Journal of Obstetrics and Gynaecology, 2014; Early Online: 1–4 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.990431
ORIGINAL ARTICLE
Uterine artery ligation at the beginning of total laparoscopic hysterectomy reduces total blood loss and operation duration A. Kale1, S. Aksu1, H. Terzi1, G. Demirayak1, U. Turkay1 & F. Sendag2 1Department of Obstetrics and Gynecology, Kocaeli Derince Training and Research Hospital, Derince, Kocaeli, Turkey
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and 2Department of Obstetrics and Gynecology, Ege University, Izmir, Turkey
The purpose of this study was to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom uterine arteries were not ligated at the beginning of TLH. In our prospective study, a total of 60 women underwent TLH. Uterine artery ligation (UAL) was done at the beginning of the procedure. Women were divided into TLH UAL (n 30) and TLH (n 30) groups. In TLH group, TLH was done without ligating the uterine arteries at the beginning of the procedure. In TLH UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. The mean operating time was longer for the TLH group (99.16 7.01) than TLH UAL group (63.27 7.16). The median total blood loss was higher in TLH group (109.38 33.03 mL) than TLH UAL group (47.50 8.12 mL). UAL at the beginning of TLH is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure and length of hospital stay. Keywords: Blood loss, hospital stay, operating time, total laparoscopic hysterectomy, uterine artery ligation
Introduction Hysterectomy is a common gynaecological procedure worldwide; ∼600,000 procedures are performed annually in the United States. More than half of hysterectomies are performed for benign surgical indications, such as menorrhagia, fibroids, adenomyosis, endometriosis, pelvic pain and uterine prolapse (Wu et al. 2007). In recent years, a number of alternatives to the established techniques of total abdominal hysterectomy, most notably laparoscopic hysterectomy, have been developed. Numerous studies have shown that laparoscopic hysterectomy is better than abdominal hysterectomy because laparoscopic hysterectomy is associated with decreased blood loss, lower transfusion rates, lower complication rates, decreased analgesic requirements, shorter hospital stays, improved cosmetic results and quicker return to normal daily activities (Walsh et al. 2009). With continuing technological advances, laparoscopic hysterectomy has gained greater popularity among gynaecological surgeons. The rate of total laparoscopic hysterectomy (TLH) operations has been increasing, and many gynaecologists want to increase their rate of TLHs (Englund and Robson 2007).
This study was undertaken to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of TLH and patients in whom uterine arteries were not ligated at the beginning of TLH.
Materials and methods This prospective observational study was conducted from January 2012 to January 2013 after approval of the local Ethics and Research Committee. All procedures were performed using conventional laparoscopic instruments. In our prospective study, a total of 60 females underwent TLH. All patients included in the study were randomised using a computer-generated random number sequence. Uterine artery ligation (UAL) was performed at the beginning of the procedure. Subjects were divided into TLH ⫹ UAL (n ⫽ 30) and TLH (n ⫽ 30) groups. In the TLH group, TLH was performed without ligating the uterine arteries at the beginning of the procedure. In the TLH ⫹ UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. In the TLH ⫹ UAL group, the peritoneal fold was opened over the bifurcation of both iliac arteries on either side, and the ureter was identified. The ureters were moved laterally so that ureter injury was avoided (Figure 1). In the TLH group, the uterine arteries were not ligated before TLH. We compared the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using 5-mm ligatures at the beginning of TLH and patients in whom uterine arteries were not ligated. The following data were recorded: operative time (from incision to port closure), estimated blood loss (EBL), peri-operative haemoglobin change and post-operative duration of hospital stay. The total blood loss was calculated from the suction device. No irrigation was used throughout the procedure until total blood loss had been calculated. The patients were followed up at 6 weeks after surgery. Inclusion criteria were all benign uterine diseases. Patients were included in the study if they had menorrhagia due to known uterine fibroids, menorrhagia resistant to medical therapy or myoma uteri; those who did not desire further childbearing were also eligible. Patients with suspicion of gynaecological malignancy were excluded, including patients with ovarian masses suggestive of malignancy (complex masses with solid components greater than 6 cm
Correspondence: Hasan Terzi, Department of Obstetrics and Gynecology, Kocaeli Derince Training and Research Hospital, Derince, Kocaeli, Turkey. E-mail address: [email protected]
2
A. Kale et al. Table I. Patient characteristics.
110.00
Operating time (min)
100.00
Characteristics
TLH ⫹ UAL (n ⫽ 30)
P value
50.2 ⫾ 2.81 2.42 ⫾ 1.66 29.25 ⫾ 5.52 211.72 ⫾ 84 4 (16.6)
49.4 ⫾ 3.91 2.39 ⫾ 1.49 30.50 ⫾ 4.72 197.22 ⫾ 75 6 (20)
0.396b 0.705b 0.347b 0.602b 0.130b
90.00
Agea 80.00
51 50
Graviditya Body mass indexa Uterine weight, ga Concomitant bilateral adnexal removal, n (%)
70.00 60.00 50.00 TLH
TLH+UAL
Group TLH: Total laparoscopic hysterectomy; UAL:Uterine artery ligation; min:minute
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TLH (n ⫽ 30)
Figure 1. Comparison of the operating time of TLH ⫹ UAL group with TLH group. TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation; min, minute.
