. Conclusion: Our experience shows that LSH-TM is a safe and easy to perform technique and that it ensures minimal blood loss. Journal of Minimally Invasive Gynecology (2015) 22, 212–218 Ó 2015 AAGL. All rights reserved. Keywords:
DISCUSS
Adenomyosis; Gynecologic benign diseases; Laparoscopy; Myomas; Supracervical hysterectomy; Transcervical morcellation
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Laparoscopic hysterectomy was originally described by Reich in 1989 [1] and successively in 1990 by Minelli et al [2]; the endoscopic access was adopted in order to reduce the frequency of postoperative pain and complications traditionally connected with the laparotomic technique [1,2]. In particular, laparoscopic supracervical hysterectomy (LSH) is a viable choice in benign gynecologic pathologies. The authors declare no conflicts of interest. Corresponding author: Roberto Marci, MD, PhD, Department of Morphology Surgery and Experimental Medicine, Section of Obstetrics and Gynecology, University of Ferrara, Ferrara, Italy. E-mail: [email protected] Submitted July 29, 2014. Accepted for publication September 29, 2014. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.09.013
This technique is easier to perform and has reduced surgical duration and intraoperative bleeding when compared with total laparoscopic hysterectomy (TLH). Moreover, it is associated with a very low rate of complications (e.g., ureteral, bladder, or bowel damage) [3,4]. We developed a minimally invasive surgical technique for supracervical hysterectomy that ensures minimal blood loss; this procedure involves extraction of the morcellated uterus through the cervical canal. The literature reports only a few studies using a similar technique, all with small samples [4–9]. In addition to these experiences, we developed a specific uterine manipulator in order to improve the morcellating phase. The aim of this study was to describe this innovative technique in a large population, analyzing efficacy and related side effects.
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Material and Methods
Surgical Instrumentation
In this retrospective study, we analyzed 365 patients undergoing LSH with transcervical morcellation (LSH-TM) from January 1, 2000, to February 28, 2014, in the Department of Gynaecology and Obstetrics, Brunico Hospital, Brunico, Italy (in partnership with Residency School of Obstetrics and Gynaecology, University of Ferrara, Ferrara, Italy). All these surgical procedures were performed by 3 skilled surgeons highly qualified in the field of endoscopic surgery. Indications for LSH-TM were myomas, menometrorrhagia, adenomyosis, dysmenorrhea, and chronic pelvic pain. All patients underwent accurate transabdominal and transvaginal sonographies in order to assess uterine volume, exclude renal diseases, and determine gynecologic malignancies. LSH-TM is not indicated in uteruses with an estimated volume .600 g. (Our experience showed that TM is potentially dangerous in larger uteruses for several reasons including the worse laparoscopic view and the intrinsic difficulty during the morcellating process.) The number and location of myomas were described; longitudinal, transverse, and anterior-posterior diameters were recorded. We evaluated the myometrial and myoma vessels using directional power Doppler imaging. A subjective, semiquantitative assessment of the amount of blood flow within the examined lesion was made (color score) according to published reports [10,11] and the International Ovarian Tumor Analysis consensus statement [12]. We also described the vascularity of the central and peripheral region of the lesion (moderate, mild, or not appreciable as previously reported) [10]. Myomas with marked peripheral and central vascularity detected on color power Doppler, a rapid increase in mean diameters (especially in postmenopausal women), or a diagnosis of myomas after menopause (in women without previous pathological evaluations) were considered at risk of potential malignancy and, thus, not eligible for the LSH-TM procedure. Patients with an abnormal Papanicolaou (Pap) smear or sonographic suspicion of a pathologic endometrium eventually confirmed by biopsies were not included in the analysis. In addition, the cervix was accurately evaluated to verify if the morcellation process could be applicable (i.e., not-too-soft consistency of the cervix, sonographically measured cervical length .2 cm, or cervical myomas .4 cm). All patients received a prophylactic single dose of antibiotics (ampicillin/sulbactam 1.5 g or clarithromycin 900 mg). The bowel preparation was not required before surgery. Postoperative follow-ups were performed after 1, 2, 6, 12, and 24 months by interview, a Pap smear (performed after 1 year), an ultrasound evaluation (both transvaginal and abdominal), and a gynecologic examination. After this interval, we offered the patients the opportunity to be evaluated each year, and many of them accepted (data not shown; we only presented complications).
