Laparoscopic hysterectomy is currently being performed with increasing frequency and broader indications. Previously, the indication of benign gynecological causes was established and nowadays, malignant gynecological diseases have been started to be treated with laparoscopy.
Abnormal Uterine Bleeding
Laparoscopic hysterectomy is performed in patients with abnormal uterine hemorrhage, which is the most common indication for hysterectomy after uterine fibroids, especially those who are resistant to medical treatment and who have completed their fertility. In patients with hysterectomy due to abnormal uterine bleeding, MIC approach (laparoscopic or vaginal) is recommended. Especially the large uterus, concomitant adnexal pathology, intraabdominal adhesion possibility and the presence of narrow vagina should be the first choice laparoscopic approach. LH (laparoscopic) is considered to be the first choice in patients who are planned for hysterectomy due to abnormal uterine bleeding and who are not suitable for VH (vaginal).
Surgical treatment of endometriosis; persistent adnexial mass (endometrioma), dysfunction in other organs (bladder or bowel), medical treatment failure and especially chronic pelvic pain. The laparoscopic approach is superior in endometriosis surgery compared to laparotomy in terms of surgical excision of endometrioma, duration of operation, recurrence and complication risk. Definitive treatment for endometriosis is frequently performed in patients who have completed fertility and have severe pelvic pain. As endometriosis is defined as benign cancer, as the infiltration increases to the surrounding tissues, the risk of complications during the dissection is increased. During laparoscopic surgery, the dissection can be made more easily due to enlargement of the areas to be dissected. However, the surgeon should be experienced in laparoscopy and to have pelvic anatomy. After laparoscopic deep infiltrative endometriosis surgery, it can be performed easily after determination of paracentral areas and determination of ureter traction.
However, it should not be forgotten that this operation should be performed by experienced surgeons in laparoscopic endometriosis surgery.
Abdomino / Pelvic Surgery and Adhesion Presence
It should be kept in mind that the primary approach should be minimally invasive surgery in all patients planned for hysterectomy, including patients with a history of surgery or pelvic adhesion. However, vaginal hysterectomy may be relatively contraindicated in these patients. Therefore, the necessity of opening the adhesions and especially the laparoscopic approach that facilitates the evaluation of the pelvis, parametrial areas and ureters with the aid of telescopic enlargement is the primary preference in these patients. However, it should be kept in mind that 20-25% of the adhesions can be seen in the anterior wall of the abdomen and 28% of them may have bowel adhesions, especially in patients with midline incision. As a result, it should be considered that these adhesions may be present at the first laparoscopic introduction to the abdomen. The ultrasonographic evaluation of the anterior abdominal wall may be helpful in this regard. Another important concept is that in these patients, we may prefer safer non-umbilicus inputs such as Palmer point at the first entry. After a sufficient pneumoperitoneum is formed by entering from the Palmer point, a 5 mm camera can enter the abdomen from this area and the adhesions in the anterior abdominal wall can be defined. Defined adhesions can be opened with the help of the other ports we have entered safely under the supervision of the 5 mm camera that we entered from the Palmer point. Another method of choice for such patients is the open entrance (Hasson) technique. Finally, laparoscopic hysterectomy can be performed safely in such patients after the adhesions are opened.
Pelvic Inflammatory Disease (PID) and Tubo-Ovarian Abscess (TOA)
Hysterectomy + bilateral salpingectomy ± oophorectomy is a suitable treatment option in patients who have completed fertility, 45 years of age or postmenopausal, and do not respond to medical treatment. In these cases, anatomy can be disrupted and serious abdominopelvic adhesions may occur. Therefore, the surgery of these cases, regardless of open or MIC approach, is quite complicated. These patients should be operated by experienced surgeons with high anatomical knowledge. Laparoscopy will be of great benefit to us with the magnifying effect of the camera in opening the adhesions. The laparoscopic approach to the patients with TOA and PID was associated with a shorter duration of stay in the hospital, fewer wound infection, and fewer fever. As a result, it should be taken into consideration that surgery can be complicated and difficult, especially due to severe adhesions between the surrounding tissues and the necrotic and inflamed tissues surrounding the abscess. Laparoscopy can help us to open these adhesions.
However, it should be kept in mind that it is appropriate to perform this operation by the surgeons with pelvic and laparoscopic surgical experience.