in diameter, with elevated CA 125 or with associated ascites). Laparoscopic surgery was recommended only after receiving a negative Pap smear, benign endometrial biopsy and radiological imaging results with no indication of malignancy. Patients were counselled about the benefits and risks of laparoscopic surgery, and informed consent was obtained. All patients were operated on by the same surgeon. During the operation general anaesthesia was used. Patients were placed in the lithotomy position. TLH was performed through four punctures with one 10-mm disposable trocar (Autosuture, Covidien, Ireland) and three 5-mm disposable trocars (Autosuture, Covidien, Ireland). One 10-mm trocar was inserted in the umbilicus with direct trocar insertion technique. After the umbilical trocar was placed, a 10-mm, 0° camera (Karl Storz, Tuttlingen, Germany) was inserted into 10-mm trocar hole to the abdominal cavity. Intraperitoneal pressure was maintained at 10–12 mm Hg during surgery. Two 5-mm trocars were inserted in the right and left lower quadrants (with transillumination and under direct view). One 5-mm trocar was inserted lateral to the umbilicus (with transillumination and direct view). This allowed the surgeon to operate with two hands and the assistant to operate the camera and assist with counter traction. The utero-ovarian ligaments were taken with the Ligasure (Valleylab, Inc. Boulder, Colorado, ABD). The anterior broad ligament peritoneum was also taken down with Harmonic Ace (Ethicon Endosurgery, Inc., Cincinnati, Ohio, ABD) dissection from the left round ligament to the right round ligament. The posterior broad ligament peritoneum was also taken down with the Harmonic Ace (Ethicon Endosurgery, Inc., Cincinnati, Ohio, ABD). The uterine vessels were skeletonised and taken down by Harmonic Ace. The cardinal and sacrouterine ligaments were taken down with harmonic energy, and the bladder was taken down off the cervix and upper vagina with Harmonic Ace. The RUMI Uterine Manipulator and KOH Cup™ (Cooper Surgical, Inc. Trumbull, CT USA) are placed onto the cervix vaginally. The anterior vaginal fornix and the vagina were opened with the Harmonic Ace over the KOH Cup™, and the vagina was then dissected free in 360 degrees using the Harmonic Ace. A tenaculum was placed through the vagina and the cervix, and the uterus was grasped, pulled into the vagina, and removed. The vagina was sutured with the laparoscopic intracorporal technique using three delayed absorbable polyglactin 0 sutures (Vicryl; Johnson & Johnson). The first suture was placed from the right cardinal ligament to the anterior vagina, then posterior, and then to the right uterosacral ligament. The second suture was then used to sew the left cardinal ligament, then the anterior vagina, then posterior, and then the left uterosacral ligament. The last suture was placed in the middle part of the
UAL, Uterine artery ligation; TLH, Total laparoscopic hysterectomy. aValues are mean ⫾ SD. bNot significant.
anterior and posterior vagina. The 10-mm trocar fascial incision was closed with delayed absorbable polyglactin 2–0 sutures (Vicryl; Johnson & Johnson). Skin was approximated with subcuticular poliglecaprone 3–0 sutures (Monocryl; Johnson & Johnson). The statistical comparison between the TLH and TLH ⫹ UAL groups was conducted using the SPSS software (version 11.0.1; SPSS Inc., Chicago, IL). All of the variables showed a normal distribution. Student’s t-test was used to evaluate the significance of differences, and p-values less than 0.05 were considered to indicate statistical significance.
Results A total of 60 patients underwent TLH. Patients were divided into two groups: the TLH with UAL group (n ⫽ 30; TLH ⫹ UAL), and the TLH without UAL group (TLH; n ⫽ 30). The groups were similar with respect to age, gravidity, body mass index and mean uterine weight (Table I). The most common indications for laparoscopic hysterectomy for both groups were menometrorrhagia and uterine leiomyoma (Table II). We were interested primarily in peri-operative outcome measures (Table III). The mean operating time was longer for the TLH group (99.16 ⫾ 7.01 min) than the TLH ⫹ UAL group (63.27 ⫾ 7.16 min; p ⬍ 0.001) (Figure 2). The median total blood loss was higher in the TLH group (109.38 ⫾ 33.03 mL) than the TLH ⫹ UAL group (47.50 ⫾ 8.12 mL; p ⬍ 0.001) (Figure 3). The average hospital stay was longer for the TLH group (43.72 ⫾ 3.04 h) than the TLH ⫹ UAL group (31.70 ⫾ 1.71 h; p ⬍ 0.001) (Figure 4). Perioperative haemoglobin change did not differ between the TLH (1.77 ⫾ 0.56 g/dL) and TLH ⫹ UAL (1.69 ⫾ 0.61 g/dL; p ⫽ 0.702) groups. There were no complications in either group.
