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Original Article
Reverse Hysterectomy: Another Technique for Performinga Laparoscopic Hysterectomy
Pietro Litta, MD, Carlo Saccardi, MD, PhD*, Lorena Conte, MD, and Pasquale Florio, MD, PhDFrom the Department of Women’s and Children’s Health, Obstetrics and Gynecology Clinic, University of Padova, Padova, Italy (Drs. Litta, Saccardi, and
Conte), and Department of Paediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynecology, University of Siena, Siena, Italy
(Dr. Florio).
ABSTRACT Study Objective: To show and evaluate outcomes of a modified laparoscopic hysterectomy technique (total reverse laparo-
The authors decla
Corresponding au
and Children’s H
Padova, Via Gius
E-mail: carlo.sac
Submitted Februa
Available at www
1553-4650/$ - se
http://dx.doi.org/1
scopic hysterectomy).Design: Observational study (Canadian Task Force classification II-2).Setting: Department of Women’s and Children’s Health, Obstetrics and Gynecology Clinic, University of Padova, Padova,Italy.Patients:One hundred one women underwent total reverse laparoscopic hysterectomy for benign disease. Indications for sur-gery, patient characteristics, surgical data, complications, and patient satisfaction were recorded.Interventions: Total reverse laparoscopic hysterectomy.Measurements andMain Results: Themodified procedurewas performed starting with the incision of the vesicouterine foldand the pubocervical fascia followed by the dissection of only the anterior layer of the broad ligament, thus preserving theintegrity of the posterior leaf (retrograde hysterectomy). This technique permits identification of the ureter until the crosswith the uterine artery, creating a ‘‘safe triangle’’ for closure of the uterine vessels. The remaining surgical time did not differfrom the standard technique. The average operating time was 112.1 6 35.6 minutes, and the average intraoperative meanblood loss was 79.56 138.4 mL. Ninety-one (90%) patients were very satisfied after surgery. No injuries to the ureter or blad-der occurred in any patients. No other major complications were recorded.Conclusion: Reverse hysterectomy is another technique for performing laparoscopic hysterectomy, and it has been proven tobe safe and efficient. Journal of Minimally Invasive Gynecology (2013) 20, 631–636 � 2013 AAGL. All rights reserved.
Keywords: Complications; Laparoscopic hysterectomy; Surgical technique
DISCUSS
You can discuss this article with its authors and with other AAGL members athttp://www.AAGL.org/jmig-20-6-JMIG-D-13-00064re that they have no conflict of interest.
thor: Carlo Saccardi, MD, PhD, Department of Women’s
ealth, Obstetrics and Gynecology Clinic, University of
tiniani, 3-35128 Padova, Italy.
ry 26, 2013. Accepted for publication April 9, 2013.
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Laparoscopic hysterectomy (LH) was first described byReich et al in 1989 [1], and within the last 2 decades, it hasbecome a widely performed procedure. The laparoscopicapproach to hysterectomy can be technically demanding, es-pecially in case of a large uterus, and sometimes it takesa long time to complete [2,3]. Benefits associated with the
laparoscopic technique include a short recovery time, lesspostoperative discomfort, improved patient outcomes, andincreased cost-effectiveness [4,5]. LH is a procedure thatrequires meticulous dissection, safe anatomic exposure, andeffective hemostasis to avoid peri- and postoperativecomplications. Severe hemorrhage and ureteral injuriesremain major challenges for gynecologic surgeons and arethe most serious events related to LH. As a consequence,the method used to secure the blood vessel pediclesinfluences the rate of complications [1–8]. Recently,a Cochrane review showed that LH has a greater risk ofdamaging the bladder or ureters [9], but the most recentworks have shown that the risk of complications for the lap-aroscopic approach could be significantly reduced by using
632 Journal of Minimally Invasive Gynecology, Vol 20, No 5, September/October 2013
specific techniques [10,11]. Education and training of thesurgeons, knowledge of electrosurgical principles, correctexecution technique, and proper selection of patients areimportant factors in safely performing hysterectomy.Alternative approaches have been proposed, such assupracervical hysterectomy [9], as well as the use of newdevices [12–14] or the validation of a standard technique[15–17] to ensure protection of the ureteres (fenestration ofthe right and left broad ligaments) and to control occlusionof the uterine pedicles (through ligatures or clipapplication). It is commonly accepted that to avoidcomplications, it is important to consider a series of basicprecautions, including isolation of the uterine artery beforecoagulation, development of the paravesical space, use ofa uterine manipulator to stretch the uterine pedicle, andespecially restoration of the normal anatomy in case ofdeeply infiltrating endometriosis and/or in the presence ofsevere adhesions [18–20]. A safe and effective surgicaltechnique is crucial, particularly for technically demandingsituations in which the risk of complications could lead thegynecologist to choose laparotomy rather than laparoscopy.In the present study, we report on the technique and clinicaloutcomes associated with LH performed using a modifiedlaparoscopic approach.
