Arch Gynecol Obstet (2014) 290:1169–1172 DOI 10.1007/s00404-014-3360-z
GENERAL GYNECOLOGY
Supracervical hysterectomy by laparoendoscopic single site surgery Jean Philippe Estrade • Patrice Crochet • Julia Aumiphin • Brice Gurriet • Maxime Marcelli Aubert Agostini
•
Received: 6 September 2013 / Accepted: 4 July 2014 / Published online: 11 July 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Objective To evaluate the feasibility of laparoscopic supracervical hysterectomy (LSH) by single port access (SPA) with transcervical morcellation. Study design Observational study conducted between September 2010 and March 2012 in two departments of Gynaecology. Forty women who required hysterectomy underwent LSH by SPA with transcervical morcellation. Results LSH by SPA with transcervical morcellation was completed successfully in 37/40 (93.5 %) patients. Mean operating time was 128 (±55) min and mean hospital stay was 3.5 (±1) days. The mean of uterus weight was 310 (±214) g. The mean estimated blood loss was 250 (±110) ml. Four women (10 %) required a second surgical intervention including two cases of endocervical bleeding. Conclusion LSH by SPA with transcervical morcellation is a feasible procedure. Keywords Supracervical hysterectomy Single port access Transcervical morcellation
Introduction Supracervical hysterectomy (SCH) remains a matter of debate. There is no clear evidence in favour of this procedure compared to total hysterectomy (TH) [1–4]. Thus, this alternative procedure should not be presented to the patient as superior to TH [5, 6]. However, most published studies comparing SCH to TH used a laparotomy approach and there is no similar study of high level of evidence using the laparoscopic approach. This is to be taken into account, as laparoscopy should be preferred to laparotomy in case of hysterectomy [7]. Many authors consider SCH an easier and safer procedure than TH, especially by laparoscopic approach. However, this procedure needs further evaluation [8]. Single port access laparoscopy (SPA) is an attempt to enhance cosmetic benefits and post-operative pain of minimally invasive surgery [9]. The feasibility of TH by SPA has been reported by several authors [10–12]. To date, only case reports and small case series have reported the use of SPA to perform SCH [13–18]. It is therefore of interest to evaluate this new approach on a larger number of patients. In the present study, we report feasibility and morbidity of SCH by SPA, with endocervical resection and trans-cervical morcellation of the uterus.
Materials and methods J. P. Estrade B. Gurriet Department of Obstetrics and Gynaecology, Bouchard Clinic, 13005 Marseille, France P. Crochet J. Aumiphin M. Marcelli A. Agostini (&) Department of Obstetrics and Gynaecology, La Conception University Hospital, 13005 Marseille, France e-mail: [email protected]
This observational study was implemented in two hospitals in Marseille (La Conception Hospital and Bouchard clinic), from September 2010 to March 2012. Women requiring an SCH for symptomatic fibroma (with no suspicion of adenomyosis at pelvic sonography) were eligible for this study. An informed consent was obtained from all included women. This study was approved by IRB of our institution.
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Arch Gynecol Obstet (2014) 290:1169–1172
All procedures were performed by five surgeons (JPE, AA, BG, MM, PC). Patient characteristics as well as intra and postoperative complications were reported. Surgical technique A 2 cm vertical trans-umbilical incision was performed. An Olympus TriPort (Advanced Surgical Concepts, Bray, Ireland) was inserted through the incision. The abdomen was insufflated with CO2, and a rigid 5 mm diameter endoscope (Olympus, Hamburg, Germany) was introduced into the peritoneal cavity. We used curved instruments for grasping and a bipolar coagulator with cutting function (Cutting Forceps, PKS Technology, Olympus, Hamburg, Germany). The surgical technique performed was identical to the conventional laparoscopic technique: both round ligaments, fallopian tubes, and ovarian ligaments were coagulated and cut using a bipolar coagulator (Fig. 1). The vesicouterine peritoneum was dissected off the anterior portion of the uterus. Both uterine vessels were coagulated and cut using a bipolar coagulator. At the level of the cervical isthmus, a supracervical hysterectomy was performed with bipolar laparoscopic loop (Olympus, Hamburg, Germany) (Fig. 2). Subsequently the cervix was dilated by vaginal approach with Hegar dilatators, allowing the insertion of an electromechanical bipolar morcellator (PlasmaSORD, PKS Technology, Olympus, Hamburg, Germany) through the cervical os to perform uterine morcellation. Uterine morcellation was performed under endoscopic control (Fig. 3). The cervical stump was closed with one laparoscopic knot. Correlation between uterine weight and operative time was calculated using the Pearson test. The statistical analyse was performed with the SPSS version 17.0 software
Fig. 2 Bipolar laparoscopic loop
Fig. 3 Transcervical morcellation
package (SPSS Inc., Chicago, IL). The statistical significance threshold was defined as p \ 0.05.
