Hysterectomy (hysterectomy) is one of the most common surgical procedures used to treat uterine disease. Approximately 600,000 hysterectomies are performed each year in the United States, and it is estimated that the number of hysterectomies performed each year in China is over 2.8 million. There are three routes of hysterectomy: transabdominal hysterectomy, transvaginal hysterectomy and laparoscopic hysterectomy. The latter two are minimally invasive surgeries, which have been increasingly used in clinical practice in recent years and are being rapidly promoted and popularized throughout the country. The following is a brief introduction to the routes, scope, indications, advantages and disadvantages of various hysterectomies, with emphasis on laparoscopic hysterectomy.
I. Modes of transabdominal hysterectomy
The scope of surgery and procedure Transabdominal Hysterectomy (TAH) is a traditional surgical procedure, which can be performed with either transverse or longitudinal incision in the lower abdomen.TAH includes total hysterectomy, subtotal hysterectomy and intrasphincteric hysterectomy. Total hysterectomy is the removal of the entire uterus; subtotal hysterectomy is the removal of the body of the uterus while preserving the cervix; if the body of the uterus is removed with a circumferential excision of the endocervical lining and some of the surrounding tissue, preserving the outer sheath of the cervix, it is called intrasphincteric hysterectomy. In addition, V- or U-shaped hysterectomy of the uterine body has been reported in recent years.
Indications It is indicated in cases of fibroids, adenomyosis, benign endometrial disease, severe atypical hyperplasia or carcinoma in situ of the cervix, endometriosis with severe dysmenorrhea and uterine haemorrhage for which general treatment has failed. It is not limited by the size of the uterus, the presence of adhesions and the presence of uterine malignancy.
Advantages and disadvantages Compared with the present minimally invasive surgery, the abdominal scar is large and the patient’s postoperative recovery is slow. Nowadays, transverse lower abdominal incisions are mostly used, which are aesthetically pleasing and have light incisional adhesions. Today, when minimally invasive surgery is advocated and vigorously promoted, it is estimated that the proportion of TAH in various hysterectomies is still over 70% in most hospitals in China. It is believed that the use of transabdominal hysterectomy will become less and less in the future, and the majority will be gradually replaced by laparoscopic hysterectomy and transvaginal hysterectomy.
Although TAH has a long history of use and is the most familiar hysterectomy procedure among gynecologists, it still does not eliminate the occurrence of surgical complications (9.3%). Possible complications include injury to the bowel, ureter and bladder and, in the case of longitudinal incisions, wound infection and dehiscence.
II. Transvaginal hysterectomy approach
Transvaginal Hysterectomy (TVH) is a hysterectomy in which the uterus is removed from the vagina and the vaginal section is closed. The procedure is usually performed as a total hysterectomy, or as a subtotal hysterectomy for skilled patients.
Indications It is indicated for uterine fibroids, adenomyosis, benign endometrial disease, severe atypical hyperplasia of the cervix or carcinoma in situ and uterine haemorrhage for which general treatment has failed. Those with uterine size below 12 weeks of gestation are suitable for TVH.
Advantages and disadvantages TVH has been used clinically for 180 years and is favored for its incisionless abdomen and aesthetic appearance. However, the indications for the procedure are limited because the exposure is not as good as TAH. In recent years, TVH is gradually gaining popularity at all levels of hospitals, and evidence-based medical data show that for uteri equivalent to 12 weeks of gestation or less, especially those without significant pelvic adhesions, TVH is completely comparable to laparoscopic hysterectomy. However, in cases with significant pelvic adhesions or combined adnexal masses that require concurrent management, the advantages of laparoscopy are obvious. The data reported in our department suggest that the negative route is more appropriate for hysterectomy in menstruating women, without pelvic adhesions and with a low likelihood of combined adnexal disease. In contrast, TVH is generally not performed in large uteri, poor uterine mobility, and in patients with estimated severe pelvic adhesions.
In addition, there are still many gynecologists who are not familiar with the TVH procedure and complications (5.3%) are inevitable. Possible complications include bladder, bowel and ureteral injuries, the former being more common, especially in patients with a history of cesarean delivery, and their occurrence is not easily prevented by those with experience. Pelvic dissection bleeding and infection may also occur; therefore, some authors recommend routine placement of pelvic drainage after surgery.
