Chapter 31: Laparoscopic Hysterectomy

RATIONALE FOR APPROACH

The first laparoscopic hysterectomy was performed by Dr Harry Reich in 1988.¹ Since then, 12% to 14% of hysterectomies for benign disease in the United States are now performed through a laparoscopic approach.^2,3 Professional societies encourage the use of minimally invasive techniques for hysterectomy when appropriate due to decreased morbidity compared with an abdominal approach.^4,5 The American Congress of Obstetricians and Gynecologists state that “vaginal hysterectomy is the approach of choice whenever feasible,” and “laparoscopic hysterectomy is an alternative to abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible.”⁵

The advantages of laparoscopic surgery over an abdominal approach include improved visualization of anatomy, shorter hospital stays, decreased postoperative pain, faster recovery times, and better cosmetic appearance of smaller incisions. Disadvantages include a steep learning curve in acquiring laparoscopic suturing skills and mastery of the techniques of retroperitoneal dissection, as well as the cost associated with disposable surgical instruments. There are few contraindications to performing a laparoscopic hysterectomy. These absolute contraindications include medical comorbidities precluding the use of appropriate anesthesia or positioning of the patient and a known or likely uterine malignancy where morcellation would be required. A relative contraindication would be insufficient training and experience in laparoscopy.

The decision to perform a laparoscopic hysterectomy may be influenced by the need for adhesiolysis, evaluation of chronic pelvic pain with treatment of endometriosis, management of large uteri, adnexal surgery, and possible lymphadenectomy for a suspected malignancy. For pelvic organ prolapse, most surgeons perform a laparoscopic total or supracervical hysterectomy with a concomitant sacrocolpopexy, as the distal uterosacral ligaments may not confer adequate apical support postoperatively. A laparoscopic hysterectomy may occur through any of the following approaches: laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic supracervical hysterectomy (LSH), or total laparoscopic hysterectomy (TLH). Any of these approaches can be performed via traditional laparoscopy, single-port laparoscopy, or with the assistance of a robot.

PREOPERATIVE CONSIDERATIONS

A thorough history and physical should be documented preoperatively, specifically any medical condition that would preclude the use of laparoscopy, such as a ventriculoperitoneal shunt. The patient must be counseled about the anticipated benefits and potential risks of the surgery, including the possibility of conversion to a laparotomy and the possibility of a salpingo-oophorectomy if adhesions or adnexal pathology is suspected. There should be a discussion about the potential need for blood products. A preoperative consultation with an internist and/or anesthesiologist may be deemed appropriate, as well as the ordering of laboratory or imaging studies.

Patients should be provided with a clear explanation of what to expect during their hospitalization, recovery, and return to normal activities. A bowel preparation prior to hysterectomy in case of an unintentional bowel injury is an accepted practice in gynecologic surgery. A sodium phosphate enema is as effective and is associated with fewer adverse effects ...