Discussion The ratio of laparoscopic hysterectomies has been increasing compared with hysterectomies performed through a laparotomy. Table II. Indications for hysterectomy. Indication, n (%)
TLH (n ⫽ 30)
TLH ⫹ UAL (n ⫽ 30)
p value
Menometrorrhagia Uterine myomas Pelvic pain Endometrial hyperplasia
15 (50) 10 (33) 3 (10) 2 (6)
16 (53) 7 (23) 4 (13) 3 (10)
0.892a 0.773a 0.851a 0.685a
UAL, Uterine artery ligation; TLH, Total laparoscopic hysterectomy aNot significant
Total laparoscopic hysterectomy 3 Table III. Peri-operative outcome measures.
Operating time, min Length of hospital stay, h, Change in haemoglobin, g/dL Total blood loss, ml
TLH ⫹ UAL (n ⫽ 30)
P value
99.16 ⫾ 7.01 43.72 ⫾ 3.04 1.77 ⫾ 0.56 109.38 ⫾ 33.03
63.27 ⫾ 7.16 31.70 ⫾ 1.71 1.69 ⫾ 0.61 47.50 ⫾ 8.12
⬍ 0.01 ⬍ 0.001 0.702b ⬍ 0.001
TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation. aValues are mean ⫾ SD. bNot significant.
Length of hospital stay (h)
Characteristics
55.00
TLH (n ⫽ 30)
50.00 45.00 40.00 35.00 35.00 25.00 TLH Group
TLH: Total laparoscopic hysterectomy; UAL: Uterine artery ligation; h; hours
Figure 3. Comparison of the length of hospital stay of TLH ⫹ UAL group with TLH group. TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation; h, hours.
is a technically feasible procedure that reduces the total blood loss and decreases the procedure duration (Sinha et al. 2008). Gol et al. (2007) used a bipolar device (LigaSure; Covidien PLC, Dublin, Ireland) to ligate uterine arteries during laparoscopy-assisted vaginal hysterectomy and found that laparoscopic hysterectomy by retroperitoneal uterine artery sealing with LigaSure is an effective, safe and fast procedure with less intra-operative bleeding. In our procedure, the peritoneal fold is opened over the right and left external and internal iliac arteries on either side and the ureter is identified. The ureters were moved laterally so that ureter injury is avoided. The uterine vessels and obliterated umbilical artery were identified, and both uterine arteries were ligated using surgical clips and cut using 5-mm LigaSure bipolar technology (Valleylab, Inc. Boulder, Colorado, ABD). Uterine vessels may be ligated at their origin, at the site where they cross the ureter, where they join the uterus or on the side of the uterus. Most surgeons use bipolar dissection to ligate these vessels, but we prefer ligation using surgical clips and cutting with 5-mm LigaSure bipolar technology (Valleylab, Inc. Boulder, Colorado, ABD). Our patients stay in hospital for a long time. We believe that the reason for this cultural differences and patients come from distant cities because our hospital is a tertiary health care centre. When UAL was performed at the beginning of TLH, there was less need to control haemorrhage because less blood was lost during the operation. Therefore, we believe that the operation time is less than that for the standard procedure.