Results
Fig. 1 Single port access with endoscope and instruments
123
During this period, 40 SCH were performed by SPA. Characteristics of patients and procedures are reported in Table 1. Conversion was necessary in three cases (7.5 %): One case of conversion to minilaparotomy because of a morcellator device failure, one case of TH by vaginal approach due to a lack of appropriate exposure by SPA and conventional laparoscopy, one case of conventional laparoscopic conversion because of bladder injury. Complications occurred in eleven patients in the post-operative course. Four cases (10 %) required a second surgical intervention: two cases of endocervical bleeding at day 6 and 10 requiring haemostasis performed by vaginal approach
Arch Gynecol Obstet (2014) 290:1169–1172
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Table 1 characteristics of patients and surgical procedures Variables
N: 40
Age Mean ± SD
47.4 ± 4 years
Median (min–max)
47 (39–54)
Previous laparotomy
19/40 (47.5 %)
BMI Mean ± SD
24.2 ± 4.3 kg/m2
Median (min–max)
33.3 (23.5–17.3)
Duration of procedure Mean ± SD
128 ± 55 min
Median (min–max)
120 (40–240)
Weight of uterus Mean ± SD
310 ± 214 g
Median (min–max)
236 (115–754)
Bilateral adnexectomy
11/40 (27.5 %)
Estimated blood loss Mean ± SD
250 ± 110 ml
Median (min–max)
200 (100–500)
Hospital stay Mean ± SD
3.5 ± 1 days
Median (min–max)
4 (1–5)
SD standard deviation, BMI body mass index
under general anaesthesia, one case of myoma forgotten in the peritoneal cavity removed by the same technique at day 7 (SPA laparoscopy and morcellation through the cervix), 1 case of pelvic abscess drained by conventional laparoscopy 2 months after the initial procedure. Seven (17.5 %) cases required a prolonged hospital stay: five cases of anaemia requiring either a blood transfusion [1] or an intravenous iron supplementation [4] one case of hematoma on the trocar insertion site and one case of prolonged hyperthermia due to a pelvic collection that did not necessitate drainage. No complication was reported at the postoperative visit 1 month after surgery. The operative time correlated significantly with the uterine weight [0.5079 (0.1993; 0.7248) (p: 0.003)].
Comment Laparoscopic SPA allows the surgeon to perform different types of hysterectomy [10, 11, 15, 16]. The advantages of the SPA are mainly a decrease in post-operative pain and a better cosmetic result [9, 11, 12]. SCH seems technically easier to perform than HT. Thus the use of SPA rather than a conventional multiport laparoscopic approach seems particularly interesting when a SCH is indicated.