Fig. 1
The first cervical landmark: the vesicouterine folder and pubocervical
fascia are resected transversely for approximately 2 cm.
Materials and Methods
Onehundred onewomenunderwent total reverseLH in theDepartment of Women’s and Children’s Health, Obstetricsand Gynecology Clinic, University of Padova, Padova, Italy.The preoperativeworkup consisted of pelvic gynecologic ex-amination; transvaginal ultrasound; Papanicolaou smear; out-patient diagnostic hysteroscopywith endometrial biopsy; andurinary and blood analysis including hemochrome, prothom-bin time, partial thromboplastin time, and electrocardiogra-phy. Prior informed consent was obtained from all patients.
The main indications for hysterectomy were abnormaluterine bleeding caused by uterine fibromatosis, chronic pel-vic pain, nonatypical endometrial hyperplasia, or benignadnexal masses in postmenopausal women. The exclusioncriteria were the following: preneoplastic or neoplasticgenital disease, anesthetic contraindications to laparoscopy,and prior pelvic or abdominal radiation therapy. All theprocedures were performed by the same 2 surgeons (P.L.and C.S), who are both skilled and experienced in the LHprocedure.
Surgical Procedures
The surgery was performed under general anesthesia withnasogastric tube insertion and a bladder catheter placed im-mediately before the operation. All patients underwent anti-biotic prophylaxis with 2 g cefazolin (Cefamezin; PfizerItalia Srl, Rome, Italy) 30 minutes before surgery. Hysterec-tomies were performed with a 10-mm telescope (Karl Storz,Tuttlingen, Germany) through 1 optic trocar located in the
umbilicus and lateral trocars placed fairly high (at 2 fingersabove the anterosuperior iliac spines and lateral to the rectusabdominal muscles). The trocar position varied according tothe uterine size. In all cases, the left trocar was 10 to 12 mmin size to allow the insertion of the morcellator to partiallyreduce the uterus, which was then removed through thevagina. The central and right lateral trocars were 5 mm insize. A Breisky-like vaginal valve was used in place of theuterine manipulator, pointing out of the anterior vaginalfornix.
All surgical times were performed with a Harmonic scal-pel (Ultracision, Ethicon Endo-Surgery, Rome, Italy), butthe same technique can be performed either with mono- orbipolar energies or by securing the uterine artery with a su-ture. Coagulation of the vessels was performed using level 2of the microprocessor of the Ultracision, whereas dissectionwas performed using the 5 microprocessor variation.
After exploration of the peritoneal cavity, the procedurewas performed as follows:
1. The anterior vaginal fornix was visualized and stretchedusing the Breisky valve, which was gently pushedthrough the vagina with its convex side upward. Wethen proceeded to the incision of the vesicouterine foldand the subsequent 2-cm transverse incision of the pubo-cervical fascia (Ultracision power level 5) beginning inthe middle. This incision represents the first cervicallandmark to perform the ‘‘reverse’’ laparoscopic hyster-ectomy (Fig. 1).
