FF

OBSTETRICS AND GYNECOLOGY ADVANCES
HYSTERECTOMY:
PROCEDURES, COMPLICATIONS
AND ALTERNATIVES
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SURGERY - PROCEDURES, COMPLICATIONS

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HYSTERECTOMY:
PROCEDURES, COMPLICATIONS
AND ALTERNATIVES
DEBORAH J. SHIMIZU
EDITOR
Nova Science Publishers, Inc.

New York
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Library of Congress Cataloging-in-Publication Data
Hysterectomy : procedures, complications, and alternatives / editor, Deborah

J. Shimizu.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61122-257-9 (eBook)
1. Hysterectomy. 2. Uterus--Surgery. I. Shimizu, Deborah J.
[DNLM: 1. Hysterectomy. 2. Uterus--surgery. WP 468]
RG391.H9827 2011
618.1'453--dc22
2010041299
Published by Nova Science Publishers, Inc. † New York

Contents
Preface vii
Chapter 1 Laparoscopic Hysterectomy: Its Appeal, Its Safety Profile
and Barriers to Widespread Use 1
Hassan Morsi
Chapter 2 Hysterectomy: Procedures, Complications and Alternatives 23
M. Gurrea, S. Domingo and A. Pellicer
Chapter 3 The Complications of Laparoscopic Hysterectomy, Compared
with Vaginal and Abdominal Total Hysterectomy 47
Kok-Min Seow, Yu-Hung Lin and Jiann-Loong Hwang
Chapter 4 Beliefs, Attitudes and Psychological Reactions to Hysterectomy 67
Ma. Luisa Marván and Rosa Lilia Castillo-López
Chapter 5 Hysterectomy‘s Effects on Quality of Life and Sexual Function:
What Does Say Evidences? 81
Güliz Onat Bayram
Chapter 6 Hysterectomy 95
Eddie Fernando Candido Murta, Gisele Agreli de Melo,
Patrícia Dias Neto Guimarães and Rosekeila Simões Nomelini
Chapter 7 Surgical Complications in Laparoscopic Histerectomy 109
Angel Martin
Chapter 8 The Use of Tumor Excision (Myomectomy) in Place
of Hysterectomy in the Management of the Majority of Benign
Uterine Tumors 123
Kuo-Chang Wen, Pi-Lin Sung, Wen-Ling Lee
and Peng-Hui Wang
Chapter 9 Surgical Management of Congenital Uterine Abnormalities:
Indications, Techniques and Outcome 135
Ignacio Zapardiel
vi Contents
Chapter 10 Total Laparoscopic Hysterectomy for Large Uterus 145

Rakesh Sinha and Meenakshi Sundaram
Chapter 11 Cost-Effectiveness Issues with Total Laparoscopic Hysterectomy 155
M. Sami Walid and Richard L. Heaton
Chapter 12 The Hysterectomy Crossroads 161
Chapter 13 Interrupted Muney Stitch versus Continuous Baseball-Like Suture
for Abdominal Myomectomy 167
Ozgul Muneyyirci-Delale (Muney), Ibrahim Joulak
and Hans von Gizycki
Chapter 14 Interrupted and Continuous Muney Stitch for Abdominal
Myomectomy and Classical Cesarean Section 173
Ozgul Muneyyirci-Delale (Muney) and Amy Sauma,
Chapter 15 Minilaparotomy for Repair of Bowel Injury at Initial
Trocar Placement 179
Index 183
Preface
Hysterectomy is one of the most prevalent surgeries worldwide in the female population.
Nine out of every ten hysterectomies are performed for non-malignant conditions that are not
life-threatening, but have a negative impact on quality of life. Indication policy must be
revised as new treatments become available. Menorrhagia is the primary indication and it is
not always a response to an anatomical disease; other common indications are genital
prolapse and malignancy. New and improved alternatives are increasingly employed for this
indication and are responsible for the fall in the rate of hysterectomies performed in the last
decade. This book presents current research in the study of hysterectomies, including
laparoscopic hysterectomy; beliefs, attitudes and psychological reactions to hysterectomy;
myomectomy in place of hysterectomy; surgical management of congenital uterine
abnormalities; and the hysterectomy crossroads.
Chapter 1 - Laparoscopic Hysterectomy (LH) is being increasingly adopted worldwide.
Ever since its inception by Harry Reich in 1989, it has been gradually introduced into many
gynaecologists‘ practices. Despite advances in ablative technologies, hysterectomy in general
will always remain an attractive option to many women. The benefits of laparoscopic
hysterectomy are well known and they mainly reflect smaller abdominal incisions with
consequent reduced pain relief requirements and quicker recovery time. It is well known that
LH is not meant to replace vaginal hysterectomy but numerous studies have shown that it is a
safe and viable alternative to abdominal hysterectomy. This makes LH more appealing to
those willing to uptake this procedure. In the 21st century, all health care systems are facing
mounting financial pressures. The focus therefore increases on procedures that will allow
shorter hospital admission times and quicker recovery rates without compromising safety.
The literature is full of publications, on safety of LH, originating from centres of excellence
in laparoscopic surgery as well as from other less well established centres. This inevitably
impacts on the wide variance seen in complication rates seen at those different centres. This
article will attempt to address LH‘s safety profile and the disparity between the reported
complication rates of established centres and other centres. Pioneers of laparoscopic surgery
argue that complication rates should be lower than in abdominal hysterectomy. Indeed, this
statement would make sense, as laparoscopy offers the benefit of magnification of tissues and
better exposure at the expense of loss of depth perception and tactile stimulation. There is
undoubtedly a learning curve, which is probably the biggest barrier to widespread use of LH.
The number of hysterectomies performed for benign disease is declining because of the
success of medical treatments, hormonal intrauterine systems and endometrial ablative
viii Deborah J. Shimizu
techniques. Trainees are receiving less surgical training because of their reduced hours of
work thereby creating a short-fall in training. Unless trainees take extra time to have
dedicated training, there will be very few gynaecological surgeons in the next generation with
advanced laparoscopic skills. In this article, the author will attempt to address those and other
barriers and how to overcome them as witnessed from a personal perspective.
Chapter 2 - Hysterectomy is, after cesarean delivery, one of the most common surgery
performed in women, and together with cholecystectomy and appendicectomy, is the most
frequent intra-abdominal surgery. Many gynaecologic surgeons continue to perform
hysterectomies by means of a laparotomy, while cholecystectomy is almost always performed
through laparoscopic surgery [1]. Many women‘s health institutions [2] recommend avoiding
laparotomy, and advise abdominal hysterectomy (AH) only when the vaginal or laparoscopic
route is ruled out. We may ask ourselves why practice sometimes tends to go against this
consensus. Vaginal surgery offers great potential in terms of access to the uterus, and fulfils
all the criteria for minimal invasive surgery, as it employs a natural orifice, thereby avoiding
an abdominal scar. The vagina becomes a new trocar port-site, permitting uterine
manipulation, pelvis dissection and easy removal of the specimen. Vaginal hysterectomy
(VH) is the safest route and has the best cost-effective ratio, making it the first choice option
in clinical practice. When any contraindications is presented or any difficulties are expected,
vaginal surgery should be performed with the aid of laparoscopy when necessary or using it
throughout the entire intervention, according to the professional opinion of the surgeon.
Though AH is not currently contraindicated, there are now sufficient surgical resources for it
to be relegated to the end of the list of options. Scientific evidence favours VH and
laparoscopic hysterectomy (LH), which have lower complication rates, produce less post-
operative pain and shorter hospital stays and allow a more rapid return to normal activity,
thereby resulting in a better quality of life (QoL) [3,4, 5]. Laparotomy continues to be the
preferred method for hysterectomy in approximately 60-70% of benign uterine processes [1].
The hysterectomy rate is showing a slight change in favour of HV rather than LH, though it
comes no way near the estimated 80-90 % of hysterectomies that could potentially be
managed with a minimal invasive approach. Unfortunately, the decision to adopt the surgical
route evidently depends more on the skill of the surgeon than the advantages this technique
may have for the patient. In this chapter the authors intend to assess the options available
when considering a hysterectomy and to establish the most appropriate indications for its
recommendation, to consider the alternatives to hysterectomy and to analyze the different
surgical techniques and their routes and their complications.
Chapter 3 - Hysterectomy is one of the most common major operations performed in the
world. Since the first introduction of laparoscopic hysterectomy by Reich et al. in 1989,
laparoscopic hysterectomy has become a well-known and common procedure worldwide. The
incidence of hysterectomy for benign lesions with laparoscopy has been progressively
increased in the recent years, and more than 45% of the procedures were performed via a
laparoscopic route in several countries. There are major subdivisions of total hysterectomies
that are performed by laparoscopy: laparoscopically assisted vaginal hysterectomy (LAVH),
vaginally assisted laparoscopic hysterectomy (VALH) and total laparoscopic hysterectomy
(TLH). Patients undergoing laparoscopic hysterectomy (LH) experienced faster bowel
recovery, less postoperative pain and shorter hospitalization compared with patients
undergoing abdominal hysterectomy. Nevertheless, LH still has associated morbidities.
Complications from hysterectomy can be diagnosed intraoperatively or postoperatively. The
Preface ix
rate of major complications has been reported to range from 0.5% to 1.7%. The most common
intraoperative complications that occur at laparoscopic hysterectomy are injuries to the
bladder, ureter, bowel and blood vessels. Postoperative complications such as urinary tract
infection, colpotomy wound bleeding, pelvic cellulitis or pelvic abscess, and fever of
unknown reason are common. Other factors associated with an increased risk of
complications related to LH are increasing age, medical illness, obesity and malignancy.
Appropriate training and experience is necessary for a physician to minimize intraoperative
complications and safely perform a new surgical technique such as LH. Proper patient
selection, knowledge of the pelvic anatomy and good surgical judgment are other keys to
minimizing complications.
Chapter 4 - For many women, the uterus is a very valuable and important organ since it
has been associated with femininity and sexuality in addition to its reproductive function. The
authors studied the beliefs and attitudes toward hysterectomy in 94 Mexican women who had
undergone hysterectomy for benign reasons, considering some psychosocial and
physiological variables. Psychological reactions to their hysterectomies were also explored.
Data were collected using two surveys: The Beliefs and Attitudes Toward Hysterectomy
(BATH) questionnaire and open questions to explore women‘s reactions to hysterectomy.
Women who showed more negative attitudes toward hysterectomy included: women who
were premenopausal prior to undergoing hysterectomy; women who had undergone bilateral
salpingo-oophorectomy as well as hysterectomy; women who were severely affected because
they could no longer have children; and women with a limited educational background. When
participants were asked if their life had changed as a consequence of the hysterectomy, 53%
of women said their life had not changed, 33% claimed their life had changed negatively, and
14% acknowledged their life had changed positively.
The major changes these participants reported were that their relationship with their
partner had deteriorated, that their sexual life had deteriorated, but also that their health had
improved. These findings could be helpful in designing support programs for women facing
hysterectomy. Efforts must be directed toward providing accurate and current information
that should include both physical and psychosocial aspects of hysterectomy in order to dispel
myths, eliminate misunderstandings and prevent women from delaying the surgery because of
unrealistic fears.
Chapter 5 - Hysterectomy increasingly has been recognized as a procedure that can affect
many aspects of a woman‘s health. Psychological and biophysical health problems may
develop after hysterectomy. It is reported that, after hysterectomy a great majority of women
may suffer psychological symptoms such as depression, fatigue, anxiety, as well as new
symptoms, including urinary inconsistence, constipation, premature ovarian failure and sexual
dysfunction. Although there are reasons to believe that removal of the uterus can have
adverse effects on female sexual functioning by disrupting the anatomical relations in the
pelvis, no consensus exists on whether hysterectomy causes sexual dysfunction.
Hysterectomy is an important operation which affects women‘s quality of life and
psychosexual states. Prehysterectomy sexual functioning and psychosocial state are
significant predictors for posthysterectomy sexual dysfunction and depression. Recent
randomized trials and prospective cohort studies have provided new information on the health
outcomes of hysterectomy for non-malignant conditions. These studies consistently have
demonstrated a marked improvement in symptoms and quality of life during the early years
after surgery especially by using laparoscopic techniques. Hysterectomy does not cause long-
x Deborah J. Shimizu
term psychiatric morbidity, and psychological status generally improves. Studies of sexual
function have shown varying results, with most suggesting improvement or no change in
sexual function for the majority of women. The evidence appears to be clearer with regard to
other prognostic factors that had an effect on postoperative sexual function: preoperative
satisfaction with sexual life, good relationship with partner, chronic disease and hormone
replacement therapy.
Most of the controversy arises from the assertion that the most of the hysterectomies are
being performed unnecessarily, although it has minor positive effects, the problems
encountered after the hysterectomy negatively affect the quality of life in women. Health care
providers should consider women‘s age, hormonal states, the type and indications of the
hysterectomy, the meaning ascribed by her to uterus and her culture, general health condition
of her partner, when determining psychosexual adaptation requirements of women who had
undergone hysterectomies. These information needs to be communicated to women requiring
hysterectomy for a benign condition and this is not often routine. Women can be informed
about hysterectomy‘s adversely effects.
The aim of this chapter is to discuss to the impacts of hysterectomy on women‘s quality
of life and psychosexual adaptation after hysterectomy under the light of evidence based
findings.
Chapter 6 - Hysterectomy is the second most frequently performed surgery after cesarean
section among women of reproductive age. The most common indication for hysterectomy
was leiomyoma uteri and this was followed by uterine prolapse, endometriosis, cancer,
hyperplasia and others (abnormal vaginal bleeding, menstruation irregularity, parametrial and
peritoneal infections, disease of cervix, ovary, tube and postpartum incidents, and other
neoplasias). Women aged 30 to 54 is the group hysterectomies are most frequently performed
on. For benign indications, many countries have favored either the abdominal or the vaginal
approach. These traditions have prevailed unaltered for decades.
However, since the late 1980s, the new option of laparoscopic hysterectomy has raised
questions about the most suitable type of approach. The overall rate of complications was
17.2% for abdominal, 23.3% for vaginal and 19% for the laparoscopic approach, with
infection the most common problem. Haemorrhage occurred in 2.1, 3.1 and 2.7% of
abdominal, vaginal and laparoscopic hysterectomies respectively. The significant difference
between the different routes was that ureteric injury was seven times more common during
operations performed by the vaginal than the abdominal route. There are alternative
procedures such as endometrial ablation (dysfunctional uterine bleeding) and uterine artery
embolization (fibroids). Seventy-five percent of women may avoid hysterectomy by the use
of these techniques. The uterine artery embolization is a promising new approach for the
treatment of uterine fibroids. However, information is lacking as to the effectiveness in
women who wish to maintain fertility. In the treatment of menorrhagia, both hysterectomy
and levonorgestrel-releasing intrauterine system (LNG-IUS) decrease lower abdominal pain.
LNG-IUS use, but not hysterectomy, has beneficial effects on back pain. Hysterectomy is
associated with high levels of satisfaction. Hysterectomy has been compared with endometrial
ablation in the treatment of menstrual problems in several studies, which have suggested that
95% of women will be satisfied. Long-term satisfaction is high even in those experiencing
pre-operative or early post-operative complications. This means that an alternative treatment
has to be extremely good in order to have a higher satisfaction rate than hysterectomy itself.
Preface xi
For women who do not wish to retain their uterus, there are gynaecologists who would
suggest that there is no necessity to seek an alternative.
Chapter 7 - Laparoscopy is now widely recognised as an indispensable tool in
gynaecologic surgery, and the rate of hysterectomies performed by laparoscopy is increasing
regularly these last years. The first hysterectomy performed by laparoscopy was described by
Reich et al. The impetus to apply laparoscopy to this procedure was to provide a lower-
morbidity alternative to abdominal hysterectomy[1, 2]. In fact, complications of gynecologic
laparoscopy are uncommon, occurring in 3 to 6 per 1000 cases. Mortality rates are low at 3.3
per 100,000.
Since the early 1990s, the number of laparoscopic procedures has continued to grow.
Both minor complications (fever >38.5 ºC after 2 days, bladder incision of <2 cm and
iatrogenic adenomyosis) and major complications (haemorrhage, vesicoperitoneal fistula,
ureteral injury, rectal perforation or fistula) have been observed during the surgical procedure
itself and postoperatively. As expected, major complications and the rate of complications
increase directly with complexity of the procedures[3]. Three possible complications and
other minor complications will be exposed: urinary tract injury, bowel injury and vascular
injury.
Uterine leiomyomas (also called myomas or fibroids, and found in 20 to 40% of women)
and adenomyosis (endometrial gland tissue within the myometrium) are the two most
common disorders among women at a reproductive age [1,2]. They are often detected
incidentally in pelvic and/or ultrasound examinations, because more than 50% of afflicted
women are asymptomatic, especially those with uterine leiomyomas [1]. However,
leiomyomas might result in significant symptoms, and subsequently affect life quality. The
various symptoms, ranging from trivial to catastrophic, include menstrual disturbance, such as
menorrhagia, dysmenorrhea, and inter-menstrual bleeding, pressure symptoms, a bloated
sensation, increased urinary frequency, bowel disturbance, and pelvic pain. Besides, some of
the leiomyomas may compromise reproductive function and induce subfertility, or contribute
to pregnancy-related complications, such as an early pregnancy loss, degeneration pain,
preterm labor, and fetal malpresentation.
Basically, the choice of treatment for benign uterine tumor depends on the patient‘s age
and preference, reasons for treatment, and the issue of fertility preservation. Hysterectomy is
the most frequently chosen option for women who have completed their child-birth. However,
more and more patients and physicians have asked for alternative treatments during the last
decade [3-4]. Of the surgical interventions to treat benign uterine tumors, tumor excision
(myomectomy and adenomyomectomy) is one of the most popular for the woman who would
like to preserve her future fertility, because the majority of symptoms can be relieved
successfully. The focus of this chapter is limited to discussing the use of tumor excision in the
management of these symptomatic benign uterine tumors. Detailed information on the
different approaches to myomectomy and adenomyomectomy is included below.
Chapter 8 - Uterine leiomyomas (also called myomas or fibroids, and found in 20 to 40%
of women) and adenomyosis (endometrial gland tissue within the myometrium) are the two
most common disorders among women at a reproductive age [1,2]. They are often detected
xii Deborah J. Shimizu

Chapter 9 - Congenital uterine abnormalities result from the abnormal maturation of
Müllerian ducts during embryogenesis being uterine abnormalities the most common.
A search in Medline was performed concerning the surgical management of congenital
uterine abnormalities. The authors found a clear benefit in the group of patients who
underwent to surgical management regarding fertility rates and miscarriage pregnancy rates
as well as in terms of pain release, for almost all subgroups of anomalies addressed by the
American Society of Reproductive Medicine.
These results were comparable between laparoscopy and laparotomy groups. Surgery
seems to be the best option for symptomatic patients with congenital uterine anomalies,
indeed, laparoscopic approach is feasible and reliable to treat them, showing the same both
anatomical and reproductive results than the laparotomic approach but with the advantages of
the minimally invasive surgery, such as cosmetic results and postoperative period, which is
essential in young patients.
Chapter 10 - Aim: The authors have assessed the feasibility of total laparoscopic
hysterectomy (TLH) in cases of very large uteri weighing more than 500 grams and analyzed
whether it is possible for an experienced laparoscopic surgeon to perform efficient total
laparoscopic hysterectomy for large myomatous uteri regardless of the size, number and
location of the myomas.
Setting: Dedicated high volume gynaecological laparoscopy centre.
Patients: 190 women with symptomatic myomas who underwent total laparoscopic
hysterectomy at their center.
Intervention: Total laparoscopic hysterectomy was done for all patients. There were
various modifications of performing the surgery by ligating the uterine arteries prior,
myomectomy followed by hysterectomy, direct morcellation of the uterus while it is still
attached to its pedicles.
Results: 72% of patients had previous normal vaginal delivery and 28% had previous
cesarean section. The median clinical size of the uterus was 18 weeks (10, 32).The median
weight of the specimen was 640 grams (500, 2240).The median duration of surgery was 120
min (40, 300) and the median blood loss was 100 ml (10, 3200).
Preface xiii
Conclusion: Total laparoscopic hysterectomy is a technically feasible procedure. All the

modifications of the procedure depending on the size and location of the myoma increase the
safety when performed by experienced surgeons.
Chapter 11 - Total laparoscopic hysterectomy is slowly gaining foothold in the treatment
of benign gynecological disease. In this paper, the authors review the literature with
concentration on articles addressing the cost-effectiveness of this procedure versus the
traditional total abdominal hysterectomy.
Chapter 12 - Hysterectomy rates are highest in middle-aged women who usually find
themselves in front of an intersection when they are faced with the reality that their uterus
needs to be removed and must make a decision with the help of their gynecologist about the
best way to do the hysterectomy. Unfortunately, the majority of women are still being treated
for benign pelvic disease with the more invasive types of hysterectomy in spite of the
superiority of the laparoscopic modality. While there are some situations where abdominal
and vaginal routes are appropriate, women need to know about the less invasive more
advanced type of hysterectomy with shorter recovery time and better cosmetic outcome.
Chapter 13 - Objective: To compare interrupted Muney Stitch with a continuous baseball-
like suture for abdominal myomectomy.
Methods: Retrospective review of patient records who underwent abdominal
myomectomy at the same time, subserosal layer closed with interrupted Muney Stitch (Group
1) or continuous baseball-like suture (Group 2). Twenty patients had Muney Stitch and 20
patients had baseball-like suture.
Results: Both groups were equivalent across several critical factors such as age, uterine
size and duration of surgery. When post-op fever was compared between the groups, only
25% of patients who received Muney suture developed fever while 60% of the patients with
baseball-like suture developed post-op fever (p=0.025). The odds of developing this
complication was estimated to be 4.5 (95% C1, 1.16-17.37 p=0.029) higher using the
baseball-like suture when compared to the Muney Stitch. Two different suture methods
produced different amount of blood loss during surgery. These significant differences were
attributable to suture type (p=.011) but not for suture position (p=0.066). A significant
correlation between incision type and suture type was found (p=0.029). Patients who had
Muney suturing of the posterior uterine wall had less blood loss.
Conclusion: Muney Stitch produces less post-op fever and blood loss in a posterior
uterine incision.
Chapter 14 - During abdominal myomectomy and classical cesarean section, the serosal
and subserosal layer of the uterus are approximated with a continuous baseball-like suture,[1]
running suture utilized to imbriate the serosa,[2,3] running locked suture,[4] continuous
inverting suture,[5] continuous running suture,[6] or interrupted.[7] These techniques do not
always control bleeding arising from congested and dilated subserosal veins,[2] and reduce
unintentional hysterectomy, adhesion formation and infertility after myomectomy and
classical cesarean section. To prevent continuous blood loss during and following the surgery
and to prevent hematoma formation in the uterus, a different suturing technique is needed to
control congested and dilated vessels in subserosal regions.[2]
In a very vascular uterus, an interrupted overlapping Muney Stitch provides good
homeostasis, and approximates the serosal layers without tension. In addition, the suture does
not pass through the surface of the uterus and thus reduces foreign body reactions and
xiv Deborah J. Shimizu
possible adhesion formation. In case of a smaller incision with less vascular uterus a
continuous Muney Stitch can be used.
Chapter 15 - Bowel injury can happen during insertion of the direct view trocar for
laparoscopy, irrelevant to the surgeon‘s experience. The authors explain how to repair the
bowel injury via a minilaparotomy and continue the laparoscopic procedure as planned.
In: Hysterectomy: Procedures, Complications and Alternatives ISBN: 978-1-61761-939-7
Editors: Deborah J. Shimizu © 2011 Nova Science Publishers, Inc.
Chapter 1
Laparoscopic Hysterectomy: Its

Appeal, Its Safety Profile and Barriers
to Widespread Use
Hassan Morsi*
Division of Medical Sciences, University of Birmingham,
Dudley Group of Hospitals NHS Foundation Trust
Russells Hall Hospital, Pensnett Road, Dudley, West Midlands,
United Kingdom, DY1 2HQ
Abstract
Laparoscopic Hysterectomy (LH) is being increasingly adopted worldwide. Ever
since its inception by Harry Reich in 1989, it has been gradually introduced into many
gynaecologists‘ practices. Despite advances in ablative technologies, hysterectomy in
general will always remain an attractive option to many women. The benefits of
laparoscopic hysterectomy are well known and they mainly reflect smaller abdominal
incisions with consequent reduced pain relief requirements and quicker recovery time. It
is well known that LH is not meant to replace vaginal hysterectomy but numerous studies
have shown that it is a safe and viable alternative to abdominal hysterectomy. This makes
LH more appealing to those willing to uptake this procedure. In the 21st century, all
health care systems are facing mounting financial pressures. The focus therefore
increases on procedures that will allow shorter hospital admission times and quicker
recovery rates without compromising safety. The literature is full of publications, on
safety of LH, originating from centres of excellence in laparoscopic surgery as well as
from other less well established centres. This inevitably impacts on the wide variance
seen in complication rates seen at those different centres. This article will attempt to
address LH‘s safety profile and the disparity between the reported complication rates of
established centres and other centres. Pioneers of laparoscopic surgery argue that
complication rates should be lower than in abdominal hysterectomy. Indeed, this
statement would make sense, as laparoscopy offers the benefit of magnification of tissues
*
Hospital Tel: +44 - (0) 1384 456111, Secretary Ext: 3524, Direct Line Ext: 3295, Fax: +44 - (0) 1384 244445, E-
mail: hassan17870@doctors.org.uk
2 Hassan Morsi
and better exposure at the expense of loss of depth perception and tactile stimulation.
There is undoubtedly a learning curve, which is probably the biggest barrier to
widespread use of LH. The number of hysterectomies performed for benign disease is
declining because of the success of medical treatments, hormonal intrauterine systems
and endometrial ablative techniques. Trainees are receiving less surgical training because
of their reduced hours of work thereby creating a short-fall in training. Unless trainees
take extra time to have dedicated training, there will be very few gynaecological surgeons
in the next generation with advanced laparoscopic skills. In this article, I will attempt to
address those and other barriers and how to overcome them as witnessed from a personal
perspective.
Introduction
Laparoscopic Hysterectomy (LH) is being increasingly adopted worldwide. In fact, we
are now seeing advances in minimal access surgery, with growing experience in single port
laparoscopic surgery and in robotic surgery. This would probably mean that laparoscopic
hysterectomy is here to stay and will not be disappearing from the gynaecologist‘s
armamentarium anytime soon. The benefits of laparoscopic hysterectomy are well known and
they mainly reflect smaller abdominal incisions, reduced tissue trauma with consequent
reduced pain relief requirements and quicker recovery time. The problem in LH is not in the
technique itself but in those applying the technique. Driving a new car involves basic training
that all car drivers have and are proficient in. This analogy cannot be applied to laparoscopic
gynaecological surgery. Gynaecological surgeons are willing to uptake such surgery and
sometimes without having sometimes even basic training in laparoscopic surgery. On the
contrary drivers getting a new car already have basic driving experience. The lack of training
in laparoscopic surgery, in my opinion, is a two faceted problem. The first is the lack of
incorporation of training in laparoscopic surgery in residency training. This is because
advances in laparoscopic surgery seen in the last 2 decades were too rapid to be incorporated
in the medical training programmes. It is often the case that these procedures are learnt by
observation and by ‗see one, do one, teach one‘. This is unsafe with laparoscopic surgery and
has undoubtedly contributed to the ‗bad press‘ surrounding laparoscopic surgery. There were
increased complications noted not due to the procedure but due to inexperience of those
performing it. The second facet is the commercialization of medical instrument and the huge
opportunity that laparoscopic instruments presented to companies interested in profit. The
modernisation in medical training programmes has not seen similar huge financial
investments within the same time frame. On the other hand, companies manufacturing
laparoscopic instruments have invested vast sums of money and recruited representatives
focused on promoting their products. Improved designs coupled with more powerful energy
sources created a false sense of security without properly conducted clinical trials and under
the attraction of ‗sponsorship and sponsored meetings / training courses‘ many less
experienced gynaecological surgeons were willing to use those instruments without
prerequisites of proper training and risk management procedures. Again this contributed to
seemingly high complication rates which are actually due to operator inexperience rather than
the technique itself. It is then interesting that the medical industry was able to quickly adopt
such technologies without proper user-training. This is surprising since new technologies in
other fields usually undergo considerable scrutiny and training before adoption. Another
Laparoscopic Hysterectomy 3
major impediment to safe laparoscopic surgery lies in the anxiety related to what is falsely
perceived as unnecessary and excessive retroperitoneal dissection sometimes required in
laparoscopic surgery. Indeed, most simple gynaecological laparoscopic surgeries do not
require retroperitoneal dissection as is the case in most cases of open surgery except those
dealing with malignancies. However, what distinguishes an experienced from a less
experienced laparoscopic surgeon is the ability to utilise anatomical landmarks to gain access
to the retroperitoneal ‗spider web‘ and to respect tissue planes while identifying vital
retroperitoneal structures by simple blunt dissection. Indeed Kadar states that ‗uncertainty
about anatomy and the inability to dissect tissues correctly are the greatest impediments to
laparoscopic surgery. Failure to recognise this has fostered a preoccupation with technology
at the expense of surgical and anatomical principles in the mistaken belief that a good
laparoscopic technique is simply a question of the right technology.‘ The author argues that
even though most cases of laparoscopic hysterectomy can be completed safely with a non-
anatomical approach, this will only suffice in uncomplicated cases with a small uterus.
Applying the anatomical approach, which essentially involves identifying laparoscopic
landmarks and retroperitoneal structures, will allow the safe laparoscopic removal of well
over 95% of unselected benign cases. The author concludes that if laparoscopic pelvic surgery
is to be safe and have wide applicability, knowledge of anatomy and the use of meticulous
techniques of dissection to identify vital structures is indispensible [1] From the patients‘
point of view, LH is appealing simply because of a rapid recovery and a better short term
quality of life, yet LH is unpopular with hospital administration. Reich explains that this is
because it demands more operating time and expensive instrumentation unless reusable
instruments are used. This combination can result in a net loss for the hospital. The insurance
industry has also refused to compensate surgeons and hospitals with reasonable
reimbursement for minimally invasive surgery performed on women. Poor reimbursement for
the time of surgery and the time necessary to acquire the skill to do it discourages
gynaecologists from mastering it [2]. In the 21st century, all health care systems are facing
mounting financial pressures. The focus therefore increases on procedures that will allow
shorter hospital admission times and quicker recovery rates without compromising safety.
The literature is full of publications, on safety of LH, originating from centres of excellence
in laparoscopic surgery as well as from other less well established centres. This explains the
wide variation in complication rates at different centres. Pioneers of laparoscopic surgery
argue that complication rates should be lower than in abdominal hysterectomy. Harry Reich
states that ‗LH remains a reasonable alternative to TAH. Laparoscopic associated
hysterectomy is a cost-effective procedure and is a safe procedure when performed by a
variety of gynaecologists with different skill levels. As TLH mimics TAH in almost every
respect, it should be easy to assimilate it into practice for the majority of patients‘ [3]. Indeed,
this statement would make sense, as laparoscopy offers the benefit of magnification of
tissues, better exposure of the uterine vessels, access to the rectum and vagina with the ability
to ensure good haemostasis and evacuate clots at the expense of loss of depth perception and
tactile stimulation. There is undoubtedly a learning curve, which is probably the biggest
barrier to widespread use of LH. The number of hysterectomies performed for benign disease
is declining because of the success of medical treatments, hormonal intrauterine systems and
endometrial ablative techniques. Trainees are receiving less surgical training because of their
reduced hours of work thereby creating a short-fall in training. Unless trainees take extra time
to have dedicated minimal access surgery training, there will be very few gynaecological
4 Hassan Morsi
surgeons in the next generation with advanced laparoscopic skills [4]. This article will attempt
to address LH‘s safety profile as well as some barriers to more widespread implementation of
LH and how to overcome them as witnessed from a personal perspective.
Classification of Hysterectomies
Involving Laparoscopy
Harry Reich [3] used the term Laparoscopic Associated Hysterectomy to describe any
hysterectomy that involves the usage of the laparoscope. The term Laparoscopic
Hysterectomy is sometimes used as a synonym for Laparoscopic Associated Hysterectomy. It
is however important to mention that ligation of the uterine pedicle laparoascopically is the
experience-defining step or at least one of the experience-defining steps. This is because
laparoscopic ligation of the uterine vessels is the sine qua non for laparoscopic hysterectomy.
The table shows Reich‘s [3] variety of procedures where the laparoscope can assist in the
hysterectomy. Whatever method the gynaecological surgeon uses primarily depends on
his/her level of experience and comfort with laparoscopic surgery. Total laparoscopic
hysterectomy (TLH) involves the complete dissection of the all the uterine attachments
including all the vascular pedicles. The uterus is then completely free within the peritoneal
cavity and it is then extracted through the vagina with vaginal and/or laparoscopic
morcellation. An integral part of TLH is the laparoscopic placement of sutures to close the
vaginal vault and reconstitute the pubovesical fascia/uterosacral ligament complex. The only
vaginal surgery needed with TLH is the morcellation of an enlarged uterus [3]. The Cochrane
review [5] states it has been unclear whether TLH offers any benefit over other forms of
laparoscopic hysterectomy. The Cochrane review mentions alternative classifications for LH
but recommend that future researchers should stick to the simple nomenclature of LAVH
(where the uterine vessels are not ligated laparoscopically), LH(a)(where the uterine vessels
are ligated laparoscopically), TLH (where the entire procedure is completed laparoscopically
including the vaginal vault closure)and LASH (laparoscopic subtotal hysterectomy)to
minimise the confusion encountered in the initial literature on LH. Garry et al. [6] recommend
that further research is needed to evaluate new techniques such as TLH. Laparoscopic-
assisted vaginal hysterectomy (LAVH) was described as a watered-down version of TLH,
which was taught by industry and became overused and expensive. Indications for LAVH
have been questioned as it is argued that a skilled vaginal surgeon, within the context of those
same indications, would probably not need the laparoscope at all. Furthermore, it was
suggested that LAVH merely adds the complications of laparoscopy to vaginal surgery [3].
Based on available evidence, the choice should then be between a vaginal hysterectomy that
is possible and a laparoscopic hysterectomy. It is important to realize that not all
gynaecologists have advanced vaginal surgery skills and the same applies to advanced
laparoscopic skills. This is mainly due to defective training on both vaginal and laparoscopic
surgery, as opposed to abdominal hysterectomy which is considered the default method
hysterectomy. In addition, most gynaecologists resist learning new techniques once they
reach their own comfort zone. This resistance could be due to misconceptions, subjective
opinions, lack of hand-eye coordination, financial restraints on equipment/trained staff or as
previously explained the lack of any financial incentive.
Table 1. Laparoscopic associated hysterectomy classification
1. Diagnostic laparoscopy with vaginal hysterectomy

2. Laparoscopic-assisted vaginal hysterectomy
3. Laparoscopic hysterectomy
4. Total Laparoscopic hysterectomy
Laparoscopic supracervical hysterectomy including classical interstitial Semm
5.
hysterectomy
Vaginal hysterectomy with laparoscopic vault suspension or laparoscopic pelvic
6.
reconstruction
7. Laparoscopic hysterectomy with lymphadenectomy
8. Laparoscopic hysterectomy with lymphadenectomy and omentectomy
9. Laparoscopic radical hysterectomy with lymphadenectomy
There are evidence-based recommendations suggesting that vaginal hysterectomy should