As demonstrated by the present study, SCH by SPA appears to be feasible. The main limitation of this technique is the need of morcellation in order to remove the uterus. The morcellator’s placement through the TriportÓ system does not allow an appropriate visual control of the morcellation process in using a rigid endoscope. Thus, we think that this technique does compromise the safety of the procedure and should be avoided. For this reasons, we opted for a transcervical morcellation, as previously reported [14–17]. With a transcervical access the morcellation can be performed safely under constant visual control, even for large uterus. Rosenblatt et al. [18] first described transcervical morcellation by conventional laparoscopy in order to avoid an additional 15–20 mm abdominal incision. One other advantage described was the endocervical excision. This technique can be easily applied to SPA laparoscopy [15–17]. It could be of interest in further works to consider the use of a flexible camera to allow both morcellator placement and endoscopic visual control through the umbilical port. In previous reports, uterine morcellation in a context of adenomyosis has been suspected to be responsible for iatrogenic endometriosis. For this reason, preoperative suspicion of adenomyosis was an exclusion criteria in order to avoid the risk of iatrogenic endometriosis leading to long term postoperative pain [19, 20]. Adenomyosis cannot always be suspected preoperatively. To minimise the risk of adenomyosis implants due to morcellation, the peritoneal cavity must be meticulously inspected, washed and all fragments of uterine corpus removed at the end of the procedure [19]. SCH performed by SPA was first reported in four patients by Pelosi et al. [14]. Park et al. [2–7] subsequently published a small series of 11 cases: The median operative time was 180 min (150–345), estimated blood loss was 400 ml (100–600) and median hospital stay was 3 days [15]. There were no intra operative complications reported. One patient required a transfusion postoperatively. Median uterus weight was 170 g (100–470). Authors considered SCH by SPA to be feasible. This study included cases of TH by SPA for smaller uterus: operative time was found to be longer for SCH than for HT. This longer operative time in case of SCH can be explained by the additional time for morcellation of the uterus. For this reason, Park et al. concluded that SPA should not be used for SCH in case of large uterus [15]. Yoon et al. [16] published a series of 7 cases: The median operative time was 157 min (140–233), estimated blood loss was 200 ml (100–300) and median hospital stay was 4 days [3, 4]. No intra operative or postoperative complications occurred. Median uterus weight was 300 g (168–427). The present study found similar outcomes with a larger number of cases. The operative time correlated significantly
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1172
with the uterine weight. Operative time dedicated to morcellation was not specifically measured. However, it appears to us that the morcellation time count for most of the operative time and is proportional to the uterus size. The conversion rate to other surgical approach is low [3/40 (7.5 %)]. Two of these conversions were not linked to the use of SPA. The postoperative complication rate observed in this study is substantial. However, it does not differ to the postoperative complication rates observed by conventional laparoscopy (up to 19 % of cases according to a recent review) [21]. Half of the complications that required a second surgical intervention were bleeding coming from the endocervix. These complications are a consequence of the transcervical use of the morcellator. A preventive endocervical bipolar coagulation at the end of the procedure could prevent these adverse events. In conclusion, rate of conversion and complication seems high in our study but some of its could decrease with an improved surgical procedure. The feasibility and safety need to be confirm by larger studies. This surgery will provide a promising option in patients with benign gynaecologic disease who are candidates for hysterectomy. Conflict of interest The authors have no commercial, proprietary, or financial interest in products or companies described in this article.
