Minimally Invasive Gynecological Surgery

11. How to Avoid Laparotomy Doing Laparoscopic Hysterectomy

Olav Istre1, 2  


Minimal Invasive Gynecology, University of Southern Denmark, Odense, Denmark


Department of Gynecology, Aleris-Hamlet Hospital, Aalborg, Scandinavia

Olav Istre


11.1 Methods

11.2 Results

11.3 Complications

11.4 Discussion


Uterine fibroids are benign smooth muscle tumors of the uterus. They are seen in approximately one in three women and cause significant symptoms in at least half of them (Gentry et al. 2001). Hysterectomy is the ultimate treatment for women suffering from symptomatic myomas, menstrual disorders, endometriosis, and malignancy in the uterus. In Scandinavia, the prevalence of hysterectomy is mostly the same in Denmark, Norway, and Sweden, while the prevalence is almost threefold in Finland (Scott and Scott 1995). About 15 % of Norwegian women will have had a hysterectomy at the age of 60, while the figure will be approximately 40 % among American women (Backe and Lilleeng 1993; Lepine et al. 1997). The difference from one country to another may reflect to what degree women accept symptoms and the impact of doctors’ advice in the current situation. This difference also reflects the treatment modalities chosen by the doctor, in particular with bleeding disorders (i.e., hysterectomy vs. transcervical resection [TCRE] or insertion of levonorgestrel intrauterine device). Since Harry Reich first described total laparoscopic hysterectomy (LH) in 1988 (Reich 1992), endoscopic hysterectomies have become a routine procedure in many gynecologic departments, even though open abdominal hysterectomy is still the dominant surgical technique worldwide. Many advocate the vaginal approach for hysterectomy as an excellent alternative to both abdominal and laparoscopic hysterectomy techniques (Garry et al. 2004). To perform hysterectomy in uterus myomatosus, there are several surgical techniques. For a uterine weight of >1,000 g, after a caesarean section and in nullipara per vaginam, the most common surgical technique for hysterectomy in patients is hysterectomy per laparotomy. There are several surgical techniques: vaginal hysterectomy, abdominal hysterectomy, laparoscopic assisted vaginal hysterectomy, laparoscopic supracervical hysterectomy, and total laparoscopic hysterectomy, according to the wishes of the patient, her parity, and the clinical findings, e.g., adhesions. With a uterine weight of >1,000 g, after a caesarean section and as a nullipara per vaginam, the patient was classified as a difficult minimal-invasive case regarding surgical intervention.

11.1 Methods

In the present study, we investigated 406 consecutive patient operated for benign reason at a private hospital in Copenhagen Denmark. No rejection of referred patient and the patients were recruited from the primary health care sector by specialists in gynecology and were referred to the Minimal Invasive Gynecological Surgery (MIGS) unit at Aleris-Hamlet Hospital in Copenhagen, Denmark. The data were obtained from the patients records in the hospital and all patients were informed about the investigation.

All patients underwent pelvic examination and transvaginal ultrasound in the outpatient department. Patients were then scheduled for surgery within 3 weeks. We were able to perform 100 % laparoscopic approach apart from vaginal hysterectomy. The technique was a 4 port laparoscopic approach; in the smaller uterus the port placement was the camera in the umbilicus and 2 lateral ports and one in the middle 6 cm from the umbilicus. In the bigger uterus more than 400 g, the mid port and the camera was changed to be 6 cm from umbilicus upward (Fig. 11.1).


Fig. 11.1

Port placement in large fibroids

11.2 Results

In the present series only one laparotomy was performed in a 2.2 kg uterus where heavy bleeding encountered when the laparoscopic dissection of the uterus was performed, otherwise laparoscopic approach was utilized. Both in the TLH group and the LSH group the time was 75 min, however in larger uterus and fibroids very often LSH was the preferred technique, no malignancies was seen. Power morcellation was performed in the LSH group without any problems.