be the primary option where feasible and that laparoscopic hysterectomy is meant to replace
abdominal hysterectomy but not vaginal hysterectomy. There is no evidence to support the
use of laparoscopic hysterectomy if vaginal hysterectomy can be performed safely.
Laparoscopic hysterectomy has many advantages compared to abdominal hysterectomy,
namely shorter hospital stay and recovery times with less pain relief requirements in addition
to lower rates of blood loss, infection and ileus. On the other hand, laparoscopic
hysterectomies take longer to perform, are more expensive and have a higher risk of urinary
tract injuries. Despite the available evidence and the well described techniques of TLH that
have been in the literature for 20 years, its uptake has been very slow. This is due to a
combination of lack of training in addition to ethical dilemmas of poor remuneration
compared to other less invasive procedures e.g. laparoscopic sterilisation [2].
Indications of Laparoscopic
Associated Hysterectomy
A recent Cochrane database review of evidence-based hysterectomy studies [5]
concluded that vaginal hysterectomy remains the primary option for hysterectomy in view of
safety, speed and low morbidity. In a recent prospective randomized study comparing vaginal
hysterectomy (VH), laparoscopic-assisted vaginal hysterectomy (LAVH), and total
laparoscopic hysterectomy in women with benign uterine disease, Drahonovsky et al. [7] also
concluded that VH and LAVH should be the preferred techniques. Other authors stated that
only experienced laparoscopists should perform LH and in cases where VH and LAVH are
quite impossible [8].
It is important to remember that vaginal hysterectomy has limitations particularly in
terms of accessibility of the uterine pedicles vaginally. There are different levels of
experience and some surgeons might feel that a uterus can not come out vaginally while
others feel differently. Most of the reasons stated to justify an abdominal approach are in fact
the same indications for a LAH except in the case of a very large uterus. Commonly cited
indications for an abdominal hysterectomy include uterine size greater than 12 weeks,
6 Hassan Morsi
nulliparity, lack of uterine descent, narrow vaginal access, poor uterine mobility, previous
pelvic surgery, adnexal pathology e.g. endometriosis, adhesive disease, obesity, the
requirement of ovarian removal or cancer [3].
With advanced laparoscopic training the above indications can be approached using a
laparoscopic hysterectomy. It is important to remember that not all types of laparoscopic
hysterectomy necessitate the same level of expertise in laparoscopic surgery. While grades 1
and 2 of the above table require more or less basic laparoscopic surgery skills (i.e. that needed
for laparoscopic management of ectopic pregnancies), once the uterine pedicles are secured
laparoscopically then this suggests that the involved gynaecologist has undergone advanced
laparoscopic training and has the experience to undertake such surgery.
Laparoscopic management of endometrial cancer and cervical cancer is becoming an
attractive option for oncologists. Laparoscopy facilitates lymphadenectomy by providing an
excellent view, haemostasis and lymph node harvest [4]. There are many reports comparing
the outcomes of early stage endometrial cancer managed by traditional abdominal
hysterectomy as compared to LAVH or TLH. O‘Hanlan and colleagues [9] were able to show
that based on clinical selection criteria, TLH performed for endometrial neoplasia has few
complications and is well tolerated by select patients. The advantages are less blood loss and
a shorter length of hospital stay for qualified patients. The surgical duration was similar for
both groups. Average blood loss was higher for TAH. Uterine weight was greater and
myometrial invasion deeper in the TAH group. More patients had Stage II or higher disease in
the TAH group. More TAH patients needed node dissection (79% vs. 28%, P<0.001). Node
yields from dissections of 23 TAH cases and 21 laparoscopic cases were similar (17 nodes).
Total and reoperative complications from TAH versus TLH were not statistically different.
Obesity is considered by some as a relative contraindication for laparoscopic surgery.
This is because it presents specific problems of ventilation with the Trendelenburg position.
However, the laparoscopic approach often provides a better view and avoids the prolonged
recovery and subsequent morbidity associated with laparotomy incisions. Chopin et al [10]
were able to show that, after adjustment with respect to the patients‘ characteristics and past
history (age, parity, past history of laparotomies, previous Caesarean section, menopausal
status), no significant difference was found whether in terms of intra-operative (haemorrhage,
transfusion, thrombosis, ureter, bladder or bowel injuries) or post-operative complications
(hyperthermia, infections, fistula) in the obese group. Only a significantly longer operating
time was noted in the case of obesity.
Uterine Manipulators
In addition to advanced training in laparoscopic surgery, uterine manipulation is one of
the most important steps in laparoscopic hysterectomy. Adequate exposure is vital in
gynaecological surgery. Uterine manipulators play an important role in facilitating ideal
exposure. The proximity of important structures to vascular pedicles makes uterine
manipulation a critical step in laparoscopic hysterectomy. Uterine manipulation is important
because it allows exposure of important vascular pedicles under tension as well as delivering
important structures closer to laparoscopic instruments. Anteversion or retroversion of the
uterus allows good exposure of the anterior wall and uterovesical pouch peritoneum and the
posterior wall and uterosacral ligaments respectively. Lateral movements allow exposure of
the lateral vascular pedicles e.g. infundibulopelvic ligaments as well as the anterior and
posterior leaves of the broad ligament. It also helps to increase the distance between the ureter
and the uterine pedicle at the level of the uterosacral/cardinal ligament complex by stretching
of the vaginal fornices. Upward elevation of the uterus is also critical as it obviates the need
for, after opening the uterovesical peritoneum, bladder dissection in women without a
previous history of Caesarean section. Upward movement of the uterus also allows safe
dissection of recto-vaginal endometriosis by exposing the uterosacral ligaments and the
Pouch of Douglas.
Mettler et al [11] reviewed all available new manipulators and compared them in respect
of the various movement ranges they offer in terms of anteversion, retroversion, lateral
movement, elevation and any special movements. They also compared their ability to distend
the vaginal fornices, the ease of assembly, handling and the maintenance of
pneumoperitoneum. In Reich‘s description of Total Laparoscopic Hysterectomy [3], he uses
the Valtchev uterine manipulator (Conkin Surgical Instruments, Toronto, Canada). They
indicate that the ideal manipulator should be inexpensive, convenient, and quick to use, safe
as well as having the ability to inject solutions into the uterine cavity and most importantly
offer the optimal range of uterine movements while avoiding the need for an assistant. The
following paragraphs summarise the important features of each manipulator as beautifully
described in the excellent paper by Mettler et al [11].
The older type manipulators that utilise balloon inflated tips do not require a tenaculum to
grasp the cervix to allow manipulation. They also allow intrauterine instillation of liquid for
chromopertubation. Some of those manipulators also have curves in their shafts to assist in
anteversion but the range of movement with those manipulators is between 45° anteversion
and 15° retroversion. The fulcrum with those manipulators is the external vaginal orifice. The
newer style manipulators use the external cervical os as the pivot point and therefore the
limitations of obesity on the range of uterine flexion are diminished.
The Clermont-Ferrand reusable model provides a 140° range of uterine movements and it
allows the uterus to flex on itself. Its graduated snap-in mechanism with five different
positions gives stability to the uterus at various angles and the snap-in release button allows
unrestricted movement. The manipulator rod when pushed inwards helps to delineate the
fornices with the aid of an anatomical blade. Its drawbacks are that it is complex to assemble
and requires cervical dilatation.
The RUMI with the KOH colpotomizer is a versatile instrument that has a 140° range of
uterine movement as well as significant movement in the lateral planes and delineates the
fornices well and thereby increases the distance between the uterine pedicle and the ureter. It
also allows stretch of the uterosacral ligaments and delineates the cervico-vaginal junction at
its uppermost point. This allows completion of the laparoscopic dissection of the cervix and
vagina easily with minimal blood loss. This also helps to incise the vagina very close to the
cervix thereby retaining the maximal length of the vaginal canal while allowing transection of
the uterosacral ligaments above their insertion point to the vagina. This step reduces the risk
of ureter injury and provides better vaginal vault support by preserving the uterosacral
ligaments as no stitches are needed to incorporate the uterosacral ligaments into the vaginal
vault. It can also be used with the Harmonic scalpel or other types of ultrasound energy
sources. It however has restricted uterine elevation and is also difficult to assemble. There
have been 2 reports in the literature of iatrogenic uterine rupture due to over inflation of the
8 Hassan Morsi
RUMI balloon manipulator. I have personally found the RUMI balloon manipulator easy to
use with occasional problems with inflation of the pneumo-occluder and also with detachment
of the manipulator while retrieving the free uterus. Nevertheless it is a good instrument with a
wide range of ante and retroversion movements. The Hourcabie is easy to use, quick to
assemble and allows easy stapling of the uterine pedicles by allowing good exposure of the
vaginal fornices leaving the lateral fornices free which helps in good exposure and grasping
of the uterine pedicles and lateral fornices by automatic staplers but it is poor in maintaining
the pneumoperitoneum after removing the anterior and posterior presenters after the
respective colpotomg incisions and it allows less range of motion. It can however be used for
LAVH and TLH. The HOHL manipulator moves the uterus in 130° arc. It however does not
lock in a specific position; nevertheless, it gives significant elevation of the uterus which is
ideal in exposing the Pouch of Douglas in procedures such as endometriosis excision. It
screws into the cervix and therefore cannot be used in situation where the cervical function is
needed later. It does not precisely delineate the vaginal fornices. It is easy to use and assemble
and is mainly used for TLH. I have found the Hohl manipulator excellent in providing
cephalad displacement of the uterus during colpotomy. Rotation of the manipulator helps
better delineate the cervico-vaginal junction by feeling for the extended side of the
manipulator cup. Rotation of manipulator cup to the contralateral side allows an anterior
approach to the uterine artery on the ipsilateral side. The only limitation I find with this
manipulator is the limited anterversion when posterior colpotomy is attempted. The Endopath
is a single-use manipulators (thereby increasing cost) and is useful only in LAVH or LASH as
it does not help in presentation of the vaginal fornices and does not maintain the
pneumoperitoneum. It does however provide anteroposterior movement in 130° arc as well as
lateral movement. The Vcare uterine manipulator is a simple single use device. It has a good
range of movements. It has a forward cup that displaces the ureter, retracts the bladder and
defines the colpotomy incision and a reverse cup to maintain the pneumoperitoneum. It may
have problems with larger uterine size due to its lightweight design. The TLH-Dr
Mangeshikar manipulator provide 130° range of movement and has good uterine elevation
(thereby facilitating dissection of the ascending uterine arteries and thereby reducing the risk
of ureteric injury) and is therefore suitable for TLH and endometriosis excision. Sliding in the
vaginal delineator helps identify the vaginal fornices and choosing the right sized delineator
drum helps maintain the pneumoperitoneum. This manipulator is a reusable, completely
detachable, low-cost uterine manipulator. Mettler et al [11] concluded that no single uterine
manipulator seems to have all the attributes of an ideal manipulator and the choice of uterine
manipulator needs to be individualized according to the procedure in which it is used. Any
laparoscopic surgeon‘s choice of manipulator should primarily depend on the adequacy of the
manipulator in moving the uterus in several directions, in presenting the vaginal fornices and
in maintaining the pneumoperitoneum [8].
Technique
There are few authors who have published their techniques. Two recent papers have
included details of techniques used [3, 4]. Here I will present the technique I use with
modifications according to the procedure performed. I do not routinely use bowel preparation
or illuminated ureteric stents. Bowel preparation is only indicated for patients where adhesive
disease is anticipated i.e. history of endometriosis or midline laparotomies or symptoms /
examination suggesting rectovaginal nodules or bowel involvement. The patient is counselled
regarding the benefits and risks of the laparoscopic approach. In particular, the benefits of
quicker recovery and less analgesia requirements and quicker hospital discharge are
highlighted. There are fewer wound or abdominal wall infections and fewer unspecified
infections or febrile episodes. The risks include longer operating times as well as an increased
risk of urinary tract injuries. I also routinely include cystoscopy in the consent form and this
is done at the end of the procedure. The patient is positioned in Lloyd Davis position. The
uterine manipulator depends on the procedure being performed. I generally use the Pelosi
uterine manipulator for LAVH and the Hohl uterine manipulator for TLH. Following general
anaesthesia the bladder is emptied. The catheter is not left in during the procedure. The
procedure is performed using 4 ports with a 10 mm intraumbilical port. The other ports are 5
mm and are placed in the suprapubic area and in the right and left lower abdominal quadrants
lateral to the inferior epigastric vessels. The higher the fundal level the higher the lateral ports
should be to allow access to the upper uterine pedicles. All ports are inserted according to the
Middlesbrough Consensus document on laparoscopic entry at an intrabdominal set pressure
of 25. As soon as all parts are in place the pressure is reduced to 15 and the patient is moved
into the Trendelenburg position. It is always preferable to attach the gas tubing to the left
hand 5mm port. This has two advantages; firstly it prevents the tubing from interfering with
the free movement of the laparoscope at the umbilical port and secondly it prevents steaming
of the lens from inflowing cold gas that rapidly reaches body temperature and thus creates
condensation on the laparoscope lens giving a ‗hazy steamy‘ image. I generally prefer to use
the bipolar diathermy with the monopolar cutting current connected to the laparoscopic
scissors. This helps to keep costs down. An alternative energy source that is sometimes used
is the Harmonic scalpel. Despite increasing costs, the benefit of the Harmonic scalpel is the
ability to coagulate and cut with one hand whilst using the other hand to create or release
tension on a pedicle as required. This decreases reliance on the assistant as opposed to the
bipolar/scissors method where the assistant needs to stretch the pedicle for the surgeon. As
soon as entry is achieved the bowel, liver and the appendix are inspected for any pathology.
The pelvis is then inspected to identify the uterine mobility particularly in anteversion and
retroversion, the course of the ureters and the Pouch of Douglas and the uterovesical fold. The
round ligaments are dessicated half way along their length and cut allowing access to the
retroperitoneum. Some authors advocate initially maintaining all the ligaments‘ integrity and
entering the retroperitoneum first. The peritoneum between the round ligament and the
infundibulopelvic (IP) ligament is opened just above and parallel to the iliac vessels. As soon
as the spider web is seen then this signals entry into the retroperitoneum. The opened
peritoneum acts as the base of the triangle with extension of the opening parallel to the round
ligament towards the uterus and also parallel to the roof of the broad ligament. Optical
dissection is then used to open the retroperitoneal space. This is done by the tip of the
laparoscope by pushing it in gently into the loosely distended areolar tissue parallel to the
uterus to identify the course of the ureter, the uterine vessels or both. In women with large
uterus, it is possible at this stage to ligate the uterine vessels to devascularise the uterus.
Pioneers of laparoscopic surgery advocate ureteral dissection either medially, superiorly
or laterally. They, however, maintain that this is optional. The key laparoscopic landmarks for
retroperitoneal dissection are the pelvic sidewall triangle, the obliterated (lateral) umbilical
10 Hassan Morsi
ligament. The pelvic sidewall triangle is exposed by moving the uterus to the contralateral
side. The base of the triangle is formed by the round ligament, laterally by the external illiac
artery, medially by the IP ligament and the apex is the point where the IP ligament crosses the
external illiac artery. The medial (Reich) approach [2] is also known as the transperitoneal
approach. For this to be done, the ureter must be identified at the level of the pelvic brim by
lifting up the IP ligament and incising the peritoneum covering it and the ureter dissected free
of the surrounding areolar tissue by blunt dissection. The peritoneal incision is extended and
the ureter progressively freed as far down as is necessary. Alternatively a window is simply
created in the medial layer of the broad ligament above the ureter to allow safe division of the
adnexal pedicle. This medial approach is suitable in the absence of peritoneal pathology or
adnexal masses. Any such pathology will make visual identification of the pelvic ureter very
difficult particularly on the left side where the ureter at the pelvic brim lies more medially and
is covered by the sigmoid mesocolon. The ureter is normally visible through the peritoneum
of the broad ligament from the pelvic brim down to the level of the distal border of the
ovarian fossa. This technique is not favoured by experienced laparoscopic surgeons as it does
not allow retroperitoneal access or identification of retroperitoneal vessels and landmarks and
in the presence of peritoneal disease the ureter is not visible to allow initial dissection. A
blind approach to look for the ureter where it is expected to be is time consuming and not
always successful. Furthermore identification of the ureter at the pelvic brim is rarely helpful
as it is often invisible distally in the pelvis which is the area of interest when dealing with
endometriosis for example.
The superior approach [2] is used if only the proximal part of the ureter needs to be
exposed. The peritoneum in the middle of the pelvic sidewall triangle is opened parallel to the
iliac vessels and the incision extended upwards towards the pelvic brim and extended to the
paracolic gutter and lateral to the IP ligament. This is a crucial step in preventing injury to the
ureter as it is important to maintain the anatomical position of the IP ligament when making
the incision to the peritoneum. An incision made lateral to the anatomical position of the IP
ligament can not injure the ureter as the ureter enters the pelvis by crossing the pelvic brim
medial to the IP ligament.
The lateral (Kadar) approach [2] utilises the pararectal spaces to identify the ureter. The
pararectal spaces are bounded medially by the ureter and laterally by the illiac vessels and
caudally by the uterine artery at the upper edge of the cardinal ligament, both of which lie at
the caudal distal border of this space. The extraperitoneal portion of the umbilical ligament is
identified by dissection under and caudal to the round ligament and then it is traced
proximally where it gives of the superior vesical artery followed by the uterine artery and
becomes a continuation of the hypogastric artery. The pararectal space is developed by blunt
dissection proximal and medial to the uterine arteries. Another technique involves identifying
the ureter at the pelvic inlet and then gently using the suction irrigation to gently push the
ureter and the broad ligament medially at successively more distal points until the pararectal
space is opened lateral to the ureter.
After the round ligaments are divided and dessicated at their midportions, the bladder is
then mobilized downwards. This is achieved by holding the anterior peritoneal edge and
lifting it upwards and using the scissors or a diathermy hook to incise the peritoneum
horizontally (perpendicular to the uterine axis) and proximal to the point of elevation of the
peritoneum. The peritoneum should be divided until reaching the left round ligament. The
upper junction of the uterovesical fold is a white line firmly attached to the uterus with 2-3
cm between it and the bladder dome [1]. The initial incision is made below the white line
while lifting the bladder. The bladder is mobilized downwards off the cervix and vagina. This
could be done bluntly using a grasper and the suction irrigation probe or by simply applying
maximum cephalad pressure on the uterine manipulator. In doing so the cervical cup stretches
the vaginal fornix upwards away from the bladder and in the absence of adhesions is usually
sufficient to delineate the fornix and displace the bladder distally. In cases of previous
caesarean section, sharp dissection is usually carried out using monopolar diathermy
connected to the scissors. If the bladder is not clearly seen then ElBishry et al have described
a way of confidently identifying the upper edge of the bladder. This is achieved by inserting a
metal catheter into the bladder and displacing it anteriorly thereby creating tension on the
bladder pillars. This helps to clearly identify the dome of the bladder laparoscopically while
reliably cutting the bladder pillars under direct vision and away from the bladder dome. I have
found this technique safe, easy to learn and helps dissection of the bladder with confidence in
cases of previous caesarean sections.
If the tubes and ovaries are to be preserved, then the tubes and the tuboovarian ligaments
are grasped at a thin portion after moving the uterus to the contralateral side and dessicating
the pedicle using the bipolar diathermy and monopolar scissors. Alternatively a 2/0 Vicryl
ligature can be passed through window created around the tuboovarian pedicle and the tube in
order to ligate the pedicle using extracorporeal knots and a knot-pusher. It a knot-pusher is
not available then any fenestrated grasper can equally be used to push knots inwards after
creating the knots proximal to the fenestration. If oophorectomy is desired, then the
peritoneum of the broad ligament is opened on each side of the IP ligament and a free ligature
is passed through the window and the pedicle tied. Two ligatures are tied proximally and one
tied distally and the pedicle divided in between. The benefit of the broad ligament
fenestration is that it allows the peritoneum holding the ureter to fall away towards the pelvic
side wall and thus allows safe division of the pedicle.
Once the upper uterine pedicles are secured, the broad ligament is dessicated sequentially
until the level of the ascending uterine vessels are reached. This is normally well above the
level of the uterosacral/cardinal ligament complex. It is important to remember that
dessication of the broad ligament should always be done while the uterus is displaced to the
contralateral side and with the adnexa pulled by the assistant towards the contralateral pelvic
side wall in order to protect the ureter from inadvertent thermal damage.
It is important to skeletonise the uterine vessels before dessication. According to Reich
[2], the uterine vessels can be ligated at their origin, at the site where they cross the ureter,
where they join the uterus or on the side of the uterus. In most cases bipolar diathermy is used
to dessicate the vessels. Some surgeons prefer suture ligation to allow for suture removal if
ureteral compromise is suggested at cystoscopy. If bipolar is used it is important to remember
that the back blade of the bipolar forceps should always be kept against the cervical cup of the
manipulator. This minimises lateral thermal spread of energy that can damage the ureter.
Once the uterine vessels are cut, any further haemostasis needed should strictly be limited to
the medial side of the uterine vessel stump and never lateral [13]. Attempts at haemostasis
lateral to the uterine stump could cause damage to the ureters. Surgeons who prefer suture
ligation use a blunt needle with 0-Vicryl (Ethicon JB260) with the knots being tied
extracorporeally using a Clarke-Reich knotpusher. In the cases a large fibroid uterus,
experienced laparoscopic surgeons advocate ligation of the uterine artery at the start of the
procedure to reduce the volume of blood within the fibroid and therefore the uterus becomes
12 Hassan Morsi
less voluminous for morcellation. The uterine artery can be identified using the well described
technique of identifying and freeing the obliterated hypogastric arteries extraperitoneally by
opening the paravesical spaces and then tracking them in a retrograde manner till the origin of
the uterine arteries.
Once the uterine vessels have been secured, an anterior colpotomy can now be preformed
if not already done. Some authors advocate anterior and posterior colpotomy on the cervical
cup ring before dessicating the uterine vessels and the cardinal ligaments. The important
consideration needed in securing the cardinal ligaments is to attempt to increase the distance
between the ureter and the uterine stump at the level of the lateral vaginal fornix. This can be
done by applying maximum cephalad pressure on the uterine manipulator. This stretches the
vaginal fornix against the rim of the cervical cup and serves to increase the distance between
the ureter and the uterine pedicle. This can help reduce lateral thermal spread from damaging
the ureter. Once again all bipolar dessication and cutting should be medial to the uterine
stump, against the rim of the cervical cup and never lateral to that. Once the cardinal
ligaments are cut, the uterosacral ligaments are also cut. Once the Uterosacral ligaments are
cut the culdotomy is completed circumferentially with maintenance of the cephalad pressure
to allow easy identification of the cervical cup as a backstop. It is important to maintain all
cutting against the rim of the cervical cup which is usually easily felt against the laparoscopic
scissors. It is important to note that continuous usage of the laparoscopic scissors with a
monopolar current for cutting can cause blunting of the instrument. Therefore it would be
more appropriate to use a laparoscopic hook to achieve circumferential culdotomy. The
cervical cup helps maintain the pneumoperitoneum and prevents loss of gas.
When the culdotomy is completed the uterus now lies free within the peritoneal cavity
and can now be pulled downwards into the vagina to maintain the pneumoperitoneum. If the
uterus is too big to be removed vaginally then morcellation is necessary. This can be done
either vaginally or laparoscopiccally. If laparoscopic subtotal hysterectomy is being
performed then morcellation has to be done laparoscopically. Vaginal morcellation involves
using a blade to make a circumferential incision into the body of the uterus and maintaining
morcellation parallel to the uterine axis and always within the uterine myometrium and away
from the vagina. Laparoscopic morcellation involves using morcellators to remove a large
uterus or a large fibroid by cutting them piecemeal until the entire specimen is retrieved.
These morcellators are usually introduced through 12 or 15 mm ports. It is preferable to use
such large ports within the midline to avoid the occurrence of incision site hernias.
The closure of the vagina involves approximating the uterosacral ligaments and the
cardinal ligaments and the rectovaginal fascia together horizontally. The uterosacral
ligaments are essential in order to achieve vault support. These can be tied extracorporeally
with the knots being pushed into position by a knotpusher. Pneumoperitoneum is maintained
by the uterus which is sitting in the vaginal canal. This remainder of the vagina can be closed
by a figure of 8 stitch incorporating the pubocervical fascia. If an LAVH is being performed
than the vagina can also be closed vaginally taking extra care to incorporate the uterosacral
ligaments into the vaginal vault for support.
A second look laparoscopy at the end of the procedure is always advisable. The
dessication lines are inspected carefully for any bleeding points and these can be controlled
using bipolar forceps using irrigation for underwater examination. It is important to reduce
the pressure to 5 mmHg to look for any bleeders that have stopped bleeding during the
procedure by the raised intraabdominal pressure. Suction irrigation is continued until the
effluent is clear. An intraperitoneal drain is advisable.
The final step should be a cystoscopy with indigocarmine injection. This is a blue dye
that is picked up fairly quickly by the kidneys and colours the urine blue within 10 minutes. It
serves to identify the patency of the ureteral orifices at cystoscopy. Furthermore, cystoscopy
gives the surgeon the opportunity to inspect the bladder mucosa for any damage, misplaced
stitches or any areas of thermal defects. Thermal defects usually give the appearance of an
area of blanching. Even though cystoscopy adds another 10 -15 minutes to the operation time
yet I feel it is an invaluable step in ruling out most injuries to the ureter. Thermal injuries to
the ureter take 10 – 14 days to manifest. At the end of the procedure the skin is closed
routinely with subcuticular stitches after expelling the gas and removing the ports under
vision.
In the author‘s opinion, cystoscopy is a valuable screening test that allows recognition of
bladder and ureteral injuries and subsequent timely repair. Within a learning curve, routine
cystoscopy with indigocarmine after LH provides evidence of a surgeon pursuing all possible
means to verify urinary tract integrity. It is known that intraoperative visualisation of ureteral
peristalsis does not prove viability as there is no fool proof mechanism to rule out
intraoperative devascularisation. Not all injuries to the ureter, particularly thermal ureteral
injuries that take 2-21 days to manifest, can be diagnosed by cystoscopy however. It is
believed that routine intraoperative cystoscopy after LH may facilitate the recognition of a
real or potential injury, allowing intraoperative repair. Repair at the primary surgery provides
the best chance of cure as it is technically easier, with minimum morbidity and helps to
reduce the chances of success of future litigation claims [2, 14, 15, 16].
Complications
Laparoscopic hysterectomy carries the risk of complications of hysterectomy in general
plus those specific to laparoscopy. The Royal College of Obstetricians and Gynaecologists‘
guideline [17] on preventing laparoscopic injuries suggests that there is a significant variation
in the reported rates of complications related to laparoscopic surgery. Figures range between
1/1000 to 12.5/1000 depending on the experience of the surgeon and the complexity of the
operation. One of the most important factors in determining the complication rate is the
surgeon‘s experience. It is known that complication rates are higher during the learning curve.
In Finland [18], the rate of complications reported to the National Patient Insurance
Association was 3.6/1000. The rate of major complications was 1.4/1000 procedures;
intestinal injuries 0.6/1000, urological injuries 0.3/1000 and vascular injuries 0.1/1000.
Jansen et al. [19] in the Netherlands reported the results of a prospective multicentre study in
which there were 145 complications from 25 764 laparoscopies (5.7/1000). There were 84
women (3.3/1000) who required a laparotomy for complications. There were 29 cases of
bowel injury (1.13/1000) and 27 injuries of vascular injury (1.05/1000); 57% of the injuries
were attributed to problems with laparoscopic entry. In a French study reported by Harkki
Siren [18], the rate of severe complications was 12.5/1000 cases after advanced laparoscopic
surgery. As described by Harkki Siren [18] complications of laparoscopic entry could be due
to failure of entry to the peritoneal cavity, damage of major retroperitoneal blood vessels
14 Hassan Morsi
(aorta, vana cava, iliac or mesenteric vessels), damage of the bowel, damage to abdominal
wall blood vessels (epigastric vessel laceration) or port site bowel herniation. Most
complications relating to entry arise as a result of failure to adhere to rules of trocar entry.
The French anonymous register of laparoscopic complications suggests that some factors
increase the risk of entry related complications regardless of the type of operation, instrument
used and the surgeon‘s experience. Such factors include previous abdominal surgery and the
patient‘s weight. Harkki Siren [18] has suggested that in the Netherlands study [19] 57% of
all complications were a result of the surgical approach with 94% of all complications in
diagnostic laparoscopies a result of the laparoscopic approach. The rate of entry-related
complications in that study was 3.2/1000.
Laparoscopic entry is an integral part of laparoscopic surgery. As shown above, more
than 50% of injuries are associated with problems in laparoscopic entry. There is no
consensus on the ideal method of entry. Gynaecologists are considered pioneers in the closed
or Veress needle entry technique. On the contrary, surgeons are very much in favour of the
Open or Hasson technique. The surgeons‘ preferences come from their training in that
particular entry technique and also from the belief that bowel injury can be more readily
diagnosed with an open entry technique. The most authoritative comparative review of the
safety of open and closed methods of laparoscopic entry was conducted by the Australian
College of Surgeons, which found a higher risk of bowel injury associated with open access
(relative risk 2.17; 95% CI 1.57–4.63). There was no significant difference in the very low
risk of vessel damage found in both groups. Two randomised trials have compared the open
and closed entry techniques. A meta-analysis does not indicate a significant safety advantage
to either technique.
A consensus document [20] on the recommended methods of laparoscopic entry was
published in 1999 named the Middlesbrough Consensus document. In summary, this
document recommends that the primary port incision should be vertical starting from the base
of the umbilicus and not too deep to avoid entering the peritoneal cavity. The Veress needle
should be sharp with a tested spring action. The abdominal wall should be palpated for any
masses. The table should be kept in the horizontal position until all ports are in. The Veress
needle should be then pushed inwards, perpendicular to the skin, to a depth just sufficient to
enter the peritoneal cavity. Usually 2 clicks are heard. A single randomised trial suggested
that non elevation of the abdominal wall during needle insertion is associated with a reduced
chance of failed entry. Several tests have been proposed to check correct placement of the
Veress needle including the saline test or the drop test. None of these tests have been shown
to be 100% effective. The single most important indicator of correct placement includes an
initial low intraabdominal pressure of less than 8 mmHg and high uninterrupted flow during
insufflation. The insufflations pressure is recommended at 25 mmHg as this helps to increase
the size of the gas bubble and thus increase the splinting effect without increasing anaesthetic
difficulties. This is provided the patient remains flat as long as the insufflations set pressure is
at 25. The mean volume of CO2 required to reach this pressure was 5.58 litres. An increased
size of the air bubble helps to reduce the risk of major vascular injury. The primary port is
inserted using a bimanual controlled entry perpendicular to the skin starting at the base of the
umbilical incision. Once the abdominal cavity is entered further inward pressure should be
stopped immediately. Once the primary port is in, the laparoscope should be rotated in 360
degrees to look for adherent bowel. If there is suspicion of adherent bowel being damaged the
primary port site should be inspected with a 5 mm laparoscope introduced through one of the
side ports. On completion of the procedure, visual inspection at the time of withdrawal of the
laparoscope helps to rule out a through-and-through injury of the adherent bowel.
Alternative entry techniques have been proposed, namely the Hasson and the direct entry
technique. Meta-analysis does not show any safety disadvantage from using direct entry in
terms of major complications. There may be an advantage when considering minor
complications. There are other devices that have been developed to try to minimise the risks
of primary trocar insertion e.g. visual access systems, radially expanding trocars and second-
generation Endotip® (Karl Storz, Tutlingen, Germany) systems. There is also an optical
Veress needle but despite the theoretical advantages of such a device there is no evidence to
demonstrate its superiority over the conventional Veress needle.
Alternative sites of insufflations have been suggested as the rate of adhesion formation at
the umbilicus may be up to 50% following midline laparotomy and 23% following low
transverse incision. The umbilicus may not, therefore, be the most appropriate site for primary
trocar insertion following previous abdominal surgery. Palmer‘s point is the preferred
alternative trocar insertion site, except in cases of previous surgery in this area or
splenomegaly. This point is 3 cm below the left costal margin in the mid-clavicular line.
Urinary Tract Injuries
Ureteral or bladder injury in Laparoscopic Hysterectomy is one of the most troublesome

complications due to the potential morbidities resulting from missed diagnosis and need for
re-operation. Seventy-five percent of ureteral injuries occur during gynecological procedures,
especially hysterectomies. The injuries in gynaecology have been noted to occur after total or
subtotal hysterectomy by laparotomy, after laparoscopic total or subtotal hysterectomy and
after laparoscopically-assisted vaginal hysterectomy (LAVH) or vaginal hysterectomy (VH).
Eight Five percent of cases occurred during dissection of the cervix. According to the
literature, the rate for such injuries resulting from hysterectomy by laparotomy is 0.03–2%, is
less in VH, and is up to 3.8% in LAVH. The ureters are commonly injured at the level of the
infundibulopelvic ligaments, the uterosacral ligaments or the pelvic sidewall. Previous
adhesions from prior abdominal surgery, endometriosis or pelvic inflammatory disease
increase the likelihood of such injury occurring. During laparoscopic hysterectomy, ureteral
injury can occur while cutting dense adhesions, fibrotic scar tissue, or while trying to control
bleeding close to the ureter with bipolar cautery or in the process of ligating the uterine
vessels with bipolar diathermy, staples or suturing. Diathermy lateral to the uterine pedicle in
an attempt to control accidental bleeding will increase the likelihood of either direct or
indirect damage to the ureter. Most ureteral injuries are not identified or even suspected
without cystoscopy [2]. Reich firmly states ‗the bottom line is that an aggressive approach to
ureteral protection can reduce but not eliminate ureteral injury‘ [3]. Prompt recognition and
management can prevent multiple surgeries and reduce morbidities as well as reduce the
prospective risk of litigation. It is inevitable that the urinary tract is vulnerable to injury
because of its subtle appearance, its retroperitoneal nature and its long course. There is a wide
variation in reported rates of injury to the urinary tract as a result of laparoscopic
hysterectomy, mainly due to differences in study design, surgeons‘ experience, technique and
case complexity. Ureteral injury would seem most likely in complicated procedures with
distorted anatomy. Paradoxically, studies reveal that most ureteral injuries occur during
16 Hassan Morsi
uncomplicated hysterectomies. This may be due to a false sense of security that surgeons who
perform routine pelvic surgeries develop and become neglectful of fundamental techniques
and surgical principles for avoiding ureteral/bladder injuries [21]. There has been conflicting
reports of the risk of urinary tract injury with Laparoscopic Hysterectomy (LH). The NICE
institute in the UK suggests [22], based on robust randomised controlled trials (RCTs) e.g.
eValuate Trial [23], that there is an increased incidence of urinary tract injury with LH. The
NICE guidance states that based on a systematic review and meta-analysis and a non-
randomised controlled trial of 10,110 women, the incidence of urinary tract injuries was
significantly higher among the laparoscopic hysterectomy (types not specified) group
compared to abdominal hysterectomy (meta-analysis: OR 2.61, 95% CI 1.22 to 5.60, 10
RCTs, n=1912; non-randomised study: 1.1% versus 0.2% for ureter injury and 1.3% versus
0.5% for bladder injury, p<0.0001), but no significant differences in urinary tract injury for
laparoscopic versus vaginal hysterectomy (1.00 (0.36 to 2.75)) or for LH(a) versus LAVH
(1.60 (0.29 to 7.83). A recent Cochrane review [5] of surgical approach to hysterectomy for
benign gynaecological disease stated that urinary tract damage, in particular ureteric injury,
remains the major concern related to the laparoscopic approach. However, the Cochrane
review concedes that this meta-analysis of Randomised Controlled Trials (RCTs) was
underpowered to detect a clinically significant increase in the incidence of bladder and ureter
damage from a laparoscopic approach. Consequently much of the data for an increased
incidence of urinary tract injury has come from non-randomised studies. Only large case
series usually have the power to detect such a rare complication, but RCTs remain the least
biased way to assess the benefits and harms of an intervention. When bladder and ureter
injuries were pooled together under ‘urinary tract injury‘, a significant increase in urinary
tract injury was detected for LH versus AH (OR 2.4, 95% CI 1.2 to 4.8) and TLH versus VH
(OR 3.7, 95% CI 1.1 to 12.2) [5]. Other respected authorities [13, 24] challenge the view of
NICE and, having addressed the biases uncovered in those RCTs and the inherent difficulties
of conducting such multicenter RCTs when the complications under question are so rare and
experience of the participating surgeons is variable, present their own impressive
retrospective and prospective tertiary centre series highlighting the low risk of urinary tract
injury and the safety of LH. Indeed, Leonard et al [13] state that provided the surgeons are
experienced in laparoscopic surgery, the risk of ureteral complications after LH is comparable
with the rate of 0.2–0.4% observed when total hysterectomy takes place by laparotomy. They
also argue that ‗the risk of ureteral complications must no longer be used as an argument
against the more widespread use of LH. A similar recommendation is echoed by Donnez et al
[24] who state that they firmly believe that LH offers multiple advantages over abdominal and
vaginal hysterectomy. They present an impressive series of 2596 patients where they show
that LASH and LH are safe procedures. They even question the need for randomized trials to
determine if LH is as valuable as or even more valuable, when only 1.5% of major
complications are encountered, than other techniques. They conclude that LH requires greater
surgical expertise and the complication rate is related to the surgeon‘s skill. They maintain
that LH is totally feasible for larger uteri and is not associated with any increase in major
complication rates. The Cochrane review [5] has stated that the surgeons‘ experience
significantly correlated inversely with the occurrence of urinary tract injuries in LH.
Therefore, it is logical to assume that with experience accrual, complication rates should fall.
However, it is also expected that with increased experience, more difficult cases will be
attempted which in turn could increase complication rates.
Bowel / Vascular Injury
In the Systematic review [6], there were no statistically significant differences in bladder,
ureter (considered independently), bowel, or vascular injuries for the comparison between
surgical approaches. The Cochrane review [5] shows that there were no significant
differences in urinary tract injuries between LH and VH (1205 women, 7 trials). When
regarding the LH subcategories, there were statistically significantly more urinary tract
injuries for TLH versus VH (OR 3.69, 95% CI 1.11 to 12.24; 440 women, 2 trials). There
were no statistically significant differences in bladder, ureter, bowel, or vascular injuries for
the comparison LH versus VH. In terms of TLH versus LAVH, there were no statistically
significant differences in bladder, ureter, urinary tract, or vascular injury for the comparison
TLH versus LAVH (186 women, 2 trials). No bowel injuries occurred in either group.
Learning Curve
It is well established that performing TLH involves a learning curve and that, with
improved skills and technique, reflective practice, ongoing audit of technique and outcome
with constant technique refinement, this will result in a safer procedure with lower morbidity.
There is, however, no consensus as to how many LHs are needed before one can safely say
that the learning curve has been achieved.
In a series of 1647 cases of TLH [25], the incidence of major complications and
laparotomy conversion rates decreased significantly with time indicating that complication
rates decrease significantly as surgeons gain experience. Makinen et al.[26], Altgassen et al
[27] and the Finnish registry [18] all reported that both urinary tract and gastrointestinal tract
injuries were significantly less common in LAVH and TLH performed by surgeons who had
completed more than 30 LH. Reports on the length of the learning curve to achieve
competency in performing LH have looked at operation time, conversion or complication
rate. Previous experience in operative laparoscopy decreases operation time dramatically
during the first 15–20 LHs, after which it dropped further only slowly. In a prospective
evaluation of the learning curve on 160 patients amongst four surgeons, Kreiker et al [28]
observed a plateau in operation time after 80 cases, with all major complications occurring in
the first 80 procedures. Wattiez et al [25] reported on the learning curve in a team of
experienced laparoscopic surgeons prior to their first LH. In a large series, 692 patients were
operated between 1989 and 1995 by nine surgeons, and 952 between 1996 and 1999 by 18
surgeons.
During that period, the major complication rate dropped from 5.6 to 1.3%, and
conversion rate dropped from 4.7 to 1.4%. The mean weight of the specimens increased with
time from 179.5 g to 292 g. These data suggest that it may take years and probably hundreds
of patients to ‗complete‘ the learning curve for LH [29].
Unlike laparoscopic surgery centres of excellence, the major drawback in district general
hospitals is the long learning curve, which needs to be tolerated in the face of persistent,
increasing operative workload and general resistance and unease of staff to change. Hospital
structures must be flexible enough to adapt to the requirements of laparoscopic surgery as this
helps to promote safe laparoscopic surgery. It is during this learning curve in which
complications occur that makes change extremely difficult. This is further compounded by
18 Hassan Morsi
the declining rates of hysterectomy due to hormonal intrauterine systems as well as

endometrial ablative technologies. The Cohrane review states that there is currently a much
larger database of trial experience involving LAVH than for TLH and this undermines the
extent to which conclusions may be drawn about TLH currently [5].
Laparotomy
A French study [30] found that 7% of TLH (29/416) were converted to laparotomy. They
determined that increased BMI, uterine width more than 10 cm and adhesions from previous
abdominal and pelvic surgery were predictive factors for laparotomy. Conversion to
laparotomy has been regarded as a prudent approach and a safe option [31].
Indeed upper gastrointestinal surgeons believe that although conversion rates for
laparoscopic cholecystectomy should be kept as low as possible and audited appropriately,
conversion to an open procedure in itself is not a major complication. They argue that, to
classify a cautious strategy of resorting to laparotomy if the laparoscopic approach poses risk,
as a major complication therefore runs the risk of dissuading surgeons from converting
appropriately and in a timely manner. In addition, it may open the way for complaints and
litigation should a laparotomy be required. The cause of conversion, not the conversion itself,
may be the major complication.
Indeed a conversion to a laparotomy may be due to a complication, to deal with a
complication or to avoid complications at all. There are differing views on an unintended
laparotomy; while some would consider it not to be a complication others would regard it a
complication mainly due to relative inexperience of the surgeon. In the eValuate trial [23], the
large difference in the complication rate between the LH and AH is largely explained by the
number of complications which was the second most common major complication. This study
had 45 (3.9%) unintended laparotomies, but 32 out of the 45 reported laparotomies had no
other major complication other than the unintended laparotomy. It is relevant to mention that
the eValuate trial was criticised because of the relative inexperience of some surgeons
participating in the study since only 25 procedures were needed prior to entry into the study
and the surgical procedures were not standardized [29].
The NICE guidance [22] on laparoscopic techniques for hysterectomy states that based
on a systematic review and meta-analysis of six RCTs including 842 women comparing
laparoscopic techniques for hysterectomy with vaginal hysterectomy, there was no significant
difference in the need for unintended laparotomy (odds ratio 1.55, 95% CI 0.75 – 3.21). In a
non-randomised controlled trial, the conversion to laparotomy seen in 7% (82/1242) of the
laparoscopic hysterectomy group. In a series on LSH, the conversion to laparotomy rate was
0.83% (14/1692). Another TLH case series reported an unintended laparotomy rate of 2.79%
(46/1647).
Operating Time
Operating time is not always a reliable indicator of the surgeon‘s technical capability, it is
also influenced by the complexity if the case, the familiarity of the assistants and nurses with
the procedure, the time required for resident teaching and the availability of equipment [32].
Harkii Siren [18] showed that the operating time was reduced to a half after 80
procedures and a plateau was achieved after 60 operations, compared with the Belcohyst
study, where a plateau was seen after 40 procedures [33].
The Cochrane review [5] suggests that the operating time overall is longer for LH versus
AH or VH. LAVH had a significantly shorter operating time than TLH indicating that when a
larger proportion of the procedure is performed laparoscopically, the operating time
lengthens.
Obesity
Obesity is sometimes considered a contraindication for LH but Chopin et al [10] showed

that obese and overweight patients could have LH without an increased risk in complications
but operating time was longer. Furthermore, laparoscopic surgery in obese women permits
incisions above the panniculus.
Long Term Complications
The Cochrane review [5] identified that there was a dearth of evidence comparing long
term outcomes in RCTS comparing surgical approach to hysterectomy, namely urinary,
bowel and sexual dysfunction, chronic pelvic or abdominal pain, vaginal prolapse as well as
fistulae. Johnson et al [6] in a systematic review in 2005 found no significant differences in
fistula formation, urinary dysfunction, sexual dysfunction, or patient satisfaction between
surgical approaches, although for most of these outcomes the analyses were underpowered to
detect important differences and data were not reported in trials for many important long term
outcomes.
Conclusion
When a new surgical technique is introduced, it is always a challenge to learn it without
causing harm to patients. Patients´ expectations are also high and the threshold for complaints
is quite low when it comes to minimal access surgery and they easily seek compensations if a
complication occurs. Whereas, a similar injury occurring during open surgery is accepted as
inevitable.
The laparoscopic surgeon has to deal with his own learning curve, the challenges of
rallying support for laparoscopic surgery amongst staff, and hospital managers as this time
consuming and expensive surgery is often disliked by theatre nurses and managers due to
prolonged theatre utilisation times. It is imperative to note that laparoscopic surgery involves
a team effort. An adequately trained assistant and an experienced scrub nurse could make a
laparoscopic procedure a safe and relatively quick procedure. The opposite is also very true.
The evidence suggests that with adequate training and in experienced hands, laparoscopic
hysterectomy is a safe procedure than can effectively reduce the number of abdominal
hysterectomies. Ongoing training is essential as well as reflective practice and audits to
20 Hassan Morsi
identify complication and conversion rates. Promoting training in laparoscopic surgery will
increase awareness among trainees and the current financial system is already creating a more
favourable environment where there is a demand for quicker patient turnover. This will
hopefully help boost the demand for laparoscopic surgery.
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Gynecological Laparoscopists, 9, 339-45.
[26] Makinen, J; Johansson, J; Tomas, C; Tomás, E; Heinonen, PK; Laatikainen, T; Kauko,
M; Heikkinen, A-M; Sjöberg, J. (2001) Morbidity of 10 110 hysterectomies by type of
approach. Human Reproduction, 16, 1473-8.
[27] Altgassen, C; Michels, W; Schneider, A. (2004) Learning laparoscopic-assisted
hysterectomy. Obstetrics Gynecology, 104, 308-313.
22 Hassan Morsi
[28] Kreiker, GJ; Bertoldi, A; Larcher, JS; Orrico, GR; Chapron, C. (2004) Prospective
evaluation of the learning curve of laparoscopic-assisted vaginal hysterectomy in a
University hospital. Journal of American Association of Gynecological Laparoscopists,
11, 229-235.
[29] Claerhout, F; Deprest, J. (2005). Laparoscopic hysterectomy for benign disease. Best
Practice and Research Clinical Obstetrics and Gynaecology, 19, 3, 357-375.
[30] Leonard, F; Chopin, N; Borghese, B; Fotso, A; Foulot, H; Coste, J; Mignon, A;
Chapron, C. (2005) Total laparoscopic hysterectomy: preoperative risk factors for
conversion to laparotomy. Journal of Minimally Invasive Gynecology, 12, 312-317.
[31] Atkinson SW. (2004). Results of eVALuate study of hysterectomy techniques. British
Medical Journal, 328, 642.
[32] Cheung, V; Rosenthal, D; Morton, M; Kadanka, H. (2007) Total Laparoscopic
Hysterectomy: a five year experience. Journal of Obstetrics and Gynaecology Canada,
29, 337-343.
[33] Deprest JA, Cusumano PG, Donnez J, Hardy A, Nisolle M, Van Herendael J, Verly M,
Koninckx R. (1996). 1992 results of the Belcohyst register on laparoscopic
hysterectomy. In: Cusumano PG, Deprest JA, eds. Advanced gynecologic laparoscopy:
a practical guide.1st ed. London: The Parthenon Publishing Group: 85-98.
Chapter 2
Hysterectomy: Procedures,
Complications and Alternatives
M. Gurrea*, S. Domingo and A. Pellicer