References 1. Learman LA, Summitt RL Jr, Varner RE, McNeeley SG, Goodman-Gruen D, Richter HE et al (2003) A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Total or supracervical hysterectomy (TOSH) research group. Obstet Gynecol 102:453–462 2. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I (2002) Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med 347:1318–1325 3. Gimbel H, Zobbe V, Andersen BM, Filtenborg T, Gluud C, Tabor A (2003) Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. BJOG 110:1088–1098 4. Kuppermann M, Summitt RL Jr, Varner RE, McNeeley SG, Goodman-Gruen D, Learman LA et al (2005) Sexual functioning after total compared with supracervical hysterectomy: a randomized trial. Total or supracervical hysterectomy research group. Obstet Gynecol 105:1309–1318 5. American College of Obstetricians and Gynecologists (2007) ACOG Committee Opinion No. 388 November 2007: supracervical hysterectomy. Obstet Gynecol 110:1215–1217 6. Kives S, Lefebvre G, Wolfman W, Leyland N, Allaire C, Awadalla A, Best C, Leroux N, Potestio F, Rittenberg D, Soucy R, Singh S (2010) Supracervical hysterectomy. J Obstet Gynaecol Can 32:62–68
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Arch Gynecol Obstet (2014) 290:1169–1172 7. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB (2009) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 3:CD003677 8. Ghomi A, Cohen SL, Chavan N, Gunderson C, Einarsson J (2011) Laparoscopic-assisted vaginal hysterectomy vs laparoscopic supracervical hysterectomy for treatment of nonprolapsed uterus. J Minim Invasive Gynecol 18:205–210 9. Fagotti A, Bottoni C, Vizzielli G, Alletti SG, Scambia G, Marana E, Fanfani F (2011) Postoperative pain after conventional laparoscopy and laparoendoscopeic single site surgery (LESS) for benign adnexal disease: a randomized trial. Fertil Steril 96(255–259):e2 10. Lee JH, Choi JS, Jeon SW, Son CE, Hong JH, Bae JW (2011) A prospective comparison of single-port laparoscopically assisted vaginal hysterectomy using transumbilical GelPort access and multiport laparoscopically assisted vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol 158:294–297 11. Yim GW, Jung YW, Paek J, Lee SH, Kwon HY, Nam EJ, Kim S, Kim JH, Kim YT, Kim SW (2010) Transumbilical single-port access versus conventional total laparoscopic hysterectomy: surgical outcomes. Am J Obstet Gynecol 203:26.e1–26.e6 12. Kim TJ, Lee YY, Cha HH, Kim CJ, Choi CH, Lee JW, Bae DS, Lee JH, Kim BG (2010) Single-port-access laparoscopic-assisted vaginal hysterectomy versus conventional laparoscopic-assisted vaginal hysterectomy: a comparison of perioperative outcomes. Surg Endosc 24:2248–2252 13. Surgit O, Gumus II (2011) Laparoscopic supracervical hysterectomy, bilateral salpingo-oophorectomy, sacrocolpopexy and Burch colposuspension performed during the same operative session via a single port. Arch Gynecol Obstet 283(Suppl 1):127–131 14. Pelosi MA, Pelosi MA 3rd (1992) Laparoscopic supracervical hysterectomy using a single-umbilical puncture (mini-laparoscopy). J Reprod Med 37:777–784 15. Park HS, Kim TJ, Song T, Kim MK, Lee YY, Choi CH, Lee JW, Kim BG, Bae DS (2011) Single-port access (SPA) laparoscopic surgery in gynecology: a surgeon’s experience with an initial 200 cases. Eur J Obstet Gynecol Reprod Biol 154:81–84 16. Yoon G, Kim TJ, Lee YY, Kim CJ, Choi CH, Lee JW, Kim BG, Bae DS (2010) Single-port access subtotal hysterectomy with transcervical morcellation: a pilot study. J Minim Invasive Gynecol. 17:78–81 17. Wenger JM, Dubuisson JB, Da¨llenbach P (2012) Laparoendoscopic single-site supracervical hysterectomy with endocervical resection. J Minim Invasive Gynecol 19(2):217–219 18. Rosenblatt P, Makai G, DiSciullo A (2010) Laparoscopic supracervical hysterectomy with transcervical morcellation: initial experience. J Minim Invasive Gynecol 17:331–336 19. Donnez O, Squifflet J, Leconte I, Jadoul P, Donnez J (2007) Posthysterectomy pelvic adenomyotic masses observed in 8 cases out of a series of 1405 laparoscopic subtotal hysterectomies. J Minim Invasive Gynecol 14:156–160 20. Sepilian V, Della Badia C (2003) Iatrogenic endometriosis caused by uterine morcellation during a supracervical hysterectomy. Obstet Gynecol 102:1125–1127 21. Nesbitt-Hawes EM, Maley PE, Won HR, Law KS, Zhang CS, Lyons SD, Ledger W, Abbott JA (2013) Laparoscopic subtotal hysterectomy: evidence and techniques. J Minim Invasive Gynecol. doi:10.1016/j.jmig.2013.01.009
GENERAL GYNECOLOGY
Supracervical hysterectomy by laparoendoscopic single site surgery Jean Philippe Estrade • Patrice Crochet • Julia Aumiphin • Brice Gurriet • Maxime Marcelli Aubert Agostini
•