The surgical instrumentation required included 4 trocars (one 10-mm trocar placed through the umbilicus and 3 ancillary 5-mm trocars in the suprapubic region and the right and left lower quadrants); a rigid 30 , 10-mm diameter laparoscope (Karl Storz GmbH & Co KG, Tuttlingen, Germany); a 5-mm bipolar instrument (Plasmakinetik; Gyrus Medical, Tuttlingen, Germany, until 2010; thereafter, LigaSure; Covidien-Valleylab, Boulder, CO); a 15-mm calibrated electromechanical morcellator (Gynecare Morcellex; Ethicon, Johnson & Johnson Gateway, Somerville, NJ, until 2008; thereafter, Rotocut G1; Karl Storz, Culver City, CA); a uterine manipulator (currently being patented); two 5-mm atraumatic fenestrated grasping forceps (Karl Storz GmbH & Co KG); a 5-mm hook scissor (Karl Storz GmbH & Co KG); an aspiration system for peritoneal lavage; and a 30-cm absorbable endoloop (Endoloop PDS II; Ethicon, Somerville, NJ, until 2008; thereafter, Serafit CISH-Endoloop; SeragWiessner, Naila, Germany). Surgical Procedure LSH-TM is a 3-step surgical procedure consisting of vaginal preparation, LSH, and TM; vaginal examination and suture are performed if needed. Vaginal Preparation After abdominal and vaginal disinfection, the surgeon puts our specific uterine manipulator (Fig. 1A and B) and a transurethral catheter into place. The uterine manipulator, designed by our team and currently being patented, is a 14 ! 600 mm cylinder with a conical end made of a material that is inexpensive, reusable, and easy to sterilize (TecapeeK MT; Ensinger, Washington, PA). A helical groove in the surface of the conical end allows insertion in the cervix by screwing, avoiding the trauma connected with dilation that might occur when using Hegar dilators (Fig. 1A). Our instrument makes it possible to core the cervix while keeping the core specimen as intact as possible, thus facilitating the pathologic analysis that it will undergo later. The device is designed to have a double function; its conical end works as a uterine manipulator during laparoscopic hysterectomy, whereas its blunt end can be used as a guide for the Rotocut blade when performing uterine morcellation. LSH-TM LSH is performed using a bipolar vessel sealing system (LigaSure since 2010) and involves the following steps: coagulation and transection of the round ligaments, preparation of the anterior leaflet of the broad ligament by dissection and development of the bladder flap, coagulation and transection of the utero-ovarian ligaments (or infundibulopelvic ligaments in women with bilateral adnexectomy), and
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Fig. 1 (A) Uterine manipulator. (B) Vaginal preparation.