III. Laparoscopic hysterectomy approach
Laparoscopic hysterectomy was first reported by Reich in 1989, which is actually a laparoscopic-assisted female hysterectomy and a modification of the female hysterectomy. After more than 10 years of clinical practice, laparoscopic hysterectomy has become a more mature surgical procedure and is one of the ideal procedures for the treatment of benign uterine diseases and is gradually replacing most of the TAHs. Assisted Vaginal Hysterectomy (LAVH) and Laparoscopic Total Hysterectomy (LTH). Procedures that preserve the cervix, such as Laparoscopic Supercervical Hysterectomy (LSH) and Laparoscopic Intrafascial Supercervical Hysterectomy (LISH). The surgical complication rate is about 3.6%.
1.LAVH procedure
The scope and procedure requires both laparoscopic and transvaginal approaches to remove the body of the uterus and all of the cervix.
Munro et al. suggested that in order to facilitate comparison of surgical results, to enable the operator to be graded according to the difficulty of the operation, to train the operation step by step, and to be alert to the surgical steps and anatomical sites prone to complications, the LAVH procedure should be standardized i.e. the operation should be divided into 4 types according to the complexity of the operation.
Type I: severance of bilateral pelvic funnel ligaments or intrinsic ligaments, fallopian tubes, and round bands.
Type II: dissection of bilateral uterine arteries and veins.
Type III: severance of part of the main ligament or separation of the severed sacral ligament.
Type IV: severance of all sacral ligaments and main ligaments.
In China, according to Li Guangyi et al, the types I and II of LAVH remain the same according to Munro’s type, while the severance of all sacral ligaments and main ligaments is type III, and after vaginal removal of the uterus, the stump is closed by negative sutures, which is type IV.
LAVH is a representative of early laparoscopic hysterectomy. In particular, types I and II are essentially a variation of the femoral hysterectomy due to the relatively small number of laparoscopically operated sections. LAVH is divided into type IV procedures from easy to difficult, and the ability to perform LTH is achieved when one has mastered the type IV procedure of LAVH and has suturing skills.
Indications For uterine fibroids, adenomyosis and benign endometrial disease, severe atypical hyperplasia of the cervix or carcinoma in situ. Uterus size should not exceed 5 months of gestation. LAVH may be considered when the uterus is poorly mobile, when the patient is estimated to have severe pelvic adhesions I and in other cases where TAH is not appropriate.
Advantages and disadvantages LAVH can make up for the shortcomings of TVH by separating the pelvic adhesions under direct vision and effectively preventing damage to the pelvic organs. lAVH is essentially a modification of the negative hysterectomy, especially types I and II. Therefore, the uterus is removed differently from LSH and LISH, it is removed from the vagina completely, which can avoid the occurrence of cervical stump cancer, and even if there is a missed diagnosis of early endometrial cancer, simple total hysterectomy can achieve the purpose of treatment.
For beginners of laparoscopy, most of them choose LAVH type I or II, most of the steps of hysterectomy are performed from the vagina, if the operator is not skillful or selects patients improperly, it will increase the chance of complications. Therefore, when learning to perform LAVH, the uterus should be less than 12 weeks gestation size and patients with pelvic adhesions or mild adhesions should be selected.
2.LSH procedure
The scope of surgery and procedure The body of the uterus is removed under laparoscopy while the cervix is preserved.
Indications It is suitable for uterine fibroids, adenomyosis and benign endometrial disease. Uterus size below 5 months of gestation is appropriate. Large uterus above 3 months of gestation is suitable for LSH, because if LISH, LTH or LAVH are used, the surgical complications may increase due to the relatively small space for pelvic manipulation and increased surgical difficulty.
Advantages and disadvantages The LSH procedure is easy to perform, with less bleeding and a simple approach. Especially with the introduction of Ligasure, PK knife and ultrasonic knife, it is easier to cut off both adnexa. This procedure can be performed with laparoscopic surgical skills and a uterine crusher. Since LSH can be performed without disconnecting the uterine vessels, there is no problem of intraoperative or postoperative bleeding as long as the lower uterine segment is firmly ligated; at the same time, the bladder and ureter are not easily injured by cutting only the peritoneal recoil of the bladder, and there is no problem of postoperative bleeding from the vaginal stump.