200.00
Total blood loss (ml)
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TLH+UAL
Laparoscopic procedures offer higher-quality tissue images and anatomic views of the abdominopelvic cavity, facilitate meticulous haemostasis, reduce the morbidity associated with laparotomy incisions and allow the performance of uterine surgery, adnexal surgery, ureterolysis and retroperitoneal dissection, as well as uterine and cervical cancer surgeries (Wu et al. 2007; Walsh et al. 2009; Englund and Robson 2007). Abdominal ligature of the uterine arteries, as first described in 1952, comprises mass ligature of the ascending branches of the uterine artery and vein 2–3 cm below the level of caesarean uterotomy, and includes 2–3 cm of myometrium in the suture (Waters 1952). Alternative UAL techniques during laparoscopic hysterectomy have been reported (Aust et al. 2011; Chang et al. 2005). Liu et al. opened the peritoneal triangle between the round ligament, infundibulopelvic ligament and external iliac vessels and then tied the uterine arteries (Liu et al. 2004). Chang et al tied the uterine arteries during laparoscopy-assisted vaginal hysterectomy using retrograde tracking of the umbilical ligament (Chang et al. 2005). Studies have reported the following benefits of UAL during laparoscopic surgery: reduction in intra-operative blood loss, improvement in symptoms and reduction in recurrence rate (Liu et al. 2011). Song et al compared the clinical characteristics and effectiveness of selective uterine artery double ligation and bipolar uterine artery coagulation in TLH on 384 patients and found that selective uterine artery double ligation in TLH was associated with lower transfusion rate, less hospitalisation and less discomfort (Song et al. 2010). Sinha et al. compared the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were sutured at the beginning of TLH and patients in whom suturing was performed after cornual pedicles. They found that UAL at the beginning of TLH
150.00
100.00
50.00
0.00 TLH
TLH+UAL
Group TLH: Total laparoscopic hysterectomy; UAL:Uterine artery ligation ; ml: mililitre
Figure 2 . Comparison of the total blood loss of TLH ⫹ UAL group with TLH group. TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation; ml, mililitre.
Figure 4. Ureter, uterine artery, superior vesical artery and obliterated hypogastric artery. Uterine artery ligated using surgical clips and cut using 5-mm LigaSure bipolar technology.
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4
A. Kale et al.
In most cases, the uterine vessels are suture-ligated as they ascend to the sides of the uterus. The broad ligament is skeletonised to the uterine vessels. Each uterine vessel pedicle is suture-ligated with 0 Vicryl (Reich 2007). Sometimes, UAL is technically difficult, but it is possible to ligate uterine arteries if the training and skill of the surgeon are adequate. Another concern is including the ureters while ligating the uterine artery. If the uterovesical fold of the peritoneum is opened and the bladder pushed down, the ureters move laterally and the chance of including them in the suture is decreased (Sinha et al. 2008; Reich 2007). Our study has some limitations. The number of cases is small and the study was conducted in a single centre. We showed that ligature of the uterine artery seems to reduce operative blood loss and decreases the time needed for the procedure and the duration of hospital stay when used as a prophylactic routine procedure at the beginning of laparoscopic hysterectomy. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. Financial disclosure: The authors declared that this study received no financial support.
References Aust T, Reyftmann L, Rosen D, Cario G, Chou D. 2011. Anterior approach to laparoscopic uterine artery ligation. Journal of Minimally Invasive Gynecology 18:792–795.
Chang WC, Torng PL, Huang SC, Sheu BC, Hsu WC, Chen RJ et al. 2005. Laparoscopic-assisted vaginal hysterectomy with uterine artery ligation through retrograde umbilical ligament tracking. Journal of Minimally Invasive Gynecology 12:336–342. Englund M, Robson S. 2007. Why has the acceptance of laparoscopic hysterectomy been slow? Results of an anonymous survey of Australian gynecologists. Journal of Minimally Invasive Gynecology 14:724–728. Gol M, Kizilyar A, Eminoglu M. 2007. Laparoscopic hysterectomy with retroperitoneal uterine artery sealing using ligasure: Gazi hospital experience. Archives of Gynecology Obstetrics 276:311–314. Liu L, Li Y, Xu H, Chen Y, Zhang G, Liang Z. 2011. Laparoscopic transient uterine artery occlusion and myomectomy for symptomatic uterine myoma. Fertility and Sterility 95:254–258. Liu WM, Tzeng CR, Yi-Jen C, Wang PH. 2004. Combining the uterine depletion procedure and myomectomy may be useful for treating symptomatic fibroids. Fertility and Sterility 82: 205–210. Reich H . 2007. Total laparoscopic hysterectomy: indications, techniques and outcomes. Current Opinion in Obstetrics and Gynecology 19: 337–344. Sinha R, Sundaram M, Nikam YA, Hegde A, Mahajan C. 2008. Total laparoscopic hysterectomy with earlier uterine artery ligation. Journal of Minimally Invasive Gynecology 15: 355–359. Song JY, Hwang SJ, Kim MJ, Jo HH, Kim SY, Choi KE et al. 2010. Comparison of selective uterine artery double ligation at the isthmic level of uterus and bipolar uterine artery coagulation in total laparoscopic hysterectomy. Minimally Invasive Therapy and Allied Technologies 19:224–230. Walsh CA, Walsh SR, Tang TY, Slack M. 2009. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis. European Journal of Obstetrics, Gynecology and Reproductive Biology 144:3–7. Waters EG. 1952. Surgical management of postpartum hemorrhage with particular reference to ligation of uterine arteries. American Journal of Obstetrics and Gynecology 64:1143–1148. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. 2007. Hysterectomy rates in the United States, 2003. Obstetrics and Gynecology 110: 1091–1095.