Department Obstetrics and Gynecology. Hospital Universitario La Fe.
Avda Campanar 21, Valencia, Spain
Keywords: hysterectomy, laparoscopic, vaginal, abdominal, guidelines, benign uterine

diseases.
Abbreviations
Abdominal hysterectomy (AH)
Vaginal hysterectomy (VH)
Laparoscopic hysterectomy (LH)
Quality of life (QoL)
American College of Obstetricians and Gynecologist (ACOG)
Society of Pelvic Reconstructive Surgeons (SPRS)
Laparoscopic assisted vaginal hysterectomy (LAVH)
Uterine vessel ligation laparoscopic hysterectomy (LH(a))
Total laparoscopic hysterectomy (TLH)
Subtotal hysterectomy (STH)
Levonorgestrel-releasing intrauterine device (LNG-IUD)
Introduction
Hysterectomy is, after cesarean delivery, one of the most common surgery performed in
women, and together with cholecystectomy and appendicectomy, is the most frequent intra-
*
Tel: +34 963 862 700 – ext. 73035, E-mail: martagurrea@gmail.com
24 M. Gurrea, S. Domingo and A. Pellicer
abdominal surgery. Many gynaecologic surgeons continue to perform hysterectomies by

means of a laparotomy, while cholecystectomy is almost always performed through
laparoscopic surgery [1]. Many women‘s health institutions [2] recommend avoiding
laparotomy, and advise abdominal hysterectomy (AH) only when the vaginal or laparoscopic
route is ruled out. We may ask ourselves why practice sometimes tends to go against this
consensus. Vaginal surgery offers great potential in terms of access to the uterus, and fulfils
all the criteria for minimal invasive surgery, as it employs a natural orifice, thereby avoiding
an abdominal scar. The vagina becomes a new trocar port-site, permitting uterine
manipulation, pelvis dissection and easy removal of the specimen. Vaginal hysterectomy
(VH) is the safest route and has the best cost-effective ratio, making it the first choice option
in clinical practice. When any contraindications is presented or any difficulties are expected,
vaginal surgery should be performed with the aid of laparoscopy when necessary or using it
throughout the entire intervention, according to the professional opinion of the surgeon.
Though AH is not currently contraindicated, there are now sufficient surgical resources for it
to be relegated to the end of the list of options. Scientific evidence favours VH and
laparoscopic hysterectomy (LH), which have lower complication rates, produce less post-
operative pain and shorter hospital stays and allow a more rapid return to normal activity,
thereby resulting in a better quality of life (QoL) [3,4, 5]. Laparotomy continues to be the
preferred method for hysterectomy in approximately 60-70% of benign uterine processes [1].
The hysterectomy rate is showing a slight change in favour of HV rather than LH, though it
comes no way near the estimated 80-90 % of hysterectomies that could potentially be
managed with a minimal invasive approach. Unfortunately, the decision to adopt the surgical
route evidently depends more on the skill of the surgeon than the advantages this technique
may have for the patient. In this chapter we intend to assess the options available when
considering a hysterectomy and to establish the most appropriate indications for its
recommendation, to consider the alternatives to hysterectomy and to analyze the different
surgical techniques and their routes and their complications.
Indications
There is considerable variation in policy concerning hysterectomy in health care centres
and gynaecological programs. Although hysterectomy rates in Western countries are
diminishing thanks to a general more conservative approach, this operation is still widely
performed [6]. However, rates differ considerably between countries, ranging from a high of
5.4 per 1000 women in the USA [7] to intermediate rates such as 3.7/1000 in Italy [8], to a
low of 1.2/1000 in Norway [9]. The hysterectomy rate in developing countries is lower. The
incidence rate has dropped approximately 1 ‰ every decade since 1980 [10, 11, 12, 13, 14].
It is estimated that the hysterectomy rate in hospitals in England and Scotland has fallen 25 %
since 1998; even so, almost 20 % of women in these countries will have a hysterectomy by
the age of 55 years [201].
The conditions that may lead to a hysterectomy cause discomfort and inconvenience
rather than threaten life. The diversity of symptoms can have an immense influence on a
woman‘s QoL, affecting aspects of her daily routine, general health and sense of well-being
Hysterectomy 25
[15]. In most women that suffer gynaecological disorders, QoL improves following a
hysterectomy.
Moreover, this surgery does not tend to produce any psychological disturbances in
otherwise psychologically healthy women. In this way, most women undegoing this operation
regain a so-called normal life. Menorrhagia is the most frequent cause for hysterectomy in
pre-menopausal women, with myomas and adenomiosis constituting the leading pathologies
of the uterus. There is a 20% to 25% incidence of uterine fibroid tumour in women of fertile
age [16], but fortunately these are ususally asymptomatic.
If a surgical approach is to be adopted, the reproductive desire of the patient must be
taken into account. Thus, a conservative myomectomy should be the first recommendation in
women without children and who are still capable of becoming mothers. If there is no
intention of preserving fertility, hysterectomy is a definitive solution, unless other more
conservative treatments can be offered, such as the levonorgestrel intrauterine device.
Other indications for hysterectomy are pelvic pain, mainly caused by
endometriosis/adenomiosis. Both these conditions can usually be managed with analgesic
drugs (non-steroides anti-inflamatory, paracetamol) and anovulatories, but if necessary,
surgery of the adnexa (endometrioma) is indicated. A hysterectomy may be proposed when
more than one pathological circumstance is present.
Uterine prolapse is also a common indication for hysterectomy, as usually it cannot be
managed in a conservative manner. Hysterectomy is recommended unless a uterine-sparing
desire is expressed, and accounts for 10 % of the global rate of surgery. Vaginal surgery is the
usual approach in the pelvic floor disorders, although it may be managed laparoscopically.
Malignancy and post-partum haemorrhage are less frequent indications, and account for only
10% of the total rate of hysterectomies.
Hysterectomy and Bilateral Salpingoophorectomy
Hysterectomy does not modify the risk of mortality from cardiovascular disease or cancer
[17] but should be adequately evaluated in case of a concurrent bilateral oophorectomy,
which is a considerably common situation among women.
Many surgeons remove the ovaries in order to avoid a hypothetical ovarian cancer
without giving sufficient thought to the impact it may have on the woman‘s health or its cost-
effectiveness. Some years ago, it was estimated that 7.1 % of future deaths would be
prevented in the future by concurrent salpingo-ophorectomy, mainly due to avoiding the risk
of ovarian cancer [18].
An age limit for was set at 45 years old for carrying out this procedure while performing
a hysterectomy. However, the evidence regarding this practice is inconclusive, as many
contradictory results have been reported.
Indeed, several studies have detected a reduced risk of ovarian cancer after hysterectomy
and without bilateral oophorectomy! [19, 20]. Current scientific evidence suggests that
elective oophorectomy is not advisable for the majority of women, as it may lead to a higher
risk of death from cardiovascular disease and hip fracture, and a higher incidence of dementia
and Parkinson‘s disease [21]. Recently it has been concluded that preserving ovaries until at
least 65 years was associated with higher survival rates [22,23].
Procedures
The American College of Obstetricians and Gynecologist‘s (ACOG) guidelines for
hysterectomy are probably the most widely accepted and most employed of those found in the
literature. The most determinant factors for choosing one or another via are surgeon skill,
uterus size, uterine mobility, nulliparity, and previous pathological conditions.
Surgeon Skill
Age, parity, uterine size, vaginal anatomy, pelvic mobility and any pelvic disease or
previous pelvic surgery are among the most important factors to take into account when
considering a hysterectomy. Yet, an even more important aspect is the quality of the
surgeon‘s training with respect to the different possible approaches. This is why continuous
training programmes must be offered to residents and gynaecologic surgeons with the
intention of developing effective guidelines for the determination of the route of hysterectomy
in every medical centre. Many publications confirm that route indication may change when
guidelines are consulted; up to 90 % of hysterectomies are performed vaginally when a
consensuated guideline is applied, reversing the abdominal /vaginal procedures to a ratio of
1:11 [28]. Each center should examine its own AH/VH ratios as a quality assistant index. This
dramatic change requires a learning curve, and that of the laparoscopic technique is more
difficult and longer than that of the vaginal. In 5 years, a VH rate of 95% could be achieved in
some centres in the United Kingdom, where only 32% of hysterectomies have until now been
performed via the vagina [29]. This highlights the strong economic argument for VH in
medical centres and confirms that the major determinant of hysterectomy route is not clinical
circumstances but rather the professional preparation of the surgeon. Appropriate practice
guidelines are needed to reduce inconsistencies in the indications for AH and VH.
Unfortunately, almost all teaching programmes focus more on AH rather than VH or LH.
Uterine Size
The ACOG and other authors assert that VH should be indicated in women with mobile
uteri <12 weeks gestational size (approximately 280 g) [203], maintaining that the contrary
can represent a handicap for surgeons. Randomized studies that compare the advantages,
disadvantage, and outcomes of AH and VH for enlarged symptomatic uteri between 200 and
1300 g have clearly demonstrated the advantages of the vaginal route in terms of operative
times, febrile morbidity, less demand for narcotics, and reduction of hospital stay [30].
Uterine size reduction is usually the principal problem confronting surgeons, and morcellation
technique skills are a limiting factor. The mechanical difficulties and the higher risk of
complications during morcellation are common contraindications of vaginal hysterectomy
and an indication for abdominal hysterectomy for many gynaecologic surgeons not trained in
the technique. Uterine morcellation techniques (such as coring, corporeal bisection and wedge
morcellation) are safe and facilitate vaginal removal of a moderately enlarged uterus without
increasing perioperative morbidity [31, 32, 33].
Hysterectomy 27
Uterine Mobility
This is another of the relevant factors in determining the route of a hysterectomy. A

vaginal route is usually indicated in cases of vaginal prolapse (stage ≥1), a wide vaginal apex
and a bimanual pelvic palpation presenting a non-adhered uterus. Occasionally, a pelvic
examination under anaesthesia is required prior to determining if vaginal access is possible.
Pathological Condition
Uterine prolapse is one of the most usual indications for hysterectomy. Although a
laparoscopic approach is feasible in such circumstances, VH with a Mc Call culdoplasty is the
standard treatment. Other situations should be atemped vaginally once malignancy has been
ruled out, such as cervical carcinoma in situ or abnormal uterine bleeding. Even if an
endometrial carcinoma is detected, the vaginal route may be possible, with a vaginal
adnexectomy being performed if lymph node dissection is not indicated (low risk of
endometrial carcinoma). Moreover, in cases of malignancy and poor patient clinical outlook,
a VH should be the first option, as it allows a loco-regional anesthesia to be administered. A
myomatous uterus is one of the most controversal indications for VH. Uterus shape is
probably more relevant than uterus size, as multiple myoma can be easier to remove than a
single myoma located above the round ligament. An ultrasound scan should assess the exact
location of the fibroids and their size. If the clinical history or pelvic examination indicates
possible extrauterine disease or adhesions (endometrosis, pelvic inflammatory disease,
ovarian disease, previous pelvic surgery, caesarean delivery), a laparoscopy should be
performed. This allows the pelvic pathology to be treated correctly and can be of assitance in
performing or finalizing the hysterectomy. Laparoscopic scoring systems have been designed
to document the severity of extrauterine pathologic conditions [34].
Nulliparity
Nulliparity usually leads to VH being ruled out, as a general consensus among health
professionals. On the other hand, there are no differences in the complication rates of AH and
LH in nulliparous women [35, 36]. The lack of cervical descent represents a problem when
performing VH. The main supports of the uterus are the uterosacral and cardinal ligaments.
When the vaginal route is chosen these ligaments are easy to identify and hold on to, and are
the first structures to be dissected, even in nulliparous women. When they are sectioned, the
uterus gains mobility, thus making the procedure easier.
Technique Characteristics
Three main types of hysterectomy are now used—abdominal, vaginal, and laparoscopic.
But the most important issue in the approach to these surgeries is not the technique per se, but
the guidelines in the clinical decision-making process. The SPRS practice guidelines comply
with recommendations of the ACOG which indicate that the route of hysterectomy should be
based on surgical indication, the patient‘s anatomic condition, relevant data, informed patient
preference, and the surgeon‘s training and experience. However, in reality physicians are
expected to adopt evidence-based practice guidelines that are cost-effective and defined by
outcomes rather than physician preference or experience.
Abdominal Hysterectomy
In benign conditions, AH should be adopted only when pathological circumstances and

the patient‘s characteristics preclude the vaginal/laparoscopic route [2, 37, 38, 39]. The
hysterectomy via abdominal route has traditionally been chosen when the uterus was too big
(> 12 wks) or the vagina too narrow, when there was little or no uterus descent and when
severe intra-abdominal conditions were suspected due to previous pelvic surgery (caesarean
section included), adhesions, endometriosis or adnexal disease. It is essential that all these
circumstances are evaluated, but in reality many of them have never been sufficiently
analyzed [1,203]. Fortunately, since the arrival of laparoscopic surgery, the majority of these
vaginal contraindications can be resolved with laparoscopy. Thus, previous pelvic surgery or
any extrauterine disease (adhesions, adnexal pathology) no longer pose a problem to less
invasive routes. When VH is not possible, LS is preferable to abdominal hysterectomy,
though it involves a higher chance of bladder or ureter injury, usually related to the learning
curve [40].
Vaginal Hysterectomy
VH should be the standard procedure for removing the uterus in most of the patients [32,
41, 42]. A significantly speedier return to normal activities and other improved secondary
outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile
episodes) endorse vaginal hysterectomy as a preferable option to AH, whenever possible [40].
Surgical morbidity and associated morbidity are much lower with VH than with AH
(3.2% and 0.9% vs 6.2% and 4 %, respectively) [43]. In a randomised controlled trial
comparing the three methods of hysterectomy, the abdominal technique required an extra day
in hospital and an extra week of convalescence. VH was also regarded to be the most cost
effective of all three types of surgery [44]. Furthermore, VH is the best approach for obese
patients and elderly patients with co-morbidity.
Currently, a real ratio of VH/ AH varies between 1:3 and 1:4 or less, depending on the
country, but as explained previously, the adequate training of medical teams could turn this
ratio around to 1:8-1:15 [25, 45, 46].
Previous pelvis surgery, usually in the form of a caesarean section, does not preclude the
vaginal route. Obviously, in this situation, the major concern is the risk of injury to the
bladder and the difficult entry into the peritoneum through a scarred anterior pouch. An
examination under anaesthesia and a diagnostic laparoscopic can help to clarify such doubts
surrounding the most appropriate indication for surgery.
VH involves two important and sometimes difficult technical steps: entrance through the
peritoneum into the two vaginal cul de sacs and examination of all the uterine attachments.
The performance of bilateral salpingo-oophorectomy and uterus morcellation are further
Hysterectomy 29
procedures that may need to be performed. Bilateral salpingo-oophorectomy is usually a

contraindication for VH, as it can be technically difficult, especially in post-menopausal
women. However, it can be successful if the correct technique is employed. In order to
provide easy access to the infundibulo-pelvic ligament, the round ligament above the broad
ligament must be separately clamped, cut and ligated as far away from the uterus as possible.
A specially devised clamp (Sheth‘s adnexa clamp or similar) is applied above the round
ligament stump to include the full length of the infundibulo-pelvic ligament. Other systems
can be employed if anatomical difficulties are present, including the endoloop suture, a
modern sealing systems... In a prospective study that evaluated oophorectomies performed
during VH, a 97.5% success rate was achieved using these techniques [47]. Uterus
morcellation can be a challenge, often because of inappropriate techniques [Figure 1]. The
ACOG‘s 1989 guidelines for choosing the appropriate route for a hysterectomy state that the
choice ―depends on the patient‘s anatomy and the surgeon‘s experience‖ and that the
operation is usually accomplished in women with mobile uteri not larger than that at 12
weeks of gestation (280 g) [30,39]. As the normal size of a uterus is < 12 weeks gestation, it
is usually enough to simply pull in order to deliver it. However, although a uterus > 13 weeks
gestation can also be easily removed through the vagina, the procedure can be complicated.
To overcome these problems, various complementary methods have been described that
permit progressive reduction of the volume of the uterus during surgery, such as
myomectomy, morcellation, corporal bisection and intramyometrial coring [Figure 2]. Once
uterine arteries have been sutured, blood supply to the uterus is dramatically diminished
(approximately 75-80%), allowing a safe morcellation without blood loss [48, 49]. Successful
large uterus VHs (> 1000 g) have been reported employing these techniques [32]. Unger [50]
reported that vaginal removal of large uteri (200- 700 g) with respect to uteri of volume <200
g is not associated with an increase in complications or length of hospital stay, but only with
the duration of the operation, which increases directly in proportion to uterine weight. In
recent years, several authors have combined VH with laparoscopic assistance in such
circumstances without observing any advantages over the standard vaginal route [41].
Laparoscopic Hysterectomy
The role of LH remains difficult to define, in spite of the extensive scientific evidence
available. Its ultimate aim is to reduce the rate of AH rather than that of VH. Initially,
laparoscopy management was devised in order to assist VH in the case of absolute/relative
contraindications such as adhesion, caesarean scars, adnexectomy and lymphadenectomy.
However, a complete laparoscopic performance of the hysterectomy has evolved over time.
LH shortens hospital stay, induces less postoperative pain and allows quicker recovery, all at
the expense of a longer operation time [51]. LH carries a higher risk of injury to adjacent
organs, but may be cost-effective, despite higher direct costs, because of the shorter hospital
stay and quicker recovery.
One of the most important ―advantages‖ of the introduction of laparoscopic surgery into
gynaecology training is that it increases surgeons‘ confidence and their vaginal surgery skill,
making vaginal hysterectomy a more feasible option. This has played an important role in
reducing the number of abdominal hysterectomies, as many surgeons feel more comfortable
taking the vaginal route.
In LH, at least part of the operation is performed laparoscopically [52]. This method
requires a longer learning curve and greater surgical skills than the vaginal and abdominal
methods. The rate of hysterectomies performed laparoscopically is gradually increasing due
to the advantages it affords. It allows a clear view of all pelvic and abdominal structures and
facilitates pelvic disease management (adhesions, endometriosis). In addition, it can be of
assistance in adnexal surgery and in checking for pelvis haemostasis once surgery has
terminated, and it is characterised by less pain and a rapid recovery time [53].
The wide variety of techniques employed makes it difficult to carry out a relevant
comparison of different reports (or even the results of the same study). As the laparoscopic
technique has many particularities, a simple classification has been proposed by which three
subcategories are distinguished [52, 54]. The laparoscopic assisted vaginal hysterectomy
Hysterectomy 31
(LAVH) is performed partly laparoscopically and partly vaginally, but the laparoscopic
component does not involve uterine vessel ligation. In uterine vessel ligation laparoscopic
hysterectomy (LH(a)), although the uterine arteries are managed laparoscopically, a part of
the operation is performed vaginally (vaginal suture, colpotomy...). In total laparoscopic
hysterectomy (TLH), the whole operation is performed laparoscopically, thus requiring great
endoscopic surgical skill.
Endometriosis is one of the major indications for LH, as the technique makes it easier to
remove peritoneal or adnexal endometriosis implants by means of different systems (excision,
coagulation, vaporization). Endoscopy offers the surgeons a magnified view of the pelvis,
with close-up images of the pouch of Douglas, ovarian fossa and visceral and parietal
peritoneum that are much clearer than those obtained during a laparotomy.
A large uterus is another indication for laparoscopy, as uterine fibroids are a common
relative contraindication for VH. Although vaginal morcellation can be achieved with the
previously mentioned techniques, it also can be performed laparoscopically with modern
laparoscopic morcellators. This management approach can be slow, but it is efficient and safe.
As expected, LH has been extensively analyzed and compared with other techniques. The
literature contains four randomized control trials comparing VH with LH [37, 55, 56, 57]. LH
was constantly associated with longer operation times than VH, but with no differences in
hospital stay, postoperative pain sensation or postoperative recovery. Twelve RCTs compared
LH to AH [3, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67], and all confirmed the advantages of
the former, describing similar overall complications but less blood loss, fewer transfusions,
less pain, shorter hospital stays and lower levels of disability and better QoL. One of the
disadvantages of LH was the longer operating times reported for the endoscopic procedure
[68, 69,70]. When endoscopic skills are adequate, TLH can be quicker, more efficient and
associated with less blood loss than LAVH, particularly in nulliparous or obese patients [
71,72]. Although not strictly necessarily, one of the more important steps of this technique is
the use of an intrauterine manipulator, which mobilizes the uterus in all directions so as to
create space in the working field and facilitate dissection and colpotomy. This instrument
significantly reduces the operating time and complication rate (usually vesical and ureteral
injury), and permits a more reproducible technique. Uterine manipulators should not be
employed in cases of endometrial malignancy, as it can increase the hypothetical risk of
vaginal relapse [73].
The learning curve is also a relevant factor in LH. This is a difficult aspect to study, and
is usually discussed in terms of operation time, conversion and complication rate. The
aforementioned laparoscopic skills of the surgeon determine the length of the curve. A The
Finnish registry demonstrated that the experience of the surgeon was directly related to the
occurrence of major complications; it highlighted that, after 30 LHs, bladder and ureter
injuries were much less frequent [74].
There are no absolute contraindications for laparoscopy, and relative circumstances are
usually related to general anesthesia and hypothetical problems in the abdomen entry. Morbid
obesity (body mass index > 30) is often a challenge when establishing the
pneumoperitoneum. Previous abdominal scars, especially midline incisions, increase the risk
of abdominal adhesions and can make abdominal entry and surgery difficult, leading to a
major incidence of bowel lesions. In the majority of cases, uterine size is not a
contraindication, as modern endoscopic morcellation facilitates removal of the uterus. A more
transcendental aspect is uterine mobility, as a fixed uterus is a challenge to the laparoscopic

approach and to any route.
Robotic Surgery
Robotics is a new step in laparoscopy and LH, and has been implanted in many centres
since 2001. It offers all the benefits of the laparoscopic approach with several key differences:
the instruments constitute an articulating wrist that mimics the movements of the human
hand, it affords 3-dimensional vision, and the usual hand trembling when performing delicate
movements is avoided. The 7 degrees of freedom of the articulating wrist make it easier to
work in the deep pelvis, and it performs perfect movements when suturing, excising and
reconstructing tissue. Little evidence concerning robotic hysterectomy has been published to
date, but reports that favour this approach are beginning to appear [75, 76]. This approach
offers the patient another minimally invasive option in addition to laparoscopy or vaginal
hysterectomy.
Complications
The two fundamental aspects to be considered when studying hysterectomy
complications are surgical and functional.
Surgical Complications
The three types of hysterectomy have been compared in terms of complications. In the
most recent meta-analysis [40], urinary tract injury was significantly higher in LH than AH
(odds ratio 2.61), while no significant differences were found in LH vs VH (odds ratio 1) or
TLH vs LAVH. No significant difference was observed between other intra-operative visceral
injuries (bowel, vascular) as a result of the surgical approaches.
The abdominal approach has constantly been related to a higher incidence of febrile
episodes and wound infections. Although no differences have been reported with respect to
blood transfusion, LH has been associated with a smaller drop in haemoglobin and blood loss.
As previously discussed, AH involves the longest hospital stay of all hysterectomy routes,
while VH and LH require similar in-patient convalescence. When analyzing operation time,
the laparoscopic approach is more time-consuming than AH (mean difference 18 min) and
VH (mean difference 44 min). The operation time of LAVH was significantly shorter than
that of LH (mean difference 23 min) [40].
Impact on Pelvis Floor Dysfunction
Recent robust studies suggest that significant postoperative morbidity due to pelvic organ
dysfunction is not common after total hysterectomy (TH). When performing a hysterectomy,
Hysterectomy 33
anatomical relationships are disrupted and local nerve supply of the pelvic organs (bladder,
rectum) is damaged, the latter of which is more frequent in radical hysterectomy. Obviously,
these complications can alter pelvic organ function and support. These adverse effects tend to
be less serious after subtotal hysterectomy (STH). In fact, this surgery was promoted in the
80‘s-90‘s, as it was thought to improve sexual function [77, 78]. The Maryland Women‘s
Health study, the largest prospective study to date, investigated the effects of hysterectomy
with and without concomitant urinary incontinence repair on incontinence severity [79].
Interestingly, they found that most women with severe and moderate urinary incontinence
before hysterectomy noted an improvement 1 year after surgery and further improvement at 2
years, but women with no incontinence before hysterectomy had new-onset incontinence 1
year after surgery (17%). Indeed, hysterectomy reduced previous urge-frequency symptoms,
and new symptoms were observed in only 4% of cases at 1-year follow-up. In the face of
these contradictory results, randomized studies comparing TH and STH [80, 81] have
concluded that simple hysterectomy does not adversely affect urinary function, and may even
lead to improvement. Furthermore, STH has been shown not to confer any benefits over TH
in terms of bladder function.
There is no evidence that hysterectomy produces bowel dysfunction or exerts a negative
influence on sexual function. Recently, a systematic review of sexuality after hysterectomy
concluded that research in this area was largely retrospective and lacked valid outcome
measures [82]. Most studies have shown either no change or an enhancement of sexuality
following hysterectomy. Even when compared with more conservative management
(endometrial ablation), no differences have been found [83]. Conservation of innervation
when performing a STH may improve sexual intercourse, but there have been no reports of a
difference in the frequency of intercourse or orgasms when TAH and STH are compared. In
fact, one study reported a significant increase in the frequency of intercourse and a decrease
in dyspareunia following hysterectomy [84], the latter of which has been confirmed by more
recent evidence [80]. This suggests that the cervix per se does not play a major role in sexual
response.
A hysterectomy is one of the most influential factors in genital prolapse. The incidence of
vault prolapse following this operation is substantial, at between 0.2 and 43% [85]. It occurs
more frequently when the vaginal route (10%) is preferred to the abdominal (2%). Indeed, the
former approach is frequently associated with some grade of prolapse [86]. However, an in-
depth analysis reveals that VH per se is not a risk factor for vault prolapse [87]. This
condition is normally due to the formation of an enterocele after a hysterectomy, which
begins as a small intestine hernia that progress to the vagina. A McCall‘s culdoplasty should
always be performed in these circumstances, as it strengthens DeLancey Level I and avoids
this physiopathological mechanism.
Alternatives
The indications for hysterectomy discussed above are not universally accepted, as other
conservative approaches may be considered first. Current alternatives are so effective that
they have had a direct bearing on the negative tendency in hysterectomy rates. Medical
treatments can be considered as a first step in the management of menorrhagia. They can
reduce the growth of uterine volume and stop hypermenorrhea and menstrual bleeding prior
to surgery. However, they tend to be only temporarily effective, and often have important side
effects. Other more conservative alternatives that can be offered include endometrial ablation,
the progestin intrauterine device, myomectomy and uterine embolization.
Medical Approaches
Sexual steroids are widely used for controlling uterine bleeding. Oral oestro-progestin
combinations or even progestin alone exert a great control over menorrhagia and
dysmenorrhea, but their efficacy is short rather than long-term [88].
Gonadotropin-releasing hormone agonists can lead to amenorrhea and a diminishment of
myoma size in 35-65% of cases within 3 months of treatment, thereby creating a menopause
status in the short-term. However, the significant menopause symptoms (vasomotor effect,
negative impact on bone density) and the gradual recurrent growth of myomas associated
with cessation of treatment rule out the long-term use of this drug [89].
Mifepristone, an antiprogesterone agent, has proved its usefulness in controlling the
symptoms of leiomyoma [90]. Several studies of highdose mifepristone have reported a
reduction of leiomyoma volume of 26–74%, which is comparable to that achieved with
analogues. Alhough amenorrhea is a common adverse effect, no negative impact on bone
mineral density has been demonstrated, while the presence of de novo endometrial
hyperplasia and elevation of transaminase levels are the most frequent side effects [91].
Further studies are required for this agent to be included in the medical algorithm treatment of
menorrhagia.
Myomectomy
Myomectomy is one of the most effective options for when aiming to spare fertility.
Although a surgical approach, the risks it represents are similar to those of hysterectomy [92].
It is a safe and effective treatment of menorrhagia, with a resolution rate that has reached 80%
[93]. The recurrence rate of leiomyoma is estimated at 11% 1 year after surgery and up to 80
% after 8 years. The reoperation rate is lower, at 6.7% at five years and 16 % at 18 years [94],
with a definite hysterectomy rate of around 10% [95]. One of the risks that must be assumed
with this approach is a unexpected hysterectomy due to surgical complications, in particular
intraoperative bleeding.
In the past, myomectomy has usually been performed abdominally, but nowadays a
laparoscopic / hysteroscopy is feasible [96]. Due to the complex nature of dissection and
suturing, a high grade of surgical skill is required.
Hysteroscopy constitutes another endoscopic method of myoma management, and has a
good outcome when these are submucous. Myomas are the cause of about 10 % of uterine
bleeding and pain, and are successfully removed in a high percentage of cases with this
technique (85-95%) [97]. As with abdominal/laparoscopic myomectomy, secondary surgery
is required in approximately 5-15% of cases. Effectiveness decreases over time, with a
Hysterectomy 35
success rate of 76% at 5 years follow-up, and other procedures, such as endometrial ablation,
are often necessary [98].
Endometrial Ablation
Several new technologies may reduce the need for hysterectomy, and among them
endometrial ablation is currently one of the most employed. We can distinguish between two
methods of this technology: selective and non-selective.
Selective methods include endometrial resection with a urological type resectoscope, a
rollerball or laser ablation. All require previous endometrial preparation in order to diminish
the thickness of the endometrium, usually with a gonadotropin-releasing hormone agonist.
Observational studies and randomised trials have not found differences between the clinical
outcomes of the different techniques employed [99, 100, 101]. Generally, these outcomes are
positive, with high satisfaction rates (approximately 75%) and quality of life measures and a
positive balance in post-treatment haemoglobins being reported [99]. This approach has been
compared with hysterectomy in randomised trials, yielding better outcome in operating time,
hospital stay, and direct costs [102, 103].
These treatments are known as first-generation endometrial ablation techniques, which
distinguishes them from the wide range of new methods for removing or destroying the
endometrium more rapidly and safely [104]. They do not depend heavily on the skill of the
surgeon, on the contrary to selective methods, which explains the positive development of
these new technologies [105]. Many non-selective ablation techniques have been developed.
In short, a thermal probe is introduced inside the uterine cavity in order to raise the
endocavity temperature sufficiently during a short interval (10-15 minutes) during which the
endometrial tissue is destroyed. This procedure can also be performed with a frozen probe. A
recently updated Cochrane review on endometrial destruction techniques concluded that
efficacy and user satisfaction with the first- and second-generation endometrial destruction
techniques are similar [106]. It is expected that in the future they will be used in day-out
protocols with a similar efficacy as that of selective endometrial procedures and at a lower
cost.
However, hysterectomy produces significantly better patient satisfaction rates than
endometrial ablation. How can this be explained? One of the problems of ablation is the need
for further surgical intervention with time. It is estimated that 15% of cases undergo a second
endometrial ablation within 5 years, while 20% of patients eventually undergo a
hysterectomy, both of which increase the direct cost of the process, thus calling into question
the real efficacy of the procedure [107, 108, 109].
Levonorgestrel-Releasing Intrauterine Device

(LNG-IUD)
LNG-IUD is one of the most important advances in the conservative management of
menorrhagia. Its simplicity, efficacy and patient security offer a very attractive alternative to
patients with hypermenorrhea, with or without myomas or adenomiosis. This device releases
levonorgestrel over a period of 5 years through a rate-limiting membrane (20 µg/day). In

addition, it is probably the best reversible contraception method, with a Pearl index of 0.11.
Its mechanism works by inducing an endometrial atrophy, with an average reduction in
menstrual blood loss of 90% over 6 months [110], and with 20% to 50% of patients
experiencing amenorrhea in the first two years after insertion [111]. Its benefits on quality of
life are evident and its outcome has been compared to that of hysterectomy, producing the
same improvement in health-related quality of life at 12 month follow-up at less than a third
of the cost [112]. Meta-analysis of trials comparing LNG-IUD with first generation
endometrial ablation techniques have shown that satisfaction rates are similar, despite the
former producing a smaller reduction of blood loss and lower amenorrhoea rate [113]. In this
way, LNG-IUD is probably the best of the conservative approaches to treat menorrhagia
[110].
In spite of the abovementioned evidence, medical therapy (progestins, anovulatories) is
sometimes preferred as an economical option in the treatment of menorrhagia. However, the
costs associated with long-term use of oral therapy can be surprisingly high, while LNG-IUD
has been shown to incur the lowest cost among available therapies [114]. That said, in many
countries oral progestins continue to be the most frequently prescribed medical therapy for
menorrhagia [115].
Uterine Artery Embolization

Transcatheter bilateral uterine artery embolization is a relatively new conservative
treatment of symptomatic myoma but one that is rapidly becoming common. The procedure is
performed under local anesthesia or sedation, and an angiography catheter is guided
percutaneously via the patient‘s femoral artery into the ipsilateral or contralateral uterine
artery. Particles of polyvinyl alcohol (PVA) 300-500 μm are injected in boluses until blood
flow has ceased. The catheter is then withdrawn from the uterine artery and the procedure is
repeated with the contralateral uterine artery [116]. Randomized trials regarding the efficacy
of uterine artery embolization are yet to be reported. Reduction of uterine and myoma size is
one of the easiest and most objective measures of confirming the efficacy of this treatment
using ultrasound scan or MRI. However, menorrhagia and its symptoms, which are clinical,
are the most relevant aspects to evaluate, and these have a resolution rate of almost 90 % at
short-term follow-up [117]. One randomized trial has demonstrated this method to be the
most economic strategy for women with symptomatic myoma [118]. This procedure
represents some complications that should be taken into account. One technical difficulty is
the impossibility of cannulating the artery due to anatomical variations, tortuosity of the
vessels or inadvertent vessel damage. Fibroid expulsion constitutes another drawback in
approximately 10 % of the cases, particularly in cases of submucous myomas, This can cause
a good deal of pain due to infection with prolonged leucorrhea, and can require surgical
intervention when expulsion is incomplete. Uterine embolization induces pain in variable
degrees because of myoma ischemia, requiring treatment with opiates, which rules out the
day-out procedure. Another important concern regarding the side effects of this procedure is
secondary amenorrhea due to ovarian compromise [119]. For clinicians, these complications
represent barriers to the implantation of this procedure, with the exception of patients with
Hysterectomy 37
menorrhagia, for whom it offers an option of conservative management. Nevertheless, the

complication rate associated with uterine artery embolization is lower than that of
hysterectomy, and if the management of events following embolization is improved,
particularly with respect to those regarding fertility, this approach can constitute an effective
alternative [120].
Ultrasound-Focused Therapy
The rationale of this therapy is based on ultrasound energy penetration of a defined tissue
(in our case, a myoma), which produces a structural and functional alteration of that tissue.
This targeted treatment causes irreversible cell damage leading to coagulative necrosis due to
thermal and non-thermal effects produced in the exposed area. The depth between the skin
and the targeted tissue is a determining aspect; when too deep, the ultrasound energy
attenuates exponentially [121]. For a correct and effective use, an endoscopic probe or
interstitial applicator is necessary, usually with a MRI/ultrasound guided system. Although
few trials with this method have been reported until now, results are encouraging. Shrinkage
of the myoma volume is often low, with a rate of 12-48% being reported, but early clinical
improvement (pain, heavy bleeding) is significant. Long-term results are necessary in order to
discern its real cost-effectiveness [122].
Conclusion
Hysterectomy rates are diminishing over time due to new and effective conservative
alternatives. When this intervention is decided on, there are aspects that need to be considered
in order for the best route to be selected. Although gynaecologists should be trained in the
three routes previously described (vaginal, laparoscopic and abdominal), a rational algorithm
should be employed in clincial decisions. Vaginal hysterectomy should be the first choice for
many reasons, the most important of which are complication rate, cost-effectiveness and
quality of life. The aim of any hysterectomy guideline is to avoid a laparotomy whenever
possible. However, it seems that education concerning appropriate hysterectomy routes is
mistaken in its objectives, as the literature continues to demonstrate a conflict between
vaginal and laparoscopic approaches. Current gynaecological practice should focus on
performing less AHs and more LHs and VHs. Which one of the latter two approaches should
be chosen? Given that the advantages of LH are similar to those of VH, we would say that the
vaginal route is preferable, but this is a decision that depends heavily on the skills of the
surgeon and the facilities available.
Key Issues
 Hysterectomy is one of the most prevalent surgeries in the female population, and
although a vaginal route is recommended by many institutions, a laparotomy is still
commonly performed.
 Hysterectomy indications show a slow but continuous diminution thanks to more

conservative approaches: LNG-IUD, ablation techniques and uterine embolization.
These have been shown to be safe and cost-effective.
 Menorrhagia is the first cause of surgery, mainly as a result of myomas and
adenomiosis. Other common indications are genital prolapse and malignancy.
 Hysterectomy appears to be cost-effective as a treatment for menorrhagia when
compared with endometrial resection, ablation and medical therapy at long-term
follow-up.
 The vaginal route is the most cost-effective approach to hysterectomy, and has been
shown to be an effective and cost-effective intervention for a variety of indications.
 Vaginal hysterectomy should be the first choice when selecting the route of
intervention. Laparoscopic surgery (assistance or a total hysterectomy) should be
performed if an absolute/relative contraindication is suspected.
 Parity, uterine size, vaginal anatomy, pelvic mobility and any pelvic disease or
previous pelvic surgery are the most important factors influencing the choice of
hysterectomy route. The most transcendental of all is the skill of the surgeon in
question.
 Uterine size should not be an indication for abdominal surgery, as vaginal
morcellation is a safe and effective alternative in such cases.
 The preservation of ovaries until the age of at least 65 years is associated with higher
survival rates, as this prevents cardiovascular disease and hip fracture.
 Abdominal hysterectomy should be performed only when pathological circumstances
and patient characteristics preclude the vaginal/laparoscopic route.
Summary
Hysterectomy is one of the most prevalent surgeries worldwide in the female population.
Nine out of every ten hysterectomies are performed for non-malignant conditions that are not
life threatening, but have a negative impact on quality of life. Indication policy must be
revised as new treatments become available. Menorrhagia is the primary indication and it is
not always a response to an anatomical disease; other common indications are genital
prolapse and malignancy. New and improved alternatives are increasingly employed for this
indication and are responsible for the fall in the rate of hysterectomies performed in the last
decade. Hysterectomy indications show a slow but continuous diminution owing the
availability of more conservative approaches, including levonorgestrel-releasing intrauterine
devices, ablation techniques and uterine embolization, which have shown to be safe and cost-
effective. Up-to-date knowledge of the surgical route and its outcome should form part of all
clinical decision-making processes if optimum short- and long-term results and cost-
effectiveness are to be achieved. Vaginal hysterectomy fulfils all these requirements and,
when combined with the laparoscopic approach, represents the best option among possible
routes. Laparoscopic surgery (assistance or a total hysterectomy) should be performed if an
absolute/relative contraindication for vaginal surgery is suspected. Parity, uterine size, vaginal
anatomy, pelvic mobility and any pelvic disease or previous pelvic surgery are the most
important factors influencing the choice of hysterectomy route, being the most transcendental
Hysterectomy 39
of all the surgeon‘s skill. Abdominal hysterectomy should be indicated only when
pathological circumstances and patient characteristics preclude the vaginal/laparoscopic
route, even though laparotomy is still commonly performed. Regarding bilateral salpingo-
oophorectomy indication, it should not be done until the age of at least 65 years as it is
associated with higher survival rates, as this prevents cardiovascular disease and hip fracture.
Financial Disclosure / Acknowledgments

The author has no relevant affiliations or financial involvement with any organization or
entity with a financial interest in or financial conflict with the subject matter or materials
discussed in the manuscript. This includes employment, consultancies, honoraria, stock
ownership or options, expert testimony, grants or patents received or pending, or royalties.
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Chapter 3
The Complications of Laparoscopic

Hysterectomy, Compared with Vaginal
and Abdominal Total Hysterectomy
Kok-Min Seow1, 2*, Yu-Hung Lin1,3 and Jiann-Loong Hwang1,4

1
Department of Obstetrics and Gynecology,
Shin Kong Wu Ho-Su Memorial Hospital, Taipei,
2
Department of Obstetrics and Gynecology, NationalYang-Ming University, Taipei,
3
School of Medicine, Fu-Jen Catholic University, Hsinchuang, Taipei Hsien,
4
Department of Obstetrics and Gynecology, Taipei Medical University, Taipei, Taiwan.
Abstract
Hysterectomy is one of the most common major operations performed in the world.
Since the first introduction of laparoscopic hysterectomy by Reich et al. in 1989,
laparoscopic hysterectomy has become a well-known and common procedure worldwide.
The incidence of hysterectomy for benign lesions with laparoscopy has been
progressively increased in the recent years, and more than 45% of the procedures were
performed via a laparoscopic route in several countries. There are major subdivisions of
total hysterectomies that are performed by laparoscopy: laparoscopically assisted vaginal
hysterectomy (LAVH), vaginally assisted laparoscopic hysterectomy (VALH) and total
laparoscopic hysterectomy (TLH). Patients undergoing laparoscopic hysterectomy (LH)
experienced faster bowel recovery, less postoperative pain and shorter hospitalization
compared with patients undergoing abdominal hysterectomy. Nevertheless, LH still has
associated morbidities. Complications from hysterectomy can be diagnosed
intraoperatively or postoperatively. The rate of major complications has been reported to
range from 0.5% to 1.7%. The most common intraoperative complications that occur at
laparoscopic hysterectomy are injuries to the bladder, ureter, bowel and blood vessels.
Postoperative complications such as urinary tract infection, colpotomy wound bleeding,
pelvic cellulitis or pelvic abscess, and fever of unknown reason are common. Other
factors associated with an increased risk of complications related to LH are increasing
*
Tel: +(886)-2-28332211, ext. 3879, Fax: +(886)-2-28389416, E-mail: m002249@ms.skh.org.tw
48 Kok-Min Seow, Yu-Hung Lin and Jiann-Loong Hwang
age, medical illness, obesity and malignancy. Appropriate training and experience is
necessary for a physician to minimize intraoperative complications and safely perform a
new surgical technique such as LH. Proper patient selection, knowledge of the pelvic
anatomy and good surgical judgment are other keys to minimizing complications.
Introduction
Hysterectomy is the second most major operation after cesarean section worldwide [1,2].
Approximately one-third of American women will have undergone a hysterectomy by the age
of 65 [3] and 20% of women with the age of 55 will have undergone a hysterectomy in the
United Kingdom [4]. There are three options to perform a hysterectomy in benign
gynecological disease. Total abdominal hysterectomy (TAH) is the oldest technique of
complete removal of the uterus and cervix through an abdominal route. Vaginal hysterectomy
(VH) is performed entirely through the vaginal canal and has clear advantages over
abdominal surgery such as less complications, shorter hospital stays and shorter healing times
[5]. VH was originally used only for the indication of uterine prolapse or dysfunctional
uterine bleeding. However, it is now found that VH is also effective in removal of the uterus
with multiple myoma or adenomyosis [6]. Since Reich et al reported the first laparoscopic
hysterectomy (LH) in 1989, laparoscopic hysterectomy has become a well-known and
common procedure worldwide. The incidence of hysterectomy for benign lesions with
laparoscopy has been progressively increased in the recent years, and more than 45% of the
procedures were performed via a laparoscopic route [7]. TAH is thus only used in cases such
as after caesarean delivery, when the indication is cancer, when complications are expected or
surgical exploration is required, or if the uterus cannot be removed by another approach.
Laparoscopic hysterectomy is a general term; more recently three major subdivisions of LH
have been described: laparoscopically assisted vaginal hysterectomy (LAVH), vaginally
assisted laparoscopic hysterectomy (VALH) and total laparoscopic hysterectomy (TLH).
LAVH is a vaginal hysterectomy assisted by laparoscopy in which the adnexal and superior
portions of the uterus are removed through a laparoscopic procedure but does not include the
ligation of uterine vessels. VALH is the hysterectomy that is performed mostly by
laparoscopy, including adnexectomy and uterine vessels ligation. However, the procedure of
total hysterectomy is completed through the vaginal phase, including vaginal incision and
repair. TLH is a total hysterectomy that is performed completely laparoscopically, including
colpotomy and vaginal incision; the vaginal vault is also sutured by laparoscopy. Generally
speaking, there is no vaginal component in the TLH.
Complications from hysterectomy can be diagnosed intraoperatively or postoperatively.
Injuries to the major organs in LH are not an uncommon event, however, the complication
rates may differ with various approaches to hysterectomy including LAVH, VALH or TLH,
and the surgeon‘s experiences. In laparoscopy, most surgeons believe that the laparoscopic
skills and experience of the surgeon are the determining factors in providing the advantages
of LH with the lowest rate of complication, especially to the pelvic organs such as the bladder
or ureters [8-10]. In this section, we will review the complications of LH versus TAH or VH.
The Complications of Laparoscopic Hysterectomy … 49
Factors Associated with Increased Risk

of Complications Related to LH
Several factors have been consistently shown to be associated with an increased risk of
complications related to LH.
1. Surgeon’s experiences: Harkki et al. [11] reported that LAVH may continue to be
safely introduced into a community hospital setting but that more complications may
be expected until surgeons gain experience. Similarly, the numbers of conversion to
laparotomy and surgical complication rates may significantly decrease after
increasing a surgeon‘s experience. We compared the complications rate before and
after 4 years of physician experience with LAVH in a retrospective study, and found
that the overall complication rate in the last 4 years was 7.1% and was significantly
lower than 13.4% in the first 4 years. [7] Altgasseen et al also showed a decrease in
overall complications from 4% in the first 40 cases to 0.5% in the next 30 cases [12].
Also, a large prospective study of 10,110 LH demonstrated that the rate of bladder
injury decreases from 2% for the first 30 procedures to 0.8% after the first 30
procedures [13]. Lafay Pellet et al. observed similar results [14]. The rate of bladder
injuries decreases from 2% for the first 40 procedures to 0.4% after 100 cases of the
surgeon‘s experience [14]. Chapron et al. [15] reported a multicenter observational
study and found that as physician experience with laparoscopy increased, there was a
statistically significant decrease in the number of bowel injuries and the rate of
conversion to laparotomy.
2. Obesity: The prevalence of obesity is progressively increased worldwide. Obesity
has been regarded as a relative contraindication to operative laparoscopy. However,
laparoscopy is currently considered to be suitable for obese patients because it is a
minimally invasive technique and surgical complications of laparotomy are often
related to the poor healing of surgical wounds and infection when diabetes is present
[16]. Nevertheless, some authors reported that LH carried out for a benign pathology
in the context of obesity may increase intraoperative and postoperative complications
[17,18]. Heiberg et al. [18] collected 106 obese women whose BMI was 30 kg/m2 or
greater, compared with 164 women whose BMI was less than 30 kg/m2. In their work
the authors reported that TLH for obese patients was 60% more likely to require at
least 2 hours to complete (relative risk: 1.6, 95%, confidence interval: 1.2, 2.0) and
was associated with a 3-fold risk of blood loss exceeding 500 ml compared with
nonobese patients; the major and minor complications rates did not differ statistically
between the two groups. Holub et al. and Chopin et al. [17,19] reported similar
results: that there was no significant difference in estimated blood loss, presence and
degree of adhesions, weight of specimen, length of hospital stay and postoperative
complications between women with high BMI and those with low BMI, although the
operating time is longer. In a prospective study to compare the morbidity of VH in
obese and non-obese women also found that the overall complication rates were not
significantly different between obese and non-obese patients (14% and 16%,
respectively) [20].
3. Previous cesarean section: Cesarean section is the most commonly performed

surgery in women, with rates of 20 to 30% of all deliveries and up to 40% in some
developing countries. Among these women, up to 20% will likely require a
hysterectomy by the age of 55. Adherence of the bladder to the lower uterine
segment due to separation of the bladder in previous cesarean section will make
dissection of the bladder at the time of hysterectomy more difficult [21]. A
prospective observational multicentre study reported by France demonstrated that
obesity, history of pelvic surgery and history of cesarean section were significantly
associated with intra- and postoperative complications in the procedure of
hysterectomy [22]. These colleagues reported that history of cesarean section might
have an odd ratio (OR) of 2.04 (95% CI 1.01-4.1, p= 0.046) associated with intra-
and postoperative complications in hysterectomy. Rooney et al. [23] collected 5,092
hysterectomies in a case-controlled study to assess if previous cesarean section is an
independent risk factor for incidental cystotomy at the time of hysterectomy. They
found that previous cesarean section is indeed a significant risk factor for damage to
the lower urinary tract at the time of hysterectomy with an overall OR of 2.04. The
risk of incidental cystotomy is significantly higher in LAVH compared with TAH or
VH (OR: 7.50, 1.26 and 3.0, respectively, p= 0.005) [23].
4. Endometriosis: Endometriosis is defined as the presence of endometrial epithelium
and stroma in an ectopic site outside the uterine cavity and musculature [24].
Endometriosis is estimated to occur in 10% of the female population, especially in
women of reproductive age [24]. Furthermore, 56% of endometriosis occurs in the
posterior cul-de-sac area [25]. The most common symptoms of endometriosis are
dysmenorrhea, dyspareunia [24,26], pelvic pain [25], infertility and pelvic adhesions
[27]. Endometriosis may in severe cases lead to obliteration of the anterior and/or
posterior cul-de-sacs in the female pelvis [28] [29]. Severe endometriosis with severe
pelvic adhesions usually constitutes a complex treatment challenge, especially in the
procedure of laparoscopy. Surgical intervention to release a scarred obliterated
posterior cul-de-sac in TLH is associated with a significant risk of intraoperative
bowel injury. Similarly, laparoscopy adhesiolysis of a scarred obliterated anterior
cul-de-sac is always with an increase risk of intraoperative bladder injury [29].
Chang et al. presented a simple method to minimize the injury of bladder in LAVH
among women with a previous cesarean section [30]. They reported that transvaginal
lateral intervention could be used to enter the anterior cul-de-sac during laparoscopic
intrafascial hysterectomy to minimize the chance of bladder injury [30]. In their
study they found that no bladder injury occurred and no other associated
complications with this method [30].
5. Other associated factors: Patients‘ age, medical illness, malignancy and pelvic
adhesions due to previous pelvic surgery [31], and previous pelvic inflammatory
disease (PID) are the other factors that are associated with an increased risk of
complications related to TLH. These conditions are beyond the control of the
gynecologic surgeon, the surgeon has to explain the risk of complication of TLH to
these women before the surgery. Pelvic adhesions due to previous pelvic surgery and
PID are also associated with increased rate of conversion to laparotomy during TLH.
Hsu and their colleagues reported in women with a partially or totally obliterated cul-
de-sac in LAVH, the operation time and blood loss are significantly higher than
women without pelvic adhesions [32]. Previous laparotomy has been shown to be a
significant risk factor for bladder injury during laparoscopic hysterectomy, with an
OR of 4.69, 95% CI: 1.59-13.8 [14].
Complications of Laparoscopic Hysterectomy