So far, the true role of the cervix has not been fully elucidated, but it is certain in both maintaining the support of the pelvic floor and maintaining normal sexual function, especially for young patients, whose removal of the cervix leaves them with a heavy sense of organ loss. By preserving the cervix, the patient feels that she has lost her uterus, but has preserved her “function” as a woman, which promotes the patient’s physical and mental health. Given the possibility of postoperative cancer of the cervical stump (incidence of about 1%), the advantages and disadvantages of preserving the cervix must be clearly explained to the patient before surgery. However, the technology of vaginal cytology is now very advanced, and together with a series of tests such as HPV testing and colposcopy, early cervical cancer can be fully diagnosed. Therefore, before deciding to keep the cervix, cervical cancer must be ruled out by various tests, and in case of CIN grade I-II, if the patient is young or insists on keeping the cervix, LSH can be considered after cervical circumferential excision with Leep knife, and the patient should be advised to have regular gynecological checkups after the procedure.
Another issue that needs attention when performing LSH is the possibility of endometrial cancer or other uterine malignancies in the patient. Because the LSH procedure involves removing the uterus by crushing the body of the uterus, if there is endometrial cancer, it may leave cancer cells in the pelvic or abdominal cavity or promote their spread. Therefore, endometrial pathological examination should be performed first for patients with abnormal menstruation over 40 years old to make sure that the endometrium is free of malignant lesions before performing LSH, and if the endometrium or fibroids are found to be suspicious of malignancy during surgery, frozen pathological sections should be performed immediately to clarify the diagnosis.
In recent years, as the level of awareness and treatment of cervical disease has improved, and also for the purpose of increasing the safety of laparoscopic surgery and reducing surgical complications, the laparoscopic hysterectomy style that preserves the cervix is again favored, and subtotal hysterectomy should be the ideal procedure. Intrathecal hysterectomy increases the operation, and the incidence of bleeding, infection and stump cyst increases, and cannot eliminate the occurrence of stump cervical cancer, so it gives people the feeling of “adding to the problem”, and its use is decreasing.
3.LISH procedure
The scope of operation and the operation style The body of the uterus is removed laparoscopically, and then the endocervical lining and some of the surrounding tissues are circumferentially removed, preserving the outer sheath of the uterine cervix.LISH is done by rotating the tissue of the cervical canal with special instruments. A similar procedure that is simple, quick and with the same results, done laparoscopically, was explored based on the experience of hundreds of operations by Li Guang Yi et al. After disconnecting the bilateral adnexa, only the cervical canal tissue needs to be rotated, and the operation can be completed by ligating the lower segment of the uterus and crushing the body of the uterus.
Indications It is indicated for uterine fibroids, adenomyosis and benign endometrial disease. The size of the uterus should be below the third trimester of pregnancy. If the uterus is too large, the pelvic cavity has less space for manipulation, and it is not easy to grasp the direction when puncturing the uterus with a guide rod or rotating the cervical canal tissue and part of the uterine body tissue, which can easily damage the organs.
Advantages and disadvantages LISH is clever and reasonable in terms of the design of the procedure, and the removal of the metastatic epithelium of the cervical canal while preserving the cervix is conducive to preventing the occurrence of cancer of the cervical stump. However, in clinical practice, if a 15-mm cervical rotator is chosen, there is a risk that some of the endocervical canal lining tissue will be left behind and the purpose of the original surgical design will not be achieved. This procedure closes the cervical stump and increases postoperative complications such as mucus retention or blood accumulation. If a 20 mm rotary cutter is chosen, there is a risk of accidental injury to the rectum, bladder and even ureter. Therefore, when choosing the LISH procedure, the uterine guide rod must be placed in the middle of the uterine fundus to check the integrity of the excised cervical canal tissue, and if it is not rotated cleanly, then monopolar or bipolar electrocoagulation of the residual cervical canal tissue can be considered.