2. Coagulation and incision of the round ligament was per-formed followed by the dissection of only the anteriorlayer of the broad ligament (Ultracision power level 5).This procedure allows for easy and quick detection ofthe ureter, which is adherent to the posterior leaf of thebroad ligament that is preserved, and enables the surgeonto follow the ureter until it crosses the uterine artery. The
Fig. 3
The ‘‘safe triangle’’: the apex of the cross between the urethra and the
uterine artery; the lateral side is represented by the ureter, and themedial
side is represented by the ascending branch of the uterine vessels.
Litta et al. Reverse Hysterectomy 633
opening of the anterior leaf of the broad ligament repre-sents the second landmark (Fig. 2). The maintenance ofthe posterior leaf of the broad ligament allows the expo-sure of a triangular area whose sides are represented me-dially by the uterine vessels (ascending branch) andlaterally by the ureter. The apex points downward andcorresponds to the crossing of the ureter and the uterineartery (Litta’s triangle) (Fig. 3). The advantage of expos-ing this triangle is to reduce the risk of damaging the ure-ter as well as to better and safely control possiblebleeding from the uterine vessels.
3. The skeletonization of the uterine vessels on the posteriorleaf of the broad ligament allows the exposure and visu-alization of the uterine pedicle (Ultracision power level 5)up to the cervical landmark. This step is relevant becauseit provides complete isolation and coagulation of the uter-ine vessels and, at the same time, allows a constant checkfor bleeding, thus reducing the risk of damage to localstructures (ureter and bladder).
4. The coagulation of the uterine vessels (Ultracision powerlevel 2) was performed at least 1 cm above the incision ofthe pubocervical fascia, pushing the uterus cranially(Fig. 4).
5. In cases of preservation of the adnexa, dissection of thefallopian tubes, and utero-ovarian ligaments, mesosal-pinx was performed, and, if necessary, removal of the ad-nexa was performed by coagulation and dissection of theinfundibulopelvic ligament (Ultracision power level 2).
6. Steps 1 to 5 were performed contralaterally.7. Circular colpotomy after exposure of the anterior vaginal
fornix (Ultracision level 3) was performed.
Depending on its volume, the uterus was removed byuterine morcellation (12–15 mmMorcellator Steinert Multi-drive; Karl-Storz Endoscope, Tuttlingen, Germany) and
Fig. 2
Second landmark: the only anterior layer of the broad ligament is dis-
sected starting from the round ligament. The posterior leaf of the broad
ligament, in which the ureter rests, is preserved.
extraction through the lateral port or through the vagina.Vaginal vault suture was performed in all cases with 2-0 pol-ydioxanone (PDS; Ethycon SpA, Pomezia, Italy) interruptedsutures and intracorporeal knots, and the vaginal vault wassuspended to the pubocervical fascia and the residual utero-sacral ligaments.
Main Outcome Measures
Demographic characteristics, surgical history, and intra-and postoperative findings were recorded for all patients.Details related to the operative time (from the insertion oftrocars to closure), uterine weight (measured by the pathol-ogist after dehydration in formaldehyde), estimated bloodloss (performed at the conclusion of the surgical procedure),length of the hospital stay, and the time needed to return tonormal activity and to work were recorded. Patients’ satis-faction with surgery was evaluated subjectively 1 month af-ter discharge with the use of a visual analog scale (VAS),which varied linearly from 1 (low satisfaction) to 10 (highsatisfaction). Early and late complications were recordedby a clinical evaluation of the patients between 7 and 30days after surgery.
Results
Total reverse laparoscopic hysterectomy was performedbecause of abnormal uterine bleeding caused by uterine fi-bromatosis in 78 (77.2%) women, for chronic pelvic painin 9 (8.9%) women, and for complex endometrial hyperpla-sia in 14 (13.9%) women. In 34 (33.7%) women, benign ad-nexal cysts were also cured. The mean age of the patients atsurgery was 52.86 8 years. Twelve of the 101 (11.9%) werenulliparous, and 40 (39.6%) women were postmenopausal(Table 1).
Fig. 4
Skeletonization and coagulation of uterine vessels: (A) the left side with bipolar energy and (B) the right side with Harmonic scalpel.