Comparing with TAH and VH
Febrile Morbidity
Febrile morbidity is a common complication in hysterectomy. It may occur in
hysterectomy no matter if the surgery is through a laparoscopic, abdominal or vaginal route.
In most of the studies, postoperative fever was considered as a body temperature equal to or
higher than 380 C, 24 hours after the surgery. Patients who underwent TAH more frequently
experienced febrile morbidity than LAVH or VH [6,33]. Hwang et al. showed than TAH has
a higher incidence of 26.7% compared with those in the LAVH and TVH groups [6]. The
most common complication of the TAH procedure was febrile morbidity [33]. The reason of
febrile morbidity in TAH is still unknown. Hunter et al. suggested that laparoscopy allows for
accurate pelvic evaluation and lavage of internal blood clots following vaginal removal of the
uterus, thus reducing the risk of febrile postoperative morbidity related to resorption of blood
clots [34]. Nevertheless, most of the febrile morbidity may resolve after intravenous fluid or
antibiotics administration. Therefore, LAVH may have a lower use of postoperative
antibiotics due to the lower rate of febrile morbidity compared with TAH [6]. In comparing
febrile morbidity between LAVH and TLH, there was no significant difference between these
two methods of hysterectomy [35, 36].
Intra-Operative Blood Loss

The mean intra-operative blood loss in LH may differ in different studies (Table 1);
laparoscopic skills, experience of the surgeon and uterine weight or myoma size are the
determining factors. Intra-operative blood loss was reported as having no significant
difference between LAVH and TAH or VH, and post-operative blood transfusion was not
significantly higher in LAVH compared with TAH in several studies [33,37-39]. Spilsbury et
al. collected 78, 577 hysterectomies for benign reason to identify population level morbidity
outcomes in all Western Australian hopitals from 1981 to 2003 [40]. They reported that
procedure-related hemorrhage was the most commonly recorded complication, with an
incidence of 2.4% [40]. They found that there was no difference in the odds of hemorrhage
between TAH and LAVH, however, the procedure-related hemorrhage was less common in
VH compared with TAH in women aged more than 60 years [40]. Nevertheless, these results
are quite different in two parallel, randomized trials (the eVALuate study: one comparing LH
with TAH, the other comparing LH with VH) reported by Garry et al [41]. Garry and their
colleagues reported that in the abdominal trial, the rates of major hemorrhage requiring
transfusion were 4.6% in LH, comparing with 2.4% in TAH; and in the vaginal trials, the
rates of major hemorrhage requiring transfusion were 5.1% in LH, comparing with 2.9% in
VH [41]. Falcone et al. also presented the similar result that LAVH had a significantly higher
amount of blood loss than TAH [42]. On the contrary, other studies reported different results;
that the estimated blood loss was statistically greater for TAH compared with LAVH
[3,43,44]. TAH also reported to have a significantly higher blood loss than TLH in a
randomised study [45].
However, the intra-operative blood loss was significantly higher in LAVH, compared
with TAH and VH (mean blood loss 343  218 ml in LAVH; 293  182 ml in TAH; 215 
134 ml in VH) for enlarged uterus with myoma or weighing at least 450 g [6].
In comparing intra-operative blood loss between LAVH and TLH, the results also differ
in different studies [35, 36, 46]. Twijnstra and their colleagues compared surgical outcomes
for LAVH with TLH in three teaching hospitals in the Netherlands; one hundred and four
women were selected to enroll this study [35]. They found that LAVH had a significantly
higher mean estimated blood loss than TLH groups (312  171.7 mL and 157.6  139.6 mL,
respectively; p<0.05). However, the other studies reported that there was no significant
difference found in intra-operative blood loss or blood transfusion between LAVH and TLH
[36,46].
Even though the estimated blood loss was different in different methods of hysterectomy,
there was, however, no significant difference in the incidence of blood transfusion in most of
the studies.
Table 1. Mean blood loss (ml) in three methods of hysterectomy
Study (years) TAH VH LAVH

Tsai et al. [33] 238  168 NA 202  130
Summitt et al. [37] 568  394
Shen et al. [43] 216.3  88.5
Falcone et al. [42] 250 NA 450
Hwang et al. [6] 343  218
Twijnstra et al. [35] 173.1  188.2 NA 456.8  893.7
Long et al. [36] NA NA 90
Perino et al. [45] 406  103.9 NA 140  41.5
Ottosen et al. [39] 225  178 287  211 311  305
Marana et al. [3] 264.7  194.4 214.4  158.1 50.3  64.6
Schütz et al. [44] 600 NA 200
TAH: total abdominal hysterectomy; VH: vaginal hysterectomy; LAVH: laparoscopic-assisted vaginal
hysterectomy.
NA: not available
Bladder Injury
Bladder injury is one of the most major complications in hysterectomy, no matter if
through an abdominal, vaginal or laparoscopic route. Lafay Pillet et al. [14] conducted a
retrospective study to evaluate the rate and the risk factors for bladder injuries in a series of
1,501 LH indicated for benign uterine pathologies. They found that the rate of bladder injuries
was 1%, and previous cesarean section and previous laparotomy are the risk factors for
bladder injuries [14]. Garry et al. in a randomized prospective trial compared on one hand the
abdominal and the laparoscopic routes and on the other vaginal and laparoscopic
hysterectomy [41]. He found that in the abdominal trial LH was associated with a higher rate
of bladder injuries than TAH (2.1% vs. 1%, respectively). In the vaginal trial he found that
LH has a lower rate of bladder injuries than VH (0.9% vs. 1.2%, respectively) [41]. However,
a retrospective study presented by Cosson et al. showed that the rate of bladder injury is
higher in TAH compared with TLH and VH (1.8% vs. 0.5% vs. 0.9%, respectively) [47]. A
meta-analysis reported by Johnson et al. included 27 prospective randomized trials with a
total of 3,643 participants including two that compared vaginal with abdominal hysterectomy,
16 that compared laparoscopic with abdominal hysterectomy, four that compared
laparoscopic with vaginal hysterectomy, and one that compared LAVH with TLH to evaluate
the complications of LAVH, TAH and VH [48]. He found that there was no significant
difference in bladder injuries for LAVH compared with TAH or VH [48]. Donnez et al.
compared the complication rate in a series of 3,190 LH for benign disease from 1990 to 2006
and they found that bladder injuries were observed in 0.44% of women after VH and 0.31%
of women after LH (p>0.05) [38]. This clearly showed that the risk of bladder damage after
LH is similar to that found after VH [38].
Table 2. Bladder injuries in LAVH, TAH and VH
Studies LAVH/TLH TAH VH

Cosson et al. [47] 0.5% 1.8% 0.9%
Darai et al. [46] 2.5% 0%
Makinen et al. [13] 1.3% 0.5% 0.2%
Long et al. [36] 3.3%, 2.4%
Tsai et al. [33] 0% 1%
Garry et al. [41] 0.9%, 2.1% 1% 1.2%
Rooney et al. [23] 1.8% 0.76% 1.3%
Seow et al. [7] 0.86%, 0.17%
Donnez et al. [38] 0.31% 0.73% 0.44%
Lafay Pillet et al. [14] 1%
However, the rate of bladder injury between the different routes of hysterectomy may
differ in different studies due to selection bias. The incidence of bladder injury risk factors is
not regularly distributed in the different methods of hysterectomy. Previous cesarean section,
previous laparotomies or previous pelvic surgery may influence the surgeon‘s choice for the
route of hysterectomy. For this patient, VH is a contraindication and a laparoscopic route may
be a better choice; this could explain why there are more bladder injuries or ureters damaged
in LH. Furthermore, surgeon experience is another important factor of increased bladder

injury in LH. A large prospective study of 10,110 LH by Makinen and their colleagues
demonstrated that the rate of bladder injury decreases from 2% for the first 30 procedures to
0.8% after the first 30 procedures [13]. Lafay Pellet et al. also reported the rate of bladder
injuries decreases from 2% for the first 40 procedures to 0.4% after 100 cases of the
surgeon‘s experience [14]. Our previous study also demonstrated the rate of bladder injury
was significantly lower after increased physician experience with LAVH. The rate of bladder
injury in the first four years of LAVH was 0.86%, compared with 0.17% after 4 years of
physician experience with LAVH [7]. The rate of bladder injury of different study is shown in
Table 2.
The complication of bladder injury is the development of vesicovaginal fistula (VVF)
after incidental cystotomy during benign hysterectomies. The estimated incidence of VVF
after incidental cystotomy or bladder injury is 10% for LAVH [49]. Duong et al. performed a
retrospective case-control study to review the risk factors for development of VVF after
incidental cystotomy during benign hysterectomies in a four-year period [50]. They found a
total of 2.6% (34/1317) incidental cystotomies occurred with 11.7% resulting in a VVF for an
overall incidence of VVF after a benign hysterectomy of 0.3%. Their results also indicate that
patients who are current smokers, have a larger uterus size and weight, have longer operative
times, have a longer hospital stay, have larger operative blood loss, or have more severe
bladder injury, such as American Association for the Surgery of Trauma grade V bladder
injury are at increased risk for developing a VVF after an incidental cystotomy [50]. Härkki-
Sirén et al. analyzed retrospectively 12 urinary tract injuries after hysterectomy; they found
that bladder injuries were most common after LH [51]. Sixty-five percent of reported bladder
injuries were fistulas, giving an incidence of VVF of 2.2 of 1000 after LH, 1.0 of 1000 after
TAH, and 0.2 of 1000 after VH [51]. They also reported that the failure rates of primary
repair of a simple bladder injury were 5%, 18%, 0%; the failure rates of primary repair of a
VVF were 17%, 20%, 0%; and the convalescence times after a bladder injury were 51 days,
118 days, and 99 days after LH, TAH and VH, respectively [51].
Ureteral Injury
Ureteral injury is one of the major complications associated with LH. Ureteral injury
during gynecologic surgery can have major personal, financial, and societal costs.
Gynecologic surgery is responsible for up to 75% of cases of iatrogenic injury to the ureter
[52]. The incidence of ureteral injury associated with LH is estimated to be 0.3 to 3.3%
[7,22,36,38,41]. Moreover, most of the urinary tract injuries are not recognized at the time of
surgery and only less than 10% of the injuries were noticed intra-operatively [51].
A systemic review and meta-analysis performed by Johnson et al. reported that there
were more urinary tract injuries with LH than TAH (odd ratio 2.61). Ostrzenski and their
colleagues review the available literature on ureteral injury (30 articles) associated with
gynecologic laparoscopic surgery in an attempt to determine the rates, time, type, location of
ureteral injury, and the mode of injury repair [53]. They found that the incidence rates of
ureteral injury was ranging from <1% to 2%, of which 20% occurred during LAVH. Besides,
70% of ureteral injuries were diagnosed postoperatively, and most of the injury was due to
transection of ureter [53]. The location of injury most often occurred at or above the pelvic
brim and electrocautery was involved in most of the reported cases. A laparotomy was used to
repair the ureteral injury in 61.4% of the cases [53]. However, Ibeanu and their colleagues
found that the most common site of injury to the ureter was at the junction of the ureter and
the uterine artery in 80% of ureteral injuries [54].
Since many urinary tract injuries go unrecognized intra-operatively, many investigators
suggested routine use of cystoscopy during hysterectomy may provide early detection of
urinary tract injury and may help to minimize the postoperative morbidity, including VVF
and the loss of a kidney [54-56]. Vakili et al. collected 471 patients in a prospective study
from three separate hospitals to evaluate the incidence of urinary tract injury due to
hysterectomy for benign disease [56]. All patients were undergoing a diagnostic
cystourethroscopy after completion of the hysterectomy. They found that 100% of the ureteral
injuries and 94.1% of the bladder injury were successfully detected intraoperatively. They
also found that ureteral injury was associated with concurrent prolapse surgery and bladder
injury was associated with concurrent anti-incontinence procedures [56].
Similar results were also noticed in a systematic review article reported by Gilmour et al
that the rate of urinary tract rates were higher when routine intraoperative cystoscopy was
used [55]. For example, the ureteral injury for LH was 7.8 per 1,000 without cystoscopy
performed, but the rates increased to 17.3 per 1,000 when routine cystoscopy was used [55].
However, the reasons for higher injury detection rates when a routine cystoscopy was
performed are unclear.
Traditionally, ureteral injuries are treated by laparotomy even when the injury is
identified during a laparoscopic procedure. However, laparoscopic ureteral injury repair is
showed as feasible, safe and effective in several articles [57,58].
Bowel Injury
Bowel injury is a rare but serious complication of LH. The incidence of laparoscopy-
induced gastrointestinal injury was estimated to be 0.13% and bowel perforation 0.22% [59].
In LAVH, the incidence of small intestine injury was reported to be 0.19% [60], and large
bowel injury was 0.29% [61]. Many of the bowel injuries are not recognized at the time
surgery, leading to increased mortality and morbidity.
Small intestine was the most frequently injured, followed by the large intestine during
laparoscopy [59]. Even though most of the bowel injury is usually discovered during the
laparoscopy or within 24 hours thereafter, some injuries were discovered postoperatively.
Therefore, the outcome of delayed discovery of the bowel injuries is poor and associated with
a high mortality rate of 3.6% [59]. The rate of bowel injury is significantly correlated with the
complexity and difficult of the laparoscopic surgery. Women who were undergoing LH due to
severe endometriosis, pelvic adhesion or malignancy are in high risk for bowel injury during
hysterectomy [62].
Several studies revealed that insertion of a Veress needle or a trocar as the most common
instrument involved in damage to the bowel during creation of a pneumoperitoneum
[59,60,63]. Chapron et al. report that about one third of the bowel injuries occurred during
creation of the pneumoperitoneum and trocar placement [62]. The incidence of trocars and
Veress needle injuries to the bowel, including small and large bowel injury during
laparoscopy, was estimated to be 0.06% [63].
Thermal injury by electrocautery is the second most common instrument that may
damage the bowel during operation [60]. However, in the retrospective study presented by
Härkki-Sirén et al. found that all of the bowel injuries were attributed to thermal injury by
electrocautery [64]. The mechanisms of bowel injury during LH may be due to direct thermal
injury because of unintentionally touching the bowel with an active electrode. The thermal
injury may occur even at the tissue (intended area), which is 3 to 5 cm beyond the point of
contact (zone of coagulation). The other possible causes of bowel injury during LH are
grasping or manipulating the bowel without using atraumatic grasping forceps, or lysis of
adhesions.
Early recognization of bowel injury during LH is important to minimize the morbidity
and mortality. Leakage of bowel contents or aspiration of gastric or feculent material through
the Veress needle is one of the important signs of bowel perforation during creation of
pneumoperitoneum. Besides, persistent excessive external fluid leak from the periumbilical
area after laparoscopic surgery with no drainage from other incisional sides may suggest
trocar-related small intestinal injury [65].
There were no statistic differences in bowel injury for the comparison LH versus VH, or
LH versus TAH [41,48,66].
Vaginal Colpotomy Wound Hemorrhage

Vaginal bleeding of a colpotomy wound after LH is not a rare event. The incidence of
acute massive vaginal colpotomy wound bleeding in LAVH ranges from 0.2% to 0.5%
[67,68]. Acute vaginal colpotomy wound bleeding was defined as bleeding of more than 500
ml from the colpotomy wound [69]. Delayed acute vaginal colpotomy wound bleeding may
occur even one month after the procedure of LAVH. Acute massive vaginal colpotomy
wound bleeding may be associated with an impendent shock and severe anemia, which
necessitate emergency blood transfusion and homeostasis [68]. Wu et al. reported that 0.2%
of the LAVH had delayed acute massive vaginal colpotomy wound bleeding several weeks
after LAVH [67].
Chronic vaginal colpotomy bleeding is a more common event than acute vaginal
colpotomy bleeding in LAVH. Chronic vaginal colpotomy wound bleeding was defined as
vaginal bleeding for more than 7 days after the operation. The amount of bleeding was < 30
ml per day or a net pad that weighed < 30 gram per day [69]. Chronic vaginal colpotomy
bleeding is different than acute massive colpotomy bleeding since the complication and
amount of bleeding is minimal compared with acute massive colpotomy bleeding. Although
chronic vaginal colpotomy bleeding may not induce an impendent shock, it may lead to
anemia if bleeding persists for more than a one-month period. So far, no effective methods for
preventing the complication of vaginal colpotomy wound bleeding in LAVH have been
reported.
The reason for chronic vaginal colpotomy wound bleeding in LAVH remains unclear.
Shen et al. reported that chronic vaginal colpotomy wound bleeding might be due to
occlusion by application of pressure of the pneumoperitoneum and placement of the patients

in steep Trendelenburg position [68].
Major Vessels Injury

Major vessels injury during laparoscopy is rare. The incidence of major vessels injury
during LH is unknown. Most of the studies reported an incidence of 0 [6,7] to 0.007%
(1/14,243) [63]. The low incidence of major vessels injury during LH may be due to the
increased surgeon‘s experience in LH. There was no statistically significant difference in
major vascular injury for the comparison LH versus TAH, or for the comparison of LH versus
VH [66]. Most of the major vascular injury is caused by trocar or Veress needle insertion
during the creation of pneuperitoneum [63,70]. Catarci and their colleagues sent a
questionnaire about all laparoscopic surgical practice to the supervisors of 28 centers of
general surgery in the area of Rome and its province participating in the Lap Group Roma,
requesting the complication of Veress needle and first trocar [70]. They found that there were
0.5% of major vascular injuries during the creation of pneuperitoneum [70]. Some
investigators suggested the complications of trocar and Veress needles during laparoscopic
procedure may be prevented by placement under direct vision with verification of the
intraperitoneal location of the trocar and needle [63,71].
Methods to Reduce the Complications

of Laparoscopic Hysterectomy
1. Increase surgeon‘s experience
Most surgeons believe that increasing the laparoscopic skills and experience of the
surgeon is associated with the lowest rate of complication in LAVH [7,9,72]. The
complication rates may decrease from 13.4% to 7.1% if the physician‘s experience increased
[7]. Especially, the rates of major organ injury, such as bladder and ureter injuries are
significantly decreased from 0.86% to 0.17% and 0.86% to 0%, respectively after increasing
4-years of experience for LAVH of the physician [7]. The rate of conversion to laparotomy
was also reduced from 5.4% to 1.7% [7]. Thus, in order to establish the proficiency in
performing LAVH, 50 cases are necessary to encounter a wide enough variation of pelvic
pathology to mandate a modification of the basic surgical techniques so that the major
complications are minimized and the surgeons could perform a more difficult LAVH [6].
Altgasseen et al also showed a decrease in overall complications from 4% in the first 40 cases
to 0.5% in the next 30 cases [12]. Other studies also presented similar results [13-15].
Visco et al. reported that even though the rate of conversion to laparotomy is significantly
decreased with increasing physician experience, no significant increase or decrease in the
complication rate was observed with increasing operator experience [73].
2. Methods to minimize bladder injury in LH among women with previous cesarean
section
Bladder injury is one of the most major complications in LH and previous cesarean
section is a significant risk factor for bladder injury during LH. Several studies demonstrated
that women with previous cesarean section might have a significantly higher odd ratio of
bladder injury or perforation during LH, than TAH or VH [21-23]. The reason of increasing
the risk of bladder injury in LH may be due to the difficulty of bladder dissection by
laparoscopy at the time of hysterectomy in previous cesarean section because of adhesion of
the bladder to the lower uterine segment [23]. Most of the adhesions between the bladder and
the lower uterine segment after cesarean section are located in the vesicocervical space, which
is in the middle of the operation field flanked by bilateral parametrial spaces inside the broad
ligaments [21].
Chang et al. developed a new method to explore the vesicocervical space during vaginal
phase of LAVH to avoid bladder injury in women with previous cesarean section [30]. They
supposed that the potential spaces lateral to the adhesion of vesicocervical space could be
developed easily by blunt finger dissection. Therefore, they suggested using a lateral
intervention method to open the lateral windows of the vesicocervical space first to avoid
bladder injury during LAVH. Once the adequate lateral spaces were dissected, the dense
midline adhesion secondary to the cesarean delivery scar were dissected and cut under direct
vision and finger guidance. Finally, the vesico-uterine fold and the anterior cul-de-sac could
be entered without much resistance [30]. With this method, all 50 patients with previous
cesarean section were safe and without bladder injury during LAVH.
Bladder catheterization to drain out all the urine before and during all laparoscopic
procedure may decrease the risk of bladder injury during LH. As little as 100 ml of urine in
the bladder may increase the risk of injury during laparoscopic surgery. However, long-term
bladder catheterization may increase the rate of urinary tract infection, especially in women
with 2-day bladder catheterization [74].
3. Prevention of bowel injury during LH
Increased surgeon experience, and improved surgical skill and technique are the
important factors to decrease the rate of bowel injury in LH. Chapron and colleagues
calculated the complication rates for two periods, 1987 to 1991 and 1992 to 1995; a
significant drop in the number of bowel injuries occurred during the latter period [15].
Hasson‘s open method for creation of pneumoperitoneum during laparoscopy may reduce
the rate of bowel injury [75]. However, with open laparoscopic techniques, intestinal injury is
not preventable [76]. Therefore, caution should be taken no matter whether the closed or open
method is used during insertion of the umbilical trocar. Especially in women with known or
suspected adhesions, alternative sites for insufflation should be considered. Left upper
quadrant entry can be used as an alternative for patients in whom umbilical bowel adhesions
is suspected [77].
Besides, always keep mind to never touch the bowel tissue with an active electrode
during surgery. Even though the bowel is 3 to 5 cm beyond the coagulation site, thermal
injury may be occurred. Therefore, continued irrigation with cold distilled water should be
performed during electrocauterization to avoid neighbor tissue thermal damage. In addition,
irrigation of distilled water to the bipolar or monopolar instrument after electrocauterization
may cool down the persistent high temperature of the electrode, and avoids unintentionally
touching injury.
Furthermore, dissection and adhesiolysis should be performed by an experienced surgeon
to minimize the risk of bowel injury during LH. If the surgery cannot be safely performed
laparoscopically, laparotomy should be chosen immediately.
4. Prevention of urologic injuries
Identification of the ureter before the surgery is the initial method to prevent urologic
injuries during LH. The ureter usually can be found along the pelvic sidewall, anterior to the
uterosacral ligaments and posterior to the adnexa. The surgeon may have a visual of the
peristalsis of the ureter beginning from lateral to the hypogastric artery, and toward the
anterior of the uterosacral ligaments. Identification of the pelvic portion of the ureter is
important before the uterosacral ligament is incised during LH to avoid ureteral injury.
Besides, Koh et al developed a simple procedure to prevent ureteral injury in LAVH [78].
They create a ―window‖ over the anterior and posterior broad ligaments, and push the areolar
tissue (in which the ureter is embedded) from the posterior broad ligament inferolaterally.
After this simple procedure, the ureter may push inferolaterally, and away from the surgical
site. No ureteral injury occurred in their report [78].
Ureteral stent placement is the other way to assist with the identification of the ureter
during LH. Ureteral stent may decrease the risk of ureteral injury in difficult cases, such as
patients with severe pelvic adhesion, endometriosis, or large ligamental fibroids. Routine use
of ureteral stent is not recommended due to the complications from ureteral stent placement
[79]. Furthermore, Kuno et al. reported that the use of prophylactic ureteral catheters did not
affect the rate of ureteral injury in their patients [79].
5. Prevention of chronic vaginal colpotomy wound bleeding
Chronic vaginal colpotomy bleeding is common after LAVH, and a local injection of
diluted vasopressin into the colpotomy wound is able to effectively prevent chronic vaginal
bleeding after LAVH. We performed a randomized and prospective study to evaluate the
effect of local injection of diluted vasopression (0.33 U/ml; 20U/ml/ampoule; 1: 60 in the
dilution for injection) into the vaginal colpotomy wound after having finished the vaginal
phase of LAVH [69]. We found that the incidence of chronic vaginal colpotomy bleeding for
more than 7 days after the operation was 18%, and bleeding had decreased to 0% one month
after LAVH in patients with vasopressin injection, compared with 58% and 4%, respectively
in non-vasopressin injection group [69].
6. Method to minimize conversion to laparotomy in LH.
Even though the popular and advanced techniques of laparoscopic surgery, the rate of
conversion to laparotomy in LH still exist and is an important issue. The estimated rate of
conversion to laparotomy in LH is approximately 3.35 to 21.5% [6,22,37,73]. Nevertheless,
rate of conversion to laparotomy is closely related to the difficulty of the surgery and patient
selection. For example, the rate of conversion to laparotomy may be higher in patients with
severe pelvic adhesion, endometriosis, cancer or large uterine fibroid. Other factors related to
the rate of conversion to laparotomy may be due to less physician experience, unexpected
hemorrhage, gas embolism, high abdominal pressure due to severe obesity or unspecified
technical problems [22,80]. David-Montefiore et al. found that obesity, history of pelvic
surgery, and uterus weight (>500 g) are significantly associated with the rate of conversion to
laparotomy [22].
Increased physician experience is one of the important factors to decrease the rate of
conversion to laparotomy [22,73]. In addition, careful selection of patients for undergoing LH
is the other factor to avoid increasing the rate of conversion to laparotomy. Women with high
risk of conversion to laparotomy should be aware that it prolongs the hospital stay and the
recovery time. Therefore, women who are suspected of high risk of conversion to laparotomy
such as severe pelvic adhesion due to previous pelvic surgery or ruptured tuboovarian abscess
should avoid laparoscopic surgery.
Nevertheless, today many gynecologists have mastered the skills or new techniques to
perform complex operative laparoscopies [32]. Hsu et al. perform a special method, i.e.
preligation of the uterine artery through retroperitoneal downstream ureter tracking to
decrease the rate of conversion to laparotomy in women with unexpected extensive pelvic
adhesions, such as a partially or totally obliterated cul-de-sac [32]. Through this technique, all
23 hysterectomies in women with severe pelvic adhesions were successfully performed
laparoscopically. Not a single case was converted to laparotomy in their patients [32].
Conclusion
In conclusion, the overall complications of LH are higher than TAH or VH; especially,
LH brings a significantly higher rate of bladder or ureter injury. However, the complication
rate of LH is low and decreases with an increase of a surgeon‘s experience. Furthermore, LH
is associated with significantly less pain, quicker recovery, shorter duration of hospital stay
and fewer unspecified infections or febrile episodes than TAH. Therefore, LH is preferable to
TAH.
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Chapter 4
Beliefs, Attitudes and Psychological

Reactions to Hysterectomy
Ma. Luisa Marván1 * and Rosa Lilia Castillo-López1,2

1
Institute of Psychological Research, Universidad Veracruzana. Mexico
2
Psychology School, Universidad Veracruzana-Xalapa. Mexico
Abstract
For many women, the uterus is a very valuable and important organ since it has been
associated with femininity and sexuality in addition to its reproductive function. We
studied the beliefs and attitudes toward hysterectomy in 94 Mexican women who had
undergone hysterectomy for benign reasons, considering some psychosocial and
physiological variables. Psychological reactions to their hysterectomies were also
explored. Data were collected using two surveys: The Beliefs and Attitudes Toward
Hysterectomy (BATH) questionnaire and open questions to explore women‘s reactions to
hysterectomy.
Women who showed more negative attitudes toward hysterectomy included: women
who were premenopausal prior to undergoing hysterectomy; women who had undergone
bilateral salpingo-oophorectomy as well as hysterectomy; women who were severely
affected because they could no longer have children; and women with a limited
educational background. When participants were asked if their life had changed as a
consequence of the hysterectomy, 53% of women said their life had not changed, 33%
claimed their life had changed negatively, and 14% acknowledged their life had changed
positively.
The major changes these participants reported were that their relationship with their
partner had deteriorated, that their sexual life had deteriorated, but also that their health
had improved. These findings could be helpful in designing support programs for women
facing hysterectomy. Efforts must be directed toward providing accurate and current
information that should include both physical and psychosocial aspects of hysterectomy
in order to dispel myths, eliminate misunderstandings and prevent women from delaying
the surgery because of unrealistic fears.
*
E-mail: mlmarvan@gmail.com
68 Ma. Luisa Marván and Rosa Lilia Castillo-López
Introduction
The uterus has had a special meaning in all cultures since ancient times and it has borne
the weight of extraordinary medical myths. Hippocrates believed that the human uterus had
seven chambers and was lined with ―tentacles‖ or ―suckers‖, an erroneous belief that persisted
until the Renaissance. He claimed that the uterus wandered through a woman‘s body, giving
rise to any number of physical, mental and moral failings. Notions that the womb dominated
the female body in ways that could cause a woman to go mad continued well into the 19th
century. Nowadays, the uterus is still culturally loaded with strong beliefs and attitudes. For
many people, it is a very special organ since it has been considered ―the fertility organ, sexual
organ, secretory organ, body function regulator, source of healthy source of energy, youth,
beauty, attractiveness and power‖ [1]. Indeed, for some women it is the most important part
of the female body [2] and therefore, having a hysterectomy may lead to serious
psychological consequences in a woman. Elson [3] interviewed 44 American women who had
undergone hysterectomy for benign reasons. She found that some women had been unnerved
by the surgery and believed that they had been essentially changed by losing their uterus
whereas other women were untroubled by the surgery and experienced neither grief nor
identity loss. In general, those women who were more likely to suffer disrupted gender
identities were: a) women who had undergone bilateral salpingo-oophorectomy (BSO) as well
as hysterectomy; b) women who were considered fertile prior to surgery, regardless of
whether or not they had already given birth; c) heterosexual women who feared diminished
sexual attractiveness and who did not have supportive partners, as well as women, regardless
of sexual orientation, who perceived negative changes in their sexual responsiveness; and d)
women regardless of sexual orientation who believed that they had no control over the
decision to undergo surgery. In a more recent study, 74 women who had been undergone a
hysterectomy were surveyed in order to explore the potential psychosocial effects of
hysterectomy on the women‘s lives. The results suggest that younger women (between the
ages of 35 and 55), in comparison to older women, expressed greater dissatisfaction with their
quality of life after the surgery and showed higher levels of depression. Moreover, these
women were less likely to view themselves in a positive light following hysterectomy than
were the older women [4]. In another study conducted in Turkey, 31 women undergoing
hysterectomy were interviewed three days after the surgery. When the women were asked
what having reproductive organs meant to them and how they were feeling after their loss, the
most frequent response was that they were rather sad but being healthy was more important
for them. When they were asked how the surgery would affect their partner/family
relationships, the majority of women remarked that it would adversely affect their sexual life
and consequently their marriage. When they were asked what their friends or relatives were
saying about the surgery, most women replied that they would have menopause-related
problems; they would feel as if they were men; they would be incapable of satisfying their
husbands as previously and consequently their husbands would be alienated from them [5].
Since the 1980s, Lalinec-Michaud & Engelsmann [6] demonstrated that sociocultural
factors and the concept of the feminine role as held in a particular culture play an important
role in cognitive representations of hysterectomy. These authors conducted a study in Canada
with women of various ethnic backgrounds who underwent hysterectomy for reasons other
than cancer. The women were surveyed prior the surgery and a year later in order to explore
Beliefs, Attitudes and Psychological Reactions to Hysterectomy 69
the presence of fears, misconceptions, and attitudes toward hysterectomy among others
issues. French-Canadian women belonging to the lower socioeconomic class and with limited
education, when compared to English-Canadians with better educational levels and more
privileged social backgrounds, perceived hysterectomy as a threat to their femininity and self-
concept. Furthermore, these women also showed more fears and misconceptions related to
hysterectomy. In a more recent study conducted in Australia, Markovic et al. [7] explored the
experiences of 30 women who had undergone hysterectomy for non-malignant conditions.
Two themes, usually oppositional but for some women experienced concurrently, were
central to women‘s experiences: hysterectomy as a loss, both of reproductive identity and
womanhood, and hysterectomy as a gain, the beginning of the ability to lead a healthy and
socially fulfilling life. In general, the latter pattern predominated although there were several
trends associated with women‘s socio-demographic characteristics and response to their
hysterectomies. Specifically, women with lower socioeconomic status (according to their
occupation) were more likely to report negative responses to hysterectomy than women from
higher socioeconomic status. Similarly, in another study conducted in Mexico, the influence
of socioeconomic status on views concerning hysterectomy was demonstrated. In that study,
both women (who had not undergone a hysterectomy) and men were surveyed and it was
found that people from the lower or lower-middle socioeconomic class (according to their
occupation and schooling) held more negative views concerning hysterectomy and had more
misconceptions about the issue than persons from the upper-middle socioeconomic class.
Moreover, lower or lower-middle class people were more likely to claim that a woman who
has had a hysterectomy is incomplete [8].
In the US, Groff et al.[9] conducted 23 focus groups with women who had not undergone
hysterectomy in order to explore their beliefs and attitudes toward hysterectomy. The results
were analyzed according to the ethnic background of participants: African American,
Hispanic or Caucasian. The authors identified four main themes: perceived outcomes of
hysterectomy; perceived views of male partners; opinions about healthcare providers; and the
decision-making process. Among the four themes identified, the different ethnic groups of
women expressed beliefs and opinions that were similar in content, differing in the degree to
which dimensions were emphasized. In the area of perceived outcomes of hysterectomy,
Hispanic women were most concerned about emotional consequences, such as depression;
African Americans more easily identified positive effects; and Caucasians stressed potentially
negative effects on their bodies, but also described positive effects. Concerning the area of
perceived views of male partners, women perceived men‘s views of hysterectomy as
overwhelmingly negative. African American women were especially aware of men‘s attitudes
regarding sex with a woman with a hysterectomy, but they also were quickest to state they did
not care what men thought. Hispanic women expressed more concern about men‘s potentially
disparaging view of women with a hysterectomy and about being seen by men as ―less than a
woman‖. Other US studies have found that African American women have more negative
perceptions concerning hysterectomy than do European American women. Some African
American women who had hysterectomies for benign reasons stated that the surgery was
undergone at a great emotional cost because they were aware of the stigma attached to
women who have had a hysterectomy and because men were non-supportive of the surgery.
These negative feelings regarding hysterectomy cause some women to delay considering the
procedure until they are left with no alternative [10, 11]. We studied the beliefs and attitudes
toward hysterectomy held by Mexican women who had undergone hysterectomy, considering
some physiological and psychosocial variables such as: Menopausal status prior
hysterectomy, type of hysterectomy and reception of hormonal replacement therapy (HRT),
number of children, possible affectation for not having more children, educational level and
age. Psychological reactions to their hysterectomies were also explored.
Method
Participants
The sample was composed of 94 Mexican women between the ages of 33 and 65, who
were living in the city of Oaxaca (capital of the state of Oaxaca) or in the city of Xalapa
(capital of the state of Veracruz). The criteria for sample selection were that women had
undergone a hysterectomy for a benign reason and that at least one year had passed since their
operation. The mean age of the respondents at the time of hysterectomy was 40.22 years and
47.59 years at the time of the survey. The sample characteristics are shown in Table 1.
Table1. Sample characteristics (n = 94)
n Percent
Reason for hysterectomy
Fibroids myomas 59 62.8
Excessive menstrual bleeding 15 16.0
Endometriosis 11 11.7
Uterine prolapse 4 4.3
Other 5 5.3
Hysterectomy + bilateral salpingo-oophorectomy
Yes 39 41.5
No 55 58.5
Menopausal status prior the hysterectomy
Premenopausal 77 81.9
Postmenopausal 17 18.1
Marital status at the moment of the hysterectomy
Married 87 92.6
Single 7 7.4
Number of children
None 5 5.3
1-2 34 36.2
3-4 39 41.5
>4 16 17
Educational level
Elementary school (complete or incomplete) 34 36.2
Middle or High school (complete or incomplete) 31 33
College (complete or incomplete) 29 30.9
Occupation
Housewife 47 50.0
Professional position 30 31.9
Non-professional self employed (low-income) 14 14.9
Clerical position 3 3.2
Instruments
Data were collected using two surveys:

a) The Beliefs and Attitudes Toward Hysterectomy (BATH) questionnaire directed to
women with hysterectomy, which was created by the first author. It was designed
using an initial pool of statements developed from a review of related literature on
the issue as well as from the results of a previous study in which people were asked if
they believed the life of a woman would change if her uterus was removed and then
had to explain what changes they anticipated [8]. All items are rated on a 5-point
Likert scale, which ranges from ―strongly disagree‖ to ―strongly agree.‖ The
individual questionnaire items were written in three parallel forms depending on the
type of respondent: a) women without hysterectomy; b) men; and c) women with
hysterectomy, which was the questionnaire used in the current study. The validity of
each item was subsequently assessed by asking nine judges to rate each item using
the Lawshe formula [12]. After discarding the items with low validity, the BATH
was piloted with 20 people who were invited to discuss with the interviewer any
items they considered difficult to understand. The questionnaire was revised
accordingly and the resultant form was then tested with 271 adults. The
discriminatory capacity of each item was calculated using the extreme groups
method - comparing the scores on each item obtained by the 27% of participants who
scored highest and the 27% who scored lowest on the entire questionnaire – [13].
Then, a principal components analysis with varimax rotation was conducted and
items were deleted when they had a factor score of less than .40, or when they loaded
on a factor that was not a good conceptual fit. The final questionnaire resulted in a
25-item instrument composed of three factors: Female devaluation, Partner’s
problems and Positive aspects. The questionnaire‘s reliability was .82 using
Cronbach‘s alpha coefficient.The items that comprise the Female devaluation factor
imply that a woman who has a hysterectomy feels incomplete, empty, and her
femininity is adversely affected: for example, ―I feel empty‖ or ―I no longer feel like
a woman‖. The Partner’s problems factor includes items that suggest the woman has
problems with her partner due to the hysterectomy: for example, ―My partner
rejected me‖ or ―my partner was upset‖. The Positive aspects factor includes some
positive consequences of hysterectomy: for example, ―I am healthier‖ or ―I can avoid
pain during sex‖.
b) Open questions: Participants were asked to answer the following questions: -Would
you have had more children if your uterus had not been removed? When participants
answered affirmatively, they were asked to rate on a scale from 0 to10 how greatly
they were affected because they could not have more children. - Did your life change
because your uterus was removed? When participants answered affirmatively, they
were asked to explain what changes they have experienced.
Procedure
Some participants (39%) were recruited in a gynecological clinic waiting room. A

researcher approached and asked women if they had undergone to a hysterectomy and, if so,
if they wanted to be part of a research project. The rest of participants were contacted through
personal networks. Once women agreed to participate, they were asked to answer a few
questions to determine if they fulfilled the criteria mentioned above for participating in the
study. After ascertaining the criteria were fulfilled, participants agreed upon a place, day and
time for the survey to be conducted. When participants had limited education, the researcher
read aloud each questionnaire item to make sure that all were properly understood by the
participants. For each item, the different response options were read aloud to assure that the
recorded answers corresponded exactly with what the participants wanted to say. Participants
who did not have a partner at the time they were underwent hysterectomy were asked not to
answer the items in the ―Partner‘s problems‖ subscale of the BATH (n = 7). All participants
were told that the information they were to provide would remain confidential and
anonymous. Each questionnaire took from 10 - 20 minutes to complete. At completion, the
interviewer immediately put the questionnaire form inside an envelope containing other
questionnaire forms.
Data analyses:
We used Pearson correlations, independent sample t-tests and one-way ANOVAs to
analyze the results of the BATH. Furthermore, the participants‘ responses to the open
question were read in order to generate scoring categories constructed according to the
participants‘ responses. After these categories were determined, all participants‘ responses
were coded by two coders who worked independently assigning each response to the
appropriate category. When discrepancies were found, the answers were reread and discussed
until 100% agreement was reached on all responses.
Results
a) Beliefs and attitudes toward hysterectomy
We analyzed the scores of the three factors of the BATH taking into account the
following physiological and psychosocial variables:
Menopausal status prior hysterectomy. Women who were premenopausal prior to
undergoing hysterectomy scored higher than women who were postmenopausal on the
―Female devaluation‖ subscale of the BATH: 2.95 ± 0.98 (mean ± SD) for premenopausal
and 2.44 ± .71 for postmenopausal women (t = 2.03, df = 92, p < .05). Moreover,
premenopausal women scored lower than postmenopausal women on the ―Positive aspects‖
subscale: 3.69 ± 0.94 for premenopausal and 4.20 ± .71 for postmenopausal women (t = 2.09,
df = 92, p < .05). However, there were no significant differences on the ―Partner‘s problems‖
subscale when both groups of women were compared.
Hysterectomy + bilateral salpingo-oophorectomy. To compare the BATH scores between
participants who had hysterectomies with BSO and those who had hysterectomies without
BSO, we conducted one analysis taking into account only those women who were
premenopausal prior to surgery, and another that included those who were postmenopausal.
Women who had BSO scored higher than the women without BSO on the ―Female
devaluation‖ and ―Partner‘s problems‖ subscales of the BATH, as well as lower on the
―Positive aspects‖ subscale, but only in the group of women who were premenopausal. To the
contrary, there were no significant differences between postmenopausal women with and
without BSO in any of the subscales of the BATH (see Table 2).
Table 2. Means (and Standard Deviations) on the Beliefs and Attitudes toward
Hysterectomy questionnaire according to menopausal status prior to hysterectomy with
or without bilateral salpingo-oophorectomy (BSO)
Premenopausal women Postmenopausal women

with BSO without with without
BSO BSO BSO
M SD M SD t p M SD M SD t p
Female 3.47 1.06 2.61 .77 4.22 .0001 2.70 .90 2.20 .41 1.50 n.s.
devaluation
Partner‘s 3.23 .91 2.67 .78 2.82 .006 3.05 .69 2.45 .46 1.99 n.s.
problems
Positive 3.22 .77 4.01 .91 3.95 .0001 4.12 .84 4.27 .62 .40 n.s.
aspects
Menopausal status prior hysterectomy, BSO and HRT. In order to conduct this analysis,
the partiacipants were divided into the following four groups: a) women who were
premenopausal prior to undergoing hysterectomy, who had undergone BSO and who received
HRT after the surgery (premenopausal-BSO-with HRT); b) women who were premenopausal
prior to undergoing hysterectomy, who had undergone BSO, and did not receive HRT after
the surgery (premenopausal-BSO-without HRT); c) women who were premenopausal prior to
undergoing hysterectomy, who had not undergone BSO (premenopausal-no BSO); and d)
women who were postmenopausal prior to undergoing hysterectomy (postmenopausal). As
can be seen in Table 3, the participants belonging to premenopausal-BSO-with HRT and
premenopausal-BSO-without HRT groups scored higher than participants belonging to
premenopausal-no BSO and postmenopausal groups on the ―Female devaluation‖ and
―Partner‘s problems‖ subscales of the BATH. Furhtermore, the women belonging to
premenopausal-BSO-without HRT group scored lower than the rest of the groups on the
―Positive aspects‖ subscale.
Number of children. There were no significant differences on the BATH‘s subscales

when the following groups of women were compared: a) women who did not have children,
b) women who had one or two children, c) women who had three or four children, and d)
women who had five or more children.
Hysterectomy questionnaire according menopausal status prior to hysterectomy,
bilateral salpingo-oophorectomy (BSO) and hormone replacement therapy (HRT)
Premenopausal Premenopausal Premenopaus Postmenopausal F p

women with women with al women women
BSO with BSO without without
HRT HRT BSO
M SD M SD M SD M SD
Female 3.27a 1.01 3.69a 1.09 2.59b .75 2.45b .73 8.62 .0001
devaluation
Partner‘s 3.16 a .83 3.31 a 1.02 2.68b .77 2.70b .65 3.09 .032
problems
Positive 3.55a .63 2.88 .78 4.03a .91 4.16a .72 9.14 .0001
aspects
Note: Within each row, means not sharing subscript differ from each other at p < .05 level.
Women adversely affected by not having more children. In order to conduct this analysis,
the partiacipants who were premenopausal prior to undergoing hysterectomy were divided
into the following three groups: a) women who were not adversely affected: those who did
not want more children or who rated zero when asked how greatly they were affected by not
being able to have more children (n = 55); b) women who were slightly affected: those who
rated from one to five when asked how much they were affected by not being able to have
more children (n = 9), and c) women who were severely affected: those who rated from six to
ten when asked how much they were affected by not having more children (n = 14).
Participants who were postmenopausal prior to undergoing hysterectomy were eliminated
from this analysis since they were already infertile prior to surgery.
As can be seen in Table 4, the participants who were severely affected scored higher than
the rest of participants on the ―Female devaluation‖ and ―Partner‘s problems‖ subscales of the
BATH. Moreover, participants who were adversly affected to any degree scored lower on the
―Positive aspects‖ subscale of the BATH than women who were not adversly affected.
Hysterectomy questionnaire for women who were not adversely affected, were slightly
affected or were severely affected by not being able to have more children
Not affected Slightly affected Severely affected