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the cervical stump (Fig. 2C). At this point, the blade can be retracted further, and the uterine manipulator is extracted completely. Finally, transcervical morcellation is performed through the cervical canal by means of a 10-mm tenaculum (Fig. 2D). The surgeon hands the uterus just near the Rotocut blade in order to minimize the dispersion of fragments into the pelvic cavity; the different position of the morcellator allows the operator to store the residues in the pouch of Douglas. Direct laparoscopic visualization of the pelvis during the coring procedure aids in avoiding injuries to the abdominal and pelvic organs. After morcellation, the surgeon checks the peritoneal cavity for uterine tissue residues, which, if found, are extracted transcervically. The blade is then extracted, and, at the same time, the endoloop gets tightened in its final position. Then, the surgeon assesses for hemostasis and performs repeated washings (Fig. 3A). Vaginal Examination and Suture (if Needed) The second assistant examines the cervical-vaginal region (Fig. 3B) and, if needed, applies absorbable sutures (2-0 absorbable suture, Vicryl Rapid, Ethicon) in the cervical stump. Results
preparation of the posterior leaflet of the broad ligament by dissection until the level of uterosacral ligaments. Both uterine arteries are skeletonized and then coagulated with LigaSure without dissecting them. An endoloop (Serafit CISH-Endo-loop since 2008) is inserted through the left trocar and is then placed around the corpus uteri at the level of the uterosacral ligaments and tightened, only after the surgeon makes sure that neither the bladder nor the bowel got caught in the loop (Fig. 2A). At this point, the second assistant (positioned between the legs of the patient) starts with the cervical coring. The coring of the cervix/uterus is then performed by removing the transformation zone in the endocervical canal by means of a 15-mm calibrated electromechanical morcellator (Rotocut G1 since 2008). The uterine manipulator is used as a guide until the morcellator blade comes out of the uterus and protrudes into the peritoneal cavity (Fig. 2B). Then, the cored cervical/uterine tissue is extracted and set aside for histology. The uterine manipulator is extracted and rotated 180 along its major axis so that its blunt end can be reinserted into the uterine cavity. The surgeon then slices the uterus right above the cervix until the morcellator’s blade becomes visible and, subsequently, retracts both the blade and the manipulator until they protrude from the cervical canal. He then cuts the rest of the corpus uteri using a 5-mm hook scissor, detaching it from
In our sample, the mean (standard deviation [SD) age was 49 (5.6) years. The mean (SD) body mass index was 27.4 (3.2) kg/m2. Most of the patients were premenopausal (85.48% of the sample, 312 patients). The primary indication for LSH-TM is reported in Table 1. All patients with abnormal uterine bleeding underwent hysteroscopy and endometrial biopsies to exclude malignant diseases. LSHTM was combined with other surgical procedures in 35.07% cases (128 patients). Table 2 shows the distribution of concomitant procedures. The mean (SD) time for LSH-TM was 72.24 (23.21) minutes; it was longer (92.35 [25.88] minutes) when other surgical procedures were performed. All patients did not develop intraoperative complications. Patients were discharged 3.0 (1.5) days after surgery. The average loss of hemoglobin (defined as the difference between preoperative and third-day postsurgery hemoglobin levels) was 1.39 (1.02) g/dL. The corpus uteri weighed 277 (252) g. In all cases analyzed, the surgeon was able to perform the cervical coring. Moreover, the pathologist was able to describe both cervical and endometrial tissue derived from the coring in all samples. The complications that occurred in our series are shown in Table 3. All women were evaluated 1 month after surgery; 301 patients (82.47%) presented at 6 months, 287 (78.63%) at 12 months, and 231 (63.29%) at 24 months. A laparoscopic revision of the cervical stump was performed in 2 women the first day after surgery because of clinically and sonographically suspected intraperitoneal hemorrhage. In both cases, these minimal bleedings were
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Fig. 2 (A) Insertion of the endoloop, (B) protrusion into the peritoneal cavity of morcellator blade, (C) separation by section of the corpus uteri from the cervix at the uterosacral level, and (D) morcellation of the corpus uteri.
properly coagulated, and the patients experienced no further complications. A low-grade endometrial stromal sarcoma was diagnosed after surgery on the surgical specimen; the patient underwent laparoscopic reoperation for the removal of the adnexa, cervical stump, pelvic lymph nodes, and suspected peritoneal tissue (all specimens were negative for malignancies). The patient was re-evaluated after 1, 2, 6, 12, and 24 months; to date, she is cancer free. A case of highgrade atypical squamous cells (cannot exclude high-grade squamous intraepithelial lesion, ASC-H) and a positive
Fig. 3 Final result: (A) laparoscopic and (B) vaginal view of the cervical stump.