Table 2
Surgical outcomes of patients who underwent total laparoscopic
reverse hysterectomy
634 Journal of Minimally Invasive Gynecology, Vol 20, No 5, September/October 2013
Surgical Outcomes
The mean duration of surgery was 112.16 35.6 minutes,and the mean uterine weight was 266.96 199.7 g. Forty-onepatients (40.6%) underwent bilateral adnexectomy, and 12(11.8%) had significant adhesiolysis. Intraoperative meanblood loss was 79.5 6 138.4 mL.
Surgical data and complications are presented in Table 2.In our sample, 36 (35.6%) patients had a large uterus (uterineweight R300 g), and 47 (46.5%) patients had undergonea previous abdominal surgery, of which 24 (51%) were uter-ine surgery (Table 1). The mean recovery time was 2.17 61.8 days. Within 2 days of surgery, 5 (4.9%) patients experi-enced fever (temperature over 38�C on 2 occasions at least4 hours apart), which was successfully treated with antibi-otics. At 7 days after surgery, no major complications wererecorded. In 5 women (4.9%), a slight subfascial hematomawas present at the ancillary level, mainly (n 5 4) on the leftaccess, and 3 patients (2.9%) experienced cystitis. Patientsreturned to normal activities 6.18 6 2.89 days after surgeryand to work 12.57 6 4.08 days after hysterectomy. With re-gard to patient satisfaction, the mean VAS was 8.476 1.48;91 (90%) patients were very satisfied after surgery (VASranging from to 10 to 7), 9 (9%) indicated a VAS rangingfrom to 6 to 4, and 1 (1%) was not satisfied with the proce-dure (VAS of 3).
Table 1
Anthropometric characteristics and surgical history of 101 patients
Patients’ characteristics Values
Age (yr) 52.8 6 8.0
Parity 1.1 6 0.7
BMI (kg/m2) 26.2 6 2.4
Menopause (n, %) 40 (39.6)
Previous pelvic surgery (n, %) 47 (46.5)
Previous uterine gynecologic surgery (n, %) 13 (12.8)
Previous cesarean section (n, %) 11 (10.8)
BMI 5 body mass index.
Discussion
It is well known that laparoscopy compared with open sur-gery offers advantages to both the patient and the surgeon.Laparoscopy provides a magnification of the operative field,facilitates accurate dissection, reduces blood loss and postop-erative pain, and permits faster recovery, but compared withabdominal or vaginal hysterectomy, it is still associated witha higher incidence of major intra- and postoperative compli-cations [4,6,7,9]. According to the literature, the incidence ofureteral injuries in total abdominal hysterectomy ranges from0.04% to 0.4% [21], whereas in LH it ranges from 0.65% to1.39% [4]. Indeed, the true rate of urinary tract injuries is noteasy to quantify because there are many different factors thatcan interferewith the surgical steps. In a study byRibeiro et al[22], with the help of cystoscopy examination performed atthe time of the procedure, overall ureteral injuries were re-ported in 3.4% of patients. However, this high percentageof ureteral damage was supposed by others authors to be
Operative data Values
Uterine weight (g) 266.9 6 199.7
Large uterus (weight R300 g) (%) 36 (35.6)
Duration of surgery (min) 112.1 6 35.6
Intraoperative blood loss (mL) 79 6 138.4
Recovery time (d) 2.17 6 1.8
Major complication
Bladder injury 0
Urethral injury 0
Bowel injury 0
Hemorrhage (needing transfusion) 0
Minor complication (%)
Fever (needing antibiotic therapy) 5 (4.9)
Subfascial hematoma 5 (4.9)
Urinary tract infection 3 (2.9)
Litta et al. Reverse Hysterectomy 635
correlated to patient selection (many patients with endometri-osis and with a large uterus) and to the technique of uterineartery closure (suture rather than bipolar electrocoagulation)[23]. The incidence of bladder injury ranges from 0.2% to1.8%, and according to recent studies, it reached rates similarto those of patients undergoing abdominal hysterectomy [24].Bladder injury appears to be significantly associatedwith pre-vious laparotomy; adhesiolysis; and, in particular, previouscesarean section [24]. Ureteral injury is strongly associatedwith thermal spread from coagulation devices or with sutureligation during uterine artery occlusion and vaginal cuff clo-sure [25]. Although bladder damage is easier to recognize andrepair, ureteral injury is more insidious, and many effortshave been made to reduce this complication. Some authorssuggest that dissection and isolation of the ureter during sur-gery is necessary to prevent ureteral