M SD M SD M SD F p
Female devaluation 2.77a .84 2.70a 1.02 3.77 1.09 7.13 .001
Partner‘s problems 2.78a .81 2.72a .77 3.58 .91 5.07 .01
Positive aspects 3.93 .84 3.73 a .92 2.83 a .84 9.38 .0001
Educational level. Years of schooling correlated negatively with the ―Female devaluation‖
subscale of the BATH (r =.335, p <. 001), as well as with ―Partner‘s problems‖ subscale (r =.262, p
<.014).
Age. There was no significant correlation between the age of participants and any subscale of the
BATH.
b) Reactions to hysterectomy
When participants were asked if their life had changed as a consequence of the
hysterectomy, 33% of women claimed their life had changed negatively, 13.8%
acknowledged their life had changed positively, and the rest of the participants (53.2%)
claimed their life had not changed.
Participants who claimed their life had changed negatively showed the highest scores on
the ―Female devaluation‖ and ―Partner‘s problems‖ subscales of the BATH. Moreover, these
participants scored lower than the rest of the women on the ―Positive aspects‖ subscale of the
BATH (see Table 5).
Hysterectomy questionnaire for women who claimed hysterectomy had changed their
life negatively, positively, or reported no change
Negative change Positive change No change

M SD M SD M SD F p
Female devaluation 3.83 .96 2.72a .61 2.29a .43 51.41 .0001
Partner‘s problems 3.47 .81 2.77a .76 2.51a .65 15.63 .0001
Positive aspects 2.95 .67 3.83a .53 4.30a .74 36.43 .0001
In the group of women who were premenopausal prior to undergoing hysterectomy and
who had undergone BSO, there were more participants who reported negative changes than
women who reported positive changes or women who reported no changes. To the contrary,
in both the group of premenopausal women without BSO and in the group of postmenopausal
women, most participants reported no changes, and similar numbers of women reported
positive and negative changes (see Table 6). Statistical anlyses were not conducted in this
case because there were some cases where there were less than five paraticipants in a
particular group.
Table 6. Number and percentage of women who claimed their life had changed
negatively, positively, or reported no change according their menopausal status prior to
hysterectomy with or without bilateral salpingo-oophorectomy (BSO)
Negative change Positive change No change Total

n % n % n % n %
Premenopausal women with 18 58.1 5 16.1 8 25.8 31 100
BSO
Premenopausal women without 14.9 63.8 47 100
BSO 10 21.3 7 30
Postmenopausal women 3 18.8 1 6.3 12 75.0 16 100
Table 7 shows changes after hysterectomy as ranked by the percentage of women who
claimed they experienced each change. As can be seen, the most frequently reported change
was that their relationship with their partner deteriored. The second most frequently reported
changes was their sexual lives deteriorated, but the third was that their health improved.
Table 7. Consequences of hysterectomy ranked according to the percentage of women

whoreported such experiences
n %
The relationship with her partner deteriorated. 14 21.9
Her sexual life deteriorated. 11 17.2
Her health improved. 10 15.6
Her general health deteriorated. 8 12.5
She has experienced emotional changes. 6 9.4
She lost something important as woman. 6 9.4
She is frustrated because she wanted more children. 4 6.3
She is happy because she no longer menstruates. 3 4.7
She is happy because she cannot get pregnant. 2 3.1
Discussion
The results of the present study show that women undergoing hysterectomy possess
different beliefs and attitudes toward hysterectomy which are influenced by several
psychosocial and physiological variables.
Unlike the Cabness study [4], in which it was found that the youngest women showed the
greatest dissatisfaction with their quality of life following hysterectomy, we did not find any
association between the age of participants and their scores on the BATH. However, we did
find that the women who were premenopausal prior to undergoing hysterectomy, as compared
with the women who were postmenopausal, were more likely to believe they were
incomplete, empty and that their femininity was adversely affected as a consequence of the
hysterectomy. These findings are consistent with a previous study in which it was found that
women who were considered fertile prior to surgery, regardless of whether or not they had
already given birth, were likely to suffer disrupted gender identity [3]. For some women, it is
difficult to accept the loss of their reproductive ability, despite their personal desire not to
have more children. Even mothers who had previously decided that their families were
complete, may find themselves yearning to have the option of future pregnancies still
available to them. Indeed, Morkovic et al. [7], who interviewed 30 women who had been
undergone hysterectomy, found that although most women held positive views about
hysterectomy, some of them felt that their ―womanhood‖ had been compromised since they
had lost control over their reproductive decision making due to the hysterectomy. Women
who embraced the ideal of having individual control over their bodies‘ reproductive function
rather than submitting to the biological determinants of health had greater difficulty
perceiving a hysterectomy as a positive event.
Although there were no differences in the BATH scores between women who did not
have children and those who did, we did find that participants who were severely affected by
not being able to have more children after the hysterectomy showed more negative scores on
the three subscales of the BATH. It is logical to assume that women who wanted to have
more children would hold the most negative attitudes toward their hysterectomy. However,
the impossibility of having more children does not imply that women are incomplete, empty
or that their femininity is adversely affected. Hence, our results highlight the need to design
support programs for couples that wanted to have more children but no longer can because
the woman has lost her reproductive capacity as a result of hysterectomy.
We also found that women with BSO showed the most negative attitudes toward
hysterectomy, but only within the group of women who were premenopausal prior the
hysterectomy. Moreover, those women who were premenopausal and had undergone BSO
were more likely than the rest of participants to claim their life had negatively changed as a
consequence of their hysterectomy. In the Elson study cited above [3], it was found that
women who had undergone BSO as well as hysterectomy tended to report a disrupted gender
identity, especially if they had been premenopausal prior the surgery. These findings could be
due to the fact that BSO causes an abrupt cessation of ―female‖ hormones and, as a
consequence, BSO may be loaded with greater symbolic meaning for women than is
hysterectomy alone.
It is important to notice that no significant differences were found between women who
were receiving HRT and those who were not on ―Female devaluation‖ and ―Partner‘s
problems‖ subscales of the BATH. However, premenopausal women with BSO who were
receiving HRT scored higher on the ―Positive aspects‖ subscale than those who were not
receiving any treatment. A possible explanation of this finding is that those women who were
not receiving HRT may have experienced menopause-related problems, and therefore, they
could have minimized the beneficial effects of hysterectomy.
Another of our findings was that women with a limited educational background were
more likely to believe they were incomplete, empty and that their femininity was adversely
affected as a consequence of the hysterectomy. They also acknowledged having more
problems with their partners because the hysterectomy than women with higher education.
It is important to note that by considering the nature of the employment of the
participants, the neighborhood in which they live, as well as their educational level, we
inferred that the most negative attitudes were held by women belonging to the lower or lower-
middle socioeconomic classes. These findings are consistent with earlier studies in which it
has been found that women with lesser educational backgrounds and having lower
socioeconomic status, when compared to those with better educations and more privileged
social backgrounds, hold more negative attitudes toward hysterectomy and have more fears
and misconceptions related to the issue [6-8]. These differences may be due to the
conjunction of unfavorable economic conditions and the fact of having limited education
which puts them at a disadvantage in obtaining information about the issue. But it is also
important acknowledge the influence of cultural beliefs on attitudes toward hysterectomy. In
the case of Mexico for example, these differences could be also caused by gender inequalities
that are more pronounced in the lower socioeconomic classes [14].
Concerning the qualitative data about the participant‘s life changes as a consequence of
the hysterectomy, we found the most frequently reported change was that the relationship
with partners had deteriorated. Some investigations have found that in certain cultures women
believe men view hysterectomy as making a woman less desirable, and thus some women feel
threatened that their partner might leave the relationship after a hysterectomy [11, 15, 16].
Indeed, these fears lead some women to choose not to inform their partners when they have a
hysterectomy[16]. Once again, these results highlight the need to design support programs for
women facing hysterectomy and their partners.
Programs should consider that couples generally discuss little about the issue [17], and
they also should take into account that beliefs and attitudes are influenced by the cultural
norms of the community in which people are brought up. For example, in a study in which
Mexican-American and Caucasian women were asked what they had heard about the effects
of hysterectomy prior to undergoing the surgery themselves, there were more Mexican-
Americans who had heard they were going to experience a change for the worse in their
experience of intercourse. This is why one Mexican-American woman postponed her surgery
for two years giving the reason that: ―I was afraid of not being able to satisfy my husband‖
[18].
Moreover, programs also should take into account the fact that men‘s perceptions
concerning health issues - especially reproductive health issues - are strongly influenced by
the social construct of masculinity [19]. In this sense, it is interesting that there are cultures -
like Sweden - in which men describe the uterus as an organ solely for pregnancy and
childbearing, and they do not believe that hysterectomy negatively influences the woman as a
female. These men show prevailing supportive attitudes and adequate reactions concerning
their partner's hysterectomy [20].
Another negative change after hysterectomy frequently reported by participants was that
their sexual lives had deteriorated. The actual effects of hysterectomy on sexual functioning
remain unclear and it is an issue of debate. Studies of sexual function have shown varying
results, and comparisons are complicated by differences in the methodology used. Vomvolaki
et al. [21] analyzed the articles published between 1996 and 2002 on sexuality and
hysterectomy that were in the MED-LINE, CINAHL, Psychlit, and Sociofile databases.The
authors concluded that most published studies on the subject show that hysterectomy has no
effect on a woman‘s sexuality and in some cases even improves it. Baryam [1] also did a
thorough review of related literature on the issue, and concluded that some of the factors that
may affect the psychosexual adaptation after hysterectomy are: age, BSO, HRT, type of
hysterectomy, culture, the meaning of uterus for women, alleviation of symptoms related to
hysterectomy and women‘s psychological reactions to the operation. Furthermore, Baryam
[22] demonstrated that sexual functioning after hysterectomy is also affected by women‘s
attitudes about sexuality and by symptoms of depression. Moreover, women who have a
satisfying sexual life preoperatively tend to continue in this way in the postoperative period,
whereas if there were sexual problems prior the surgery, such problems tend to continue after
hysterectomy. In the current study, women who did report sexual problems scored higher than
the rest of the participants on both ―Female devaluation‖ and ―Partner‘s problems‖ subscales
of the BATH. We do not know if they scored higher because they have sexual problems, or if
sexual problems are due to their negative beliefs and attitudes.
It is important to notice that the participants also acknowledged that their lives had
changed in a positive way since their health had improved. In general, most women who had
undergone hysterectomy claim that their quality of life improved as a consequence of
alleviation of their symptoms after the surgery. In a specific study conducted with both
Caucasian and Mexican-American women who had undergone hysterectomy, it was shown
that although they expressed some negative attitudes toward hysterectomy, only 3 of 64
women expressed either real disappointment over having had the operation or displeasure at
the results [18].
Our findings could be helpful in designing effective support programs for women facing
hysterectomy and their partners. Efforts must be directed to provide accurate and current
information, which should include both physical and psychosocial aspects of hysterectomy in
order to dispel myths, eliminate fears and to prevent women from delaying the surgery
because of unnecessary worries. Moreover, healthcare providers must be made aware that
many factors besides medical necessity and relief of symptoms should be carefully considered
when women make decisions about hysterectomy.
Finally, the findings of this study must be interpreted in the context of its limitations.
First, the participants were self-selected, representing only women who felt open to and
comfortable with sharing information of a personal nature. Another limitation is that the data
could be affected by errors in memory. However, since a reminiscence can be seen as a
process of reframing the past, in the context of the present, what women remember about
their experiences provides insight into what was most salient about the event not only when it
occurred but as it is reconsidered over time [23].
Acknowledgments
The authors wish to thank Rafaela Barradas and Alberto Antonio Martínez Virue who
put us in touch with the patients in the gynecological clinic, as well as Vanessa Quiros who
assisted us in the collection of data.
This research was supported by grant PROMEP/103.5/09/4482 from Secretaría de
Educación Pública: Programa de Mejoramiento del Profesorado.
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[4] Cabness J. The psychosocial dimensions of hysterectomy: Private places and the inner
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y a la medición. 4th ed. Mexico: McGraw Hill; 2000.
[13] Anastasi A, Urbina,S. Psychological Testing. 7th ed. New Jersey: Prentice Hall; 1998.
[14] Marván ML, Quiroz V, Vázquez-López E, Ehrenzweig Y. Mexican beliefs and attitudes
toward hysterectomy and gender-role ideology in marriage. Health Care Women Int. in
review for publication.
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2000 9 (suppl 2):51-61.
[17] Bernhard LA, Harris C R, Caroline HA. Partner communication about hysterectomy.
Health Care Women Int. 1997;18: 73-83.
[18] Williams MA. Cultural factors and hysterectomy. In AJ Dan, EA Graham, CP Beecher
(Eds.). The menstrual cycle: A synthesis of interdisciplinary research (pp. 319-327).
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Welfare 2002;48:67-76.
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[21] Vomvolaki E, Kalmantis K, Kioses E, Antsaklis A. The effect of hysterectomy on
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Chapter 5
Hysterectomy’s Effects on Quality

of Life and Sexual Function:
What Does Say Evidences?
Güliz Onat Bayram

Istanbul University Bakırkoy Health School, 34740, Bakirkoy/Istanbul-Turkey
Abstract
Hysterectomy increasingly has been recognized as a procedure that can affect many
aspects of a woman‘s health. Psychological and biophysical health problems may develop
after hysterectomy. It is reported that, after hysterectomy a great majority of women may
suffer psychological symptoms such as depression, fatigue, anxiety, as well as new
symptoms, including urinary inconsistence, constipation, premature ovarian failure and
sexual dysfunction. Although there are reasons to believe that removal of the uterus can
have adverse effects on female sexual functioning by disrupting the anatomical relations
in the pelvis, no consensus exists on whether hysterectomy causes sexual dysfunction.
Hysterectomy is an important operation which affects women‘s quality of life and
psychosexual states. Prehysterectomy sexual functioning and psychosocial state are
significant predictors for posthysterectomy sexual dysfunction and depression. Recent
randomized trials and prospective cohort studies have provided new information on the
health outcomes of hysterectomy for non-malignant conditions. These studies
consistently have demonstrated a marked improvement in symptoms and quality of life
during the early years after surgery especially by using laparoscopic techniques.
Hysterectomy does not cause long-term psychiatric morbidity, and psychological status
generally improves. Studies of sexual function have shown varying results, with most
suggesting improvement or no change in sexual function for the majority of women. The
evidence appears to be clearer with regard to other prognostic factors that had an effect
on postoperative sexual function: preoperative satisfaction with sexual life, good
relationship with partner, chronic disease and hormone replacement therapy.
Most of the controversy arises from the assertion that the most of the hysterectomies
are being performed unnecessarily, although it has minor positive effects, the problems
encountered after the hysterectomy negatively affect the quality of life in women. Health
care providers should consider women‘s age, hormonal states, the type and indications of
82 Güliz Onat Bayram
the hysterectomy, the meaning ascribed by her to uterus and her culture, general health
condition of her partner, when determining psychosexual adaptation requirements of
women who had undergone hysterectomies. These information needs to be
communicated to women requiring hysterectomy for a benign condition and this is not
often routine. Women can be informed about hysterectomy‘s adversely effects.
The aim of this chapter is to discuss to the impacts of hysterectomy on women‘s
quality of life and psychosexual adaptation after hysterectomy under the light of evidence
based findings.
Keywords: Hysterectomy, quality of life, sexual function, evidence-base practice.
Introduction
Hysterectomy has been performed for over 150 years, and is currently the most common
major gynaecological operation both in the United Kingdom and the United States of
America [Thakar et al 2004]. Thus its consequences concern a large number of women
[Rannestad 2005].
Hysterectomy increasingly has been recognized as a procedure that can affect many
aspects of a woman‘s health [Fogel and Woods 2008]. 40% of hysterectomies are elective and
these elective procedures are expected to treat abnormal bleeding, chronic pelvic pain and
symptomatic myomas, and to improve health related general quality of life [Cimen 2007;
Uzun et al 2009; Teplin et al 2007]. However according to American College of Obstetrics
and Gynecology, 70% of performed hysterectomies are unwarranted and accurs as the result
of the lack of diagnostic evaluation or the failure to try alternative treatments [Flory et al
2005]. Medical approaches sometimes fail to relieve symptoms or cause adverse effects,
leading to the clinical dilemma of whether to continue efforts with medical approaches or to
elect hysterectomy. The benefits and harms of these two approaches at this stage of decision
making have not been studied in a randomized clinical trial [Kuppermann et al 2004].
The uterus is considered important for a woman‘s self-image and sexual image and some
women fear that they will be ―less of a woman‖ to their sexual partners. Therefore a
hysterectomy may also interfere with the woman‘s body image [Hehenkamp et al 2007].
Psychological and biophysical health problems may develop after hysterectomy. It is reported
that, after hysterectomy a great majority of women may suffer psychological symptoms such
as depression, fatigue, anxiety, as well as new symptoms, including urinary inconsistence,
constipation, premature ovarian failure, sexual dysfunction and small mortality risk
[Kuppermann et al 2004].
Psychosexual adaptation and quality of life (QoL) after hysterectomy have been a subject
of concern to women and gynaecologists. Most controversy arises from the assertion that
many hysterectomy are performed unnecessarily, although it has minor positive effects, the
problems encountered after hysterectomy negatively affect QoL, and psychosexual health
problems may develop [Schuiling and Likis 2006]. Shortening of the vaginal vault after
hysterectomy, particularly after a horizontal closure, could result in dyspareunia, while
oestrogen and testosterone deficiency caused by hysterectomy with oopherectomy may cause
vaginal dryness and libido loss. Even when ovaries are preserved, hysterectomy may result in
ovarian failure and increased menopausal symptoms, including vaginal dryness. It has been
suggested that removal of the cervix inhibits internal orgasm. Vaginal hysterectomy has been
Hysterectomy‘s Effects on Quality of Life and Sexual Function 83
implicated in greater sexual morbidity than abdominal [McPherson et al 2005]. Debate about
post-hysterectomy sexuality is complex, due to many confounding variables, although most
studies do not confirm a negative impact on sexual satisfaction [Schuiling and Likis 2006].
The limited evidence is conflicting and points towards equally plausible mechanism for
improvement as well as for deterioration. Hysterectomy for a bening indication, such as
dysfunctional uterine bleeding, eliminates inconvenient, excessive or prolonged bleeding and
removes the threat of unwanted pregnancy. But considering its plausible detrimental effects
on ovarian function, damage to pelvic plexus‘ innervations, ligaments and tissue, and injury
to the remaining pelvic organs, what this actually does to sexual wellbeing in aggregate, in
comparison with a less invasive conservative surgical treatment remains unknown
[McPherson et al 2005]. The answer to why hysterectomy affects some women positively and
others negatively has not been researched sufficiently. Whether there are specific factors such
as surgical techniques or psychosocial factors which increase the women‘s risk of
experiencing negative outcomes, is another controversial issue [Cimen 2007].
This article reviews basic concepts of female sexuality and defining quality of life and
analyzing evidences related hysterectomy‘s impact on them; the article also provides
suggestions for researchers to attain clear evidence concerning the subject.
Defining Quality Of Life

Quality of life (QoL) became an important priority in Western society following Word
War II, and has increasingly been recognized as an important outcome variable in medicine
and nursing research and practice. Many scientific disciplines have been engaged in QoL-
related aspects over time. The interest is multidisciplinary, but the different sciences approach
QoL from different perspectives. No single, universally accepted definition of the concept
exists, which complicates the operationalisation of the concept. World Health Organization‘s
(WHO) definition of QoL is organized into six broad domains: physical, psychological, level
of independence, social relationship, environment and spirituality/religion/personal beliefs.
The different domains have reciprocal influences on each other and QoL encompasses a
totality and wholeness. WHO also emphasizes the individual‘s goals, expectations, standards
and concerns as an important facet of QoL. Hence, QoL is a multidimensional evaluation of
an individual‘s current life circumstances in the context of the culture and value system in
which they live and the values they hold [Rannestad 2005].
Health-related quality of life (HRQoL) has been increasingly recognized as an important
outcome variable in clinical research, in addition to the more traditional biomedical measures
[Yang et al 2006]. HRQoL is a multidimensional concept referring to an individual's total
well-being. Although many definitions of HRQL have been proposed, a recent consensus
conference of international experts concluded that the fundamental dimensions essential to
any HRQL assessment are physical, social, and emotional functioning, as well as perceptions
of overall QoL or general life satisfaction. For specific investigations, however, the
assessment of other dimensions of HRQL may be important. These dimensions include:
cognitive or neuropsychological functioning, sexual functioning and intimacy, personal
productivity, pain, symptoms, and sleep disturbance [Naughton and Mcbee 1997].
HRQoL is an important concept for gynecologic medical and nursing staff to understand
in order to provide patients with accurate information during pre- and postsurgical
counseling, thereby enhancing the appropriateness of treatment and care [Yang et al 2006].
The Evidences Related to Effects of Hysterectomy

on HRQoL
QoL is an important outcome variable in clinical research as medical interventions can
affect it in both positive and negative ways. Psychiatric symptoms can arise as a result of
physical illness, or might influence the manifestation and/or outcome of treatment of that
illness. In this regard, arguably the example par excellence is the impact of hysterectomy.
While early research suggested that hysterectomy might be associated with adverse
psychological outcome [Polivy 1974], recent studies tend to suggest either no change
[Alexander et al 1996], or an improvement [Kjerulffe et al 2000] in psychological outcome.
Recent research also suggests that hysterectomy might improve QoL [Rannestad et al 2001],
but no evidence hysterectomy‘s side effect on HRQoL. According to studies, a great majority
of women who had undergone hysterectomies report that their QoL improved as a result of
alleviation of their problems after the operation, their perception of general health improved,
pain and physical symptoms decreased [Cimen 2007; Uzun et al 2009]. Another study by
Thakar et al [2004] reported that hysterectomy, whether total or subtotal, may improve QoL
and psychological outcome. According to SOGC (Society of Obstetricians and
Gynaecologists of Canada) clinical guidelines for hysterectomy, in the properly selected
patient, the result from the surgery should be an improvement in the QoL [Lefebvre et al
2002].
Nevertheless, in 40 to 50% of women who had undergone hysterectomies, complications
like haemorrhage, urinary system injuries, bowel perforation and infections may be observed
in the early post-operative period. Moreover, in the literature it is emphasised that women are
experiencing physical, social and sexual problems such as post-operative fatigue, weight
changes, irritability, insomnia, poor concentration or poor memory, crying spells, poor
appetite, diarrhoea or constipation, sadness, changes in sexual behaviour [Esen and Cam
2006; Saylam 2005; Schuiling and Likis 2006]. In a study by Carlson et al. [1997] it was
reported that the women who had undergone hysterectomy suffered new symptoms: 13% of
them suffered hot flashing, 8% depression, 6% anxiety and 7% low sexual desire.
Carlson et al. [1997] report that, in women who had undergone hysterectomy, the QoL
improved with the relief of symptoms within 6-12 months in the postoperative period. The
study by Uzun et al. [2009] which was conducted with 50 Turkish women revealed that the
total abdominal hysterectomy (TAH) performed due to myoma uteri improves general QoL
with its all sub-dimensions. The study conducted by Cimen [2007] which evaluates the sexual
functioning and general QoL in 50 women who had undergone myomectomy and 50 women
who had undergone hysterectomies, it was observed that in the 6th month of the postoperative
period the QoL was better in both groups compared to preoperative period, and compared to
myomectomy, the hysterectomy provided more improvement in general QoL. A 2 years
prospective study by Kjerulff et al. [2000], it was observed that, after hysterectomy there
were a significant decrease in severity of symptoms, levels of depression and anxiety, and
improvement in general QoL and especially in social functioning. Kuppermann et al [2004]

reported that among women with abnormal uterine bleeding and dissatisfaction with
medroxyprogesterone, hysterectomy was superior to expanded medical treatment for
improving HRQoL after 6 months. With longer follow-up, half the women randomized to
medicine elected to undergo hysterectomy, with similar and lasting QoL improvements; those
who continued medical treatment also reported some improvements.
In contrast with the positive results reported in the studies on hysterectomy, in a study by
Bislawska Batorawicz [1991] on Polish women, which evaluated the impact of hysterectomy
on physical, psychological and sexual functions, it was observed that the QoL was affected
negatively.
Concepts of Female Sexual Functions

and Hysterectomy
Sexuality is an important QoL issue. Sexuality is more than the ability to have sexual
intercourse. Sexuality is a concept that involves the sexual satisfaction and a harmonic
partnership of a couple. To many women, sexuality includes feelings about their body
apperance, their feminity, their ability to bear children, and their ability to function sexually.
Sexuality is an integral aspect of a woman‘s personality, with emotional, intellectual, and
sociocultural components. Feelings about sexuality change as a woman moves through the
life cycle, and different issues emerge as priority concerns, depending upon her age,
developmental stage, and stage of her family development [Wilmoth and Spinelli 2000].
In the 1980s, there were suggestions that fears related to postoperative sexual function
were the most frequent pre-hysterectomy anxiety. Since then, randomized controlled trials
and cross-sectional studies indicated that the postoperative improvements were more likely
than any deterioration. The findings were that women who have sex, have sex more
frequently after hysterectomy and concluded that sexual wellbeing improves after
hysterectomy. But while to some, more sex is likely to be equivalent to improved sex life,
female sexual functioning may be more a matter of quality rather than quantity, and
understanding sexuality after hysterectomy requires care in interpretation of data. Moreover,
sexual wellbeing may not be the same as the absence of sexual dysfunction. The physiology
of sexual function may be an important issue [McPherson et al 2005].
Sexual functioning refers to the physiologic and anatomic capacity to engage in sexual
activity. Components of this include human anatomy, the sexual response cycle, hormonal
levels, and life cycle changes in sexual physiology. Satisfactory sexual functioning is
dependent upon the complex interaction between physiologic and psychologic factors. The
sexual response cycle consists of three phases: desire, arousal, and orgasm [Wilmoth and
Spinelli 2000].
Hysterectomy can theoretically lead to changes in any stage of sexual response cycle.
[Flory et al 2005]. Desire is the most complex component of the sexual response cycle and is
though to be affected by testesterone, luteinizing hormone, dopamine and, serotonin level.
Desire can be intibited by emotions such as anger, concers over body image and self-esteem,
or enhanced through touch, visual imagery, and fantasy. These factors are important to
remember when caring for women have concerns about their body image after surgical
intervention such as hysterectomy [Wilmoth and Spinelli 2000].
There is little evidence to suggest that the removal of the uterus alone causes lowered
sexual desire. The main reasons suggested for a reduction in sexual desire following
hysterectomy are hormonal and psychological. Approximately half of hysterectomy patients
undergo the surgical removal of their ovaries (oophorectomy), resulting in surgical
menopause. Even hysterectomy without oopherectomy hastens ovarian failure, thereby
leading to earlier menopause. The decline of ovarian hormones has been proposed to cause
low sexual desire and depressive mood. In addition to hormonal factors, low libido
posthysterectomy has been attributed to such psychological factor as depression and body
image impairment [Flory et al 2005].
Arousal to the point of orgasm is dependent on a functional parasympathetic system with
adequate psychic or somatic sexual stimulation. The physiologic response to this stimulation
is vasocongestion in the target organs causing vaginal dilation, an increase in lenght and
diameter of the vagina, and enlargement of the clitoris, labia, and uterus, with nipple erection
and elevations in blood pressure and pulse rate [Wilmoth and Spinelli 2000].
The empirical evidence with regard to changes in sexual arousal due to the removal of the
uterus is weak. It has been theorized that hysterectomy reduces sexual arousal due to several
mechanism. First, the reduced quantity of tissue resulting from the removal of the uterus
and/or cervix and/or upper parts of the vagina reduces pelvic vasocongestion. Second, the
disruption in the blood circulation to the pelvis may impair an adequate lubrication. Third, the
formation of scar tissue in the upper part of the vagina may prevent the full ballooning of the
vagina, thereby limiting arousal. Finally, loss of oestrogen and androgen after hysterectomy-
oopherectomy and ovarian failure following hysterectomy may lead to vaginal atrophy,
dryness, decreased lubrication, and arousal difficulties [Flory et al 2005].
Orgasm, the release of sexual tension, is dependent on an intact sympathetic nervous
system, specifically either an intact pudental or the pelvic nerve. Orgasm reached through
clitoral or vaginal stimulation is mediated by the pudental nerve. Depending on the extent of
the surgery, an abdominal hysterectomy may damage the pudental or pelvic nerve, thus
impairing a woman‘s orgasmic ability [Wilmoth and Spinelli 2000].
It has been suggested that the uterus and cervix are not necessary for orgasmic
functioning, however, that vaginal muscle contractions were accompanied by rhythmic
smooth-muscle contractions of the uterus during orgasm [Flory et al 2005]. A study by
Virtanen et al [1993], 21% of hysterectomy patients reported decreased orgasmic frequency
following total hysterectomy. However, postoperative changes in the frequency, intensity, and
quality of orgasm have not been adequately assessed, which may be partly due to the lack of
reliable and valid measures. While hysterectomy seems to have no systematic negative effect
on orgasmic potential in most women, a subgroup of 15-25% appears to experience adverse
changes in the frequency of orgasm [Flory et al 2005].
Female sexual functioning is complicated because of the role pyschic factors play in
mediating response to sexual stimulation, the interplay of the neurohormonal system, and the
monthly variations in estrogen and progesterone levels. However, these physiologic factors
are only part of the composition of female sexuality. Much of female sexuality is beside on
sociocultural norms of appearance, age, and childbearing ability [Wilmoth and Spinelli 2000].
The factors which could affect the psychosexual adaptation after hysterectomy are listed
below:
1) Age
2) Hormones (Hormone therapy, ooforectomy, etc.)
3) Type of Hysterectomy
4) Culture
5) Reasons Related to Sexual Partner
6) The Meaning of Uterus for Women
7) Alleviation of Symptom Related to Hysterectomy
8) Woman‘s Psychological Reactions to the Operation
The Evidences Related to Effects of Hysterectomy

on Sexual Function
To many women, having an intact uterus with the presumed ability to bear children is
what defines them as ―woman‖. The loss of this ability before planned completion of
childbearing can affect a woman‘s sense of herself as female, change intimate relationship,
and affect a woman‘s body image. Other fears include questions about the ability to continue
pleasurable sexual activity, experience orgasm, and satisfy her partner [Wilmoth and Spinelli
2000]. Several studies have suggested that sexual functioning following hysterectomy is a
major concern of patients, yet doctors, nurses, and other health care professionals are
reluctant to discuss sexual issues [Flory et al 2005]. Clinicians often focus on ―objective
findings‖, such as fibroid size and number, along with patient age and reproductive plans,
when they recommend hysterectomy, rather than discussing the impact of symptoms on the
patient‘s QoL and her attitudes toward her uterus [Kuppermann et al 2010]. No consensus
exists on whether hysterectomy causes sexual dysfunction. According to resrospective studies
published from the 1970s to early 1990s, estimates of the percentage of hysterectomized
women who experience impairments in sexual functioning range from 10% to 53% [Flory et
al 2005]. Recent prospective studies show that, for the overwhelming majority of patients,
hysterectomy improves their sexual lives, although a subgroup of 10-25% may develop a
sexual problem after surgery. There are preliminary reports suggesting greater sexual
impairments following abdominal hysterectomy as compared with other approaches, but
definite conclusions are not yet possible [Flory et al 2005]. Sexual problems after
hysterectomy that have been reported include dyspareunia related to vaginal shrinkage and
decreased lubrication, low libido, and not experiencing orgasm [Naughton and Mcbee 1997;
Dragisic and Milad 2004]. Prevalence of sexual dysfunction among women undergone
hysterectomy varies depending on methodological factors [Meston and Bradford 2004]. As
many as one-third of women having hysterectomies report decreased orgasm and excitement
related to absence of cervical stimulation and decreased pelvic congestion [Wilmoth and
Spinelli 2000]. Several mechanisms for adverse effects on sexual function after hysterectomy
have been proposed, including decreasing ovarian function, changes in pelvic anatomy after
surgery, decreased orgasmic ability because of loss of the uterus, and the symbolic
psychological meaning of loss of the uterus. Impaired sexual function can occur in women
who feel that their sexuality is dependent on the presence of the uterus [Fogel and Woods
2008]. However it was reported that hysterectomy increases sexual satisfaction by relieving
the complaints like dysmenorrhoea [Saylam 2005]. Factors proposed to explain the increase
in sexual desire include absence of fear of pregnancy and absence of the pain related to the
condition requiring hysterectomy [Fogel and Woods 2008]. Some studies in the literature
have helped to clarify the issue of psychosexual effects of hysterectomy, although
comparisons are complicated by differences in studied populations and outcome measures
(Table 1).
Since the study of Ayoubi et al. [2003] is retrospective, inaccuracies about recall
bias/memory are unavoidable. Yet in the other studies which are prospective, the fact that the
evaluations are made just a couple hours/days before the operations, will affect the answer
given by the women who suffer the symptoms and experience preoperative anxiety [Flory et
al 2005]. In the studies of Rhodes et al. [1999], Dragisic and Milad [2004], Bayram and Şahin
[2008], Jeng et al. [2005] and Aziz at al. [2005], postoperative sexual functions are compared
with the operation-time sexual functions. However, sexual functions during the operation may
be affected negatively by the complaints like bleeding, pain, etc. One other limitation of these
studies is not conducting the statistical analyses which allow comparison of the outcomes
with the type of the hysterectomy and the hormonal state, as is in the study by Rhodes et al.
[1999]. The researchers except Kuppermann et al. [2005], Aziz et al. [2005] and Bayram
[2008], used the questionnaires prepared by themselves instead of scales useful in providing
objective data in the evaluation of psychosexual state. Due to limited use of objective
diagnostic methods and not being able to determine the subjective aspect of sexuality, many
scales are developed today as diagnostic tools. Used for objective diagnosis, these
questionnaires enquire the desire, excitation, orgasm and satisfaction sexuality and the pain
during the coitus [Meston and Bradford 2004; Hakim 2006].
Usually, one of the indicators affecting the postoperative sexual behaviour is the
preoperative sexual adaptation. The woman who has a satisfying sexual relationship
preoperatively tends to resume it from where she left in the postoperative period. If
preoperative sexual problems exist, those will not vanish but remain after the operation
[Youngkin and Davis 2004]. In the study by Saylam [2005] on 30 women who had undergone
hysterectomy, it was reported that the women with preoperative sexual problems informed
that these problems continued after the operation. Studies evaluating preoperative sexual
functions and comparing them with the postoperative functions are highly useful in
determining the impact of hysterectomy on sexual functions. However, existing state of the
sexual functions before the operation is not sufficient alone to explain the impact of
hysterectomy on sexual functions. Because the sexuality is a highly complex concept shaped
by many factors such as previously taken medications, chronic diseases, level of hormones,
satisfaction of the relationship between partners, social norms, etc. [Youngkin and Davis
2004; Berek et al 1998; Masters and Johnson 1966]. It is extremely difficult,
methodologically, to bring all of these external factors under control. In a study by Rhodes et
al [1999], it is reported that 6, 12, 18, 24 months after hysterectomy, sexual functions
eventually improve compared to previous period. This research finding suggests that sexual
functions improve gradually, after the hysterectomy, thus the evaluation time of the sexual
functions after the operation is the most important methodological factor in explaining the
different results of study findings. It is reported that the recovery period for pelvic organs
after the operation is at least 6 months, and 80% of women prefers to restart sexual activities
after this period elapses. Therefore psychosexual effects must be observed at least 6 months
after the operation [Flory et al 2005].
On the other side, there are studies which first of them by McPherson et al [2005]
reported that five years after hysterectomy more women reported having bothersome
psychosexual function than did the woman who had a less invasive operation.
The other studies by Bayram and Şahin [2008] and Yeoum and Park [2005], in which the
psychosexual evaluations following hysterectomy were made in the 3rd month of
postoperative period, it is observed that, in this period sexual functions after hysterectomy
were affected negatively.
Table 1. Summary of the studies related to psychosexual adaptation after hysterectomy
Researcher Method Measuring Tool Result

Rhodes et al. n:1101, Pre-op, Post-op Questionnaire Decrease in dyspareunia (from
(1999) 6,12,18,24th months, 18.6% to 3.6%) and sexual
Prospective, desire (from 10.4% to 6.2%)
Comparative
Bayram (2008) n: 93, Pre-op, post-op FSFI (Female Sexual 34.3% decrease in total FSFI
3rd month, Prospective, Function Index), score, decrease in Beck
Comparative Beck Depression Scale Depression Scale total score
(from 32.3% to 11.8%), negative
correlation between depression
levels and sexual functions
DragisicandMilad n:75, Pre-op, Post-op Questionnaire Increase in severity of orgasm,
(2004) 6th month, Prospective, decrease in dyspareunia (from
Comparative 43% to 8.1%)
Ayoubi et al. n: 170, TAH, VAH, Questionnaire No change in sexual functions
(2003) Laparoscopic (60.4%), improvement (21.3%),
hysterectomy, deterioration (18%)
Retrospective
YeoumandPark n:89, Post-op 3rd Questionnaire Decrease in lubrication (68%),
(2005) changes in frequency of coitus
and severity of orgasm (25%)
Jeng et al. (2005) n:78, Vaginal Questionnaire, Analog Decrease in sexual desire (5.1%),
hysterectomy, Pre-op scale decrease in frequency of orgasm
6th , post-op 6th month, (21%)
Prospective,
Comparative
Aziz et al. (2005) n: 323, (217 only McCoy‘s Sex Increase in postoperative well-
hysterectomy and 106 Questionnaire, being for both groups, positive
TAH+BSO), Pre-op, Psychological Well- correlation between Mccoy‘s SQ
Post-op first year, being Index, and PGWB
Prospective, Kupperman‘s Index
Comparative
Kuppermann et al. n:135, TAH, Post-op Medical Outcomes, Improvement in sexual functions
(2005) 6th month and second Study Sexual in the 6th month, some new
year, Problems Scale problems in sexual functions in
Randomised, the second year
Prospective,
Comparative
TAH: Total Abdominal Hysterectomy VAH: Vaginal Hysterectomy BSO: Bilateral Salphingo-
ooferectomy
Summary and Recommendations for Researchers

Hysterectomy is an important operation which affects women‘s QoL and psychosexual
states. Positive outcomes of hysterectomy included decreases in chronic pelvic pain and pain
during intercourse, as well as the elimination of menstrual pain and dysfunctional uterine
bleeding.
However, psychological and biophysical health problems may develop after
hysterectomy. Health care providers should consider women‘s age, hormonal states, the type
and indications of the hysterectomy, the meaning ascribed by her to uterus and her culture,
general health condition of her partner, when determining psychosexual adaptation
requirements of women who had undergone hysterectomies. Kuppermann‘s [2004] reported
that in his study there are numerous important determinants of hysterectomy use and
satisfaction that can be used to inform discussions between patients and their provider
regarding the optimal use of hysterectomy and alternative treatments for noncancerous uterine
conditions.
Recent randomized trials and prospective cohort studies have provided new information
on the health outcomes of hysterectomy for non-malignant conditions. These studies
consistently have demonstrated a marked improvement in symptoms and QoL during the
early years after surgery.
Hysterectomy does not cause long-term psychiatric morbidity, and psychological status
generally improves. Studies of sexual function have shown varying results, with most
suggesting improvement or no change in sexual function for the majority of women. Positive
predictors for psychosexual outcomes of hysterectomy are high levels of preoperative sexual
functioning, orgasmic capacity, coital frequency, frequency and cyclicity of sexual desire, as
well as the quality of the partner relationship. Negative predictors are menopausal hormonal
changes, reduced physical and emotional well-being, depression, anxiety, and life stressors
(Flory et al 2005). It is possible that many of the suspected negative consequences of
hysterectomy may be related to the natural aging process rather than the proposed
postsurgical complications; this demonstrates the importance of conducting research with
appropriate control groups.
It is thought that methodological variances should be considered in explaining the
variations between the study findings. In order to attain clear evidence concerning the subject,
the following methods are suggested to the researchers:
- To conduct studies comparative and prospective studies which evaluate the preoperative
and postoperative psychosexual state and QoL,
- In quantitative researches which evaluate psychosexual adaptation and QoL, in order to
ensure the objectivity of data, scales passed from validity and reliability tests should be used,
- To prepare qualitative designs for research questions which are unobtainable with
qualitative researches, to use ―Methodological Triangulation‖ models comprising both
qualitative and quantitative research methods which enable multidimensional inquiry of the
problem,
- To evaluate the psychosexual adaptation at least 6 months after the operation,
- To take into considerations the factors that may affect psychosexual adaptation, to
conduct case-control studies with homogeneous groups that could enable taking these factors
under control.
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Chapter 6
Hysterectomy
Eddie Fernando Candido Murta*, Gisele Agreli de Melo,