test for human papillomavirus was detected in a patient 5 years after LSH-TM. Colposcopy was not definitive; therefore, we performed a vaginal trachelectomy. An asymptomatic supracervical hematoma (mean diameter ,2 cm) was detected in 5 patients (1.37%) 30 days after surgery. Five women presented with persistent cervical bleeding 30 days after surgery: they underwent thermoablation, and they experienced no further complications. Seven patients complained of persistent pelvic pain; this symptom resolved after 6 months in 3 of them, and the other 4 women
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Table 1
Table 3
Main indication for laparoscopic supracervical hysterectomy with
Complications associated with laparoscopic supracervical
transcervical morcellation
hysterectomy with transcervical morcellation
Indication for surgery Uterus fibromatosis Menometrorrhagia Chronic pelvic pain Adenomyosis Endometriosis Uterine prolapse Other*
No. of patients (n) 270 38 6 27 12 10 2
No. of patients (%) 73.97 (270/365) 10.41 (38/365) 1.64 (6/365) 7.40 (27/365) 3.29 (12/365) 2.74 (10/365) 0.55 (2/365)
* Surgical completion in patient diagnosed with ovarian disease.
were successfully treated by operative laparoscopy (2 cases of adhesiolysis, 1 case of trachelectomy, and 1 case of combined adhesiolysis and trachelectomy). Discussion Coring of the cervix was first described by Semm in 1993 [1] associated with traditional supracervical hysterectomy (Classische intrafascial Supracervicale Hysterektomie with Teilerhalt des Geb€armutterhalses, supracervical hysterectomy intrafascial Classic Conservation of Cervical [CISH]). The removal of the endocervix was purposed in order to solve the problem of postoperative cyclical bleeding and the potential risk of cervical malignancies [13]. We presented a minimally invasive surgical technique for supracervical hysterectomy that involves coring of the cervical canal as in the CISH procedure and reduces the incidence of postoperative bleeding and, eventually, the development of cervical dysplasia. In the original CISH procedure, morcellation was performed through an abdominal approach, increasing the risk of herniation through the enlarged access [3]. Indeed, in Table 2 Distribution of concomitant surgical procedures Concomitant surgical procedure
No. of patients (n)
No. of patients (%)
Adhesiolysis Adnexectomy Salpingectomy Endometriosis removal* Sacrocervicopexis Othery
56 25 27 8 10 2
43.75 (56/128) 19.53 (25/128) 21.09 (27/128) 6.25 (8/128) 7.81 (10/128) 3.33 (2/128)
* Excision of a nodule in the rectovaginal septum (n 5 3), removal of endometriosis in uterosacral ligaments (2 patients), removal of endometrioma (1 patients), removal of endometriosis in the vesicouterine pouch (1 patient), and removal of endometriosis in the paraovarian fossae (1 patient). y Intracervical myoma excision.
Complications
No. of patients (n)
No. of patients (%)
Endometrial stromal sarcoma Intraperitoneal bleeding Cervical bleeding Pelvic pain Hematoma around the cervical stump Recurrence of prolapse Dysplasia in the cervical stump Total
1 2 5 7 5 2 1 23
0.27 (1/365) 0.55 (2/365) 1.37 (5/365) 1.92 (7/365) 1.37 (5/365) 0.55 (2/365) 0.27 (1/365) 6.30 (23/365)
LSH-TM, the extraction of the morcellated uterus was performed through the cervical canal. We have used this technique for LSHs since the 1990s and have thus decided to adopt it routinely in surgical treatment of benign gynecologic diseases. The literature reports only a few studies using a similar technique, all with small samples [4–9]. The evaluation of a larger sample allowed us to conclude that LSH-TM is an easy and faster technique (mean time 5 72 minutes) that minimizes the risks connected with intraoperative bleedings. A second laparoscopy was performed in 2.1% of cases, and 1.37% of patients required outpatient treatment for persistent bleeding. However, it is mandatory to perform an adequate stratification of indications for surgery. Two cases (a diagnosis of endometrial stromal sarcoma and high-grade atypical squamous cells as shown in the Results section) should not be included in this analysis because their indication to reintervention was not a surgical complication. Two patients underwent surgery because of intraperitoneal bleeding; in accordance with Rosenblatt et al [6–8], we speculate that a reduced hemorrhagic rate (in our sample 0.55%) could be explained by the synergic action of coagulation of uterine vessels, the pressure of the uterine morcellator upon the endocervical surface, and the role of the endoloop in cervical stump suture. Thus, the endoloop has a double function; it closes the cervical