Obesity is known to increase complication rates in all types of hysterectomy. According to body mass index (BMI) of patients who underwent laparoscopic hysterectomy; There was no significant increase in intraoperative or postoperative major complication rates except for the duration of operation, amount of bleeding, and rate of return to laparotomy. In a meta-analysis in which hysterectomy types were compared in terms of complication rates in obese patients in 2015, AH was reported to have higher complication rates and longer hospital stay. It was reported that there were lower rates of LH and VH in terms of wound infections and dehiscence compared to AH. 26 In another study comparing AH, VH and LH; In patients with AD and BMI> 40 kg / m2, a 5-fold increase in wound infection, wound site opening and sepsis risk was observed. This increase was not detected in the LH group. Bohlin et al. In their study, 28,537 hysterectomies were examined; They found increased bleeding rate, peroperative complication, postoperative complication, postoperative infection and prolonged operation time in patients with BMI ≥ 30 kg / m2. In laparoscopic hysterectomy, only the operation time was reported to be prolonged. In the light of recent developments, it is reported that LH is the method that should be applied primarily in patients with BMI> 30 kg / m2. However, it should be kept in mind that the operation time may be prolonged and the possibility of open surgery may increase.
When the indication of hysterectomy is placed in obese patients, it will be a correct approach to apply MIC methods by experienced surgeons.
It is known that large uterus may cause difficulty to the surgeon during hysterectomy. In this case, there is no definite recommendation about what should be the most ideal surgical approach. In general, AH is preferred in cases where uterine fundus is at umbilicus level. The definition of large uterus varies from source to source; in some publications the uterine weight was defined as> 300 g, and in some publications> 500 g. In a study evaluating laparoscopic supracervical hysterectomy cases,> 500 g of uterus was associated with increased operation time and increased bleeding. There was no significant difference in hospital stay and intraoperative complication rates. In another study in which total LH cases were evaluated, the limit value for the large uterus was 300 g and there was no difference in the hemoglobin reduction, complication rates and length of hospital stay. The authors suggested the Lee-Huang point to enter the abdomen in cases where the uterine fundus was 2 cm below the umbilicus. There are few studies comparing hysterectomy types in large uterus. In these studies, it was stated that intra and postoperative complication rates were independent of uterine weight, LH could be performed even in uterus with a weight of> 1 kg, and open surgery rates were gradually decreasing in large uterine cases over the years.
As a result, the large uterus does not constitute a contraindication for laparoscopic hysterectomy and is a safe method that can be performed by experienced surgeons. However, preoperative evaluations of patients with large uterus should be done in detail and the correct port location entry points should be determined in order for the LH procedure to continue properly. It is important to keep in mind that additional hygienic procedures may be needed to remove the uterus from the vaginal vaginal orifice after hysterectomy. In large uterine cases with high risk of bleeding (myoma uteri, adenomyosis, etc.), ligation of the uterine arteries from the area originating from the hypogastric artery may be an appropriate approach.
Leiomyomas affect approximately 25% women. Symptomatic women can be treated medically or surgically. In premenopausal and menopausal patients who have completed fertility and have symptomatic fibroids, hysterectomy is still the first choice of surgery. Considering the advantages of MIC, laparoscopic approach comes to the fore in patients who are planned for hysterectomy because of myoma uteri. In a study comparing laparoscopic and open hysterectomy in women with premenopausal and myoma, the rate of vaginal cuff dehiscence was higher in the laparoscopy group, while blood transfusion, wound infection, venous thromboembolism and incisional hernia rates were reported to be lower. LH was found to be superior in terms of quality of life. However, it should be kept in mind that the size and localization of the fibroids may complicate the LH procedure. LH application may be difficult due to the fact that the myomas larger than 8 cm, more than 7 cm in size, intraligamenter or cervical can cause adhesions, make uterine artery and ureter identification difficult, cause reduction in uterine mobility and create difficulty in observing the operation area. In such cases, preoperative physical examination, ultrasound, and if necessary magnetic resonance imaging, a detailed examination of the location and size of the fibroids and the necessity of determining the size of the uterus should be kept in mind. After the evaluation, determining the port settlements and planning the surgical steps will be the right approach. It should be noted that specially designed endoscopic scalpels can be used to allow the removal of the specimen from the vagina after hysterectomy in the uterus which is very large in the uterus.
In patients undergoing hysterectomy for adenomyosis, the operation can be performed by vaginal, abdominal or laparoscopic procedures. Preferably, the MIC approach will be more appropriate in these patients. In a study (Furuhashi et al.), The risk of bladder injury was higher in patients with adenomyosis during vaginal hysterectomy. Considering the advantages of the MIC approach and the Furuhashi finding, the laparoscopic approach may be of importance in patients with adenomyosis. Yavuzcan et al. They investigated the effect of adenomyosis on operative outcomes in patients with LH and did not find a significant difference in perioperative procedures such as hemoglobin reduction, pelvic catheterization, and invasive procedure in the urinary tract. Postoperative blood transfusion, fever, hospital stay and urinary catheterization time were similar between the two groups. It has been reported that LH reduces the risk of injury by providing better dissection of anatomic plans and is a safe method in patients with adenomyosis.
In conclusion, laparoscopic hysterectomy can be performed safely in patients with planned adenomyosis.