Patrícia Dias Neto Guimarães and Rosekeila Simões Nomelini
Research Institute of Oncology (IPON)/Discipline of Gynecology and Obstetrics, Federal
University Federal of Triângulo Mineiro (UFTM), Uberaba-MG, Brazil
Abstract
Hysterectomy is the second most frequently performed surgery after cesarean section
among women of reproductive age. The most common indication for hysterectomy was
leiomyoma uteri and this was followed by uterine prolapse, endometriosis, cancer,
hyperplasia and others (abnormal vaginal bleeding, menstruation irregularity, parametrial
and peritoneal infections, disease of cervix, ovary, tube and postpartum incidents, and
other neoplasias). Women aged 30 to 54 is the group hysterectomies are most frequently
performed on. For benign indications, many countries have favored either the abdominal
or the vaginal approach. These traditions have prevailed unaltered for decades.
However, since the late 1980s, the new option of laparoscopic hysterectomy has
raised questions about the most suitable type of approach. The overall rate of
complications was 17.2% for abdominal, 23.3% for vaginal and 19% for the laparoscopic
approach, with infection the most common problem. Haemorrhage occurred in 2.1, 3.1
and 2.7% of abdominal, vaginal and laparoscopic hysterectomies respectively. The
significant difference between the different routes was that ureteric injury was seven
times more common during operations performed by the vaginal than the abdominal
route. There are alternative procedures such as endometrial ablation (dysfunctional
uterine bleeding) and uterine artery embolization (fibroids). Seventy-five percent of
women may avoid hysterectomy by the use of these techniques. The uterine artery
embolization is a promising new approach for the treatment of uterine fibroids. However,
information is lacking as to the effectiveness in women who wish to maintain fertility. In
the treatment of menorrhagia, both hysterectomy and levonorgestrel-releasing
intrauterine system (LNG-IUS) decrease lower abdominal pain. LNG-IUS use, but not
hysterectomy, has beneficial effects on back pain. Hysterectomy is associated with high
levels of satisfaction. Hysterectomy has been compared with endometrial ablation in the
*
Phone: 55 34 3318 5342, Fax: 55 34 3318 5342, E-mail: eddiemurta@mednet.com.br
96 E. Fernando Candido Murta, G. Agreli de Melo, P. Dias Neto Guimarães et al.
treatment of menstrual problems in several studies, which have suggested that 95% of
women will be satisfied. Long-term satisfaction is high even in those experiencing pre-
operative or early post-operative complications. This means that an alternative treatment
has to be extremely good in order to have a higher satisfaction rate than hysterectomy
itself. For women who do not wish to retain their uterus, there are gynaecologists who
would suggest that there is no necessity to seek an alternative.
Introduction
Hysterectomy is a common gynaecological surgery that involves removal of the uterus
and cervix, and some cases, the fallopian tubes and ovaries [1]. The first hysterectomies were
performed by the vaginal route in Europe (Langenbeck, 1813; Sauter and de Constance 1822;
Recamier 1829) and in America (Warren in Boston, 1829) [2]. The first abdominal
hysterectomy was performed in 1843 by Clay in Manchester, England. Since then,
hysterectomy has grown to be the second most commonly performed major gynecologic
surgery after cesarean section, with some 600,000 cases annually in the United States at an
estimated cost of $5 billion per year [3]. Indications, route, risks and costs of the operation
have grown to be increasingly controversial [4-8].
Hysterectomy is a major surgical procedure that requires several weeks, and sometimes
several months of post-surgery recuperation. A study carried out in Glasgow suggests that it is
associated with significant morbidity in 3% of cases and minor morbidity in 14% [9].
However, hysterectomy is usually a very successful surgery with as many as 85-90% of
women being satisfied with the operation and reporting improved quality of life.
The decision-making process leading to hysterectomy is often complex and may involve
several years of alternative treatments before surgery is performed. If hysterectomy is under
consideration as treatment for a particular problem, three major decisions must be made:
whether the indications warrant hysterectomy, weighed against the mortality risk inherent in
all major surgeries; whether the surgery should be done abdominally or vaginally; and
whether or not ovaries should be removed. Many unknowns add to the complexity of this
decision-making process. Patients and physicians must often rely on personal opinion or
currently accepted practice as a guide to how to proceed at these decision junctures.
Indications
A variety of distinctly different medical conditions may lead to hysterectomy, including
uterine fibroids, endometriosis, uterine prolapse, cancer, infections, benign neoplasms,
menstrual problems, pelvic pain, and obstetrical problems, most for benign surgical
indications [10]. Hysterectomy occurs in females of all ages, races, and socioeconomic strata.
Women aged 30 to 54 is the most frequently hysterectomy performed-on group
(100.5/10,000). The hysterectomies for this age group contribute 74% of all hysterectomies
[11]. One third of all women in the United States will have a hysterectomy by 60 years of age.
That has been the highest hysterectomy rate among industrialized countries [12].
Hysterectomy is very unusual in females under the age of 20, but it does occur. The most
common indications in these young women were pregnancy-related problems, such as
Hysterectomy 97
postpartum hemorrhage, or sterilization. Fibroids, menstrual problems, and endometriosis

were the most common reasons for hysterectomy among women between the ages of 20 and
59. For women over 60 uterine prolapse and cancer were the most common indications for
hysterectomy [13].
Leiomyomas (fibroids) are the most common tumors in women, with prevalence between
30% and 50% [14]. They are responsible for one third of hysterectomies. Women with uterine
fibroids may have problems with abnormal or excessive bleeding, pelvic pain, an enlarged
abdomen, urinary or bowel problems, or no symptoms at all. The cause of fibroid tumors is
unknown, but it is generally believed that estrogen causes fibroid tumors to grow and that
these tumors usually shrink in postmenopausal women who are not treated with estrogen
therapy [14,15]. Large uterine size, excessive bleeding and prior surgery for pelvic adhesions
or gallbladder removal are agents possibly associated with increased likeliness of
hysterectomy due to fibroids [16].
Ojeda found that the rate of normal specimen was 9% and 15% in total abdominal
hysterectomy and total vaginal hysterectomy groups, respectively [17]. Foster reported that
16.9% of 485 uteri removed were considered normal anatomically [18]. This controversy still
exists as noted in the study of Broder et al., which indicated the inappropriate misuse or
overuse of hysterectomy in the current practice [19]. Hysterectomy is a relatively safe
surgical procedure, and morbidity and mortality can be reduced if the rate of unnecessary
surgery is minimized[20].
The decrease in the rate of unnecessary total abdominal hysterectomy operations and the
increase in the normal specimen in total vaginal hysterectomy operations can be attributed to
the increase in the use of ultrasound in the diagnosis of pelvic problems and the progress in
the ultrasound technology and the expertise gained throughout the years as well.
After all, unnecessary hysterectomies fail to get the preferred results and cause the
development of pain, depression, and dyspareunia in 6.6% of the patients [21].
Posthysterectomy minor symptoms that were recently reported by DeCherney et al., should be
considered in the debate of unnecessary hysterectomies (fatigue 74%, pain 63%, difficulties
in concentration 42% and depression 37%) [22].
Obstetric haemorrhage is a major cause of maternal death and morbidity. The main
causes of haemorrhages are abruption of the placenta, placenta praevia and postpartum
haemorrhage. Hysterectomy is considered in severe cases. Other options are ligation of the
uterine arteries, ovarian arteries and hypogastric arteries will usually control uterine bleeding
and arterial embolization. All gynecologists should be able to perform an urgent hysterectomy
[23].
Procedures
There are three principal routes of hysterectomy that are nowadays used: laparoscopic
assisted vaginal hysterectomy (LAVH), total vaginal hysterectomy (TVH) and total
abdominal hysterectomy (TAH) [24].
The frequency of the abdominal approach to hysterectomy relative to that of vaginal
approach for nonmalignant disease is 3:1 in the United States [25,26]. In the United
Kingdom, vaginal hysterectomy for leiomyoma was carried out only in 3.9% of cases [27,28].
In Japan, although a cohort study has not been published, the main indication for vaginal
hysterectomy is prolapsed uteri, while surgery for uterine leiomyoma or adenomyosis is still
carried out via abdominal hysterectomy in the majority of cases [29].
Generally an abdominal approach is used when the indication suggests that a full view of
the abdomen is necessary for exploratory purposes (e.g., when cancer is present or suspected),
when the uterus is enlarged (> 12 weeks) and would be difficult to remove vaginally (as is
often the case with fibroids), or the vagina too narrow, when the uterus has limited mobility
because of adhesions from previous surgery or strong pelvic support, or when ovaries are to
be removed (as is usually the case with adnexal conditions) [13,30].
It is also generally reported that nulliparity, absence of prior vaginal delivery, or previous
pelvic surgery, are relative contraindications for a vaginal approach to hysterectomy
[24,28,31]. The inconvenience of abdominal hysterectomy is the prolonged recovery and the
high incidence of abdominal adhesions [24]. However, the choice of whether to perform the
surgery abdominally or vaginally is to a certain extent a function of physician practice style,
the patient‘s anatomic condition and the medical equipment [24,30]. Kovac, Christie, and
Bindbeutel [32] found that some physicians performed the majority of their hysterectomies
abdominally, whereas others had no particular preference. These two practice styles were
related to training. The lack of training in vaginal surgery is one of the principal reasons that
vaginal hysterectomy is not the predominant procedure [33].
Whether the hysterectomy is done abdominally or vaginally also has consequences for
the patients. Vaginal hysterectomy has been associated with lower mortality and complication
rates. Vaginal hysterectomy has a lower perioperative morbidity, faster postoperative
recovery, and shorter hospitalization than abdominal hysterectomy [30]. There is less danger
of injury to the ureter during hysterectomy when operating vaginally than when operating
abdominally [34].
In addition, women having vaginal hysterectomy spend fewer days in the hospital on
average, and because of that, they have a less costly surgery [7]. Obese and elderly patients
with comorbidity benefit from this procedure [30]. However, despite the benefits of vaginal
hysterectomy, possible risks must also be considered. If technical difficulties in carrying out
vaginal hysterectomy appear considerable, it may be best to abandon the procedure in favor
of the abdominal approach [33].
In relation to abdominal hysterectomy, an important technical detail is the dissection of
the ureter in cases of malignancy of the cervix, since the spread is for the parametrium and
vagina. Figure 1 shows the anatomy of important structures in cross section. Figures 2 and 3
show details of a hysterectomy for benign disease (the parametrium is sectioned close to the
uterus avoiding injury of the ureter, which is about 1.5 cm lateral to the supravaginal cervix)
and a hysterectomy for uterine cervical cancer (the ureter is dissected and the parametrium
and upper vagina are removed safely).
There are many techniques for vaginal hysterectomy, described by several surgeons [29].
The classic Heaney technique and the Döderlein technique are known as the basic and safer
methods of vaginal hysterectomy. Most vaginal hysterectomies in the United States are
performed by variations of the classic Heaney technique. This technique entails initial
peritoneal entry through the posterior cul-de-sac [33]. In the Döderlein technique, however,
the uterine fundus is delivered through peritoneal entry after anterior colpotomy and the
pedicles are secured in the same order as in the abdominal procedure [35]. Posterior cervical
incision and colpotomy are not usually performed in the Döderlein technique [33].
Hysterectomy 99
Figure 1. Hysterectomy for benign disease. 1. Uterosacral ligament. 2. Parametrium. 3. Uterine vessels.
Based on Salvatore [45].
Figure 2. Cross section of uterus, ligaments and ureter. 1. Uterosacral ligament. 2. Vesicocervical
fascia. 3. Parametrium. 4. Ureter. 5. Bladder. Based on Salvatore [45].
Figure 3. Dissection of the ureter in surgery for cervical cancer. 1. Bladder. 2. Ureteral canal. 3. Ureter.
4. Parametrium. Based on Salvatore [45].
Posterior colpotomy is not readily accomplished if the distance from the cervix to the
rectum is short. In addition, if there is pelvic inflammatory disease or endometriosis, it is
difficult to enter the peritoneal cavity by posterior colpotomy, and the risk of rectal laceration
arises. Naturally, it may occur that entry into the peritoneal cavity through the anterior cul-de-
sac (i.e., the Döderlein technique) is unexpectedly difficult. If dissection of the anterior
portion of the cervix is too superficial, there is the danger of bladder injury; conversely, if it is
too deep, identification of the anterior peritoneal cul-de-sac will be difficult. In addition,
scarring from previous cesarean section or myoma nodule distorts the base of bladder, and it
may be impossible to loosen the bladder from the anterior wall of the uterus. Bladder injury
often occurs in patients with prior cesarean section because dissection is begun directly in the
area of scarring. This makes identification of the appropriate plane much more difficult than
that with the vaginal approach [36].
The principal element for successful vaginal hysterectomy seems to be the preoperative
evaluation of adhesions around the uterus or Douglas pouch, and completely fixed and
immobile uteri must be excluded from the indications for vaginal hysterectomy. As
previously noted, entry into the peritoneal cavity through the anterior or posterior cul-de-sac
may be unexpectedly difficult. In large uteri, the size could make the procedure difficult by
the vaginal route. In these cases, techniques like morcellation can be used to progressively
reduce the volume of the uterus during surgery [30].
For benign indications, many countries have favoured either the abdominal or the vaginal
approach. These traditions have prevailed unaltered for decades. However, since the late
1980s, the new option of laparoscopic hysterectomy has raised questions about the most
suitable type of approach. The application of videolaparoscopic technology represents the
Hysterectomy 101
first major innovation in the technique of hysterectomy in the past one and a half centuries
[37]. When new technology is applied to a clinical practice of such large magnitude, an
especially careful review of its effectiveness and efficiency must be undertaken.
Before laparoscopy assisted vaginal hysterectomy (LAVH), 75% of hysterectomies were
total abdominal hysterectomies and the rest were total vaginal hysterectomies [20]. Total
abdominal hysterectomy (TAH) ratio decreased to 39% while total vaginal hysterectomy
(TVH) remained the same (29%) after the introduction of LAVH 16. In 1990, 73% of all
hysterectomies were reported as TAH and it dropped to 63% in 1997 whereas the rate of
LAVH, which was 0.3% in 1990, increased to 9.9% in 1997 [38]. The rates of TVH did not
change significantly (24% to 23%). The selection of the mode of the hysterectomy seems to
be modified by the experience and the familiarity of the surgeon to the procedure rather than
the indication. LAVH has fewer complication rates (hereby note the higher incidence of
bladder injury) and long operation time but fast recovery compared to TAH [20,30].
Compared with the abdominal approach, the advantages for the patient are the avoidance
of a conventional surgical incision, less pain, reduced use of analgesics, superior cosmetic
results, early ambulation, less problems with postoperative ileus and risk of thrombophlebitis
and minor peri-operative complications and blood loss. In addition, rapid recovery allows
earlier return to work and family [10,30].
For the operating gynecologist, laparoscopy assisted vaginal hysterectomy (LAVH)
permits improved visualization of the anatomy and pathology because of better directed light,
zoom, and magnification in addition to the capability of video or photo documentation, with
close-up images of the bag of Douglas, ovarian fossa and visceral and parietal peritoneum.
The vaginal morcellation can also be made by laparoscopic route, using modern laparoscopic
morcellators. Although this kind of approach may be slower, it is efficient and safe. However,
an entire set of new surgical skills needs to be practiced under conditions of a coaxial
approach and monocular vision, resulting in a new configuration of eye-hand coordination on
a two-dimensional field, all without the benefit of tactile feedback. The use of an intrauterine
manipulator can decrease the operating time and complication rate (usually vesical and
ureteral injury) [30].
Supracervical hysterectomy (subtotal hysterectomy) is an alternative to the total
abdominal hysterectomy and may be an alternative to LAVH, when the operation is
performed via minilaparotomy [20]. Supracervical hysterectomy is not done anymore because
of the fear of complications that could arise for the cervix when left in its place, especially the
carcinoma of the cervical stump. Today, supracervical hysterectomy has been gaining its
popularity with the wider use of cervical smears and application of newer techniques that
enables the removal of the transformation zone [20] and also provides easy performance
during minilaparotomy, fast recovery, shorter operation time and shorter hospital stay. The
rate of subtotal hysterectomy has increased from 3,664 (1994) to 11,815 (1997) in USA [39].
A review of the clinical indications reveals that the three approaches to hysterectomy are
not strictly interchangeable, and LAVH was not selected simply for the sake of performing
the procedure by the vaginal route. Rather, the technical advantages applied to specific
indications were the major determinants for selecting LAVH. Pelvic pain, endometriosis,
adnexal pathology, and the need to guarantee removal of the ovaries were major indications
for the laparoscopic technique. Removal of the uterus and adnexae in patients with pain due
to endometriosis may not result in relief of the symptoms if viable endometrial deposits are
left behind on the pelvic sidewall, serosa of the bowel, or dome of the bladder. Laparoscopy
proved to be an excellent tool to mobilize the adnexa, remove endometrial implants, develop
a plane between the vagina and the rectum, and perform a transabdominal colpotomy in
preparation for completing the hysterectomy vaginally. A large pelvic mass, pelvic pain of
uncertain etiology, and the possibility of pelvic malignancy alone or in association with
abnormal vaginal bleeding have remained the leading reasons for the abdominal approach.
Uterine prolapse, cystocele/rectocele, and genuine urinary stress incontinence were the main
reasons for selecting the vaginal route. Pain, bleeding, and fibroids weighing up to 250 g were
also indications for VH in women with uterine mobility and vaginal anatomy conducive to the
vaginal approach.
Bilateral Oophorectomy and the Menopause

Bilateral oophorectomy before the menopause is a particular concern to many women,
and, therefore, it deserves an especially detailed consideration in selecting the approach to
hysterectomy. After a balanced presentation of benefits and risks of oophorectomy, the
patient should become a partner in the decision making process. If the decision is for ovarian
conservation, absence of any disease in the retained ovaries must be guaranteed by careful
evaluation under direct vision. If the decision is for oophorectomy, removal of the ovaries
must be guaranteed.
Bilateral oophorectomy has increased from a rate of 25% in 1965 to a rate of 41% as of
1984 in the United States. In a study performed in the University of Maryland both ovaries
were removed during 39.5% of the hysterectomies, and one ovary was removed during
12.3%. Both ovaries were removed in 33% of premenopausal women having hysterectomy
(women under 50), and one ovary was removed in 15% of these women [13]. It is unclear
why ovaries were removed so often during hysterectomy. If ovaries are not removed there is a
small chance (between 0.2% and 1.2%) that the woman will subsequently develop ovarian
cancer. If ovaries are removed in a premenopausal woman she is then at an increased risk for
cardiovascular disease and osteoporosis, unless she takes estrogen during the remaining years
of her life. Because many premenopausal oophorectomized women do not maintain estrogen
therapy [13], and because cardiovascular disease and osteoporosis are considerably more
prevalent than ovarian cancer, premenopausal women having hysterectomy with bilateral
oophorectomy have a lower life expectancy than premenopausal women who retain their
ovaries during hysterectomy. However, premenopausal women who have both ovaries
removed during hysterectomy have an increased life expectancy (compared with women
having hysterectomy without oophorectomy) if they maintain estrogen therapy for the rest of
their lives. The rate of bilateral oophorectomy peaks in women aged 50-59 and is uncommon
among women having vaginal hysterectomy.
Although the feasibility of bilateral oophorectomy with vaginal hysterectomy is well
documented in several small series, nationally it is performed in less than 2% of this
procedure. The dilemma is not whether the ovaries can be removed during vaginal
hysterectomy but whether vaginal hysterectomy or laparoscopic assisted vaginal
hysterectomy is the more suitable procedure for the purpose of evaluating or removing the
adnexae. A study with combined judgment of 10 gynecologists skilled in all three approaches
Hysterectomy 103
of hysterectomy showed that LAVH was the procedure of choice when oophorectomy was a
possibility [12].
Complications
The overall rate of complications in hysterectomies has been 17.2% for abdominal,
23.3% for vaginal and 19% for the laparoscopic approach, with infection being the most
common problem. Hemorrhage has occurred in 2.1, 3,1 and 2.7% of abdominal, vaginal and
laparoscopic hysterectomy respectively. The significant difference between the different
routes was that ureteric injury was seven times more common during operations performed by
the vaginal than the abdominal route [40].
In the meta-analysis of Walsh et al., total perioperative complications and minor
complications occurred more frequently in the total abdominal hysterectomy compared with
total laparoscopic hysterectomy. Concerning major complications, there was no significant
difference between the groups [10].
As with any major surgery, a risk of mortality accompanies hysterectomy, with the
majority of the deaths prior to hospital discharge occurring in women with cancer. The small
number of women who died prior to discharge and who did not have cancer usually died
because of cardiac arrest, respiratory failure or hemorrhage [13]. The risk of death also
increased with age, in part because older women were more likely to be having a
hysterectomy for an indication of cancer.
Alternatives
At last but not least there are alternative procedures such as endometrial ablation
(dysfunctional uterine bleeding) and uterine artery embolization (fibroids) [40]. Seventy-five
percent of women may avoid hysterectomy by the use of these techniques [20]. Treatment
options, in general, will depend on if the woman has offspring. Other fators that influence the
treatment choices are the level of education and employment status [41].
The standard medical treatments for menorrhagia are less effective in the presence of
uterine fibroids. Prostaglandin synthetase inhibitors are effective in a proportion of women
and GnRH agonists or danazol (agents that produce amenorrhoea), can be useful. For women
who wish to maintain their fertility, myomectomy is the usual option. In most centers, the
majority of surgeries are performed by the abdominal route. However, if the fibroid protrudes
into the uterine cavity, myomectomy can be achieved hysteroscopically. The number of
myomectomies performed is small, which calls the overall success of the operation into
question and explains why alternatives are being sought. These alternatives include uterine
artery embolization and myolysis.
Embolization is a well-established radiological technique, which has been in clinical
practice for the last 25 years. It has been used successfully in the female pelvis in cases of
trauma and post-partum haemorrhage with good effect [42]. Uterine fibroids appear to be
particularly sensitive to the effects of the acute ischaemia produced by embolization and
undergo necrosis. Consequently, they usually shrink significantly and occasionally even
disappear. The integrity of the uterus is preserved by collateral blood flow from other vessels
with revascularization of the normal myometrium, but not of the fibroids.
For women with uterine fibroid-associated symptoms who didn‘t respond well to medical
treatments and who desire future pregnancies or who wish to retain their uterus for other
reasons, myomectomy is the operation of choice. For multiple myomas or a significantly
enlarged uterus, this will be achieved, most often, by the abdominal route. Where fibroids
impinge on the uterine cavity, hysteroscopic resection is possible and smaller fibroids can
also be removed laparoscopically [43]. This is a much less common operation than
hysterectomy, with about one-tenth of the number being performed annually. Myomectomy
appears to be an effective treatment for menstrual problems in many instances, although
overall these studies have used subjective means of assessment with variable length and
enthusiasm of follow-up. For women with submucous fibroids, hysteroscopic myomectomy
may be the most appropriate route. Accessible myomas can be resected with an operating
endoscope through the cervix. Good pregnancy rates have also been reported. In conclusion,
myomectomy can relieve the symptoms associated with myomas, but does not affect the
underlying process.
The levonorgestrel-releasing intrauterine system (LNG-IUS) (Schering Co, Turku,
Finland) has been advocated for the treatment of menorrhagia as an alternative to surgery. The
LNG-IUS is an intrauterine system that releases 20 µg of levonorgestrel every 24 hours over 5
years, wich results in endometrial atrophy and reduced menstrual loss [41].
In the study of Souza et al., that compares the use of the levonorgestrel-releasing
intrauterine system (LNG-IUS) and thermal balloon ablation (TBA) for the treatment of
heavy menstrual bleeding, the hemoglobin levels found confirm that both are effective,
although posttreatment uterine bleeding patterns may vary between the two methods.
Moreover, these methods should be considered as choice for the control of abnormal uterine
bleeding, with advantage of LNG_IUS to be reversible, preserve fertility and is cost-effective
and gives contraception [44].
The LNG-IUS treatment is cheaper than hysterectomy, beyond fewer hot flushes, and it
can be used as the progestogen component of hormonal therapy. The rate of patients satisfied
with both procedures are similarly high with women randomized, although there was a 42 %
of hysterectomy in the LNG-IUS group by 5 years [41].
According to a Cochrane systematic review, the improvement in heavy menstrual
bleeding and satisfaction rates after hysterectomy was bigger than after endometrial ablation.
A new approach surgery because of failure of initial treatment was more likely after
endometrial ablation than after hysterectomy. Regarding cost, the endometrial destruction was
significantly lower than hysterectomy, despite the high cost of re-treatment in the endometrial
ablation [41].
Conclusion
Hysterectomy has come under increasing scrutiny in recent years concerning the extent to
which it is a necessary treatment for specific conditions and the extent to which it provides
beneficial outcomes. Despite the possible complications, hysterectomy is associated with a
high level of satisfaction. It has been compared with endometrial ablation in the treatment of
Hysterectomy 105
menstrual problems in several studies, which have suggested that as many as 95% of women
will be satisfied. Long-term satisfaction is high even in those experiencing pre-operative or
early post-operative complications. This means that an alternative treatment has to be
extremely good in order to have a higher satisfaction rate than hysterectomy itself. For
women with uterine fibroids who do not wish to retain their uterus, there are gynaecologists
who would suggest that there is no necessity to seek an alternative.
Hysterectomy will cure problems associated with menstrual bleeding in most cases.
However, in women with other symptoms, there is a less consistent response.
In the last 30 years there has been a marked shift in the character of physician-patient
relations away from a more paternalistic relationship, built on trusting the physician to do
what is best for the patient, toward a more mutual one, with much greater emphasis placed on
the autonomy (or right to self-determination) of the patient. This change has had its greatest
impact on end-of-life treatment decisions. In spite of these advances, however, there has been
little study of how decisions are made about treatments that are frequent enough to be
considered routine. Hysterectomy for nonlife-threatening conditions and prophylactic
bilateral oophorectomy are very commonly performed. However, there is little available
information about how women make decisions to seek treatment for symptoms that may lead
to hysterectomy and to decide to undergo these procedures. It has been shown that women
can process scientific information regarding the benefits and risks of hysterectomy, but much
work is needed on the practical aspects of how to deliver information appropriately, how to
assist women in processing the information and weighing benefits and risks, and how to
empower women to interact effectively with the healthcare system and to bring their own
values into their decisions regarding treatment options.
Acknowledgments
We thank Douglas Cobo Micheli for drawing the figures, and CNPq and FAPEMIG for
support.
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Chapter 7
Surgical Complications in Laparoscopic

Histerectomy
Angel Martin
Hospital Son Llàtzer, Balear Health Institute, Palma de Mallorca, Spain
Introduction
Laparoscopy is now widely recognised as an indispensable tool in gynaecologic surgery,
and the rate of hysterectomies performed by laparoscopy is increasing regularly these last
years. The first hysterectomy performed by laparoscopy was described by Reich et al. The
impetus to apply laparoscopy to this procedure was to provide a lower-morbidity alternative
to abdominal hysterectomy[1, 2]. In fact, complications of gynecologic laparoscopy are
uncommon, occurring in 3 to 6 per 1000 cases. Mortality rates are low at 3.3 per 100,000.
Since the early 1990s, the number of laparoscopic procedures has continued to grow.
Both minor complications (fever >38.5 ºC after 2 days, bladder incision of <2 cm and
iatrogenic adenomyosis) and major complications (haemorrhage, vesicoperitoneal fistula,
ureteral injury, rectal perforation or fistula) have been observed during the surgical procedure
itself and postoperatively. As expected, major complications and the rate of complications
increase directly with complexity of the procedures[3]. Three possible complications and
other minor complications will be exposed: urinary tract injury, bowel injury and vascular
injury.
1) Vascular Injury
Injury to vessels could be a complication of laparoscopic hysterectomy but most of
vessels complications are due to laparoscopy entry technic. Over 50 % of all major
complications in gynecological laparoscopic occur during the entry into the abdomen.
Majority of major vascular injuries occur at this moment too.
110 Angel Martin
There are different methods to access to the abdomen: open laparoscopy , Veress needle
entry or direct trocar entry. When you compare these different techniques to entry, there is no
consensus on the overriding safety of any one. Surgeons should be familiar with 3 techniques
and know their risks, and use the most appropriate for each patient.
- Open laparoscopy was described by Hasson in 1971. It consists in a small subumbilical
laparotomy in skin, rectus sheath and peritoneum incision under direct vision. It is widely
used by general surgeons more than gynecological laparoscopists. Unfortunately, there is no
evidence available to support this preference.
For some authors[4] the open entry was used on special indications like patients who
suspected adhesions or with previous laparotomy, obese or very thin patients. Some studies
showed significantly more gastrointestinal lesions, failed access into abdominal cavity and
infection. (P <0.001). For other authors this technique is associated to a decreased risk of
major vascular injury5 and sooner recognition of bowel injury.
- Closed entry with Veress needle is commonly used by gynecologists to establish the
pneumoperitoneum. It consists in use of needle for insufflation followed by the blind
insertion of a sharp trocar and cannula. You can use an alternative insufflation point (eg
Palmer‘s point) in case of patients who were at risk for entry complications.
-Direct trocar entry (without previous Veress needle insufflation) is commonly used too.
This technique obviates the risk of gas embolism on entry and reduces the risk of
preperitoneal insufflation and failed entry.
The most important with the three techniques is the inspection of the area underneath any
entry site because this is the optimal time to identify any potential bowel injury or vessel
injury before moving the patient (figure 1).
Figure 1. Anatomy of the left upper quadrant for trocar insertion. (Adapted from Tulikangas PK)
Surgical Complications in Laparoscopic Hysterectomy 111
Major vascular injuries occur five times more often during blind entry than during
laparoscopic operation. It seems to be more frequent if you use blind entry technique, but it is
not clear. However these are infrequent 0.04-0.1%[6].
The most common devices causing vascular injuries are trocars, Veress needles and
electrosurgical intruments. There are different types of trocars: bladed trocars, dilating
trocars, optical trocars … All types of trocar are equally implicated in vascular injury; that
suggests that it depends on the technique not the type of the trocar used[3].
The most common vessels injured during primary entry are aorta, the inferior vena cava
and iliac vessels (more frequent in the right side. This is because of most of surgeons are on
the patient‘s left side). Mesenteric vessels can also be injured. At the time of lateral trocar
placement, the inferior epigastric vessels are the most commonly injured vessels.
It's unclear whether extremes of weight are risk factors for vascular complications.
Recognition of vascular injury may be obvious if it occurs under direct visualization or if
there is obvious blood return from needle or trocar after replacement. But vascular injuries
can be hidden temporaly if bleeding is below omentum or retroperitoneal. If any patient
deteriorates suddenly after inicial entry we have to think about major vascular injury until
proven otherwise. A good communication with the operating room team is very important to
improve the survival pacient and outcome.
Major vascular injuries that occur after entry are much infrequent than others which
occur during the entry phase of the operation. The reported incidence ranking is from 0.01%
to 0.64%[7]. These kind of complications are more frequent in complex surgery performed
near large vessels (like complex retroperitoneal dissection, linphadenectomies and sacral-
colpopexy) but it could occur with operations for bening process like hysterectomy.
Laparoscopic surgery6 is a useful technique to resolve these complications in 50% of cases,
but the rest need laparotomy. It depends on the localization, the size, the type and
visualization of the injury. Morbility rate is high in these patients and one half will require
blood transfusion. The incidence of entry access injury is 5 to 30 per 10,000 procedures,
representing one-third to one-half of total. 20 to 25 percent of these complications are not
recognized until the postoperative period[3].
2) Urinary Tract Injury in Laparoscopic

Hysterectomy
One of the major risks with total hysterectomy is that of urological complications,
overcoat ureteral lesions[8, 9]. This is due to the fact that the ureters are located about 2 cm
from the lateral edge of the cervix in women with normal pelvic anatomy. Urinary tract
injuries are generally feared by the gynecologic surgeon. These injuries are reported in
approximately 1 percent of women who undergo pelvic surgery. However, the exact
incidence of these injuries is difficult to ascertain. Intraoperative discovery of injury permits
prompt repair. Delayed diagnosis of urinary tract injuries is of greater concern, since they
may result in genitourinary fistula formation or severe complications. Bladder lesions are 2 to
3 times more common than ureteral injuries and are also more notably intraoperative
identified than ureteral injuries[9]. Even if operative laparoscopy is not inherently
dangerous10, some authors consider that the risk of ureteral injury is higher after laparoscopic
112 Angel Martin
hysterectomy compared with tradicional hysterectomy[11, 12] while other authors

demonstrate that this risk is comparable to that observed with laparotomy, provided the
surgeon has sufficient experience[13].
The main risk factors to have a urinary tract injury in laparoscopic hysterectomy are:
prior pelvic surgery, endometriosis, urinary tract abnormalities (eg: duplicated ureter, pelvic
kidney), history of pelvic irradiation, obesity and a large pelvic mass. As with other surgical
procedures, the number of complications appears to be related to the surgeon‘s experience
and the number of procederes performed. Formal training and didactic lectures are important
but do not substitute for continued operating room experience with a more experienced
laparoscopist[14].
The routine intraoperative use of cystoscopy for women undergoing major gynecologic
surgery has been proposed as a secondary preventive measure for urinary tract injury[15].
Cystoscopy detects a greater proportion of injuries than visual inspection of the urinary tract.
Visual inspection detects a greater proportion of bladder injuries than ureteral injuries.
Cystoscopy is not effective for the detection of parcial ureter injury. Cystoscopy only shows
the absence of urine flow by ureteral orifice indicating that there is a problem. The meticulous
and careful ureterolysis remains the best measure to prevent and detect ureteral injury.
Laparoscopic Bladder Injury:
Bladder injury is the most common urologic complication during a laparoscopic

hysterectomy. It usually occurs during disecction of the vesicouterine fold or sometimes
occurs secondary to introduce the suprapubic trocar. Bladder lesion that occurs with sharp,
rather than blunt dissection can often be easier to repair. Bladder injury can also be avoided
by placement of the secondary trocar under direct visualization and by making certain that the
bladder is emptied befote trocar placement. Incidence of bladder injury decreases with
surgeon‘s experience. It decreases from 2% for the first 30 procedures to 0.8% after the first
30 procedures. The main risk factors are previous cesarian section, previous laparotomy and
the presence of cervical or anterior subserosal myomas. This complication has a low
morbidity especially if the diagnosis is performed at the time of surgery and the bladder
repared laparoscopically. Characteristic signs of bladder injury are hematuria or gas in the
collecting bag[13]. Another times it‘s is obvious when we see the Foley catheter at the
moment of vesical dissection. Confirmation of lesion is easily accomplished by irrigation of
saline solution with methylene blue over the Foley catheter in retrograde way. Sometimes it is
necessary to open the bladder to inspect the mucosa. Thermal injury of the bladder often
occurs during the dissection of vesicouterine fold or with the coagulation of endometriosic
focus. Primary closure of the cystotomy can be performed by an absorbable suture simple
continuous or discontinuous on one or two layers. If there are multiple injuries, it is
recomended to join the small defect in a single defect before to repair. Bladder heals in 3-4
days and its strength and endurance return after 21 days. Generally 4-7 days with vesical
catheter are sufficient to ensure bladder healing.
In patients with a history of pelvic radiation therapy or a complex bladder injury may be
necessary to repair this defect with a flap of omentum.
It is important to make sure before suture injuries which are near from bladder trigone
that both ureteral meatus are free.
Laparoscopic Ureteral Injury:
Injury to the ureter occurs in 0.1 to 1.5% of pelvic surgeries. It occurs most commonly
(80%) at the level of the junction of the ureter and the uterine artery or, another times, near
uterosacral ligament. Other steps of the procedure associated with injury to the ureter are
ligation of the ovarian vessels and vaginal cuff closure. Ureteral injuries occur most
frequently on the right side[13]. Principal concern is that ureteral injuries are rarely identified
intraoperatively[16], but if so, they should be treated immediately by an experienced surgeon.
Thermal injuries to the ureters are more difficult to identify due to necrosis takes time to
develop. The problem is that routine cystoscopy does not guarantee recognition of all ureteral
injuries[17]. Ureteral injuries that are not recognized intraoperatively are likely to present
within the first two weeks after surgery. In case of fever, flank pain or haematuria, the
surgeon must be ready to consider the possibility of ureteral complications and to request
blood samples and radiological investigation (intravenous pyelography). Others symptoms
are: leakage of urine from the vagina, oliguria, anuria, nausea with or without vomiting or
ileus.
The most important points to avoid ureteral injures during laparoscopic hysterectomy are:
(1) the surgeon must be certain where the ureters are located during all phases of the
operation. (2) In difficult situations (associated adnexal masses adherent to the lateral pelvic
sidewall, endometriosis, dense adhesions and myoma in the broad ligament), the surgeon
must be capable of using a retroperitoneal approach and carring out ureterolysis. (3) In case of
bleeding near the ureter during ureterolysis, haemostasis must not be performed with bipolar
coagulation but by using endoscopic clips to avoid thermal injuries. (4) Bipolar coagulation of
the uterine artery must be performed only at the level of the ascending branch in order to
remain as far as possible from the ureter[13]. (5) During laparoscopic hysterectomy, at the
level of vaginal cuff, the bladder must be dissected off the surface of the vagina or cervix and
displaced inferiorly to protect the ureters and bladder from injury prior to cuff closure. (6)
Other option is to perform a subtotal hysterectomy.
Repair of ureteral injuries often involves ureteral stenting or advanced surgical repair.
Small injuries often can be repaired with ureteral stenting. Injuries such as transaction or
other types of extensive damage (eg crush injury, thermal damage) may require reanastomosis
or ureteroneocystostomy[18]. Repair of such injuries is usually performed by urologist or
other surgical specialist.
3) Bowel Injury
Injuries to the bowel occur in gynecologic laparoscopy with a reported incidence of 0,06
to 0,65%. In large studies, bowel injuries account for approximately 20% of all complications
and almost half of all major complications of laparoscopy[3]. Bowel and retroperitoneal
vascular injuries comprised 76 percent of all injuries and almost 50 percent of small and large
bowel injuries were unrecognized for at least 24 hours. The type and proportion of organ
injury during entry is: small bowel (25 %), iliac artery (19 %), colon (12 %), iliac or other
retroperitoneal vein (9 %), secondary branches of a mesenteric vessel (7 %), aorta (6 %),
114 Angel Martin
inferior vena cava (4 %), abdominal wall vessels (4 %), bladder (3 %), liver (2 %), other (less
than 2 %).
RISK FACTORS — Procedures on patients who have had prior surgeries or
intraabdominal disease (endometriosis, pelvic inflammatory disease) are associated with a
higher risk of complications than simple procedures in women without this past history.
Conditions that increase the risk of complications include extensive bowel distention, very
large pelvic or abdominal masses, extensive pelvic/intraabdominal adhesions,
cardiopulmonary disease, and diaphragmatic hernia. The complexity of the surgery, the
presence of intra-abdominal adhesions, and the experience of the surgeon are 3 predominant
risk factors for bowel complications. Some authors suggest that the operador experience
needed to improve safety is over 100 laparoscopies per year[3]. Rates of bowel injuries (per
1000 cases) according to procedure have been reported as follows: diagnostic laparoscopy 0.2
to 1.5, laparoscopic sterilization 0.34 to 0.8, and operative/advanced laparoscopic procedures
1.5 to 2.4.
One study noted that 68% of women with bowel injury during access have had prior
laparotomies and 87% of women who suffer intraoperative bowel injury have adhesive
disease, predominantly endometriosis[3]. About port placement in women with previous
surgeries, we should remember that if the patient has had a previous vertical incision or there
is suspicion of periumbilical adhesions, either an open laparoscopic technique or a 5mm left
upper quadrant port has been recommended. It‘s been reported the prevalence of umbilical
adhesions as follows: 0.68% in patient with no history of prior surgery, 1.6% in patients with
previous laparoscopy, 19.8% in patients with previous pfannestiel, and 51.7% in patients with
prior vertical laparotomy[1].
Bowel injury—Bowel injury is one of the most serious complications because it may be
missed at the time of the initial laparoscopy and any delay increases the risk of fecal
peritonitis and death. Unrecognized bowel injuries are reported at widely varying rates, from
15% to 100%, and about 51%. Mortality associated with delayed diagnosis of bowel injury is
as high as 28% in one case series[3].
In studies in which the majority of complications arise intraoperatively (after entry), the
large intestine (specifically the rectosigmoid) is the most commonly injured organ. Surgical
forceps, scissors, and electrosurgical instruments are most often involved in operative
injuries[3].
Injury to the bowel may result from insertion of the pneumoperitoneum needle,
placement of the laparoscopic trocar, electrosurgical injury, or trauma during dissection.
Symptoms from penetrating trauma generally manifest within 12 to 36 hours, but may occur
up to five or seven days later. Presumably, patients who present after several days have
experienced either delayed necrosis of damaged bowel, or had a leak which temporarily
sealed off. Penetrating injuries due to the pneumoperitoneum needle can be managed
conservatively and generally do not require any treatment. The vast majority of trocar
punctures require only suture reapproximation.
It is important to restore bowel anatomy so that there is no leakage of bowel contents.
The techniques used are similar to those employed at laparotomy. Colostomy is rarely
indicated, and should be avoided
BOWEL INJURY. DIAGNOSIS and MANAGEMENT. — Aspiration of bowel contents
from the Veress needle, feculent odor from trocar sites, and the overt spillage of bowel
contents are obvious signs of bowel injury. Injury to the bowel should also be suspected if
opening pressure is elevated and between 8 and 10mm Hg. Blanched or deserosalized bowels
indicate termal and traumatic injuries, respectively. These injuries are easy to miss and result
in delayed perforation. Surgeons should be especially vigilant about such injuries in patients
undergoing extensive adhesiolysis[3].
Decompressing the stomach with a nasogastric tube prior to insertion of a Veress needle
in the left upper quadrant may help prevent perforation of a distended stomach. The
subumbilical trocar should be retracted to the peritoneal surface immediately after initial entry
to help assess whether viscera have been penetrated. It is also recommended that the
umbilical or first trocar insertion be visualized via another, more inferior, port at the
conclusion of every procedure. Through and through perforation of the colon has been
detected this way after what appeared to be a perfectly smooth laparoscopic ovarian
cystectomy.
The golden rule of laparoscopic surgery is that patients gradually get better with each
passing hour following the operation. Worrisome symptoms include nausea and vomiting,
abdominal pain, abdominal bloating/distention, and fever. Ileus after laparoscopy is not
normal, and warrants thorough patient evaluation. Symptoms of bowel injuries seem within 1
to 21 days after surgery, with mechanical injuries presenting earlier than thermal injuries.
White blood cell count may be elevated or depressed, and if the patient is severely ill there
may also be electrolyte and pH imbalances. Patients with perforated viscous are at higher risk
for developing sepsis and warning signs should be treated immediately. Abdominal x-ray is
less helpful than computed tomography (CT) scan with oral contrast (±rectal contrast) for
identifying injuries, hernias, or abscess3. The demonstration of free intra-abdominal air on an
upright abdominal radiograph has been used to diagnose a ruptured intraperitoneal viscus.
This radiographic sign is generally not helpful after laparoscopic surgery because
approximately 40 percent of patients will have more than 2 cm of free air at 24 hours
postlaparoscopy, despite lack of any clinical evidence of bowel perforation. Free air often
may be seen on a radiograph up to a week postoperatively, but the volume should gradually
decrease. Increasing amounts of intraabdominal air during the period of observation is
concerning. The finding of increasing free intra abdominal air indicates ruptured viscus until
proven otherwise. Intravenous contrast is administered to simultaneously evaluate the
genitourinary tract. If suspicion is high and radiographic evidence is inconclusive, it is
appropriate to perform a diagnostic laparoscopy. If this route is chosen, a general surgery
consultation should be considered[3]. Patients may have fecal contamination of the abdominal
cavity and still have bowel movements, be ambulatory and not display peritonitis. Repeat
open laparoscopy is a consideration in patients in whom there is a high level of concern for
possible bowel injury, or the surgeon may go straight to laparotomy. Antibiotics should be
administered if a bowel injury is recognized[3]. Some authors do not recommend additional
antibiotics to woman who have already received prophylaxis prior to surgery; if no antibiotics
were given, can be administered broad spectrum antibiotics if the bowel lumen is entered.
Postoperatively, enemas and rectal probe temperatures are proscribed in patients with rectal
injuries.There are no postoperative dietary restrictions unless the bowel injury and repair
involved a large area. Usually, nasogastric tubes are not used.
Management of bowel injuries recognized at the time of surgery varies depending on the
size and extent of the injury. The type of injury (mechanical vs. thermal) and the location
(small vs. large bowel) are also important factors. Historically, a large majority, if not all,
bowel injuries have been repaired by laparotomy but there is no contraindication to a
116 Angel Martin
laparoscopic repair if it is technically feasible. Extending trocar site incisions to create a mini
laparotomy is another approach[3]. Serosal abrasions need not be repaired, but injuries
involving the muscularis or muscularis and mucosa should be repaired. It is important to
consider the direction of the injury in relationship to the circumference of the bowel when
sewing the edges together. Defects should be closed transversely, parallel to the
circumference of the bowel, to ensure the diameter of the lumen is not narrowed, causing
stricture[3]. Mechanical injuries such as puncture wounds inflicted by the Veress needle to
the small intestine, large intestine, or stomach can be managed expectantly or repaired with a
figure-of-eight small caliber (3.0) delayed-absorption suture. If expectant management is
chosen, the injury site must be thoroughly examined to ensure only minimal damage
occurred. Puncture wounds caused by trocars must be repaired, and it may be useful to leave
the trocar in place until a surgical plan for repair is prepared. When the trocar is not removed,
spillage of bowel contents is minimized and it remains easy to identify the small but
significant injury. Superficial abrasions or lacerations to the serosa or seromuscular layer of
the small and large bowel should be oversewn with a 3.0 PDS suture in 1 layer. Full-thickness
lacerations of the small or large bowel may require a 2-layer closure, the first closing the
mucosa with a 3.0 absorbable suture, and sometimes a second layer closing the muscle and
serosa with 2.0 or 3.0 permanent suture such as silk. Interrupted or running stitches are
acceptable[3]. Electrosurgical injuries may not become symptomatic for several days. Burn
injuries require resection of 1 to 2 cm of viable tissue around the injury site to ensure that all
of the damaged tissue has been removed. The resected loop of bowel should be examined by
the pathologist to ensure that all of the damaged tissue has been excised; cytologic changes
associated with electrothermal injuries can be identified and should not extend all the way to
the resected margin.Thermal injuries to the small and large bowel are more difficult to assess.
Blanched tissue is likely injured but depending on the density of the energy applied, the
damage may extend beyond what is visible. Small, superficial, witnessed injuries may be
reinforced or oversewn with a single layer of absorbable suture. Extensive injuries recognized
alter a significant delay may require bowel resection with wide margins. Any significant
trauma to the bowel, mechanical or thermal in origin, should be evaluated and managed by
surgeons experienced with such bowel repairs. Bowel resections, reanastamoses, and
diversions may be indicated[3]. The value of a mechanical bowel preparation for prevention
of infectious complications of an intraoperative bowel leak or for reducing the rates of
anastomotic leak if bowel surgery is performed has been challenged.It does not seem
necessary to ―bowel prep‖ all patients undergoing a hysterectomy for benign disease solely in
case of an inadvertent enterotomy[19].
Small bowel injury— Roughly, half of all bowel injuries occur during entry, with the
small intestine at highest risk. Rarely, the stomach is injured with Veress needle insertion[3].
Small defects of the serosal or muscularis may be repaired using continuous or interrupted 3-0
silk or synthetic absorbable suture material. Single layer closure of small bowel is adequate in
most cases. Suture lines should be perpendicular to the long axis of the bowel to prevent
narrowing of the bowel lumen. Large defects can sometimes be closed with a stapling device,
or resection with reanastomosis may be necessary. Colonic injury—The rectosigmoid
intestine is the most commonly injured organ. Surgical forceps, scissors, and electrosurgical
instruments are most often involved in operative injuries[3]. Repair is similar to that
described above for the small bowel. Lack of preoperative bowel prep is not an indication for
colostomy. After the bowel is repaired, the abdomen is copiously irrigated. If rectosigmoid
injury is suspected, a bowel integrity test should be performed. To evaluate for perforation,
the pelvis is filled with sterile water whereas air is injected into the rectum with a 60-mL
catheter-tip syringe. Laparoscopically, the proximal sigmoid is compressed with a blunt probe
to keep the air distal. As air fills the rectum, the surgeon observes for any evidence of bubbles
in the water-filled pelvis, indicating bowel perforation. Alternatively, to visualize thinned,
deserosalized, or perforated bowel, the rectum can be filled with indigo–carmine-stained
sterile water. Blue dye spillage or visibility through the bowel wall indicates damage that
necessitates immediate repair[3]. Occasionally, a segment of bowel must be resected, and if
reanastomosis is performed, routine care can resume. If bowel reanastomosis cannot be
performed due to extensive injury or pathology (ie, dense adhesions or inflammatory
changes), a diverting colostomy may be required. Closed-system drains are commonly placed
in the pelvis, but are not used by all surgeons.
Fistulae — Gastrointestinal fistulae after gynecologic surgery are rare. They occur 10 to
14 days postoperatively, and may be heralded by spiking temperatures with no clear source,
no response to antibiotics, and a tender, but otherwise normal-appearing, incision. The
diagnosis and site of the fistula are determined radiographically by injecting dye into the
fistula (fistulogram) and subsequently performing a small and large bowel series.
Management consists of resting the gastrointestinal tract by eliminating oral intake, and
possibly by using inhibitors of pancreatic and gastric secretion (eg, somatostatin). Healing
occurs over weeks. However, the fistula will not heal if there is an obstruction distal to it.
Parenteral nutrition is indicated in most cases. Rectovaginal and anovaginal fistulas
frequently result from obstetric trauma. Rectovaginal fistulas may also result from difficult
hysterectomies, especially those performed for severe endometriosis with involvement or
obliteration of the posterior cul-de-sac (pouch of Douglas), and from surgical procedures
involving the posterior vaginal wall, perineum, anus, and rectum. Inflammatory bowel
disease, such as Crohn's disease and ulcerative colitis, is another important cause of
rectovaginal fistulas in women. In elderly women, rectovaginal fistulas can occur as the result
of diverticulitis, colon cancer, or fecal impaction. Fistula-in-ano describes a communication
between the anal canal and the perianal skin or perineum. These fistulas are typically initiated
by an infection such as an anal abscess, trauma, anal fissure, or Crohn's disease, or as a
complication of episiotomy. Anatomically, the fistula may originate anywhere below the
dentate line internally and exists externally along the perianal skin or perineum.
Histologically, fistula-in-ano differs from anovaginal fistulas in that the fistulous tract is
typically lined with chronically inflamed granulation tissue, rather than the epithelialized tract
typical of anovaginal and rectovaginal fistulas. Diverticulitis, and to a lesser extent
hysterectomy, is strongly associated with the risk of fistula formation. Hysterectomized
women with diverticulitis have the highest risk of developing surgically managed fistula. The
highest rates of fistula formation in nonhysterectomized women with diverticular disease are
observed between the intestine and the bladder or urinary tract, with intestinogenital fistulas
being the second most common type. The opposite situation is observed in hysterectomized
women with diverticulitis: an increased rate of intestinogenital fistula (presumably
colovaginal fistulas) and a relatively lower rate of urointestinal fistula. These findings lend
support to the proposition that in women with diverticular disease the uterus acts as a
protecive buffer by preventing an inflammatory process from reaching the vagina and
resulting in genital fistula formation. The risk of pelvic fistula disease is higher in women
having had their hysterectomy at 50 years or older. This can presumably be attributed to
118 Angel Martin
perimenopausal and postmenopausal estrogen deficiency resulting in degenerative changes of

the vaginal tissues, which in turn may affect tissue susceptibility to infectious and/or
inflammatory processes. Older women may also have a higher incidence of other diseases
associated with poor tissue healing and susceptibility for infections[20, 21]. Closure— The
incidence of trocar site hernia has been described at <1%. Many surgeons recommend
reapproximation of the fascial defects created at laparoscopy to prevent bowel herniation.
Fascial closure is required for trocar sites of 10 mm or greater in diameter, and can be
achieved in a variety of methods (Carter-Thomason, Endoclose device, and traditional closure
with a curved needle)[1]. However, multiple studies have shown that closure of the fascial
defect does not in and of itself guarantee that a hernia will not form.
4) Other Laparoscopic Complications