stump after coring, and it enhances hemostasis in order to obtain a safer surgery (especially in enlarged uteruses complicated by myomas or adenomyosis). We observed a decrease in postoperative abdominal pain. We hypothesized that the transcervical approach could avoid the enlargement of the abdominal access required in traditional morcellation. However, 4 women underwent a second surgery because of persistent pelvic pain (preexisting diagnosis of deep endometriosis or adhesions syndrome). All of these cases were treated in 2007; 2 (or more if needed) monofilament endoloops were used to close the cervical stump. Since 2008, we started to use a single polyfilament endoloop, and we had no further complications. Thus, we had a real percentage of postoperative complications that required
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surgery with the actual instrumentation of about 0.55% in agreement with the literature [14,15]. In fact, a recent prospective analysis of 1952 patients undergoing LSH or TLH, respectively, reported a 0.6% and 4.8% rate of shortterm complications requiring reoperation (p , .001) and a 0.8% and 1.7% rate of long-term complications requiring surgery (p 5 .173) [15]. Persistent bleeding presented in 1.3% of women; all of them were treated with outpatient coagulation, with no further complications. In the literature, the incidence of bleeding after LSH amounted to 1% to 25% [16,17]; thus, cervical coring minimized the problem of postoperative bleeding. In the last decades, LSH was usually associated with lower rates of sexual dysfunction, pelvic organ prolapse (POP), and urinary tract injuries when compared with TLH [17]. To date, the improvement of endoscopy has reduced the risk of ureteral injury to less than 1%. As stated in a recent systematic review, the overall urinary tract injury rate is actually 0.73% (0.84% in TLH, 0.23% in LSH, and 0.74% in laparoscopic-assisted vaginal hysterectomies) [18]. In our series, none of the patients reported ureteral injuries; these results are lower but comparable with the latest obtained with TLH experience. Similarly, maintenance of the cervical stump for the prevention of POP in LSH is still debated. There is a growing opinion that the uterus could have a passive role in genital prolapse. Several authors stressed the role of an adequate colposuspension or cervical suspension at the time of hysterectomy in patients with POP [7,8,19,20]. Sacrocolpopexy in addition to TLH is associated with an increased risk of mesh exposure at the site of the vaginal cuff (incidence between 0.8% and 9%) [19,20]. Conversely, Rosati et al [19] showed an alternative technique involving LSH and the suspension of the cervical stump to the anterior longitudinal ligament of the sacrum. This approach showed a low recurrence rate, absence of mesh erosion, and preservation of an adequate length of the vaginal canal. We prefer to perform LSH-TM in association with adequate cervicosacropexy when POP is diagnosed. Literature concerning sexual function and preservation of the cervical stump is still poor and often conflicting [6,21– 27]. The improvement of sexual outcomes in LSH could be explained with preservation in cervical-vaginal innervation, an adequate production of genital secretion, and the maintenance of the physiological length of the vaginal canal [21]. Several authors reported an improvement in sexual function in women undergoing LSH [21–23] when compared with TLH. Recently, a prospective study on a large sample detected better outcomes regarding quality of life and sexual outcomes assessed with specific questionnaires in LSH than in TLH [23]. Conversely, other studies found no differences in sexual function regarding the surgical technique [24–27]. Our study did not analyze sexual outcomes in patients undergoing LSH-TM; further prospective randomized trials are necessary to evaluate
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quality of life and sexual function, allowing the surgeon to choose the adequate intervention for each patient. In April 2014, the Food and Drug Administration discouraged the use of laparoscopic power morcellation for removal of the uterus or uterine myomas because of the potential risk of spreading undetected cancerous tissue in women with unsuspected cancer (i.e., leiomyosarcoma). Recently, laparoscopic societies (e.g., American Association of Gynecologic Laparoscopists and Advancing Minimally Invasive Gynecology Worldwide) have been critically analyzing this statement, and several concerns about the interpretation of data were found. Prospective and population-based studies are needed to