European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 97–101

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Retroperitoneal and retrograde total laparoscopic hysterectomy as a standard treatment in a community hospital Eugenio Volpi *, Luca Bernardini, Moira Angeloni, Stefano Cosma 1, Paolo Mannella Department of Obstetrics and Gynecology, Sant’ Andrea Hospital – ASL n 5, Via Vittorio Veneto 197, 19100 La Spezia, Italy



Article history: Received 18 May 2013 Received in revised form 10 September 2013 Accepted 9 October 2013

Objective: To report our experience with a modified procedure for total laparoscopic hysterectomy based on a retrograde and retroperitoneal technique. This surgical approach is analyzed on a consecutive series of patients in a community hospital and theoretical educational advantages are proposed. Study design: All patients undergoing hysterectomy from January 2012 to April 2013 were included in the study. A detailed description of the technique is given. As main outcome measures we evaluated: the number and rate of patients excluded from laparoscopic approach, the rate of late complications need readmission, the rate of transfusions, the rate of conversion to laparotomy and the number of minor complications. The main concern of the study was ureteral complications. Results: Overall 174 patients underwent hysterectomy in our unit. The rate of patients submitted to laparoscopic hysterectomy was 97.5%. The number of complications needing re-admission was three (2%). The rate of conversion was 2.7%. In the study period, two (1.2%) ureteral complications were observed (late fistulae). There were four bladder lesions but the patients were released on the same day as the patients with no lesion. Conclusions: Opening the retroperitoneum allows rapid control of the main uterine vessels by coagulation, and constant checks on the ureter. Difficult benign situations can be managed. Even in a non-referral center about 94% of hysterectomies can be performed by laparoscopic surgery. This approach is helpful and may be reproducible in gynecological procedures. ß 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords: Total laparoscopic hysterectomy Retrograde hysterectomy Retroperitoneal hysterectomy

1. Introduction The exponential growth achieved in the last decade in the field of endoscopic surgery has allowed a tremendous diffusion of total laparoscopic hysterectomy (TLH). Minimally invasive approaches have been applied with success to an increasing number of gynecological procedures. While in the USA robotics has spread to many referral centers, setting the state of the art in minimally invasive gynecological procedures [1], in Europe, on the contrary, laparoscopic surgery is much more widely distributed, being actually the main alternative to abdominal hysterectomy (TAH) [2]. TLH is associated with less blood loss, shorter hospital stay and extremely low rates of infection and ileus [3]. Patients avoid a painful abdominal incision and return more quickly to their activities [3].

* Corresponding author. E-mail address: [email protected] (E. Volpi). 1 Department of Obstetrics and Gynecology, SS Antonio e Biagio e Cesare Arrigo Hospital, Via Venezia 16, 15100 Alessandria, Italy. 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved.

The most widespread technique for TLH involves intrafascial dissection of vascular pedicles and the use of a manipulator for the mobilization of the uterus and the cervix. With some minor changes from one place to another, most TLHs are nowadays performed according to the original studies reported by the French and Finnish schools [2–5]. In these laparoscopic procedures the transection of the uterine vessels is performed close to the uterus, medially to the ureter, repeating the steps of a conventional TAH. Coagulation or dissection of the ascending and descending branches may be sometimes difficult, however, due to a wide variety of anatomical conditions such as endometriosis, intraligamentary fibroids or sequelae of infections. In addition, when coagulation is extensively done, there is increased risk of ureteral lesions [6–8]. In this paper, we present a modified procedure for retroperitoneal (dissection of the uterine arteries) and retrograde (dissection of the bladder and of the vagina) TLH with the aim of providing optimal control of the ureter and against post-operative hemorrhage. With this aim, we have adopted a combination of the retroperitoneal laparoscopic approach as originally described by Kohler et al. [9] and Roman et al. [10], with that of retrograde culdotomy reported a long time ago by Delle Piane [11], Hudson