Received: 6 September 2013 / Accepted: 4 July 2014 / Published online: 11 July 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Objective To evaluate the feasibility of laparoscopic supracervical hysterectomy (LSH) by single port access (SPA) with transcervical morcellation. Study design Observational study conducted between September 2010 and March 2012 in two departments of Gynaecology. Forty women who required hysterectomy underwent LSH by SPA with transcervical morcellation. Results LSH by SPA with transcervical morcellation was completed successfully in 37/40 (93.5 %) patients. Mean operating time was 128 (±55) min and mean hospital stay was 3.5 (±1) days. The mean of uterus weight was 310 (±214) g. The mean estimated blood loss was 250 (±110) ml. Four women (10 %) required a second surgical intervention including two cases of endocervical bleeding. Conclusion LSH by SPA with transcervical morcellation is a feasible procedure. Keywords Supracervical hysterectomy Single port access Transcervical morcellation
Introduction Supracervical hysterectomy (SCH) remains a matter of debate. There is no clear evidence in favour of this procedure compared to total hysterectomy (TH) [1–4]. Thus, this alternative procedure should not be presented to the patient as superior to TH [5, 6]. However, most published studies comparing SCH to TH used a laparotomy approach and there is no similar study of high level of evidence using the laparoscopic approach. This is to be taken into account, as laparoscopy should be preferred to laparotomy in case of hysterectomy [7]. Many authors consider SCH an easier and safer procedure than TH, especially by laparoscopic approach. However, this procedure needs further evaluation [8]. Single port access laparoscopy (SPA) is an attempt to enhance cosmetic benefits and post-operative pain of minimally invasive surgery [9]. The feasibility of TH by SPA has been reported by several authors [10–12]. To date, only case reports and small case series have reported the use of SPA to perform SCH [13–18]. It is therefore of interest to evaluate this new approach on a larger number of patients. In the present study, we report feasibility and morbidity of SCH by SPA, with endocervical resection and trans-cervical morcellation of the uterus.
Materials and methods J. P. Estrade B. Gurriet Department of Obstetrics and Gynaecology, Bouchard Clinic, 13005 Marseille, France P. Crochet J. Aumiphin M. Marcelli A. Agostini (&) Department of Obstetrics and Gynaecology, La Conception University Hospital, 13005 Marseille, France e-mail: [email protected]
This observational study was implemented in two hospitals in Marseille (La Conception Hospital and Bouchard clinic), from September 2010 to March 2012. Women requiring an SCH for symptomatic fibroma (with no suspicion of adenomyosis at pelvic sonography) were eligible for this study. An informed consent was obtained from all included women. This study was approved by IRB of our institution.
123
1170
Arch Gynecol Obstet (2014) 290:1169–1172
All procedures were performed by five surgeons (JPE, AA, BG, MM, PC). Patient characteristics as well as intra and postoperative complications were reported. Surgical technique A 2 cm vertical trans-umbilical incision was performed. An Olympus TriPort (Advanced Surgical Concepts, Bray, Ireland) was inserted through the incision. The abdomen was insufflated with CO2, and a rigid 5 mm diameter endoscope (Olympus, Hamburg, Germany) was introduced into the peritoneal cavity. We used curved instruments for grasping and a bipolar coagulator with cutting function (Cutting Forceps, PKS Technology, Olympus, Hamburg, Germany). The surgical technique performed was identical to the conventional laparoscopic technique: both round ligaments, fallopian tubes, and ovarian ligaments were coagulated and cut using a bipolar coagulator (Fig. 1). The vesicouterine peritoneum was dissected off the anterior portion of the uterus. Both uterine vessels were coagulated and cut using a bipolar coagulator. At the level of the cervical isthmus, a supracervical hysterectomy was performed with bipolar laparoscopic loop (Olympus, Hamburg, Germany) (Fig. 2). Subsequently the cervix was dilated by vaginal approach with Hegar dilatators, allowing the insertion of an electromechanical bipolar morcellator (PlasmaSORD, PKS Technology, Olympus, Hamburg, Germany) through the cervical os to perform uterine morcellation. Uterine morcellation was performed under endoscopic control (Fig. 3). The cervical stump was closed with one laparoscopic knot. Correlation between uterine weight and operative time was calculated using the Pearson test. The statistical analyse was performed with the SPSS version 17.0 software
Fig. 2 Bipolar laparoscopic loop
Fig. 3 Transcervical morcellation
package (SPSS Inc., Chicago, IL). The statistical significance threshold was defined as p \ 0.05.