develop a better understanding of morcellating techniques and eventually identify a population of women who may be at high risk of an unrecognized uterine cancer [28–30]. At the present time, a specific diagnostic tool applicable for the definitive exclusion of uterine malignancies is still missing. However, our patients undergo an accurate preoperative evaluation (comprehensive of sonographic evaluation improved with Doppler analysis) to minimize this risk. If malignancy is suspected, we perform total laparoscopic hysterectomy without morcellation. Moreover, our peculiar morcellation (through the cervical canal) allows the surgeon to accumulate morcellated chips in the pouch of Douglas. This advantage does not have a clear protective value, but we hypothesized that it could reduce the risk of morcellated tissue spreading [4–9]. Possible solutions to decrease the incidence of hidden malignancies on surgical specimens may include the detection of specific classes of risk (i.e., large myomas in postmenopausal women), preliminary assessment of the uterine cavity via office hysteroscopy, or development of specific bags for safer morcellation [28–30]. Conclusion Our experience shows that LSH-TM is a viable surgical procedure in benign gynecologic diseases in patients with a uterine estimated volume ,600 g. Sacrocervicopexy should always be adopted when POP is diagnosed. LSHTM is a safe and easy to perform technique, and it ensures minimal blood loss. In addition, it does not require enlargement of the abdominal openings, which results in minimal esthetic damage and a lower incidence of postoperative pain. The evaluation of medical history and clinical/ultrasonographic screening are mandatory in order to exclude cases at risk of malignancy. References 1. Reich H. Laparoscopic hysterectomy. Surg Laparosc Endosc. 1992;2: 85–88. 2. Minelli L, Franciolini G, Franchini MA, Mutolo F, Momoli G. Laparoscopic hysterectomy. Minerva Ginecol. 1990;42:515–518. 3. Gimbel H. Total or subtotal hysterectomy for benign uterine diseases? A meta-analysis. Acta Obstet Gynecol Scand. 2007;86:133–144.
218 4. Wenger JM, Dubuisson JB, D€allenbach P. Laparoendoscopic single-site supracervical hysterectomy with endocervical resection. J Minim Invasive Gynecol. 2012;19:217–219. 5. Yoon G, Kim TJ, Lee YY, et al. Single-port access subtotal hysterectomy with transcervical morcellation: a pilot study. J Minim Invasive Gynecol. 2010;17:78–81. 6. Rosenblatt P, Makai G, DiSciullo A. Laparoscopic supracervical hysterectomy with transcervical morcellation: initial experience. J Minim Invasive Gynecol. 2010;17:331–336. 7. Rosenblatt PL, Apostolis CA, Hacker MR, DiSciullo A. Laparoscopic supracervical hysterectomy with transcervical morcellation and sacrocervicopexy: initial experience with a novel surgical approach to uterovaginal prolapse. J Minim Invasive Gynecol. 2012;19:749–755. 8. Rosenblatt PL, Adams SR, Shapiro A. Microlaparoscopy in urogynecology: LSH and sacrocervicopexy. J Minim Invasive Gynecol. 2013; 20:411. 9. Estrade JP, Crochet P, Aumiphin J, Gurriet B, Marcelli M, Agostini A. Supracervical hysterectomy by laparoendoscopic single site surgery. Arch Gynecol Obstet. 2014 [Epub ahead of print]. 10. Exacoustos C, Romanini ME, Amadio A, et al. Can gray-scale and color Doppler sonography differentiate between uterine leiomyosarcoma and leiomyoma? J Clin Ultrasound. 2007;35:449–457. 11. Timmerman D, Verrelst H, Bourne TH, et al. Artificial neural network models for the preoperative discrimination between malignant and benign adnexal masses. Ultrasound Obstet Gynecol. 1999; 13:17–25. 12. Timmerman D, Valentin L, Bourne TH, et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet Gynecol. 2000;16: 500–505. 13. Semm K. CISH (pelviscopic intrafascial hysterectomy–without colpotomy), TUMA (total uterine mucosa ablation) and IVH (intrafascial vaginal hysterectomy). Gynakologe. 1993;26:378–384. 14. Grosse-Drieling D, Schlutius JC, Altgassen C, Kelling K, Theben J. Laparoscopic supracervical hysterectomy (LASH), a retrospective study of 1,584 cases regarding intra- and perioperative complications. Arch Gynecol Obstet. 2012;285:1391–1396. 15. Wallwiener M, Taran FA, Rothmund R, et al. Laparoscopic supracervical hysterectomy (LSH) versus total laparoscopic hysterectomy (TLH): an implementation study in 1,952 patients with an analysis of risk factors for conversion to laparotomy and complications, and of procedure-specific re-operations. Arch Gynecol Obstet. 2013;288: 1329–1339. 16. Ghomi A, Hantes J, Lotze EC. Incidence of cyclical bleeding after laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol. 2005; 12:201–205.