injury, but this techniqueextends operative time, increases the risk of bleeding, and re-quires a long learning curve [18,26]. Koh et al [26], in a seriesof laparoscopic-assisted vaginal hysterectomies, proposed tocreate windows over both sides of the broad ligament and topush away inferolaterally the posterior broad ligament inwhich the ureter and uterine vessels are embedded. To reducecomplications, favorable opinions were expressed with re-gard to opening the anterior page of the broad ligament infront of the round ligament to safely coagulate the uterine ar-tery [27] and with regard to performing hemostatic suture atthe level of the uterine artery as a referential lateral point, be-yond which thermal devices should not be used [10]. Somesurgeons suggest that laparoscopic subtotal hysterectomy orlaparoscopic-assisted vaginal hysterectomy should be per-formed whenever possible, but in a recent study the rate ofmajor complications, including bladder, ureteral, and bowelinjury, was not statistically significantly different amongthe 3 laparoscopic techniques [28]. The complications afterlaparoscopic hysterectomy are influenced by the surgeon’sexperience. Tan et al [29] showed that after a decade of sur-gical experience, the overall complication rate during totalLH was significantly reduced from 4.5% (LH between1994 and 2001) to 1.5% (LH between 2001 and 2007) [29].It appears that at least 30 procedures are necessary to achievea significant decrease in bladder and ureter injury [30].
In the present preliminary observational study, we refer tothe surgical technique and outcomes related to a modifiedapproach for LH that we called ‘‘total reverse laparoscopichysterectomy.’’ The name was derived from the steps, thefirst of which is the dissection of the vesicouterine foldand pubocervical fascia followed by the coagulation and in-cision of the round ligament. The second step is the openingof the anterior fold of the broad ligament between the lateral(round ligament incision) and central (pubocervical fasciaincision) landmarks. This way better visualization of theuterine vascular pedicle is obtained, and a real plane, repre-sented by the posterior layer of the broad ligament, is createdthat permits the identification of the ureter until it crosses theuterine artery, thus creating a ‘‘safe triangle.’’ The consecu-tive coagulation and dissection of uterine vessels, at least
1 cm above the anterior incision of the pubocervical fascia(first landmark), is of relevance for the management of po-tential bleeding. In other words, the uterine pedicle is re-sected, leaving a sufficient caudal part that can be easilyseen and quickly identified, and in the case of bleeding or re-traction after the dissection, this area can be immediatelyand safely sealed without injuring the ureter. Coagulatingthe uterine vessels 1 cm above the pubocervical fascia is al-ready well away from the ureter. However, in the classictechnique, the broad ligament is entirely dissected or fenes-trated. Thus, in case of bleeding while dissecting the uterinevessels, the course of the ureter must be detected to safelyexecute the hemostasis, and this can be accomplished bypulling the posterior dissected broad ligament. The time re-quired could result in a delay of hemostasis and thus increasethe risk of direct (thermal or mechanic by suture) and/or in-direct (thermal spread) ureteral injuries.
Data obtained from 101 patients who underwent ‘‘total re-verse laparoscopic hysterectomy’’ show that this technique isassociated with low blood loss and similar operative times tothose reported in the literature for the standard technique[9,24,30], even among patients with a large uterus (R300 g)or previous uterine surgery. In our study, the 36 patientswith a large uterus and the 24 patients with previous uterinesurgery (gynecologic and obstetric) presented similaroperative times and surgical outcomes to the overall sample.No cases of bladder or ureter injuries were reported. It is notalways necessary to identify or isolate the ureter duringa simple hysterectomy. We believe that this alternativeapproach to LH could be proposed, especially in cases ofabnormal pelvic anatomy, such as large uteri, severeendometriosis, and previous gynecologic or pelvic surgery.
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