E. Volpi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 97–101

and Chir [12], and more recently by Bristow et al. [13]. We also want to analyze our experience in a community hospital and not a referral center. 2. Material and methods From January 9th 2012 to April 30th 2013, 174 patients underwent hysterectomy overall in the unit. The patients’ characteristics and indications are shown in Table 1. Their median age was 48 years (range 37–80) and mean body mass index (BMI) was 22.41 (range 18.16–39.64). Inclusion criteria were all patients needing an abdominal hysterectomy according to the policy of the unit where the vaginal approach is reserved for prolapsed uterus. Two types of indication were excluded from TLH: uterine size larger than the first supraumbilical transverse line in benign diseases and endometrial cancer in which morcellation was foreseen. Patients over the age of 45 are offered bilateral adnexectomy, but the patient’s choice to keep or remove the adnexa was respected. Prophylactic removal of the salpinges was not suggested to the patients. Informed consent was obtained for all patients about risks of anesthesia, hysterectomy, laparoscopy and risk of conversion to laparotomy. All patients underwent general anesthesia and endotracheal intubation. Urinary catheterization was performed just before the beginning of the procedure and kept in place for the first night after intervention. On the day of surgery, i.v. cefazolin 2 g was administered. Prophylactic anticoagulant therapy was given for up to 28 days. As the main outcome measures we considered: the number and rate of patients excluded from the laparoscopic approach, the rate of late complications needing readmission, the rate of transfusions, the rate of conversion to laparotomy and the number of minor complications. Minor complications were defined as complications not needing readmission nor having an impact on the clinical course and the release of the patient. The critical steps of the procedure are the following: (1) Patients are placed in the dorsal lithotomy position with legs apart and semiflexed, and the arms tucked at the sides. The monitor is placed between the patient legs or on her left foot if morcellation is foreseen, facing the two surgeons to facilitate an ergonomic working position. Simplified equipment is used including a scissors, two grasping forceps, a washing-aspiration cannula, and a 5-mm bipolar coagulation forceps. Recently, the Ligasure 5 mm–37 cm (Covidien LF1537) forceps was added to the instrumentation avoiding the use of disposable scissors. No uterine manipulator is placed in situ. No monopolar currents have ever been used in the procedures. (2) Access to the peritoneum is obtained through direct trocar insertion as reported elsewhere [14]. Only patients with previous surgery are accessed via the Palmer point and a

Fig. 1. Opening the pararectal space above the m. psoas and creating a medial leaf of peritoneum with the ureter.

Verress needle. Five-millimeter optics are used. Three 5-mm trocars are placed in the lower abdomen under direct vision, in the usual diamond-shaped positions. Variations may be due to the uterine size. (3) The first surgical step is isolation of the ureter and of the uterine artery. The second operator moves the utero-ovarian ligament medially to stretch the broad ligament. The incision is made up to where the broad ligament overlies the iliac vessels thus allowing entry into the pararectal space. The peritoneum is opened parallel to the infundibulo-pelvic ligament above the crossing with the external iliac artery at the pelvic brim, taking care to move the ureter on the medial sheet of the peritoneum (Fig. 1). The ureter is then followed to the crossing with the uterine artery. The peritoneum and all the structures are now severed by the Ligasure forceps. Previously and in the case of dissections needing sharp instruments, disposable scissors are opened and used. After dissection, the uterine artery is coagulated at its origin from the internal iliac artery (Fig. 2). Often the uterine veins are grasped and coagulated altogether. No transection of the uterine vessels is performed. Because the infundibulo-pelvic ligament is not divided, the medial leaf is entirely pulled medially thus avoiding any bowel interference during the operation. The same steps are performed on the other side.

Table 1 Patients’ characteristics of the group undergoing hysterectomy. # Total TLH TAH Age BMI Previous cesarean Main indications Fibroids/adenomyosis Metrorraghia Endometriosis Endometrial cancer/hyperplasia H-SIL

174 169 5 48 22.41 42 95 9(5.3%) 22 39 4


37–80 18.16–39.64

(56.2%) (13.0%) (23.0%) (2.3%)

Fig. 2. The left uterine artery as it appears after bipolar coagulation at its origin.

E. Volpi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 97–101


Fig. 4. Relationship between the resection line on the vagina and ureteral course in retrograde hysterectomy. Fig. 3. Blunt dissection of the paravescical space beneath the anterior leaf of the broad ligament.