11.3 Complications

In the 445 patients so far the complications rate is low 6 % compared to the 16 % in the database for hysterectomy database Denmark. The most serious we had were 2 vesicoc-vaginal fistula and one urether lesion, one bladder perforation during the surgery.

Hematoma and postoperative infection encountered in 5 % of the patient (Table 11.1).

Table 11.1

Laparoscopic hysterectomy (N = 404, year 2014)




Vag Hyst


N = 206, BMI=24

N = 156, BMI=25

N = 41, BMI=25

N = 406

Age 47

Age 48

Age 61

OR time

75 (35–175)

75 (35–150)

85 (50–120)


Uterine weight (g)

394 (60–1,750)

263 (56–1,035)

75 (42–79)


Bleeding (ml)

77 (5–800)

57 (10–300)

63 (20–200)


Normal activity (days)

5 (1–14)

6 (1–14)

6 (1–14)


Back to work (days)

14 (1–42)

17 (7–35)

24 (14–49)


Postop complication

N = 100

4 (3 %)

7 (6.8%)

2 (4 %)

12 (4.5 %)

In 44 cases the uterine size exceeded 700 g and from Table 11.2 you can see that the operating time amount of bleeding increased significantly.

Table 11.2

Operation details in pat with weight >700 g


Or time (min)

Weight (g)

Bleeding (ml)













Lately, there has been discussions and concern of remnants of fibroid tissue left behind in the abdominal cavity after power morcellation (FDA Issues Safety Communication on Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy 2014). It is feared to cause spread of malignancies. This could be reduced using a bag, as this technique facilitates safely morcellation of uterus and fibroids (Fig. 11.2).


Fig. 11.2

Safe morcelation in a bag. Peritoneum completely cover in a articificiel space

11.4 Discussion

In the present study we were able to perform all the hysterectomies with the laparoscopic technique and with the use of morcellating in the larger uteri and fibroids, this is also in line with other studies in the literature. A retrospective cohort study of 957 patients who underwent laparoscopic supracervical (LSH), total (TLH), and assisted vaginal (LAVH) hysterectomies between January 2003 and December 2009. Among 957 hysterectomies LH, 799 (83.5 %) were LSH, 62 (6.4 %) TLH, and 96 (10.1 %) LAVH. Estimated blood loss, operating time, and length of hospital stay were significantly reduced with LSH. Meaning that the morcellation technique is beneficial and that the larger fibroid can come out this way avoiding big laparotomies.

Abdominal hysterectomy in Denmark is the main treatment for enlarged uterus in Denmark 53 % (The Danish hysterectomy database 2011) 8. Laparoscopic hysterectomy is performed in 12 % and vaginal route is utilized in 35 % in the smaller uterus. Complication rate was 18 %, readmission rate 5.4 %, and repeat surgery 4 % (The Danish Hysterectomy database 2010). In our intuition we have specialized in doing the hysterectomies even with large fibroid with the laparoscopic route. The benefits of minimally invasive surgery (MIS) for treating a variety of gynecologic conditions are well documented (Wright et al. 2012; Warren et al. 2009; Kongwattanakul and Khampitak 2012; Lenihan et al. 2004; Nieboer et al. 2012; Wiser et al. 2013). Nearly half of the estimated 400,000 inpatient-based hysterectomies performed annually in the United States for benign indications employ these innovative techniques. Thousands more women benefit from MIS in uterus-sparing procedures such as myomectomy. The ability to offer less invasive surgery to women often requires the removal of large tissue specimens through small incisions, which may be facilitated by morcellation. The term morcellation encompasses a variety of surgical techniques, some used in concert with specific devices, used to enable removal of large specimens from the peritoneal cavity, avoiding the need for laparotomy. In order to overcome the problem with spread of remnants from morcellation we have introduced the use of bags. In many ways this technique represents major benefits, the tissue and blood will stay within the bag so less cleaning at the end is needed however, more studies of this issue will be needed.


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