4.1. Neurologic Injury
Malpositioning of the patient or patient shift during surgery may result in serious
neurologic impairment. Patients whose surgery lasts more than 4 hours, whose legs are
moved up and down in the stirrups frequently, or who are in steep Trendelenburg are at the
greatest risk for posicional injuries. In these cases, the patient‘s position should be reassessed
periodically throughout the procedure. Neurologic injury to the lower extremity may involve
the femoral, sciatic, or peroneal nerves. If the leg is hyperflexed during surgery the femoral
nerve can be injured by compression against the inguinal ligament. If the leg is externally
rotated or abducted at the hip, the femoral nerve may be stretched to excess. Injury to the
femoral nerve presents as a motor weakness of the quadriceps muscle, causing difficulty
ambulating, climbing steps, and a decreased patellar reflex. This injury is generally not
painful. The sciatic nerve suffers stretch injury if a leg is straightened in the stirrups with the
hip flexed for a long period of time. Symptoms of sciatica include posterior leg pain and
weakness. Peroneal nerve injuries occur when the lateral knee is compressed against the
stirrup where the nerve crosses the head of the fibula. This injury causes foot drop, with
weakness and/or numbness of the dorsal foot. Neurologic injury to the upper extremities
occurs predominantly at the brachial plexus, which is stretched in patients who are in steep
Trendelenburg for long periods of time, especially if shoulder braces are used.
Hyperextension of the shoulder (greater than 90 degree in the outstretched arm) can cause a
similar stretch injury. For injuries that are physically limiting, such as weakness due to a
femoral nerve injury, knee braces or other supportive devices can be used. Steroid injections
are used to decrease inflammation of nerves, and are rarely part of the treatment for positional
injuries, which result from stretching and ischemia. The majority of these neurologic injuries
will resolve completely with time[3].
4.2. Complications from Pneumoperitoneum
Decreased venous return, increased systemic and pulmonary vascular pressures,

increased ventilation pressures, and elevation in CO2 levels are physiologic consequences of
pneumoperitoneum and Trendelenburg positioning required Turing gynecologic

laparoscopy.These changes to the circulatory and respiratory Systems are often not tolerated
by patients with finely compensated cardiopulmonary status. 15 Decreasing insufflation
pressures, temporarily releasing pneumoperitoneum, and placing the patient flat or in reverse
Trendelenburg position may help if a patient decompensates intraoperatively. Aborting the
procedure or conversión to laparotomy may be necessary if a patient cannot be stabilized.
Subcutaneous emphysema is the Trucking of CO2 gas above the level of peritoneum and
fascia, which can extend as low as the inguinal creases or as high as the submandible. This
can happen when trocars or gas inflow slips retroperitoneally into the thickness of the
abdominal wall. It can also result if trocars are under significant torque that causes the
incisions to stretch and allows for gas influx above the peritoneal layer (this is especially
pertinent in obese patients or if trocars are inserted at the wrong angle)[3].
Conclusions
Hysterectomy remains one of the most commonly performed major surgical operations in
the developed world. Numerous large series reporting on laparoscopic surgery estimate
overall complication rates at 0.34% to 0.57%[3]
In experienced hands, laparoscopic hysterectomy is a safe, cost-effective and beneficial
technique for both the patient and the surgeon. Expertise in laparoscopic procedures and
adherence to the safety rules are nevertheless paramount to avoid any serious complications
that may occur. Abdominal, vaginal and laparoscopic procedures all have their own
indications and need to be performed with the same level of application and skill[2]. Most
gynaecologists and their patients would gree that the optimum procedure is the one that can
be performed with the greatest safety and produce the greatest relief of symptoms and
improvement in quality of life in the most cost-effective manner. The eVALuate study was
able to demonstrate that when compared with abdominal hysterectomy, laparoscopical was
less painful, was associated with a shorter recovery and better short-term quality of life[22]. It
is important to note that serious complications relating to thermal damage can happen, even if
the rate of complications is low. For this reason, the laparoscopic technique requires a high
level of expertise and perfect knowledge of all the safety rules[2]. In fact, through the
comprehensive understanding of the relevant anatomy, surgical instruments, complex
maneuvers, and optimal surgical technique, gynecologic laparoscopists can avoid most of the
complications described. Even in the best of hands, however, complications will occur. Most
importantly, surgeons should be diligent in recognizing and managing these events[3].
References
[1] Sokol AI, Green IC. Laparoscopic Hysterectomy. Clin. Obstet. Gynecol. 2009;52:304-
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[2] Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic
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[3] Makai G, Isaacson K. Complications of Gynecologic Laparoscopy. Clin. Obstet.

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[4] Jansen FW, Kolkman W, Bakkum EA, de Kroon CD, Tribos-Kemper T, Trimbos JB.
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not inherently dangerous for patients presenting with benign gynaecologic pathology.
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[11] Mäkinen J, Johansson J, Tomás C, Tomás E, Heinonen PK, Laatikainen T, et al.
Morbidity of 10.110 hysterectomies by type approach. Hum. Reprod. 2001;16:1473-78.
hysterectomy: systematic review and meta-analysis of randomised controlled trials. Br.
Med. J. 2005;330:1478-81.
[13] Léonard F, Fotso A, Borghese B, Chopin N, Foulot H, Chapron C. Ureteral
complications from laparoscopic hysterectomy indicated for benign uterine pathologies:
a 13-year experience in a continuous series of 1300 patients. Hum. Reprod.
2007;22:2006-11.
[14] Coleman RL, Muller CY. Effects of a laboratory-based skills curriculum on
laparoscopic proficiency: A randomized trial. Am. J. Obstet. Gynecol. 2002;186:836-42.
[15] Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery.
Am. J. Obstet. Gynecol. 2003;188:1273-77.
[16] Saidi MH, Sakler RK, Ancaillie TG, Akright BD, Farhart SA, White AJ. Diagnosis and
Management of serious urinary complications after major operative laparoscopy.
Obstet. Gynecol. 1996;87:272-6.
[17] Dandolu V, Mathai E, Chatwani A, Harmanli O, Pontari M, Hernandez E. Accuracy of
cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery. Int.
Urogynecol. J. Pelvic. Floor Dysfunct. 2003;14:427-31.
[18] Kim JH, Moore C, Jones JS. Management of ureteral injuries associated with vaginal
surgery for pelvic organ prolapse. Int. Urogynecol. J. Pelvic. Floor Dysfunct.
2006;17:531-36.
[19] Falcone T, Walters MD. Hysterectomy for Benign Disease. Obstet. Gynecol.
2008;111:753-67.
[20] Forsgren C, Lundholm C, Johansson A, Cnattingius S, Altman D. Hysterectomy for
Benign Indications and Risk of Pelvic Organ Fistula Disease. Obstet. Gynecol.
2009;114:594-99.
[21] Altman D, Forsgren C, Hjern F, Lundholm C, Cnattingius S, Johansson AL. Influence

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[22] Garry R. The best way to determine the best way to undertake a hysterectomy. BJOG
2009;116:473-77
Chapter 8
The Use of Tumor Excision

(Myomectomy) in Place of
Hysterectomy in the Management of
the Majority of Benign Uterine Tumors
Kuo-Chang Wen1,2,3, Pi-Lin Sung1,2,3, Wen-Ling Lee1,4,5 and

Peng-Hui Wang1,2,3,4 *
1
Institute of Clinical Medicine, National Yang-Ming University School of Medicine,
Taipei, Taiwan
2
Department of Obstetrics and Gynecology, Taipei Veterans General Hospital and
Chutung Veterans General Hospital, Taiwan
3
Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, and
National Yang-Ming University Hospital, Ilan, Taiwan
4
Institute of Systems Biology and Bioinformatics, Department of Life Sciences, National
Central University, Tao-Yuan, Taiwan
5
Department of Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan
Introduction
Uterine leiomyomas (also called myomas or fibroids, and found in 20 to 40% of women)
and adenomyosis (endometrial gland tissue within the myometrium) are the two most
common disorders among women at a reproductive age [1,2]. They are often detected
*
E-mail: phwang@vghtpe.gov.tw; phwang@ym.edu.tw
124 Kuo-Chang Wen, Pi-Lin Sung, Wen-Ling Lee et al.

Myomectomy by Laparotomy (LT-M)

Although hysterectomy has been considered as a definitive procedure in the management
of symptomatic uterine myomas for a long time, myomectomy can be performed for women
who are young, who wish to retain their fertility, and who desire childbearing in the future. In
the beginning of the nineteenth century, Victor Bonney advocated myomectomy for the
restoration and preservation of the physiological function of the uterus, and as a higher
surgical ideal than hysterectomy [3]. Instead of hysterectomy, myomectomy through
exploratory laparotomy (LT) can be finished successfully and large leiomyomas can be
removed [3], even during cesarean section [4].
In LT-M, an 8- to 12-cm skin incision, either a Pfannenstiel incision or a midline vertical
incision, is made to allow the mostly general inspection of the uterus and leiomyomas [5-6].
The advantage of this approach is the adequate exposure of the operative field, which makes
the entire surgical procedure smooth and easy. The abdominal wall is opened as usual with
the assistance of the self-retractors and some warm normal saline-rinsed gauzes or pads.
Because of the adequate exposure of the surgical field, the intact tumor can be easily
removed, and in theory, all visible and palpable tumors can be removed during the operation,
and the accompanying uterine defects can be securely repaired by conventional suture
techniques.
The surgical outcome and operative risk of LT-M and hysterectomy have been compared
and the results were consistent with the concept that LT-M can be used in place of
hysterectomy for women with uterine myomas. One study showed that the risk of
intraoperative visceral injuries and infection was decreased in the LT-M group compared with
the hysterectomy group, although the uterine size in the hysterectomy group was significantly
larger in that study [7]. Another cohort study showed similar overall morbidities, including
febrile morbidity, hemorrhage, unintended procedures, life-threatening events, and
readmission between LT-M and hysterectomy [8]. An important finding was that although
operative time was significantly longer in the LT-M group than in the hysterectomy group
The Use of Tumor Excision (Myomectomy) in Place of Hysterectomy… 125
(200.9 ± 68.1 versus 175.5 ± 56.2 min), blood loss was significantly less in the LT-M group
(227 versus 484 mL) [8]. The larger uterine mass can be managed successfully with LT-M.
One study enrolled women with a uterine mass up to 21 gestational weeks, ranging from 16 to
36 weeks [9]. The number of leiomyomas ranged from 1 to 25 (mean, 7) and the weight of the
removed leiomyomas ranged from 102 to 2,467 g (mean, 668 g). The mean operative time
was 236 minutes (120~390 minutes), and mean estimated blood loss was 794 mL (50~3,000
mL). Because of the absence of conversion to hysterectomy and few cases with
complications, the outcome was favorable [9].
Taken together, the morbidity of myomectomy is quite comparable with that of
hysterectomy. The use of LT-M may be considered as a primary treatment for uterine
myomas regardless of advanced childbearing [10].
Laparoscopic Myomectomy (LM)

The initial application of LM was performed by Semm in 1979 [11]. In LM, the main
trocar (10 mm port) is inserted through the umbilicus to introduce the video system after
pneumoperitoneum by insufflation with carbon dioxide. Two or three other accessory trocars
(5 mm port and/or 12 mm port) were inserted into the abdomen at the left lower quadrant,
right lower quadrant, and suprapubic area, for the operative instruments and the suction
irrigator machine. For larger sized uterine leiomyomas, the Lee-Huang point can be
considered in place of the traditional main trocar site [12]. When using the Lee-Huang point,
the main trocar site is moved to the midpoint between the xiphoid process and umbilicus
(middle upper abdomen). The accessory trocar can be made in a paramedian line parallel to
the umbilicus [12-13]. Myomectomy is then performed after grasping with the second needle
and injection with Pitressin into the myometrium around the leiomyomas. Leiomyomas can
be extracted completely by either a culdotomy (vaginal approach) or an electronic morcellator
(abdominal approach) [14]. Then, the myometrial defects can be repaired by either standard
(traditional) laparoscopic intracorporeal suture or a modified suture technique with the
assistance of a pusher [15]. The modified laparoscopic suture technique is easier; therefore,
the less-experienced surgeon might prefer this suture technique. The technique involves
pulling the strip outside the abdomen through the trocar after finishing the suture at the
uterine defect. The tension of the suture is maintained by the operator‘s and assistant‘s hand
and the knot is pushed into the abdomen and uterus side by the pusher.
LM has gained wide acceptance after advances in instruments and techniques. LM seems
to be superior to LT-M [16]. A recent summarized study (n= 576) showed that LM appears to
have less blood loss, a lower hemoglobin drop, faster recovery, less postoperative pain,
shorter hospital stay, and a better cosmetic effect [17]. In selected patients, LM is a better and
[more considerable??] choice than open surgery.
Although LM seems to be more feasible compared with open myomectomy, there is no
doubt that LM is technically highly demanding and requires specialized surgical instruments.
In addition, surgeons need a longer training course and skilled assistants. All contribute to the
longer operative time in LM compared with that in open myomectomy [17]. Finally, uterine
rupture or dehiscence after LM is still a concern, although it is considered as an uncommon
complication [18-19].
To overcome the above-mentioned limitations, robot-assisted laparoscopy, a new

technology, has been developed for every aspect of surgery. Robot-assisted LM provided a
significant decrease in estimated blood loss and hospital stay, if the number of uterine
leiomyomas was limited (≦3) [20-21]. However, several negative aspects of using robot-
assisted LM, including longer operative time (mean, 231.38 ± 85.10 versus 154.41 ± 43.14
minutes) and higher cost (mean, $30,084.20 ± $6,689.29 versus $13,400.62 ± $7,747.26),
have limited its popularity and acceptability [20].
Myomectomy by Minilaparotomy (MLT-M)

LM seems to be feasible compared with LT-M. However, LM still remains a challenging
procedure for most surgeons and may not be easily used with most patients (those with a lot
of tumor masses, and large-sized tumors). The minilaparotomy (MLT), ultraminilaparotomy
(UMLT), and laparoscopically-assisted ultraminilaparotomy (LA-UMLT) procedures were
born of the concept of the similar smaller wounds created by LM.
In MLT-M, a minimal suprapubic skin incision, ranging from 4 to 9 cm in length, was
made [22]. Surgery by MLT was used successfully in the management of most women with
uterine myomas. The technique in only 3 cases (4%) was converted to LT-M due to more
obesity, isthmic leiomyomas, and pelvic adhesion [22]. A comparison of LT-M, MLT-M, and
LA-MLT-M showed that MLT-M had the efficacy of an early outcome similar to LA-MLT-
M, but greater than LT-M. MLT-M had the further advantage of the least operative time
compared with LT-M and LA-MLT-M (85.9 ± 7.2 versus 91.3 ± 7.2 and 92.6 ± 4.4,
respectively) [23]. MLT-M may be used as an ambulatory operation, because operative time
was 73 min and blood loss was 96 mL, and of most importance, all patients were discharged
smoothly on the same day [24].
Myomectomy by Ultraminilaparotomy (UMLT-M)

Since MLT-M is considered as an alternative to LM (the minimally invasive surgery) and
MLT-M is a safe procedure in an ambulatory and outpatient setting [24], a further shortened
incision wound might provide an additional benefit, if the operation can be successfully
finished. Therefore, UMLT is defined as having an upper limit to the wound of ≦ 4 cm (often
3 cm). A transverse incision (modified Pfannenstiel incision: MPI) below the pubic hairline is
made [6-7, 25-27]. The assistant retractors used during UMLT-M include small Deaver
retractors (width 2.5 cm) and thyroid retractors (width 1.5 cm). All surgical procedures are
completed within the abdominal cavity. Some critical points for successful surgery are shown
below. An easy-to-use instrument, such as the Backhaus towel clamp (Robbins Instruments
Inc, Chatham, NJ) is often requested to grip the leiomyomas toward the incision wound, and a
―piece by piece‖ procedure, similar to peeling an apple, is applied to bigger leiomyomas [7].
However, the maintenance of a wound smaller than 4 cm is not always achieved, if the tumor
size is larger than 8 cm and the tumor number is more than 5 [6-7].
To overcome these limitations of UMLT-M, the alternative midline incision (midline
vertical incision: MVI) can be used in place of the MPI. This approach leads to a 100%
success rate in UMLT-M. MVI has additional advantages, including less operative time and
less estimated blood loss, and this procedure seems to be much easier and more friendly for
the operators, although MVI is compromised by more postoperative wound pain, delayed free
ambulation after surgery, longer hospital stay, and a lower return to work capability compared
with MPI. In addition, the cosmetic effect of MVI might not be as good as that of MPI. The
entire MPI incision wound can be embedded completely within the pubic hair covered skin
and have less scar formation because the wound incision is parallel to the natural ―Langer
line‖ of the body. The advantage of the UMLT procedure is not only in exploratory
laparotomy, but also in assisting laparoscopy. UMLT in the long-term, is considered as a
rescue method for laparoscopic surgery, because it overcomes the limitation of technique
difficulty and the absence of the palpability of the fingers during laparoscopic surgery. Two
modified procedures of LM and LA-UMLT-M were compared with LT-M in the management
of uterine leiomyomas, with a median follow-up of 52 months [5]. Compared with LT-M,
UMLT-M and LA-UMLT-M had significantly better surgical parameters, including a low risk
of paralytic ileus, shortened number of days to discharge, and lower visual analog scale
(VAS) score. Among the two modified procedures, UMLT-M had an additional benefit of
less operative time (98.0 ± 28.2 versus 106.3 ± 30.5 min), and LA-UMLT-M had less blood
loss (92.3 ± 67.2 versus 111.7 ± 108.4 mL). If the patients underwent laparoscopic uterine
vessel occlusion (LUVO) first, followed by immediate UMLT-M or LM, the surgical
parameters were significantly better in LUVO+UMLT-M, because LUVO+UMLT-M
required less operative time (56.1 ± 16.9 versus 73.4 ± 26.9 min; P=.009) and all patients
could be finished successfully, compared with the 8.2% conversion rate in LUVO+LM
(P=.018). Taken together, UMLT-M has the advantages of less operative time and possibly a
better cosmetic effect, since the UMLT-M wound is a single incision wound and completely
embedded within the pubic hair-covered skin. The latter was confirmed, since women with
previous abdominal surgery favored using the Pfannenstiel incision, hidden in the pubic hair,
as the choice for hysterectomy over LA vaginal hysterectomy (80% versus 18%) [30].
Laparoscopically-Assisted Myomectomy (LA-M)

As mentioned above, not all surgeons are so familiar with laparoscopic surgery and
cannot palpate the tissue with their hands or fingers, which contributes to some modification
of pure laparoscopic surgery, such as LA-M, LA-AM (laparoscopically-assisted abdominal
myomectomy) and LA-VM (laparoscopically-assisted vaginal myomectomy). This
modification combines the minimally invasive advantage of laparoscopy and the easy
manipulation of conventional surgery. The LA-AM procedure is very similar to LM, except
the removal of tumors and repair of the uterine wound from an enlarged suprapubic trocar
wound. The advantages of LA-AM include the availability of electronic morcellator or
requested instruments for tumor removal, the palpability of surgeons‘ hands or fingers to
minimize the risk of missing tumors (smaller size), and conventional techniques for repairing
the wound. The final laparoscopic procedure cleans the abdominal cavity and avoids
undetectable bleeders. All provide an improvement in postoperative pain, blood loss, febrile
morbidity, time of paralytic ileus, and discharge day, compared with pure MLT-M or UMLT-
M [6,23].
Figure 1. A figure shows the frequently used incision wounds for myomectomy. A: Pfannenstiel
incision is often used in exploratory laparotomic myomectomy or mini-laparotomic myomectomy. B:
Ultramini-laparotomy is often used in ultramini-laparotomic myomectomy and laparoscopy-assisted
ultramini-laparotomic myomectomy. C: laparoscopic myomectomy.
Some modifications provide additional help in LA-AM, for example, the specific
abdominal wall sealing device, LAP DISK contacting 2 plastic circles (diameter, 10 cm) and
one flexible wire ring, and gasless laparoscopic surgery. The former allows the operator‘s
hand to enter the abdominal cavity without air leakage of the pneumoperitoneum [31].
Pneumoperitoneum is not necessary in gasless laparoscopy, which is performed under the
assistance of an abdominal wall retraction-lifting device. Gasless LA-UMLT-M had
significantly less operative time and a better postoperative outcome than MLT-M [32].
If enucleation and removal of leiomyomas, repair of the uterine defect, and hemostasis
are finished through a culdotomy incision, the procedure is called LA-VM. The advantages of
LA-VM include less postoperative pain and easy manipulation of the lower-lying posterior
uterine leiomyomas compared with LA-AM.
Figure 1. summarizes the frequently used incision wounds for myomectomy.
Adenomyomectomy
Adenomyosis, characterized by the presence of ectopic endometrial gland tissue within
the myometrium, is typically noted in women between the age of 30 to 50 years [2], and often
causes painful (dysmenorrhea) and/or plentiful menstruation (menorrhagia). Female hormone

deprivation or hysterectomy is believed to be a definite treatment for women with
adenomyosis. However, fertility-requested made minimally invasive surgery possible,
including endomyometrial ablation, laparoscopic myometrial electrocoagulation, and surgical
excision of adenomyomas (adenomyomectomy). All provide various degrees of symptom
control [33-34]. In adenomyomectomy, which is similar in concept to cytoreduction, the
operators remove the disease sites while preserving the uterine structure. The techniques
include careful excision, delicate electro-cauterization, avoiding tubal and endometrial injury
and minimizing dead space formation. The outcome of adenomyomectomy varies
dramatically because of the severity of illness and residual tumor burden. In theory, it is
impossible to have complete excision. One report showed up to 64% symptom control during
the 24-month follow-up [33]. Adjuvant medical treatment with gonadotropin-releasing
hormone agonist (GnRH agonist) might enhance symptom control after adenomyomectomy
[35]. One 2-year prospective study showed a significantly better symptom control rate with
the combination of adenomyomectomy and postoperative adjuvant GnRH agonist compared
with adenomyomectomy alone. Further investigations are needed to determine the long-term
benefit due to the relatively short follow-up of these studies.
Adenomyomectomy through the laparoscopic approach is also used in the management
of adenomyosis [37], and offers successful symptom control, including improvement of
dysmenorrhea and menorrhagia; a few women have even been able to conceive successfully.
However, similar to LM, the risk of uterine rupture after laparoscopic adenomyomectomy is
still of deep concern [38].
Taken together, and similar to myomectomy, adenomyomectomy can be considered as a
rescue method for women with apparent symptoms who cannot tolerate long-term
medication, have a strong-desire for uterus preservation, and hope to retain childbearing
potential.
Medical or Surgical Interventions Reducing Blood

Loss During Myomectomy
Since myomectomy through either laparotomy (LT-M, MLT-M, UMLT-M) or
laparoscopy (LM, LA-MLT-M, LA-UMLT-M) may be associated with heavy bleeding, there
are many strategies to minimize blood loss during operation.
GnRH agonist may be one of the most frequently used tools, and can be used before the
operation to stop menstruation (improving anemia), reduce the uterine and tumor size, and
decrease intra-operative blood loss [39, 40].
Pitressin, a synthetic vasopressin agonist, can induce contraction of the uterine smooth
muscle and vessel. Intramyometrial injection of pitressin (20 units diluted to 20 mL in normal
saline, 1:20) was effective in decreasing the amount of intra-operative bleeding and the
demand for blood transfusion during myomectomy [41]; this was confirmed by Cochrane
database systematic reviews [42]. Other interventions, such as misoprostol (prostaglandin E1
analogue), bupivacaine plus epinephine (local vasoconstrictors), tranexamic acid
(antifibrinolytic agent), mesna (chemical dissociation of leiomyomas), and a tourniquet
(elastic cord to fasten the vessels that supply the uterus), also showed clear benefits in
decreasing blood loss during operation, although oxytocin and morcellation did not [42].
Finally, uterine vessel occlusion or ligation, or uterine artery embolization appears to
minimize blood loss and facilitate myomectomy [43-45]. Tixier and colleagues found
minimal blood loss and a rare occurrence of febrile morbidity during myomectomy if the
women were previously treated with uterine artery embolization [43]. In addition to the
benefit of significantly decreased blood loss during operation, the recurrence rates of
leiomyomas after myomectomy were significantly decreased with combined uterine vessel
occlusion and myomectomy, compared with myomectomy alone [44-48].
Potential Developmental Issues

Without doubt, malignant uterine tumor should be an absolute contraindication for
conservative therapy. Before treating uterine leiomyomas without evidence of pathology, the
most important issue to determine is whether the uterine sarcomas arose from the malignant
transformation of pre-existing leiomyomas. If a physician is unable to answer this question
with certainty, myomectomy for uterine leiomyomas might carry a risk.
Several studies have investigated uterine leiomyoma by analyzing clustered genes via
array experiments and have provided us some promising ideas about the pathogenesis of
uterine myoma [49]. Nevertheless, discordant results exist in those preliminary findings and
have to be resolved through establishing an appropriate statistical analysis as well as
confirming the genes in question via functional studies.
Combinations of several treatments for uterine leiomyomas may be a potential
therapeutic modality in the future.
Although the types of minimally invasive surgery for myomectomy have expanded
during the past 20 years, no myomectomy surgery is available as a definitive treatment for
uterine leiomyomas, as yet. Myomectomy used for the treatment of uterine leiomyomas may
be effective in the removal of all visible and/or palpable tumors.
However, the reported efficacy of myomectomy through different approaches is usually
inconclusive. The controversy is in part derived from the inconsistent criteria of efficacy.
Heterogeneous studies trying to investigate the therapeutic response have included decrement
of the leiomyomas. Different measurement settings and methods make comparisons difficult.
Furthermore, the evaluation of the clinical outcome of leiomyomas is also not easy. For
instance, the degree of change in menstrual blood loss is subject to significant variability,
even when using pictorial blood loss assessment charts. There are a few validated
questionnaires available for the assessment of leiomyoma symptoms, but they often are not
used in studies and a more general assessment of symptom control is provided. The current
lack of standardization of symptom assessment significantly limits our ability to interpret
outcomes from these various studies.
Conclusions and Recommendations

If no symptoms exist, no therapy is required. Regular follow-up may be the best choice
for women with uterine leiomyomas. However, if symptoms exist, treatment should be
initiated without hesitance. The advanced techniques of minimally invasive surgery for
leiomyomas will be an alternative in treating uterine leiomyomas. Finally, a definite
hysterectomy or subtotal hysterectomy should not be neglected as a rescue method in the
management of uterine leiomyomas.
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Loffroy R, Filipuzzi L, Grevoul J, Mutamba W, Cercueil J, Krausé D, Douvier S, Sagot
P. J. Radiol. 2008 Dec; 89(12):1925-9.
[46] Laparoscopic uterine artery occlusion combined with myomectomy for uterine
myomas. Cheng Z, Yang W, Dai H, Hu L, Qu X, Kang L. J. Minim. Invasive Gynecol.
2008 May-Jun;15(3):346-9.
[47] Combining the uterine depletion procedure and myomectomy may be useful for treating
symptomatic fibroids. Liu WM, Tzeng CR, Yi-Jen C, Wang PH. Fertil. Steril. 2004 Jul;
82(1):205-10.
[48] A comparison of combined laparoscopic uterine artery ligation and myomectomy
versus laparoscopic myomectomy in treatment of symptomatic myoma. Alborzi S,
Ghannadan E, Alborzi S, Alborzi M. Fertil. Steril. 2009 Aug;92(2):742-7.
[49] Efficacy of combined laparoscopic uterine artery occlusion and myomectomy via
minilaparotomy in the treatment of recurrent uterine myomas. Liu WM, Wang PH,
Chou CS, Tang WL, Wang IT, Tzeng CR. Fertil. Steril. 2007 Feb;87(2):356-61.
[50] Use of uterine vessel occlusion in the management of uterine myomas: two different
approaches. Lee WL, Liu WM, Fuh JL, Tsai YC, Shih CC, Wang PH. Fertil. Steril.
2009 Dec 31.
[51] Uterine myoma: a condition amenable to medical therapy? Cheng MH, Wang PH.
Expert Opin. Emerg. Drugs 2008;13(1):119-133.
Chapter 9
Surgical Management of Congenital

Uterine Abnormalities: Indications,
Techniques and Outcome
Ignacio Zapardiel*
Gynecology Department. Santa Cristina University Hospital. Madrid. Spain.
Abstract
Congenital uterine abnormalities result from the abnormal maturation of Müllerian
ducts during embryogenesis being uterine abnormalities the most common.
A search in Medline was performed concerning the surgical management of
congenital uterine abnormalities. We found a clear benefit in the group of patients who
underwent to surgical management regarding fertility rates and miscarriage pregnancy
rates as well as in terms of pain release, for almost all subgroups of anomalies addressed
by the American Society of Reproductive Medicine.
These results were comparable between laparoscopy and laparotomy groups. Surgery
seems to be the best option for symptomatic patients with congenital uterine anomalies,
indeed, laparoscopic approach is feasible and reliable to treat them, showing the same
both anatomical and reproductive results than the laparotomic approach but with the
advantages of the minimally invasive surgery, such as cosmetic results and postoperative
period, which is essential in young patients.
Keywords: Congenital uterine anomalies; Müllerian anomalies; Surgical treatment.
*
Address: C/ Maestro Vives 2, 28009 Madrid. SPAIN. Phone: +34 915574358, Fax: +34 916325052, E-mail:
ignaciozapardiel@hotmail.com
136 Ignacio Zapardiel
Introduction
Congenital uterine abnormalities result from the abnormal maturation of Müllerian ducts,
most of them because of either a defect of development or fusion in the two ducts during
embryogenesis, when the embryo is just 20 millimetres length. It may involve uterus,
fallopian tubes, cervix and vagina but, among them, uterine abnormalities are the most
common[1]. The estimate prevalence of uterine malformations is 7-8% in fertile population
and 25% in women with recurrent spontaneous abortions[2,3]. Most of the anatomical
variations have been sorted by the American Society of Reproductive Medicine (before
named American Fertility Society) in 1988[4] (Figure 1), according to this, the Müllerian
abnormalities may be grouped in hypoplasia and agenesis, unicornuate uterus, bicornuate
uterus, didelphic uterus, septate uterus, arcuate uterus and the anomalies related to
diethylstilbestrol intrauterine exposure. Maybe the most common of them are the arcuate,
septate or bicornuate uterus depending on the population under study. Most of the studies find
the highest prevalence in the septate uterus (33-35%), but some of them find following it the
arcuate uterus (32%), whereas others find in the bicornuate uterus second higher prevalence
(25%) following by arcuate uterus (20%)[5,6,7]. Clinical presentation will vary among the
different uterine anomalies, but in general most of them may present abnormal bleeding or
amenorrhea (in case of agenesis), dysmenorrhea or non-cyclic diffuse pelvic pain, infertility,
endometriosis symptoms or recurrent pregnancy loss. Other symptoms we may find are
ectopic pregnancy as well as preterm delivery and malpresentation when they succeed in
getting pregnant. Despite the wide spectrum of symptoms we can find, some of them remain
asymptomatic, usually due to minor or incomplete anomalies[1]. Concerning the diagnostic
imaging techniques, the MRI seems to be the gold standard for the diagnosis of Müllerian
abnormalities (Figure 2), although three-dimension sonography has obtained almost the same
results by means of the new coronal view which can be obtained with the new softwares[8-
11], it has been reported a sensitivity and specificity up to 98-100% for both techniques[12].
Indeed, the hysterosalpingography can be useful to complete the diagnosis as well as
computed tomography scan and renal imaging techniques because often renal anomalies are
associated (20-30%)[1,5,13].
Figure 1. Classification of Müllerian abnormalities by the American Society of Reproductive

Medicine[4].
Surgical Management of Congenital Uterine Abnormalities 137
Figure 2. Magnetic resonance which shows the unicornuate uterus (UU), the rudimentary horn (RH)
and the looped hematosalpinx (HS)
In this review we have sorted out the anomalies following the American Society of
Reproductive Medicine[4] (ASRM) classification to better understand the role of surgical
approach and specific outcome of each one.
Type I. Hypoplasia and Agenesis

Type I ASRM anomalies includes tubal, uterine, cervical and vaginal anomalies.
Regarding uterine hypoplasia or agenesis, uses to cause abdominal pain due to the blood
accumulation in the uterine cavity often with the menarche[14] if there is enough
endometrium, or amenorrhea if there is not, it also causes infertility and reproductive
problems. We should carry out the surgical correction when the patient complaints of any of
those symptoms. When the anomaly is placed in the vaginal or cervical area the pain is more
frequent and can be solved by draining the hematometra, placed at uterine cavity or vagina,
with a fistulisation in the occluded area[15,16]. For a definitive solution, a neovagina could
be performed by means of a skin graft or bowel transposition[17,18], as well as uterovaginal
anastomosis which has been reported by laparoscopy[19]. The laparoscopic approach seems
to be also useful when it is not clear the nature of vaginal or uterine anomaly, when there is a
need of searching for associate endometriosis or when adhesions make laparoscopy preferable
to laparotomy in order to avoid new adhesions formation[20]. Laparoscopically assisted

uterovestibular anastomosis in twelve women has been reported as well with optimal results
after 12-month follow up[21]. These techniques have appeared to be very useful, so
successful pregnancies have been reported with cesarean section delivery, in fact more than
50% of the women with vaginal anomalies who underwent to in-vitro fertilization techniques
achieved pregnancy as it is reported in the current literature[22]; moreover, over 80% of
patients become sexually active after genital reconstructive surgery. If the agenesis or
hypoplasia is placed in the uterine corpus, the treatment will depend on the kind of
malformation but hysterectomy is often the only possible treatment because there is not
enough uterine tissue to reconstruct the uterine walls and try to accomplish pregnancy.
Type II. Unicornuate Uterus

The incidence of unicornuate uterus is near 6% of whole uterine abnormalities. Among
them, the unicornuate uterus with a noncomunicating uterine horn is the most common form
(80% of the unicornuate uterus)[14,23]. It is not clear whether it happens more often in the
right side or not, while some papers report a frequency around 80% right-sided, other estimate
a frequency of 62% or even less8. This subtype of anomalies have an association with
endometriosis, by means of a retrograde menstruation, and also with renal abnormalities
(40%) which should be checked out before any treatment[9,24]. In these cases it is mandatory
to perform a complete and strict preoperative evaluation and diagnosis, including the presence
of functional endometrium in the rudimentary horn due to pregnancy and life-threatening
hemorrhage it is possible[25-27]. The patients used to present diffuse pelvic pain and
dysmenorrhea caused by hematometra in the cavitated rudimentary horn, endometriosis,
pyometra or torsion of the abnormal portion or the Fallopian tube. These patients also have a
higher rate of ectopic pregnancies[1]. The surgical technique has to be adapted to the
malformation type, in case of rudimentary uterine horn firmly joined to an unicornuate uterus
there some details to keep in mind: firstly, in some cases there is not a well-defined limit
between the unicornuate uterus and the rudimentary horn, being necessary to extreme
precautions and it can be useful the hysteroscopic transillumination avoiding to open the
uterine cavity which can affects the reproductive outcome[1]; secondly, it is recommended to
remove the ipsilateral tube in order to avoid tubal pregnancies and other tubal complications
because of its underdevelopement; finally, it is important to remember that the ipsilateral
ureter has a higher course and would be better to identify it before the dissection[1]. A
carefully dissection of the rudimentary horn has to be carried out with the precautions
previously described, and finally the suture of miometrium is recommended to be performed
in multiple layers as well as visceral peritoneum using baseball fashion closure to reduce the
adhesions formation. Nowadays laparoscopic surgery seems to be feasible to accomplish this
kind of surgeries with the same outcomes but with the benefits of minimally invasive surgery
(Figure 3). Regarding fertility outcomes this group has the worst rates in terms of preterm
deliveries (43%), ectopic pregnancies (4%), spontaneous abortion (15%), live births
(54%)[28,29]. The cause could be that the decreased uterine tissue is not capable of holding
the pregnancy so the embryo migrate to the Fallopian tubes or miscarriage occurs when it is
placed in the uterine cavity.
Figure 3. (a) Anatomy before removing rudimentary horn in a unicornuate uterus. (b) View after
removal. Unicornuate uterus (UU), rudimentary horn (RH).
Although the pregnancy outcomes are not improved by surgical treatment, it is

recommended to remove the rudimentary horn in order to avoid ectopic pregnancies or
painful hematometras when it has functional endometrium.
Type III. Didelphic Uterus

The didelphic uterus has a low incidence among uterine anomalies. Due to the duplicity
of genital pelvis structures, obstruction may happen which could cause hematometra and
abdominal pain. Indeed, slightly better fertility outcomes have been reported compared to
unicornuate uterus: ectopic rate of 2%, miscarriage rate of 20-32%, preterm delivery rate of
24-28% and live birth rate of 55-68%[6,30]. This data might justify the surgical management
in selected cases, which would consist in vaginal septum extirpation and/or reconstruction of
uterine corpus by means of laparoscopic Strassman procedure.
Strassman surgery consists in the extirpation of the medial portion of both uterine
cavities, suturing them together to accomplish a unique uterus. The live birth rate after
Strassman metroplasty is close to 80%, so the results are significantly better after this surgical
repair[1]. Few cases has been reported in literature of laparoscopic approach to didelphic
uterus by Strassman surgery but all of them with minimal abdominal adhesion formation
compare to open surgery and with good uterine compliance to high intrauterine pressure.
After surgery it would be recommended to perform a hysteroscopy to control intrauterine
adhesions formation[31,32].
However, some authors do not agree with this approach, considering that this benefit is
not enough to justify the surgery. Moreover, long-term follow-up (mean 6.1 years) does not
reveal that didelphic uterus is associated with increased frequency of endometriosis or genital
neoplasm, which makes more necessary case selection[30,33]. Although nowadays, due to
minimally invasive surgery the surgical management might be worthy, we do not have
enough data about abortion rate or preterm deliveries after Strassman surgery in type III
malformation.
Type IV. Bicornuate Uterus

Bicornuate uterus seems to be one of the most common anomalies (25%), and the main
difference with the septate uterus is that bicornuate uterus has an indented fundus, usually
deeper than 1 cm, which makes surgical treatment more complicated because we need to
enter into the abdominal cavity and hysteroscopy becomes unsuitable on first approach
compared to septate uterus where hysteroscopy is the best option. Symptoms are pretty
similar to other anomalies like didelphic uterus, so the indications to operate are the same as
well, often infertility complaints such as recurrent abortion. There are some papers assessing
a miscarriage rate of 60%, live birth rate of 55% and term delivery rate of 40%6, but some
other reviews better rates such as miscarriage rate of 20%, live birth rate of 75% and take-
home-baby rate of 100% after surgery [34-37]. Symptomatic patients with poor reproductive
outcomes should undergo surgical management, and the elective surgery would be Strassman
metroplasty which achieves live pregnancy rates around 80-90% and decreases miscarriage
rate from 60% to 20%[38,39] as mentioned before. Classically that surgery had been carried
out by laparotomy, but in the last years several papers have been published on totally
laparoscopic or laparoscopic-assisted vaginal approach to bicornuate uterus treatment
performing Strassman metroplasty achieving pregnancy after surgery, and with less length of
hospital stay and less blood loss[39-41].
Type V. Septate Uterus

This group of anomalies has the highest prevalence among the whole uterine anomalies;
in fact, it has a prevalence of 1% among fertile population[42]. It has a regular external
uterine shape or an indented fundus less than 1 cm depth. Inside cavity, there is a septum
which may be partial or complete, dividing the cavity in two portions, but always there is just
one cavity and one cervix.
It is essential to differentiate both bicornuate and septate uterus because the treatment
approach will be different. The most frequent complaint among women with septate uterus
concerns to their reproductive outcomes, obtaining the greatest benefit of the surgical
treatment. Recurrent abortion is the most frequent symptom (57%) followed by primary or
secondary infertility (42%)[6].
The gold standard for its treatment is the hysteroscopic resection of the septum which
improves the live birth rate from 6% to 83%, the miscarriage rate from 86% to 16% and term
deliveries from 3% to 76%[6], and also resection of cervical septum in case of complete
septate uterus makes the procedure easier and safer[43].
Indeed, the procedure is not complicate, but it needs an accurate diagnosis of the
malformation done by means of MRI or US in addition to hysteroscopy and laparoscopy[44],
which makes the hysteroscopic approach the best option for these patients and has to be
addressed in every patient with infertility problems. All patients with septate uterus are
elective for surgery, Heinonen PK[45] reported that complete septate uterus with longitudinal
vaginal septum was not associated with primary infertility, and pregnancy might progress
successfully without surgical treatment; moreover, his results did not support elective
hysteroscopic incision of the septum in asymptomatic patients or before first pregnancy.
Type VI. Arcuate Uterus

Arcuate uterus has been study widely. There are many papers which show preterm
delivery rate of 5%, live birth rate of 66% to 82% and term delivery rate of 78%[7], but same
rates have been found in historical controls. The arcuate uterus does not seem to have any
influence in fertility outcomes so it is not usually recommended to be treated[7].
Some papers suggest a higher rate of second trimester pregnancy loss and preterm
deliveries maybe because it might be very near in some cases to broad low subseptate uterus,
so hysteroscopic surgery could be indicated in selected cases. When general fertility
outcomes have been compared before and after surgical treatment, studies have shown no
differences[46,47].
Type VII. Diethylstilbestrol Related