ORIGINAL ARTICLE
Uterine artery ligation at the beginning of total laparoscopic hysterectomy reduces total blood loss and operation duration A. Kale1, S. Aksu1, H. Terzi1, G. Demirayak1, U. Turkay1 & F. Sendag2 1Department of Obstetrics and Gynecology, Kocaeli Derince Training and Research Hospital, Derince, Kocaeli, Turkey
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and 2Department of Obstetrics and Gynecology, Ege University, Izmir, Turkey
The purpose of this study was to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom uterine arteries were not ligated at the beginning of TLH. In our prospective study, a total of 60 women underwent TLH. Uterine artery ligation (UAL) was done at the beginning of the procedure. Women were divided into TLH UAL (n 30) and TLH (n 30) groups. In TLH group, TLH was done without ligating the uterine arteries at the beginning of the procedure. In TLH UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. The mean operating time was longer for the TLH group (99.16 7.01) than TLH UAL group (63.27 7.16). The median total blood loss was higher in TLH group (109.38 33.03 mL) than TLH UAL group (47.50 8.12 mL). UAL at the beginning of TLH is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure and length of hospital stay. Keywords: Blood loss, hospital stay, operating time, total laparoscopic hysterectomy, uterine artery ligation
Introduction Hysterectomy is a common gynaecological procedure worldwide; ∼600,000 procedures are performed annually in the United States. More than half of hysterectomies are performed for benign surgical indications, such as menorrhagia, fibroids, adenomyosis, endometriosis, pelvic pain and uterine prolapse (Wu et al. 2007). In recent years, a number of alternatives to the established techniques of total abdominal hysterectomy, most notably laparoscopic hysterectomy, have been developed. Numerous studies have shown that laparoscopic hysterectomy is better than abdominal hysterectomy because laparoscopic hysterectomy is associated with decreased blood loss, lower transfusion rates, lower complication rates, decreased analgesic requirements, shorter hospital stays, improved cosmetic results and quicker return to normal daily activities (Walsh et al. 2009). With continuing technological advances, laparoscopic hysterectomy has gained greater popularity among gynaecological surgeons. The rate of total laparoscopic hysterectomy (TLH) operations has been increasing, and many gynaecologists want to increase their rate of TLHs (Englund and Robson 2007).
This study was undertaken to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of TLH and patients in whom uterine arteries were not ligated at the beginning of TLH.
Materials and methods This prospective observational study was conducted from January 2012 to January 2013 after approval of the local Ethics and Research Committee. All procedures were performed using conventional laparoscopic instruments. In our prospective study, a total of 60 females underwent TLH. All patients included in the study were randomised using a computer-generated random number sequence. Uterine artery ligation (UAL) was performed at the beginning of the procedure. Subjects were divided into TLH ⫹ UAL (n ⫽ 30) and TLH (n ⫽ 30) groups. In the TLH group, TLH was performed without ligating the uterine arteries at the beginning of the procedure. In the TLH ⫹ UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. In the TLH ⫹ UAL group, the peritoneal fold was opened over the bifurcation of both iliac arteries on either side, and the ureter was identified. The ureters were moved laterally so that ureter injury was avoided (Figure 1). In the TLH group, the uterine arteries were not ligated before TLH. We compared the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using 5-mm ligatures at the beginning of TLH and patients in whom uterine arteries were not ligated. The following data were recorded: operative time (from incision to port closure), estimated blood loss (EBL), peri-operative haemoglobin change and post-operative duration of hospital stay. The total blood loss was calculated from the suction device. No irrigation was used throughout the procedure until total blood loss had been calculated. The patients were followed up at 6 weeks after surgery. Inclusion criteria were all benign uterine diseases. Patients were included in the study if they had menorrhagia due to known uterine fibroids, menorrhagia resistant to medical therapy or myoma uteri; those who did not desire further childbearing were also eligible. Patients with suspicion of gynaecological malignancy were excluded, including patients with ovarian masses suggestive of malignancy (complex masses with solid components greater than 6 cm
Correspondence: Hasan Terzi, Department of Obstetrics and Gynecology, Kocaeli Derince Training and Research Hospital, Derince, Kocaeli, Turkey. E-mail address: [email protected]
2
A. Kale et al. Table I. Patient characteristics.
110.00
Operating time (min)
100.00
Characteristics
TLH ⫹ UAL (n ⫽ 30)
P value
50.2 ⫾ 2.81 2.42 ⫾ 1.66 29.25 ⫾ 5.52 211.72 ⫾ 84 4 (16.6)
49.4 ⫾ 3.91 2.39 ⫾ 1.49 30.50 ⫾ 4.72 197.22 ⫾ 75 6 (20)
0.396b 0.705b 0.347b 0.602b 0.130b
90.00
Agea 80.00
51 50
Graviditya Body mass indexa Uterine weight, ga Concomitant bilateral adnexal removal, n (%)
70.00 60.00 50.00 TLH
TLH+UAL
Group TLH: Total laparoscopic hysterectomy; UAL:Uterine artery ligation; min:minute
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TLH (n ⫽ 30)
Figure 1. Comparison of the operating time of TLH ⫹ UAL group with TLH group. TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation; min, minute.