Results
Fig. 1 Single port access with endoscope and instruments
123
During this period, 40 SCH were performed by SPA. Characteristics of patients and procedures are reported in Table 1. Conversion was necessary in three cases (7.5 %): One case of conversion to minilaparotomy because of a morcellator device failure, one case of TH by vaginal approach due to a lack of appropriate exposure by SPA and conventional laparoscopy, one case of conventional laparoscopic conversion because of bladder injury. Complications occurred in eleven patients in the post-operative course. Four cases (10 %) required a second surgical intervention: two cases of endocervical bleeding at day 6 and 10 requiring haemostasis performed by vaginal approach
Arch Gynecol Obstet (2014) 290:1169–1172
1171
Table 1 characteristics of patients and surgical procedures Variables
N: 40
Age Mean ± SD
47.4 ± 4 years
Median (min–max)
47 (39–54)
Previous laparotomy
19/40 (47.5 %)
BMI Mean ± SD
24.2 ± 4.3 kg/m2
Median (min–max)
33.3 (23.5–17.3)
Duration of procedure Mean ± SD
128 ± 55 min
Median (min–max)
120 (40–240)
Weight of uterus Mean ± SD
310 ± 214 g
Median (min–max)
236 (115–754)
Bilateral adnexectomy
11/40 (27.5 %)
Estimated blood loss Mean ± SD
250 ± 110 ml
Median (min–max)
200 (100–500)
Hospital stay Mean ± SD
3.5 ± 1 days
Median (min–max)
4 (1–5)
SD standard deviation, BMI body mass index
under general anaesthesia, one case of myoma forgotten in the peritoneal cavity removed by the same technique at day 7 (SPA laparoscopy and morcellation through the cervix), 1 case of pelvic abscess drained by conventional laparoscopy 2 months after the initial procedure. Seven (17.5 %) cases required a prolonged hospital stay: five cases of anaemia requiring either a blood transfusion [1] or an intravenous iron supplementation [4] one case of hematoma on the trocar insertion site and one case of prolonged hyperthermia due to a pelvic collection that did not necessitate drainage. No complication was reported at the postoperative visit 1 month after surgery. The operative time correlated significantly with the uterine weight [0.5079 (0.1993; 0.7248) (p: 0.003)].
Comment Laparoscopic SPA allows the surgeon to perform different types of hysterectomy [10, 11, 15, 16]. The advantages of the SPA are mainly a decrease in post-operative pain and a better cosmetic result [9, 11, 12]. SCH seems technically easier to perform than HT. Thus the use of SPA rather than a conventional multiport laparoscopic approach seems particularly interesting when a SCH is indicated.