Journal of Minimally Invasive Gynecology, Vol 22, No 2, February 2015 17. Greer WJ, Richter HE, Wheeler TL, et al. Long-term outcomes of the Total or Supracervical Hysterectomy (TOSH) Trial. Female Pelvic Med Reconstr Surg. 2010;16:49–57. 18. Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic hysterectomy: a systematic review. J Minim Invasive Gynecol. 2014;21:558–566. 19. Rosati M, Bramante S, Bracale U, Pignata G, Azioni G. Efficacy of laparoscopic sacrocervicopexy for apical support of pelvic organ prolapse. JSLS. 2013;17:235–244. 20. Rosati M, Bramante S, Conti F. A review on the role of laparoscopic sacrocervicopexy. Curr Opin Obstet Gynecol. 2014;26:281–289. 21. Ellstr€om Engh MA, Jerhamre K, Junskog K. A randomized trial comparing changes in sexual health and psychological well-being after subtotal and total hysterectomies. Acta Obstet Gynecol Scand. 2010;89: 65–70. 22. Lyons T. Laparoscopic supracervical versus total hysterectomy. J Minim Invasive Gynecol. 2007;14:275–277. 23. Brucker SY, Taran FA, Bogdanyova S, et al. Patient-reported qualityof-life and sexual-function outcomes after laparoscopic supracervical hysterectomy (LSH) versus total laparoscopic hysterectomy (TLH): a prospective, questionnaire-based follow-up study in 915 patients. Arch Gynecol Obstet. June 29, 2014 [Epub ahead of print]. 24. Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev. 2012;4:CD004993. 25. Radosa JC, Meyberg-Solomayer G, Kastl C, et al. Influences of different hysterectomy techniques on patients’ postoperative sexual function and quality of life. J Sex Med. 2014;11:2342–2350. 26. Lermann J, H€aberle L, Merk S, et al. Comparison of prevalence of hypoactive sexual desire disorder (HSDD) in women after five different hysterectomy procedures. Eur J Obstet Gynecol Reprod Biol. 2013; 167:210–214. 27. American Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for laparoscopic subtotal/supracervical hysterectomy (LSH). J Minim Invasive Gynecol. 2014;21:9–16. 28. FDA. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. April 17, 2014. Available at: http://www.fda.gov/medicaldevices/safety/alertsandnotices/ ucm393576.htm. Accessed November 6, 2014. 29. FDA Executive Summary. Laparoscopic power morcellation during uterine surgery for fibroids. Prepared for the July 10-11, 2014 Meeting of the Obstetrics and Gynecology Devices Advisory Committee. http://www. fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/ MedicalDevices/MedicalDevicesAdvisoryCommittee/Obstetricsand GynecologyDevices/UCM404148.pdf. Accessed November 6, 2014. 30. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: morcellation during uterine tissue extraction. J Minim Invasive Gynecol. 2014;21:517–530.