(4) The round ligament may or may not be divided at this time at the crossing with the umbilical artery, generally using the Ligasure forceps. Blunt dissection of the vesico-vaginal fascia is performed from the lateral side medially (Fig. 3). The vesicouterine peritoneal fold is left aside and retrograde dissection initiated just distal to the uterine arteries. Dissection is stopped when the white vaginal fornix is reached. At the end of this step, transection of the round ligament is completed by dividing all the anterior leaf down to the vesico-uterine peritoneal fold. This is finally mobilized from connections to the lower uterine segment. The infundibulo-pelvic or the utero-ovarian ligaments are coagulated and dissected after fenestration of the broad ligament, watching the ureter. (5) The posterior aspect of the broad ligament is incised toward the posterior vaginal apex and recto-vaginal septum. The uterine artery is now coagulated and dissected, checking the ureteral course which is directly visible. The parametria and uterosacral ligaments may be severed at this time, but normally are controlled by retrograde resection. By means of a ring forceps, the anterior fornix is exposed by a third operator or by a nurse. This is incised on the bulging of the rings and opened by means of a grasping and the Ligasure forceps. Alternatively scissors can be used. A vaginal plug is then used to stop gas loss. Whilst the second operator grasps and elevates the distal margin of the vagina, the first operator moves the cervical margin of the vagina proximally and starts the retrograde incision of the vagina. This is facilitated by strongly pulling the cervix cranially. Vagina, parametrium and utero-sacral ligaments are severed, moving from the anterior aspect to the posterior and from the vagina toward the cervix, parallel to the ureteral course. Classic vaginal morcellation to extract the uterus is performed. In the case of very restricted vaginal access, the removal of the uterus is performed by abdominal morcellation (Fig. 4). (6) Finally, the vagina is closed laparoscopically by a running suture using a 2–0 tapered needle V-Lock suture (Covidien) or Caprosyn (Ethicon). 3. Results Out of 174 procedures, 5 patients were excluded from TLH, 3 for uterine size and 2 with endometrial cancer (2.8%). The mean operative time was 125  49 min, but after excluding endometrial cancer, the mean operative time dropped significantly to 66  15 min. Duration of steps 2 and 3 including identification and

Table 2 Complications of TLH. Early Conversion Lesion of the epigastric artery Bladder lesion Late Ureteral fistula Transfusion Vaginal vault dehiscence a

5a (2.9%) 1 4 (2.3%) 2 (1.2%) 1 1

Conversion may not be considered a complication.

isolation of ureter, opening the pararectal space, identification and coagulation of the uterine artery, averaged 5 min per side. The median uterine weight was 120 g (range 40–870). Five of the 169 procedures were converted to laparotomy (2.9%), three for difficulties during hysterectomy for benign condition, one for hematoma of the epigastric vessel in an endometrial cancer and one for uterine size in endometrial cancer. Thus in total 5.7% of the patients underwent laparotomy (10/174). Complications are reported in Table 2. The total complication rate was 4.7% (8/169). Three patients needed readmission, two for ureteral fistula and one because of vaginal vault dehiscence (1.7%). Only one patient needed transfusion, because of a hematoma of the abdominal wall, and was released on day 7. The mean drop in hemoglobin level was 1.5  1 g%. Median hospital stay was 2 days (range 1–7). 4. Comment We report our experience in a community hospital using a modified technique for TLH based on the combination of lateral coagulation of the uterine artery and a retrograde approach to the lower structures of the pelvis. In fact, the retrograde vesical dissection and the retrograde culdotomy have been previously described specifically only for abdominal laparotomies in surgical oncology [11–13], while the retroperitoneal approach has been emphasized mainly as a strategy during vaginally assisted laparoscopic hysterectomies [9,10,15–17]. To date, there is only one study reporting the application of a retroperitoneal approach for TLH in cases of enlarged uteri [10]. In the present series about 94% of hysterectomies could be performed laparoscopically, although a limitation in size of the uterus is admitted. We observed a low rate of complications (4.7%). The main problems were the two ureteral fistulas. The first fistula