in diameter, with elevated CA 125 or with associated ascites). Laparoscopic surgery was recommended only after receiving a negative Pap smear, benign endometrial biopsy and radiological imaging results with no indication of malignancy. Patients were counselled about the benefits and risks of laparoscopic surgery, and informed consent was obtained. All patients were operated on by the same surgeon. During the operation general anaesthesia was used. Patients were placed in the lithotomy position. TLH was performed through four punctures with one 10-mm disposable trocar (Autosuture, Covidien, Ireland) and three 5-mm disposable trocars (Autosuture, Covidien, Ireland). One 10-mm trocar was inserted in the umbilicus with direct trocar insertion technique. After the umbilical trocar was placed, a 10-mm, 0° camera (Karl Storz, Tuttlingen, Germany) was inserted into 10-mm trocar hole to the abdominal cavity. Intraperitoneal pressure was maintained at 10–12 mm Hg during surgery. Two 5-mm trocars were inserted in the right and left lower quadrants (with transillumination and under direct view). One 5-mm trocar was inserted lateral to the umbilicus (with transillumination and direct view). This allowed the surgeon to operate with two hands and the assistant to operate the camera and assist with counter traction. The utero-ovarian ligaments were taken with the Ligasure (Valleylab, Inc. Boulder, Colorado, ABD). The anterior broad ligament peritoneum was also taken down with Harmonic Ace (Ethicon Endosurgery, Inc., Cincinnati, Ohio, ABD) dissection from the left round ligament to the right round ligament. The posterior broad ligament peritoneum was also taken down with the Harmonic Ace (Ethicon Endosurgery, Inc., Cincinnati, Ohio, ABD). The uterine vessels were skeletonised and taken down by Harmonic Ace. The cardinal and sacrouterine ligaments were taken down with harmonic energy, and the bladder was taken down off the cervix and upper vagina with Harmonic Ace. The RUMI Uterine Manipulator and KOH Cup™ (Cooper Surgical, Inc. Trumbull, CT USA) are placed onto the cervix vaginally. The anterior vaginal fornix and the vagina were opened with the Harmonic Ace over the KOH Cup™, and the vagina was then dissected free in 360 degrees using the Harmonic Ace. A tenaculum was placed through the vagina and the cervix, and the uterus was grasped, pulled into the vagina, and removed. The vagina was sutured with the laparoscopic intracorporal technique using three delayed absorbable polyglactin 0 sutures (Vicryl; Johnson & Johnson). The first suture was placed from the right cardinal ligament to the anterior vagina, then posterior, and then to the right uterosacral ligament. The second suture was then used to sew the left cardinal ligament, then the anterior vagina, then posterior, and then the left uterosacral ligament. The last suture was placed in the middle part of the
UAL, Uterine artery ligation; TLH, Total laparoscopic hysterectomy. aValues are mean ⫾ SD. bNot significant.
anterior and posterior vagina. The 10-mm trocar fascial incision was closed with delayed absorbable polyglactin 2–0 sutures (Vicryl; Johnson & Johnson). Skin was approximated with subcuticular poliglecaprone 3–0 sutures (Monocryl; Johnson & Johnson). The statistical comparison between the TLH and TLH ⫹ UAL groups was conducted using the SPSS software (version 11.0.1; SPSS Inc., Chicago, IL). All of the variables showed a normal distribution. Student’s t-test was used to evaluate the significance of differences, and p-values less than 0.05 were considered to indicate statistical significance.
Results A total of 60 patients underwent TLH. Patients were divided into two groups: the TLH with UAL group (n ⫽ 30; TLH ⫹ UAL), and the TLH without UAL group (TLH; n ⫽ 30). The groups were similar with respect to age, gravidity, body mass index and mean uterine weight (Table I). The most common indications for laparoscopic hysterectomy for both groups were menometrorrhagia and uterine leiomyoma (Table II). We were interested primarily in peri-operative outcome measures (Table III). The mean operating time was longer for the TLH group (99.16 ⫾ 7.01 min) than the TLH ⫹ UAL group (63.27 ⫾ 7.16 min; p ⬍ 0.001) (Figure 2). The median total blood loss was higher in the TLH group (109.38 ⫾ 33.03 mL) than the TLH ⫹ UAL group (47.50 ⫾ 8.12 mL; p ⬍ 0.001) (Figure 3). The average hospital stay was longer for the TLH group (43.72 ⫾ 3.04 h) than the TLH ⫹ UAL group (31.70 ⫾ 1.71 h; p ⬍ 0.001) (Figure 4). Perioperative haemoglobin change did not differ between the TLH (1.77 ⫾ 0.56 g/dL) and TLH ⫹ UAL (1.69 ⫾ 0.61 g/dL; p ⫽ 0.702) groups. There were no complications in either group.