As demonstrated by the present study, SCH by SPA appears to be feasible. The main limitation of this technique is the need of morcellation in order to remove the uterus. The morcellator’s placement through the TriportÓ system does not allow an appropriate visual control of the morcellation process in using a rigid endoscope. Thus, we think that this technique does compromise the safety of the procedure and should be avoided. For this reasons, we opted for a transcervical morcellation, as previously reported [14–17]. With a transcervical access the morcellation can be performed safely under constant visual control, even for large uterus. Rosenblatt et al. [18] first described transcervical morcellation by conventional laparoscopy in order to avoid an additional 15–20 mm abdominal incision. One other advantage described was the endocervical excision. This technique can be easily applied to SPA laparoscopy [15–17]. It could be of interest in further works to consider the use of a flexible camera to allow both morcellator placement and endoscopic visual control through the umbilical port. In previous reports, uterine morcellation in a context of adenomyosis has been suspected to be responsible for iatrogenic endometriosis. For this reason, preoperative suspicion of adenomyosis was an exclusion criteria in order to avoid the risk of iatrogenic endometriosis leading to long term postoperative pain [19, 20]. Adenomyosis cannot always be suspected preoperatively. To minimise the risk of adenomyosis implants due to morcellation, the peritoneal cavity must be meticulously inspected, washed and all fragments of uterine corpus removed at the end of the procedure [19]. SCH performed by SPA was first reported in four patients by Pelosi et al. [14]. Park et al. [2–7] subsequently published a small series of 11 cases: The median operative time was 180 min (150–345), estimated blood loss was 400 ml (100–600) and median hospital stay was 3 days [15]. There were no intra operative complications reported. One patient required a transfusion postoperatively. Median uterus weight was 170 g (100–470). Authors considered SCH by SPA to be feasible. This study included cases of TH by SPA for smaller uterus: operative time was found to be longer for SCH than for HT. This longer operative time in case of SCH can be explained by the additional time for morcellation of the uterus. For this reason, Park et al. concluded that SPA should not be used for SCH in case of large uterus [15]. Yoon et al. [16] published a series of 7 cases: The median operative time was 157 min (140–233), estimated blood loss was 200 ml (100–300) and median hospital stay was 4 days [3, 4]. No intra operative or postoperative complications occurred. Median uterus weight was 300 g (168–427). The present study found similar outcomes with a larger number of cases. The operative time correlated significantly
123
1172
with the uterine weight. Operative time dedicated to morcellation was not specifically measured. However, it appears to us that the morcellation time count for most of the operative time and is proportional to the uterus size. The conversion rate to other surgical approach is low [3/40 (7.5 %)]. Two of these conversions were not linked to the use of SPA. The postoperative complication rate observed in this study is substantial. However, it does not differ to the postoperative complication rates observed by conventional laparoscopy (up to 19 % of cases according to a recent review) [21]. Half of the complications that required a second surgical intervention were bleeding coming from the endocervix. These complications are a consequence of the transcervical use of the morcellator. A preventive endocervical bipolar coagulation at the end of the procedure could prevent these adverse events. In conclusion, rate of conversion and complication seems high in our study but some of its could decrease with an improved surgical procedure. The feasibility and safety need to be confirm by larger studies. This surgery will provide a promising option in patients with benign gynaecologic disease who are candidates for hysterectomy. Conflict of interest The authors have no commercial, proprietary, or financial interest in products or companies described in this article.
References 1. Learman LA, Summitt RL Jr, Varner RE, McNeeley SG, Goodman-Gruen D, Richter HE et al (2003) A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Total or supracervical hysterectomy (TOSH) research group. Obstet Gynecol 102:453–462 2. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I (2002) Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med 347:1318–1325 3. Gimbel H, Zobbe V, Andersen BM, Filtenborg T, Gluud C, Tabor A (2003) Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. BJOG 110:1088–1098 4. Kuppermann M, Summitt RL Jr, Varner RE, McNeeley SG, Goodman-Gruen D, Learman LA et al (2005) Sexual functioning after total compared with supracervical hysterectomy: a randomized trial. Total or supracervical hysterectomy research group. Obstet Gynecol 105:1309–1318 5. American College of Obstetricians and Gynecologists (2007) ACOG Committee Opinion No. 388 November 2007: supracervical hysterectomy. Obstet Gynecol 110:1215–1217 6. Kives S, Lefebvre G, Wolfman W, Leyland N, Allaire C, Awadalla A, Best C, Leroux N, Potestio F, Rittenberg D, Soucy R, Singh S (2010) Supracervical hysterectomy. J Obstet Gynaecol Can 32:62–68
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