Intraoperative and postoperative complications of LISH are higher than those of other laparoscopic hysterectomy procedures. Among the 1323 LISH procedures reported by Guang Yi Li, there were 2 cases of bladder injury (1 case of intermediate opening), 1 case of uterine vascular injury with intermediate opening, and 18 cases of slip of the ligature coil (1 case of intermediate opening). In the postoperative follow-up, there were 46 cases of vaginal bleeding (32 cases requiring treatment), 6 cases of cervical retention cysts (3 cases requiring puncture and aspiration), and 2 cases of cervical stump abscess. If intraoperative and postoperative complications were added, the complication rate was 4.08% (75/1323). Of course, some complications are somewhat preventable. For example, the slippage of the cervical ligature coil is related to the operating technique. If the technique of crushing the uterine body is properly mastered, the chance of bleeding due to coil slippage will be greatly reduced. In contrast, almost all of the postoperative complications are caused by vaginal factors. When K. Semm designed the CASH procedure, the stump of the uterine cervix after spinotomy was hemostatic with an endocoagulator and no sutures were required, therefore, mucous cysts and abscesses at the stump simply did not exist according to the original design procedure, and the occurrence of postoperative stump bleeding would be greatly reduced with the hemostasis by endocoagulation. However, the management of the cervical stump in the modified LISH differs from the original procedure in that it screens out the expensive endocoagulator in favor of suturing the stump, but increases the incidence of postoperative complications. Therefore, when dealing with the cervical stump, the following issues can be considered: ① check whether the excised cervical canal tissue is intact, as mentioned before, and remove the residual tissue by electrocoagulation if it is found to be left behind; ② when closing the cervical stump, a film can be placed in the middle to drain the cervical stump to ensure its patency and reduce the formation of postoperative mucous cysts, hematomas or abscesses; ③ when suturing the cervical stump, it is better to use The suture point should be chosen at 1.5 cm from the external cervical opening, with an interrupted “8” suture.
Therefore, when endometrial cancer or uterine sarcoma is missed, it will contaminate the pelvic or abdominal cavity or contribute to its spread.
4.LTH procedure
The scope of surgery and procedure The body of the uterus and the entire cervix are removed laparoscopically and the vaginal section is sutured. Some foreign scholars believe that the suturing of the vaginal dissection can be considered as LTH even if it is done transvaginally, as long as all steps, including circumferential vaginal fornix incision, are done laparoscopically.
Indications For uterine fibroids, adenomyosis and benign endometrial disease, severe atypical hyperplasia of the cervix or carcinoma in situ. When the uterus is larger than 3 months of gestation, the operation is more difficult and the complication rate is higher due to the small pelvic space. Therefore, LTH needs to be chosen with caution when the uterus is larger than 3 months of gestation.
Advantages and disadvantages The uterus is removed vaginally in this procedure, which maintains the integrity of the uterine body and does not contaminate the pelvic or abdominal cavity even if there is a missed diagnosis of early endometrial cancer. Because there is no prolonged vaginal dilatation and outward pulling of the pelvic floor, the impact on the pelvic floor tissues is less severe.
LTH involves laparoscopic dissection of blood vessels and ligaments and microscopic suturing of the vaginal stump, which is the most difficult and skillful of all laparoscopic hysterectomies. If one is familiar with the principle and use of ultrasonic knife, PK knife or Ligasure, the difficulty of using these instruments correctly will decrease. If one is proficient in LTH procedure, it means that laparoscopic surgery has reached a milestone and a good foundation for further laparoscopic extensive total hysterectomy is laid.
LTH is the most time-consuming of the various hysterectomy procedures and is prone to intraoperative complications, most commonly bleeding when dealing with uterine vessels and injuries to the bladder, ureter and intestinal canal. Our experience is that for LTH in a large uterus, the uterine body can be crushed and removed in the LSH style, but not as completely as in LSH, and then the following procedure is performed, which some authors call a “two-step hysterectomy”, and the heaviest uterus we have removed in this way was 900 g (6 months gestation size). The heaviest uterus removed in this way was 900g (6 months gestation size).
In conclusion, there are many different types of hysterectomy, and the choice of which method a particular surgeon can use to achieve the best results for a particular patient needs to be analyzed on a case-by-case basis. The success of minimally invasive surgery depends primarily on the surgeon’s minimally invasive surgical skills and the availability of surgical equipment and instruments, with the size of the uterus and the presence of adhesions being secondary factors. How to choose these procedures safely and reasonably in today’s new human-centered medical model is a frequent consideration for gynecologic laparoscopists. At the same time, enhancing patient-doctor communication and emphasizing informed consent are also important factors in ensuring the success of the chosen procedure.
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