E. Volpi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 97–101

was a complication of too wide a dissection of the ureter due to a very large (12 cm) infraligamentary fibroid, and was managed by reimplantation. In that case, the pelvic ureter was much longer than usual and so dissection resulted in excessive devascularization. The second is difficult to explain since dissection was easy and no coagulation was performed near the ureter managed by stenting. Both complications were late and appeared at 10–15 days from surgical procedure. The results of this series based on about 170 cases are comparable to those reported by most centers where laparoscopic hysterectomy is routinely performed according to a completely different principle (intrafascial dissection and constant use of uterine manipulator) [9,10,18,19]. Remarkably, the rate of urologic complications (1.2%) observed in this experience may be also justified by the absence of selection of the patients except for uterine size and is in agreement to that reported by similar studies using a retroperitoneal approach [8–10,19–23]. Four patients had bladder perforation. The lesion was sutured laparoscopically and the patients released on the 3rd day with the catheter in situ. When the patients came back for check-up as usual the catheter was removed. The study by Kohler et al. [9] has been taken into particular consideration. During laparoscopic assistance to 267 vaginal hysterectomies those authors were able to demonstrate full safety and clinical advantages of an extraperitoneal technique properly arranged for optimal isolation, coagulation and transection of uterine artery and constant control of the ureter. In their experience, the interruption of blood supply in this way resulted in particular advantage during the vaginal removal of enlarged uteri (when bleeding generally is a problem in traditional vaginal operations). Importantly, according to this article 70% of the operations were performed by residents with only limited experience in hysterectomy and the use of non-disposable instruments and no uterine manipulator allowed important financial savings. Chang et al. [16] also reported minimal blood loss (two patients had excessive hemorrhage, >500 mL) and low complication rate (two patients had bladder laceration) among 225 women with myomas or adenomyomas who underwent uterine artery ligation through retrograde tracking of the umbilical ligament in laparoscopic-assisted vaginal hysterectomy. The average time from identification of the umbilical ligament to ligation of the uterine artery was approximately 10 min and operations were performed by residents with aid of the attending physician. In this experience, the technique to dissect the uterine artery is different, but the time is similar. Laparoscopic hysterectomy of large uteri with uterine artery coagulation at its origin was later reported also by Roman et al. in more than 50 cases [10]. These authors could confirm that the retroperitoneal approach is feasible and reproducible by gynecological surgeons avoiding the use of laparotomy in enlarged uteri. According to the authors the key to a successful procedure is the performance of the uterine devascularization before initiating further uterine surgical action. In their department one surgeon began using the technique and subsequently it was acquired and easily reproduced by others. Other studies confirm this [15,16,20– 22]. The technique we describe joins for the first time different steps already reported but not unified in a single procedure. First, the uterine vessels are not dissected but simply coagulated at their origin and the pararectal space is firstly created. Second, approaching the bladder from the lateral aspect helps a safer dissection particularly when anatomical difficulties are present. Third, the ureter is thoroughly checked through the whole procedure. Fourth, a retrograde circular colpotomy is done after minimal preparation of the recto-vaginal septum with no use of manipulator and quite safely far from the ureter. This allows easy control of the final coagulation of the vaginal arteries. Lastly the

whole procedure can be performed only with reusable instruments, decreasing the costs. There may be doubts that the oncological preparation of the surgical field as done during the creation of the Latzko’s procedure (preparation of the uterine arteries at their origin) might be excessive but the post-operative course of the patients shows that it is very similar to traditional TLH. We believe, however, that this approach uses all the known advantages of laparoscopic surgery such as magnification of the anatomy and pathology, access to the uterine vessels, vagina, rectum, lymph nodes, better exposure of ureter and achievement of clot drainage and hemostasis [23,24]. Furthermore, when experience is gained in isolating the ureters, this step does not increase the time of operation. In this series, the average time to isolate the ureter, reach and coagulate the uterine artery was five minutes, but the operator was experienced in oncologic procedures and has developed skill to deal with the retroperitoneum. The median time to complete hysterectomy was 66 min, which is acceptable and comparable to other experiences. The operating time is also lessened by using the Ligasure forceps and the V-Lock suture. The main advantage of not using the manipulator is that the movements of the uterus are free at the level of the isthmus and are guided by the first assistant, so exposure of the lateral aspect of the uterus is easier. The disadvantage with a larger uterus is that all the movements are dependent on the laparoscopic instruments and it may need some skill. The lateral approach to the uterine arteries and the retrograde resection of the vagina are independent of a uterine manipulator, but it may be used in this same procedure. In our opinion, it is in fact a cultural rather than a technical question. Despite facing, at the beginning, a more challenging hysterectomy it is possible to acquire progressively the right confidence with anatomic spaces and tissues of critical importance in the case of more complex pathology (treatment of endometriosis and cancer). It is well known that the retroperitoneal approach is mandatory for pelvic lymphadenectomy and advisable for preventive occlusion of the uterine arteries in cases of symptomatic fibroids and ovarian cystectomies with severe adhesions [21,24]. For patients with a fixed uterus or endometriosis, this alternative procedure of uterine artery coagulation through downstream ureter tracking in the retroperitoneum not only reduces the risks of massive bleeding and ureteral injury, but also shortens the operative time and minimizes the conversion rate to open laparotomy [17]. In conclusion, this experience shows that about 94% of hysterectomies can be carried out by laparoscopic surgery in a community hospital. This modified technique of extraperitoneal and retrograde laparoscopic hysterectomy, although at first it can appear challenging, allows a routine approach to almost all hysterectomies and can offer a great chance for ideal education in gynecological surgery.

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Retroperitoneal and retrograde total laparoscopic hysterectomy as a standard treatment in a community hospital.

To report our experience with a modified procedure for total laparoscopic hysterectomy based on a retrograde and retroperitoneal technique. This surgi...
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