Discussion The ratio of laparoscopic hysterectomies has been increasing compared with hysterectomies performed through a laparotomy. Table II. Indications for hysterectomy. Indication, n (%)
TLH (n ⫽ 30)
TLH ⫹ UAL (n ⫽ 30)
p value
Menometrorrhagia Uterine myomas Pelvic pain Endometrial hyperplasia
15 (50) 10 (33) 3 (10) 2 (6)
16 (53) 7 (23) 4 (13) 3 (10)
0.892a 0.773a 0.851a 0.685a
UAL, Uterine artery ligation; TLH, Total laparoscopic hysterectomy aNot significant
Total laparoscopic hysterectomy 3 Table III. Peri-operative outcome measures.
Operating time, min Length of hospital stay, h, Change in haemoglobin, g/dL Total blood loss, ml
TLH ⫹ UAL (n ⫽ 30)
P value
99.16 ⫾ 7.01 43.72 ⫾ 3.04 1.77 ⫾ 0.56 109.38 ⫾ 33.03
63.27 ⫾ 7.16 31.70 ⫾ 1.71 1.69 ⫾ 0.61 47.50 ⫾ 8.12
⬍ 0.01 ⬍ 0.001 0.702b ⬍ 0.001
TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation. aValues are mean ⫾ SD. bNot significant.
Length of hospital stay (h)
Characteristics
55.00
TLH (n ⫽ 30)
50.00 45.00 40.00 35.00 35.00 25.00 TLH Group
TLH: Total laparoscopic hysterectomy; UAL: Uterine artery ligation; h; hours
Figure 3. Comparison of the length of hospital stay of TLH ⫹ UAL group with TLH group. TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation; h, hours.
is a technically feasible procedure that reduces the total blood loss and decreases the procedure duration (Sinha et al. 2008). Gol et al. (2007) used a bipolar device (LigaSure; Covidien PLC, Dublin, Ireland) to ligate uterine arteries during laparoscopy-assisted vaginal hysterectomy and found that laparoscopic hysterectomy by retroperitoneal uterine artery sealing with LigaSure is an effective, safe and fast procedure with less intra-operative bleeding. In our procedure, the peritoneal fold is opened over the right and left external and internal iliac arteries on either side and the ureter is identified. The ureters were moved laterally so that ureter injury is avoided. The uterine vessels and obliterated umbilical artery were identified, and both uterine arteries were ligated using surgical clips and cut using 5-mm LigaSure bipolar technology (Valleylab, Inc. Boulder, Colorado, ABD). Uterine vessels may be ligated at their origin, at the site where they cross the ureter, where they join the uterus or on the side of the uterus. Most surgeons use bipolar dissection to ligate these vessels, but we prefer ligation using surgical clips and cutting with 5-mm LigaSure bipolar technology (Valleylab, Inc. Boulder, Colorado, ABD). Our patients stay in hospital for a long time. We believe that the reason for this cultural differences and patients come from distant cities because our hospital is a tertiary health care centre. When UAL was performed at the beginning of TLH, there was less need to control haemorrhage because less blood was lost during the operation. Therefore, we believe that the operation time is less than that for the standard procedure.
200.00
Total blood loss (ml)
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TLH+UAL
Laparoscopic procedures offer higher-quality tissue images and anatomic views of the abdominopelvic cavity, facilitate meticulous haemostasis, reduce the morbidity associated with laparotomy incisions and allow the performance of uterine surgery, adnexal surgery, ureterolysis and retroperitoneal dissection, as well as uterine and cervical cancer surgeries (Wu et al. 2007; Walsh et al. 2009; Englund and Robson 2007). Abdominal ligature of the uterine arteries, as first described in 1952, comprises mass ligature of the ascending branches of the uterine artery and vein 2–3 cm below the level of caesarean uterotomy, and includes 2–3 cm of myometrium in the suture (Waters 1952). Alternative UAL techniques during laparoscopic hysterectomy have been reported (Aust et al. 2011; Chang et al. 2005). Liu et al. opened the peritoneal triangle between the round ligament, infundibulopelvic ligament and external iliac vessels and then tied the uterine arteries (Liu et al. 2004). Chang et al tied the uterine arteries during laparoscopy-assisted vaginal hysterectomy using retrograde tracking of the umbilical ligament (Chang et al. 2005). Studies have reported the following benefits of UAL during laparoscopic surgery: reduction in intra-operative blood loss, improvement in symptoms and reduction in recurrence rate (Liu et al. 2011). Song et al compared the clinical characteristics and effectiveness of selective uterine artery double ligation and bipolar uterine artery coagulation in TLH on 384 patients and found that selective uterine artery double ligation in TLH was associated with lower transfusion rate, less hospitalisation and less discomfort (Song et al. 2010). Sinha et al. compared the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were sutured at the beginning of TLH and patients in whom suturing was performed after cornual pedicles. They found that UAL at the beginning of TLH
150.00
100.00
50.00
0.00 TLH
TLH+UAL
Group TLH: Total laparoscopic hysterectomy; UAL:Uterine artery ligation ; ml: mililitre
Figure 2 . Comparison of the total blood loss of TLH ⫹ UAL group with TLH group. TLH, Total laparoscopic hysterectomy; UAL, Uterine artery ligation; ml, mililitre.
Figure 4. Ureter, uterine artery, superior vesical artery and obliterated hypogastric artery. Uterine artery ligated using surgical clips and cut using 5-mm LigaSure bipolar technology.
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4
A. Kale et al.
In most cases, the uterine vessels are suture-ligated as they ascend to the sides of the uterus. The broad ligament is skeletonised to the uterine vessels. Each uterine vessel pedicle is suture-ligated with 0 Vicryl (Reich 2007). Sometimes, UAL is technically difficult, but it is possible to ligate uterine arteries if the training and skill of the surgeon are adequate. Another concern is including the ureters while ligating the uterine artery. If the uterovesical fold of the peritoneum is opened and the bladder pushed down, the ureters move laterally and the chance of including them in the suture is decreased (Sinha et al. 2008; Reich 2007). Our study has some limitations. The number of cases is small and the study was conducted in a single centre. We showed that ligature of the uterine artery seems to reduce operative blood loss and decreases the time needed for the procedure and the duration of hospital stay when used as a prophylactic routine procedure at the beginning of laparoscopic hysterectomy. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. Financial disclosure: The authors declared that this study received no financial support.
References Aust T, Reyftmann L, Rosen D, Cario G, Chou D. 2011. Anterior approach to laparoscopic uterine artery ligation. Journal of Minimally Invasive Gynecology 18:792–795.
Chang WC, Torng PL, Huang SC, Sheu BC, Hsu WC, Chen RJ et al. 2005. Laparoscopic-assisted vaginal hysterectomy with uterine artery ligation through retrograde umbilical ligament tracking. Journal of Minimally Invasive Gynecology 12:336–342. Englund M, Robson S. 2007. Why has the acceptance of laparoscopic hysterectomy been slow? Results of an anonymous survey of Australian gynecologists. Journal of Minimally Invasive Gynecology 14:724–728. Gol M, Kizilyar A, Eminoglu M. 2007. Laparoscopic hysterectomy with retroperitoneal uterine artery sealing using ligasure: Gazi hospital experience. Archives of Gynecology Obstetrics 276:311–314. Liu L, Li Y, Xu H, Chen Y, Zhang G, Liang Z. 2011. Laparoscopic transient uterine artery occlusion and myomectomy for symptomatic uterine myoma. Fertility and Sterility 95:254–258. Liu WM, Tzeng CR, Yi-Jen C, Wang PH. 2004. Combining the uterine depletion procedure and myomectomy may be useful for treating symptomatic fibroids. Fertility and Sterility 82: 205–210. Reich H . 2007. Total laparoscopic hysterectomy: indications, techniques and outcomes. Current Opinion in Obstetrics and Gynecology 19: 337–344. Sinha R, Sundaram M, Nikam YA, Hegde A, Mahajan C. 2008. Total laparoscopic hysterectomy with earlier uterine artery ligation. Journal of Minimally Invasive Gynecology 15: 355–359. Song JY, Hwang SJ, Kim MJ, Jo HH, Kim SY, Choi KE et al. 2010. Comparison of selective uterine artery double ligation at the isthmic level of uterus and bipolar uterine artery coagulation in total laparoscopic hysterectomy. Minimally Invasive Therapy and Allied Technologies 19:224–230. Walsh CA, Walsh SR, Tang TY, Slack M. 2009. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis. European Journal of Obstetrics, Gynecology and Reproductive Biology 144:3–7. Waters EG. 1952. Surgical management of postpartum hemorrhage with particular reference to ligation of uterine arteries. American Journal of Obstetrics and Gynecology 64:1143–1148. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. 2007. Hysterectomy rates in the United States, 2003. Obstetrics and Gynecology 110: 1091–1095.