Diethylstilbestrol (DES) began to be used in 1948 and banned in 1971. The intrauterine
exposure to this drug was related to T-shaped uterus as the main anomaly, but it could be
related to many others such as adhesions, constriction rings or hypoplasia. Since those women
should be nowadays close to 40 years old, the cases we find have decreased dramatically and
probably DES related anomalies will tend to disappear, however we should keep in mind that
we will have several more cases during the next 10-15 years. The consequences due to uterine
deformations include preterm deliveries, miscarriage and ectopic pregnancies. Because of the
variety of abnormal uterine forms we can find, we should just treat those patients with fertility
problems by means of reconstructive surgery of uterus via laparoscopy if it is possible, to
reduce the morbidity associated to laparotomic surgery. Hysteroscopic metroplasty has also
shown good results, decreasing abortions rates from 88% to 12.5% and increasing the rate of
term delivery from 3% to 87.5%[48]. The only difference with the other ASRM groups we
can find is the increased cervical incompetence rate which may be solved by cervical
cerclage, although outcomes are still poorer than among patient with cervical incompetence
non-related to DES exposure[49,50].
Conclusions
Uterine abnormalities may cause many different symptoms, but among them, the most
common ones are the recurrent abortion, infertility problems or abdominal pain. Surgical
management seems to be a good option for those symptomatic patients because it increases
the term delivery rates and live birth rates and it decreases the miscarriage pregnancy rates;
moreover, surgical treatment may solve painful symptoms. Most of the anomalies could
benefit from surgical reconstruction, although any other could not, such arcuatus uterus, so
careful selection of cases is requiered.
Laparoscopic surgery seems to be feasible and reliable to treat Müllerian abnormalies,
showing the same both anatomical and reproductive results than the laparotomic approach but
with the advantages of the minimally invasive surgery, such as cosmetic results and
postoperative period, which is essential in young patients.
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Chapter 10
Total Laparoscopic Hysterectomy

for Large Uterus
Rakesh Sinha and Meenakshi Sundaram*

BEAMS Hospital, 674,16th cross road, Khar west, Mumbai-400052, India
Precis: Total laparoscopic hysterectomy is a feasible option for any size of uterus in the
hands of an experienced surgeon.
Abstract:
Aim: We have assessed the feasibility of total laparoscopic hysterectomy (TLH) in
cases of very large uteri weighing more than 500 grams and analyzed whether it is
possible for an experienced laparoscopic surgeon to perform efficient total laparoscopic
hysterectomy for large myomatous uteri regardless of the size, number and location of the
myomas.
Setting: Dedicated high volume gynaecological laparoscopy centre.
Patients: 190 women with symptomatic myomas who underwent total laparoscopic
hysterectomy at our center.
Intervention: Total laparoscopic hysterectomy was done for all patients. There were
various modifications of performing the surgery by ligating the uterine arteries prior,
myomectomy followed by hysterectomy, direct morcellation of the uterus while it is still
attached to its pedicles.
Results: 72% of patients had previous normal vaginal delivery and 28% had previous
cesarean section. The median clinical size of the uterus was 18 weeks (10, 32).The
median weight of the specimen was 640 grams (500, 2240).The median duration of
surgery was 120 min (40, 300) and the median blood loss was 100 ml (10, 3200).
Conclusion: Total laparoscopic hysterectomy is a technically feasible procedure. All
the modifications of the procedure depending on the size and location of the myoma
increase the safety when performed by experienced surgeons.
*
E-mail: drmeena25@yahoo.com, Phone: 919600017975
146 Rakesh Sinha and Meenakshi Sundaram
Introduction:
Total laparoscopic hysterectomy (TLH) is an acceptable alternative to standard
abdominal hysterectomy [1]. The laparoscopic approach offers a superior view of the
anatomy, facilitates meticulous hemostasis, enables the surgeon to perform adnexal surgery
and pelvic reconstructive surgery, and reduces morbidity associated with large abdominal
incisions [2].
Laparoscopy is indicated for hysterectomy in situations where vaginal surgery is difficult,
where there is poor vaginal accessibility, where there is associated adnexal pathology, and in
the context of endometriosis or history of adhesion causing surgery[3].
The term laparoscopic hysterectomy is used to define various types of hysterectomy with
a laparoscopic access to the abdominal cavity[4].Laparoscopic hysterectomy (LH), defined as
the laparoscopic ligation of the major vessels supplying the uterus by electrosurgery
desiccation, suture ligature, or staples was first performed in 1988[5]. Today, LH is a safe and
feasible technique to manage benign uterine pathology as it offers minimal postoperative
discomfort, shorter hospital stay, rapid convalescence, and early return to the activities of
daily living[6]. The rationale for TLH is to convert abdominal hysterectomy into a
laparoscopic procedure and thereby reduce trauma and morbidity[7].
Most studies set an upper limit for uterine size, usually 15 to 16 weeks‘ gestation or
weight more than 500 grams as large uterus[8]. It was suggested that very enlarged uteri
should be treated by laparotomy. The difficulties with enlarged uteri are limited access to
uterine vascular pedicles depending on size and location of myomas, and high risk of
complications such as haemorrhage. Other concerns of laparoscopic management of large
uteri are the risk of bowel and urinary tract injury due to poor exposure, difficulty extracting
the uterus, and duration of the procedure. To overcome these limitations, TLH in cases of
enlarged uteri should be modified and made feasible in all cases. In this article we have
discussed the feasibility of TLH in 190 patients with uteri more than or equal to 500 grams
and the technical modifications we have adopted for the procedure.
Materials and Methods:

190 women who underwent TLH in our centre from January 2001- June 2009 were
enrolled in the study. Main indications for Total laparoscopic hysterectomy were
symptomatic leiomyomas or abnormal uterine bleeding. Patients with other pathology like
adnexal mass or endometriosis were excluded from the study. The clinical size of the uterus
varied from 10 weeks to maximum 32weeks. All patients underwent pelvic ultrasound
examination and basic blood investigations. Patients were kept on a liquid diet 2 days before
the procedure and a laxative was given 12 hours before the surgery to empty the bowel.
Antibiotic prophylaxis was given to all patients included in the study. Subcutaneous low-dose
heparin and a sequential compression device were also given to all patients for prophylaxis
against possible thromboembolic episodes.
Total Laparoscopic Hysterectomy for Large Uterus 147
Operative Procedure
All the surgeries were performed under general anesthesia with the patient in modified
lithotomy position. The Veress needle was inserted at the Palmer‘s point in all patients. In
some studies the Veress needle is placed supraumbilical in the case of very large uteri[7]. The
Palmer‘s point [9] (a point 3 cm below the left costal margin in the midclavicular line) is a
safe zone in all patients other than those with splenomegaly.
After insufflations with carbondioxide, a 5-mm trocar is inserted blindly in the left upper
quadrant lateral to the inferior epigastric vessels at the level of or above the upper limit of the
uterus. If the uterus is large, the Veress and the 5-mm port may be placed at the Palmer point.
A 5-mm telescope is introduced through this port and the uterus with the adnexa is evaluated.
The 10-mm port is inserted under vision at the supraumbilical site or higher depending on the
size of the uterus. Entry under vision avoids damage to major vessels directly beneath the
insertion site and also has the added advantage that the port can be placed at a variable point,
depending on the size of the uterus. This not only helps the surgeon to obtain a good operative
field but also allows smooth manipulation of the instruments above the uterus. We generally
perform the surgery with three five mm accessory ports: the port placed initially in the left
lateral upper quadrant is used as the first accessory port. The second port is placed under
vision in the right lateral upper quadrant and the third port is placed in the left lateral lower
quadrant. If necessary, in the case of very large uteri, a fourth port is placed in the right lateral
lower quadrant.
The pelvis and the abdomen are inspected and any other pathology (endometriotic
lesions, adhesions, ovarian pathology etc), if present, is tackled first. The course of the ureters
is traced out at the start of the procedure. The size, site and the number of myomas are
assessed (Figure 1, 2, 3,). Manipulation of the uterus to expose all the pedicles with a uterine
manipulator maybe technically very difficult in a large uterus. We prefer to insert a five mm
myoma spiral into the uterus for manipulation. In cases of previous normal delivery where
there are no bladder adhesions, we start the hysterectomy with ligation of the uterine pedicles
as the first step[10].
The uterovesical fold of peritoneum is identified and opened from the round ligaments on
either side. The bladder is dissected down completely so that the uterine vessels on either side
can be clearly seen. A window is created in the broad ligament close to the uterine vessels.
This helps visualization of the posterior aspect and prevents accidental suture placement
through bowel loops. The ascending branch of the uterine artery is identified close to the
isthmus. The uterine vessels are ligated at this level close to the uterus by transfixation using
1-0 delayed absorbable suture material (Figure 4). Dissecting the uterovesical fold and
pushing the bladder down moves the ureters laterally and decreases the risk of including them
in the suture. We prefer to use the contralateral ports for suturing. The right midquadrant port
and the left lower quadrant port are ergonomically apt for suturing. The vasculature of the
uterus is thus secured and this is evidenced by the color change in the fundus, which becomes
pale (Figure 5, 6).
Figure 1. Uterus with fundal fibroid.
Figure 2. Uterus with cervical fibroid.
Figure 3. Uterus with broad ligament fibroid.

Figure 4. Uterine artery ligation.
Figure 5. Uterus before devascularisation.
Figure 6. Uterus after devascularisation.

Figure 7. Morcellation while still attached.
The cornual pedicles are then dessicated and cut either using bipolar diathermy or the
harmonic ultracision. The ligated uterine pedicles are cut. The uterosacrals and cardinal
ligaments are dessicated and cut. The vaginal vault is opened from one side. The position of
the myoma spiral is then changed so that the opposite side pedicles can be taken. The cornual,
uterine, and uterosacral aspects of the other side are taken in a similar way and the vaginal
vault is opened. The specimen is detached completely.
If both ovaries need to be removed, the infundibulopelvic ligaments are desiccated and
cut, and the ovaries are delivered vaginally. The vaginal vault is then sutured with No. 1
delayed absorbable interrupted figure-of-eight sutures. In cases of previous caesarean sections
where the bladder is densely adherent, we start from the left cornual structures. The
uterovesical fold is opened and the bladder is dissected down by the lateral approach. A
definitive plane can be identified between the cervix and the bladder by this approach and the
bladder is dissected down. The uterine vessels are then ligated on either side and the
dissection is completed.
The specimen is retrieved by Morcellation through the left upper quadrant 5-mm port,
which is converted to 15-mm port. The 15 mm port is closed with port closure needle (Reza
Granee) under vision. The rest of the ports are closed with subcuticular sutures using No 3-0
delayed absorbable suture.
This standard technique of total laparoscopic hysterectomy is performed in most cases.
However in the case of very large myomas that render the procedure very difficult, certain
modifications to the above technique are adopted. Myomectomy may be done prior to the
hysterectomy so as to create space for the procedure. In case of large cervical fibroids, uterine
artery ligation may be done at its origin from the internal iliac in order to reduce the blood
loss. The anterior leaf of the broad ligament is opened by making an incision lateral to the
uterus in the triangle enclosed by the round ligament, the external iliac artery and the
infundibulopelvic ligament. The uterine artery is identified and then ligated by means of
intracorporeal suturing with No 1 Vicryl. The uterus is seen to turn pale following the
bilateral ligation of the uterine vessels and the blood loss is considerably reduced.
In large uteri, it may be difficult to debulk the uterus completely due to limitations in
space and inaccessibility to uterosacrals. In such cases, we first do a supracervical
hysterectomy after securing the uterine pedicles.
Once the uterus is debulked, we go ahead and remove the cervix. In some cases we
perform direct morcellation of the uterus after uterine artery ligation in order to debulk the
specimen (Figure 7). Once the bulk of the uterus has been morcellated, there is enough space
for performing the final stages of the procedure, namely the desiccation and division of the
uterosacral ligaments and colpotomy. The separated cervix is then delivered vaginally.
Bleeding does not pose a problem as the ovarian and uterine vessels have been desiccated and
cut. The vagina is closed with intracorporeal interrupted sutures with No 1 Vicryl.
The duration of the surgery was calculated from the insertion of the Veress needle till the
placement of the last skin suture. The total blood loss is calculated. No irrigation is used
throughout the procedure until the calculation of the total blood loss.
Peritoneal lavage is given with normal saline solution and 500 ml of normal saline is left
in the peritoneal cavity. The specimen is weighed. The catheter is removed after 6 hours and
liquids are started after peristalsis is established. The patient is discharged the following day
and called for follow-up after 7 days.
Data Analysis:
Analysis was done using SPSS for Windows, Version 14.0 (SPSS, Inc., Chicago, IL).
Results are expressed as median (minimum, maximum). 190 patients who underwent
hysterectomy for large uterus (more than 500 grams) were included in the study. TLH was
successfully performed in all patients. The mean age of patients was 45 years. The main
symptoms of patients were menorrhagia (63%), mass abdomen (30%), pain abdomen (5%),
multiple complaints (2%). 72% of women had previous normal delivery and 28% had
previous caesarean section. Ligating the uterine arteries earlier was more feasible in women
without previous caesarean section as bladder mobilization was not difficult. Clinical size of
the uterus ranged from 10 weeks to 32 weeks with the median clinical size being 18 weeks.
The hemoglobin levels in all patients were above 9 g/dL. All specimens were retrieved by
morcellation. The median weight of the specimen was 645 grams (500, 2240).
The median total duration of surgery was 120 min (40, 300) and median morcellation
time was 32 min (10,120). Median total blood loss was 100 ml (10, 3200).
The data reveal that there was a significant decrease in blood loss and need for blood
transfusion in patients who underwent earlier ligation of uterine vessels. Nine patients
underwent blood transfusion in view of blood loss being more than 750 ml. Three patients
underwent supracervical hysterectomy followed by removal of cervix. Two patients
underwent morcellation while the specimen was still attached after uterine ligation. One
patient with previous caesarean section and dense bladder adhesions had bladder injury which
was detected intraoperatively and sutured laparoscopically. Urinary catheter was kept for one
week and patient recovered uneventfully.
One patient had serosal rectal tear which was sutured laparoscopically. Patient was kept
nil oral for three days and on liquids for three days. Two patients had delayed complication of
ureteric fistula and rectovaginal fistula. Ureteric fistula occurred in a patient with large
cervical fibroid. The fistula was repaired laparoscopically by ureteroneocystostomy.
Rectovaginal fistula was repaired by temporary colostomy and then reanastomosis at a later
date.
Discussion:
Laparoscopic hysterectomy has been the subject of many controversial comments
especially when it comes to large uterus. Compared with abdominal hysterectomy, however,
compelling evidence indicates that laparoscopy provides specific benefits[11].
The main conclusion that comes from our study is that TLH is a feasible and safe
technique in cases of enlarged uteri, which permits efficient avoidance of laparotomy incision
in most of the procedures with evident benefits for the patients. Our study indicates that there
is a lower rate of intraoperative complication laparoscopically compared to studies of
hysterectomy done by open laparotomy [12].
Literature suggests that greatly enlarged uteri should be treated by laparotomy. Most
studies set an upper limit for uterine size, usually 15 to 16 weeks gestation[7]. A multicenter
randomized clinical trial [13] in 1998 compared LH with total abdominal hysterectomy
(TAH). Myoma uterus was the indication for hysterectomy in most cases in this trial. The
largest uterus in the LH group was 1550 g; the greatest blood loss was in the TAH group and
was 3000 mL. The mean blood loss was significantly less for the LH group than the TAH
group.
Therefore, no evidence exists that the average blood loss is less if one does TAH rather
than LH.
In case of large uteri, there is distortion of normal anatomy especially the ureters and the
uterine vessels. In the case of lateral wall myomas that arise below the entry of the uterine
vessels, the ureter is pushed outwards and almost raised onto the superior surface of the
myoma. The uterine vessels are raised high up almost to the level of the ovarian vessels.
Lateral wall myomas that arise above the level of the uterine vessels push the ureter outwards
and downwards. Large anterior wall and cervical myomas flatten the bladder, which can get
raised high up on the anterior uterine surface. A major concern is that such distortions as well
as the poor exposure may increase the risk of bladder, ureteric and bowel injury. This is
compounded by the technical difficulty involved in extracting the uterus and the skill that is
necessary to suture the uterine vessels. Therefore it has often been suggested that grossly
enlarged uteri are a contraindication for total laparoscopic hysterectomy. Before attempting to
perform TLH in women with huge uteri, several modifications to current technique are
suggested. Poor access and exposure are the main concerns, and can be overcome by few
modifications in hysterectomy technique. First, the optical trocar is placed supraumbilically to
facilitate proper visualisation.The use of myoma spiral increases the mobility of the uterus
and frequent changes in its positioning can help access to all pedicles. Another concern is the
risk of hemorrhage, which in cases of very enlarged uteri can be increased due to difficult
exposure.We have minimised the blood loss by ligating the uterine pedicle as the first step in
the hysterectomy procedure. There are several options available to the laparoscopic surgeon
for securing the pedicles including bipolar diathermy, harmonic ultracision, vessel-sealing
device, endoscopic suturing techniques, or staples[14]. Complications such as hemorrhage,
bladder injuries, and ureteric injuries are directly or indirectly related to the method of
securing the vascular pedicles. The author has described the used of laparoscopic reusable
clamps for all the pedicles in his earlier publication, which adopts the basic principles of
TAH[15]. The clamp is a versatile instrument that can be used to secure a vascular pedicle in
other operative procedures such as salpingectomy, salpingo-oophorectomy, and
appendicectomy. Given adequate training in laparoscopic surgery and with proper technique,
TLH can be performed successfully in most women with very enlarged uteri, with no increase
in complication rates and short-term recovery. In skilled hands, these patients could benefit
all the advantages related to minimally invasive approach such as minimal blood loss, short
hospital stay, prompt recovery, obtaining a satisfactory result. From our data, there is no
reason any longer to consider enlarged uteri a contraindication to TLH; and in accordance
with other authors‘ opinion, laparoscopy should be considered instead of laparotomy in all
cases irrespective of the size of the uterus[16].
References
[1] Nezhat F, Nezhat C, Gordons S, et al: Laparoscopic versus abdominal hysterectomy. J.
Reprod. Med. 1992; 37: 247–250.
[2] Nicholas Elkington, Gregory Cario, David Rosen et al. Total laparoscopic
hysterectomy: A tried and tested Technique. J. Minim. Invasive Gynecol. 2005 : 12,
267-274.
[3] Franck Leonard, Nicolas Chopin, Bruno Borghese et al. Total laparoscopic
hysterectomy: Preoperative risk factors for conversion to laparotomy. J. Minim.
Invasive Gynecol. 2005; 12, 312-317.
[4] Harding S. Laparoscopic hysterectomy. Br. J. Hosp. Med. 1997; 57: 512-4.
[5] Reich H. Laparoscopic hysterectomy. Surg. Laparosc. Endosc. 1992; 2:85– 88.
[6] Reich H, Roberts L. Laparoscopic hysterectomy in current gynaecological practice.
Rev. Gynecol. Pract. 2003;3:32– 40.
[7] Boike G, Efstrand E, DePriore G, et al: Laparoscopically assisted vaginal hysterectomy
in a university hospital: Report of 82 cases and comparison with abdominal and vaginal
hysterectomy. Am. J. Obstet. Gynecol. 168: 1690–1701, 1993.
[8] A. Wattiez, M.D., D. Soriano, M.D., A. Fiaccavento, M.D et al. Total Laparoscopic
Hysterectomy for Very Enlarged Uteri. J. Am. Assoc. Gynecol. Laparosc..2002;
9(2):125–130.
[9] Sinha R, Hegde A. Safe entry techniques during laparoscopy. J. Minim. Invasive
Gynecol. 2005;12: 463– 465.
[10] Rakesh Sinha, MD, Meenakshi Sundaram, MD, DNB*, Yogesh A. Nikam et al. Total
Laparoscopic Hysterectomy with Earlier Uterine Artery Ligation. J. Minim. Invasive
Gynecology.2008 :15; 3: 355-359.
[11] Phipps JH, John M, Nayak S: Comparison of laparoscopically assisted vaginal
hysterectomy and bilateral salpingo-oophorectomy with conventional abdominal
hysterectomy and bilateral salpingo-oophorectomy. Br. J. Obstet. Gynaecol. 100:698–
700, 1993
[12] David-Montefior E, Routier R, Chapron C, Darai E. Surgical routes and complications
of hysterectomy for benign disorders: a French prospective observational study in
French university hospitals. Hum. Reprod. 2007; 22: 260 –265.
[13] Summitt RL Jr, Stovall TG, Steege JF, et al. A multicentered randomized comparison
of laparoscopic assisted vaginal hysterectomy and abdominal hysterectomy in
abdominal hysterectomy candidates. Obstet. Gynaecol. 1998; 92:321–326.
[14] Phipps JH. Thermometry studies with bipolar diathermy during hysterectomy.
Gynaecol. Endosc. 1994;3:5–7.
[15] Sinha RY, Warty N, et al. A safer laparoscopic hysterectomy: laparoscopic
hysterectomy using clamps; a new concept. Gynaecol. Endosc. 2000;9:293–299.
[16] Salmanli N, Maher P. Laparoscopically-assisted vaginal hysterectomy for fibroid uteri
weighing at least 500 grammes. Aust. N. Z. J. Obstet. Gynaecol. 1999;39:182–184.
Chapter 11
Cost-Effectiveness Issues with Total

Laparoscopic Hysterectomy
M. Sami Walid and Richard L. Heaton*

Heart of Georgia Women‘s Center, 209 Green Street, Warner Robins, GA 31099
Abstract
Total laparoscopic hysterectomy is slowly gaining foothold in the treatment of
benign gynecological disease. In this paper, we review the literature with concentration
on articles addressing the cost-effectiveness of this procedure versus the traditional total
abdominal hysterectomy.
Keywords: hysterectomy, laparoscopic, cost-effectiveness.
Total laparoscopic hysterectomy (TLH) is a procedure surrounded by controversy for

different reasons including cost. For decades, abdominal hysterectomy has been the only
available operation for female patients requiring the removal of their uterus before the
introduction of vaginal hysterectomy as a less invasive procedure. After that, laparoscopic
hysterectomy was introduced as a competing minimal invasive option. Most gynecologists
have reasonable skills at performing total abdominal hysterectomy (TAH) and total vaginal
hysterectomy (TVH) as these are part of residency training. This is not the case with total
laparoscopic hysterectomy (TLH). Most residency programs do not have proficiency
requirements in the area of laparoscopic hysterectomy. Data in the literature clearly show that
at least 30 total laparoscopic hysterectomies are needed to get through the initial learning
curve [1,2,3]. From our personal experience, we know that improvement in performance
occurs through the first 100 cases. Technically, when the uterus is of normal size, TLH is like
a TAH done through small holes. The vascular pedicles are taken and dissection is performed
similarly to abdominal hysterectomy except for the use of energy sources (bipolar or
*
Phone: (478) 328-3399, E-mail: riclheaton@yahoo.com
156 M. Sami Walid and Richard L. Heaton
harmonic cautery) instead of suturing. A clamp is put up through the vagina while watching
the monitor and the uterus is pulled out; no vaginal setup or retraction is needed; the vaginal
cuff is repaired laparoscopically. This results in the same closure seen with abdominal
hysterectomy that preserves vaginal length. Furthermore, no vaginal retraction is needed so
no bacteria are pushed into the pelvis and no pelvic floor pain as a result of retraction (with
pelvic floor muscle injury). Also, very limited suturing is needed with less tissue ischemia
and, therefore, less pain than usually happens after laparoscopically assisted vaginal
hysterectomy (LAVH).
The laparoscopic route is still not widespread and less used by gynecologists than the
abdominal and vaginal routes due to lack of experience, unwarranted fear of complications,
and cost issues. In a study by Sculpher et al. 2004 [4] based on the eVALuate trial of Garry et
al. 2004 [5], the authors found the procedure "not cost effective." Examining the text of that
paper reveals serious defects. First, the surgeons doing laparoscopic hysterectomy were not
advanced laparoscopic surgeons because a competent surgeon in their paper was defined as "a
surgeon who had completed at least 25 of each technique." So, if a surgeon did 25 LAVHs,
these could have been minimal laparoscopic interventions - just looking inside
laparoscopically and then doing a vaginal hysterectomy [7]. Moreover, the instrument they
were using in 36 % of ovarian pedicles and 19% of uterine artery pedicles was the disposable
linear stapler. Surgeons that are uncomfortable with laparoscopic dissection and suturing and
with the use of energy sources for hemostasis after appropriate dissection of the pedicles use
this instrument. Staplers require large 12 mm trocar placement then suturing the fascia to
decrease the risk of wound hernia. This results in significant pain at trochar sites resulting in
longer hospital stay due to pain. In addition, the 11.1% major complication rate of
laparoscopic hysterectomy in their data is exaggerated by conversion rate being included as a
major complication. Even so, the remaining complication rate is excessively high and speaks
to inexperience in advanced laparoscopy [6]. The high conversion rate clearly demonstrates
lack of experience in advanced laparoscopy.
The next clear discrepancy in the abovementioned paper is the failure to define
laparoscopic hysterectomy. We assume that it meant anything from diagnostic laparoscopy
followed by vaginal hysterectomy to total laparoscopic hysterectomy. Many well-trained
vaginal surgeons hold that the use of laparoscopy is to turn abdominal hysterectomies into
vaginal hysterectomies by excluding contraindications to the vaginal approach [8]. In the
above paper, the use of stapler and the data supplied by the authors stating that 36% of
ovarian pedicles were taken with staplers but only19 % of uterine pedicles were taken with
staplers led us to believe that the other 17% after the ovarian pedicles were done were
converted to the vaginal approach. If the usual approach was to limit the laparoscopic
component to the minimum required to do a vaginal hysterectomy, i.e. laparoscopically-
assisted vaginal hysterectomy (LAVH), the paper should have identified itself as a
comparison of diagnostic laparoscopy with vaginal hysterectomy or LAVH against abdominal
hysterectomy. This would have prevented the confusion about the type of procedure under
investigation.
Diagnostic laparoscopy with vaginal hysterectomy and LAHV have all the drawbacks of
vaginal hysterectomy with none of the advantages of laparoscopic hysterectomy: (1) Double
setup instead of a single setup; (2) Vaginal retraction causing bruising and straining of the
pelvic floor musculature; (3) Seeding the pelvic cavity with vaginal bacteria; and (4)
Foreshortening of the vagina via vaginal closure. The use of large trocars for staplers
Cost-Effectiveness Issues with Total Laparoscopic Hysterectomy 157
increases both cost and hospital time as abdominal wall pain increases with the size of
trochars and fascial closure. So, intuitively, a hysterectomy that could be done vaginally will
be cheaper than if done by LAVH (which requires disposable instruments) with the same pain
and infection risk.
The Sculpher et al. 2004 paper describes significantly higher operation times for
laparoscopic hysterectomy as opposed to vaginal hysterectomy and abdominal hysterectomy.
We would remind that the double setup in LAVH adds 15 to 30 minutes to go from the
laparoscopic phase to the vaginal phase of the operation. TLH is done as a single setup
procedure as long as one avoids the use of vaginal manipulator and KOH colpotomizer® that
will also add time to the case as well as cost of disposables. When these savings are added in,
even with the use of some disposables, clearly outpatient TLH would be superior to inpatient
TAH and TVH. The setting of surgery in the above paper is confusing as well. The paper
describes lengths of hospital stay of 3.95 to 5.11 days. In our intent-to-treat study we
published the results of over 600 TLHs [9]. The overwhelming majority of these patients
went home between 8 and 24 hours with large cost savings.
The authors also gave inadequate information on the quality of life data in the first six
weeks after surgery. In our practice, we routinely let outpatient TLH patients return to desk
jobs in one week and to standing jobs in 2 weeks, only requiring patients that do heavy lifting
and straining to wait 4 weeks to return to work. We have had patients ignore our
recommendations because they felt so well and wanted to return to work sooner, none with
adverse effects.
Most importantly, the study did not take into account the lost wages and lost corporate
productivity and lost tax revenues, both corporate and personal. You can imagine a single
mother living from paycheck to paycheck, working two part-time jobs, and the doctor says to
her that she will be out of work for six to eight weeks after hysterectomy, whether abdominal
or vaginal [10]. It is devastating to be without income and not be able to pay the rent, car loan
…etc.
The speed of return to work may be the best measure of economic impact of healthcare
policies. When evaluating the damage to the Gross Domestic Product (GDP), the short-term
disability cost of 2 weeks of lost productivity after laparoscopic hysterectomy should be
compared with disability costs of 6 to 8 weeks of lost productivity after abdominal or vaginal
hysterectomy (Figure 1). TLH is clearly economically viable compared with TAH; savings in
disability costs and the increased contribution to the GDP offsets any additional costs from
disposable instruments.
The Sculpher et al. 2004 study evidently did not thoroughly address the cost-
effectiveness of laparoscopic hysterectomy due to shortfalls in procedure definition. We
would recommend only using the term laparoscopic hysterectomy when describing a TLH.
In the current system, insurance companies and hospitals profit interests come in collision
with the National interest. When studying the economic impact of laparoscopic surgery,
productivity and social factors must be taken into account. Insurance work principle is based
on a risk pool whereby the cost of a premium is based on the cost of treatment, not the ability
of the subscriber to return to work. An economic and social cost-benefit analysis must be
extrapolated to a national scale before conclusions are made on the cost-effectiveness of a
certain procedure, such as total laparoscopic hysterectomy.
Source: Reed, Presley. "Hysterectomy - Medical Disability Guidelines." Disability Guidelines – Return
to Work Durations and Treatment - MDGuidelines. 11 Sep. 2009
<http://www.mdguidelines.com/hysterectomy>.
Figure 1. Days of disability after abdominal (left) and vaginal (right) hysterectomy.
Reprinted with permission from MDGuidelines.
Then there is the rest of the story. There is no doubt that when women have the choice
between severe pain and little pain and between a big scar and little scars in a market society
they choose the minimal invasive route. If women are going to be denied less painful and less
disfiguring treatment based on cost arguments, all the cost defraying information should have
been included in the Sculpher et al. 2004 paper. Not including these factors shows the bias of
the study against minimally invasive surgery.
The papers that correctly address total laparoscopic hysterectomy are the two Canadian
studies by Thiel and Gamelin 2003 and by Thiel and Kamencic 2006 in which TLH was
assessed as an outpatient procedure [11,12]. Of 66 cases completed in their first study, three
(4.5%) patients had minor intraoperative complications and seven (11%) had minor
postoperative complications. The total cost for 224 TLH procedures in their second study was
$238,573 and the average cost per TLH was $1065. These numbers seem lower than
American numbers but the conclusion still applies to the American system where 600,000
hysterectomies are performed each year. The authors found outpatient TLH to be safe and
cost-effective despite the use of some disposable instruments thanks to reduced postoperative
stay making hospital beds available for needful patients having other surgeries. They
concluded their paper saying: “With the current constraints in the Canadian health care
system, it offers an opportunity to save significant health care costs while continuing to
provide excellent results and patient satisfaction.‖ This statement is worth attention because
of the similar and even more difficult challenges the American healthcare system is facing
regarding cost and accessibility.
We believe that outpatient TLH can replace 50-60% of inpatient TAHs in this country
with with earlier return to work, in one to three weeks instead of four to six weeks. Knowing
that hysterectomy rates are highest in women 40–44 years old, at the peak of their productive
lives, we emphasize the significant impact of longer postoperative convalescence periods on
economic productivity. Moreover, the complication rate related to wound infection,
pneumonia and pulmonary embolism (PE) … etc. with TAH compared to TLH is
significantly higher [13,14,15]. TAHs that result in surgical intensive care unit (SICU)
Cost-Effectiveness Issues with Total Laparoscopic Hysterectomy 159
admissions for respiratory support or require prolonged wound care massively increase the
overall cost of surgery [16]. These are a few of the problems that are not adequately reflected
in the literature perhaps due to inadequate numbers for statistical significance. In our intent-
to-treat study, we had no SICU admissions among our TLH patients [9]. We had no PE, no
severe wound infections and no returns to Operating Room (OR) within 24 hours. Organ
injuries during surgery were immediatly detected and intraoperatively repaired except of one
case of partial ureteral obstruction due to a vaginal suture. The suture was removed and
ureteral stent placed. One month later the stent was removed with no long-term sequelae. The
literature supports that most of intraoperative complications of laparoscopic hysterectomy are
predominantly mild to moderate in severity [17,18]. The complication rate of laparoscopic
hysterectomy does not exceed that of traditional hysterectomy if the surgeon exclusively
specializes in total laparoscopic hysterectomy [9,19].
The bottom line is, TLH performed in an outpatient setting is more cost effective with
reduced pain and suffering and has the advantage over vaginal hysterectomy of diagnosing
and treating concomitant adnexal diseases and endometriosis which prevents reoperation and
further expenditures. And a final point we want to emphasize is that making everything about
cost is unacceptable in a civilized society claiming to have the best healthcare in the world.
Decreasing pain, scarring and emotional distress is important even if there is a small cost
increment, which is questionable when all factors are put together including early return to
work and productivity.
References
[1] Vaisbuch E, Goldchmit C, Ofer D, Agmon A, Hagay Z. Laparoscopic hysterectomy
versus total abdominal hysterectomy: a comparative study. Eur. J. Obstet. Gynecol.
Reprod. Biol. 2006 Jun 1;126(2):234-8.
[2] Wattiez A, Cohen SB, Selvaggi L. Laparoscopic hysterectomy. Curr. Opin. Obstet.
Gynecol. 2002 Aug;14(4):417-22.
[3] Mäkinen J, Johansson J, Tomás C, Tomás E, Heinonen PK, Laatikainen T, Kauko M,
Heikkinen AM, Sjöberg J. Morbidity of 10 110 hysterectomies by type of approach.
Hum. Reprod. 2001 Jul;16(7):1473-8.
[4] Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness
analysis of laparoscopic hysterectomy compared with standard hysterectomy: results
from a randomised trial. BMJ. 2004 Jan 17;328(7432):134.
[5] Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, Clayton R, Phillips G,
Whittaker M, Lilford R, Bridgman S, Brown J. The eVALuate study: two parallel
randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other
comparing laparoscopic with vaginal hysterectomy. BMJ. 2004 Jan 17;328(7432):129.
[6] McPherson K, Metcalfe MA, Herbert A, Maresh M, Casbard A, Hargreaves J,
Bridgman S, Clarke A. Severe complications of hysterectomy: the VALUE study.
BJOG. 2004 Jul;111(7):688-94.
[7] Porges RF. Alternative techniques of hysterectomy. N. Engl. J. Med. 1997 Jan
23;336(4):290.
[8] Kovac SR. Guidelines for Hysterectomy. In: Kovac SR, Zimmerman CW (Eds)
Advances in reconstructive vaginal surgery. Lippincott Williams & Wilkins, 2006, pp
91-92 (418 pages). ISBN: 9780781762359.
[9] Walid MS, Heaton RL. An intention-to-treat study of total laparoscopic hysterectomy
Int J Gynaecol Obstet. 2010 Oct;111(1):57-61.
[10] Hysterectomy: Length of Disability. MDGuidelines. Accessed 08/09/2009. Available
from: http://www.mdguidelines.com/hysterectomy/length-of-disability
[11] Thiel J, Gamelin A. Outpatient total laparoscopic hysterectomy. J. Am. Assoc. Gynecol.
Laparosc. 2003 Nov;10(4):481-3.
[12] Thiel JA, Kamencic H. Assessment of Costs Associated With Outpatient Total
Laparoscopic Hysterectomy. J. Obstet. Gynaecol. Can. 2006; 28(9):794–798.
[13] Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol
BW, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological
disease. Cochrane Database Syst. Rev. 2009 Jul 8;(3):CD003677.
[14] Brooks-Brunn JA. Risk factors associated with postoperative pulmonary complications
following total abdominal hysterectomy. Clin. Nurs. Res. 2000 Feb;9(1):27-46.
[15] Juillard C, Lashoher A, Sewell CA, Uddin S, Griffith JG, Chang DC. A national
analysis of the relationship between hospital volume, academic center status, and
surgical outcomes for abdominal hysterectomy done for leiomyoma. J. Am. Coll. Surg.
2009 Apr;208(4):599-606.
[16] Meyers ER, Steege JF. Risk adjustment for complications of hysterectomy: utility of
routinely collected administrative data. Prim. Care Update Ob Gyns. 1998 Jul
1;5(4):202-203.
[17] Schwartz RO. Complications of laparoscopic hysterectomy. Obstet. Gynecol. 1993
Jun;81(6):1022-4.
[18] Nezhat F, Nezhat CH, Admon D, Gordon S, Nezhat C. Complications and results of
361 hysterectomies performed at laparoscopy. J. Am. Coll Surg. 1995 Mar;180(3):307-
16.
[19] Harris WJ. Complications of hysterectomy. Clin. Obstet. Gynecol. 1997 Dec;40(4):928-
38.
Chapter 12
The Hysterectomy Crossroads

Heart of Georgia Women‘s Center, 209 Green Street, Warner Robins, GA 31099
Abstract
Hysterectomy rates are highest in middle-aged women who usually find themselves
in front of an intersection when they are faced with the reality that their uterus needs to
be removed and must make a decision with the help of their gynecologist about the best
way to do the hysterectomy. Unfortunately, the majority of women are still being treated
for benign pelvic disease with the more invasive types of hysterectomy in spite of the
superiority of the laparoscopic modality. While there are some situations where
abdominal and vaginal routes are appropriate, women need to know about the less
invasive more advanced type of hysterectomy with shorter recovery time and better
cosmetic outcome.
Keywords: hysterectomy, laparoscopic, abdominal, vaginal, laparoscopically-assisted.
*
Hysterectomy continues to be a topic for debate in the medical and lay communities. It is
a major gynecological procedure with roughly 600,000 operations performed every year in
the United States with a considerable impact on patients, insurance companies, healthcare
providers and the society in general [1-2]. The most common indications for hysterectomy are
fibroid disease, endometriosis, and uterine prolapse [2-3]. Metrorrhagia, chronic pelvic pain
and dyspareunia are the most common clinical manifestations of benign gynecologic disease
that lead to hysterectomy [4-7]. Gynecologists usually keep myomectomy for cases where
fertility needs to be preserved. If fertility is not in question, hysterectomy is recommended.
Hysterectomy was the most common operation in the US in the mid-seventies (727-880
operations for every 100,000 women in 1975), then declined in popularity (to 560 per
100,000 women in 1997) and moved to the second place as the most common major surgery
for women of reproductive age, second only to Cesarean section [2, 8-11]. The national rate
has since then oscillated around 600,000 with enormous disparities between regions and
between different countries [11].
The United States (US) has one of the highest rates of hysterectomy in the world. By the
age of 60, over a third of all women in the US would have had hysterectomy versus a fifth of
Canadian and United Kingdom (UK) women [2, 12-14]. American women are more likely to
have a hysterectomy (538 per 100,000 in 2003) than Canadian women (462 per 100,000
during 1998-1999), Finnish women (414 per 100,000 in 1992), French women (294 per
100,000 in 1992), British women (225 per 100,000 in 2004-2005), Swedish women (210 per
100,000 in 2003) and Norwegian women (198 per 100,000 in 1990) [4, 11-13, 15-19]. Many
factors are embodied in these differences, including cultural attitudes, physician training,
access to elective surgery in a particular country, ability to pay for care, etc.
Hysterectomy rates are highest in middle-aged women who usually find themselves in
front of an intersection when they are faced with the reality that their uterus needs to be
removed and they have to make a decision with the help of their gynecologist about the best
way to do the hysterectomy. For many years, total abdominal hysterectomy (TAH) was the
only available operation then people started to shift to vaginal hysterectomy and more
recently the laparoscopic technique was developed for hysterectomy. The abdominal route
gives the surgeon a good view of the uterus and other pelvic organs during surgery and is
typically the preferred method if the patient has large tumors or if cancer is suspected. Total
laparoscopic hysterectomy (TLH), also known as the coelioscopic route in French literature,
is still not widespread due to lack of experience.
The ratio of abdominal to vaginal hysterectomies ranges from 1:1 to 6:1 across North
America and is around 6:1 in the US and 3:1 in Canada [10, 13]. From 1990-1997, 63% of
operations in the US were performed via the abdominal route (1997) and 9.9%
laparoscopically [10]. A more recent study reported that among the 538,722 hysterectomies
for benign disease performed in 2003 (a rate of 4.81 per 1,000 women-years), the abdominal
route was prevalent (66.1%), followed by the vaginal (21.8%) and laparoscopic (11.8%)
routes [20]. In the UK and Ireland, approximately 60% of hysterectomies were abdominal,
37% vaginal and 4% laparoscopically-assisted [21]. In France, the vaginal route was the route
of choice for benign disorders [7]. More recent French data still show that hysterectomy is
performed by the laparoscopic, laparoscopically-assisted vaginal, laparotomic and vaginal
routes in approximately 19%, 8%, 24% and 48% of cases, respectively [22]. The situation in
Scandinavian countries is somewhat better laparoscopically. In Sweden, vaginal hysterectomy
makes 31% of all hysterectomies for benign disease and abdominal hysterectomy 48%
The Hysterectomy Crossroads 163
(2003), leaving around 21% for the laparoscopic route [15]. In Finland, laparoscopic
hysterectomy accounts for 24% of operations, vaginal for 18% and abdominal for 58% (2000)
[23].
A recent Cochrane review of surgical approach to hysterectomy for benign gynecological
disease concluded that the vaginal approach is preferred over the abdominal approach; and
when vaginal hysterectomy is not possible, laparoscopic hysterectomy may offset the need for
the laparotomic route [24]. Laparoscopic hysterectomy may be more expensive due to the
cost of disposable instruments and increased operative time. Only a few studies reported no
significant difference in total hospital cost or less expenses with laparoscopic surgery [25-26].
Based on the fact that patients undergoing laparoscopic procedures have shorter lengths of
stay and controlling for the cost of nosocomial infection laparoscopic hysterectomy can save
significant hospital resources [27]. Besides, the major complication rate in the laparoscopic
group is generally lower than in the abdominal group (14.3% vs. 15.9%) [28]. Additionally,
the laparoscopic route requires shorter hospitalization time, shorter recovery time, less
caregivers‘ time and less pain medication than the abdominal route [29-35]. Patients who
undergo gynecological laparoscopic procedures suffer less frequently from postoperative
fever, require less postoperative analgesia, and can usually tolerate a full diet within 24 hours
[36]. Thus, the direct cost of the laparoscopic route may be higher with longer operating times
and the cost of disposable instruments [37]; however, the total cost of treatment may be less
because of shortened post-operative stay, which needs a thorough and unbiased investigation
[32, 34, 38-39]. According to American and British sources, after laparoscopic surgery,
hospital stay is shorter by 6-8 days with less drug use, blood transfusion and fluid infusion
and the duration of the sick leave is shorter by 20-30 days [40].
The national cost of hysterectomy in the US is around 5 billion dollars, not considering
the 144 million work hours lost to the average six-week recovery time [1-2]. Women at the
peak of their productive lives (aged 40–44 years) are impacted by lost wages and their
employers by lost corporate productivity and the government by lost tax revenue. The cost of
two weeks of lost productivity after laparoscopic hysterectomy is no match for the cost of six
to eight weeks of lost productivity after abdominal or vaginal hysterectomy [41].
It is disappointing to see the majority of women still being treated for fibroids and
menorrhagia with the more invasive types of hysterectomy even though they have longer and
more painful recovery phase and despite the increasing evidence pointing to the superiority of
the laparoscopic method. Surgeons who complete the full learning curve and acquire the
necessary manual and visuo-spatial skills can replace abdominal, vaginal and
laparoscopically-assisted vaginal hysterectomy with laparoscopic hysterectomy, sometimes
with competitive operative times [42]. After years of experience, surgeons may even be able
to laparoscopically deal with large fibroid uteri of several kilogram mass [43-45]. While there
are some cases where abdominal and vaginal routes are appropriate, women need to know
about the less invasive more cosmetic type of hysterectomy that may be more suitable for
their condition and will get them quicker out of hospital and back to their normal lives.
References
[1] Matteson, K.A., et al., Factors associated with increased charges for hysterectomy.
Obstet. Gynecol, 2006. 107(5): p. 1057-63.
[2] Whiteman, M.K., et al., Inpatient hysterectomy surveillance in the United States, 2000-
2004. Am. J. Obstet. Gynecol, 2008. 198(1): p. 34 e1-7.
[3] Luoto, R., E.M. Rutanen, and J. Kaprio, Five gynecologic diagnoses associated with
hysterectomy--trends in incidence of hospitalizations in Finland, 1971-1986. Maturitas,
1994. 19(2): p. 141-52.
[4] Blanc, B.J. and L. Cravello, [Is hysterectomy a good indicator of public health in
France?]. Gynecol. Obstet. Fertil, 2003. 31(7-8): p. 579-80.
[5] Luoto, R., et al., Incidence, causes and surgical methods for hysterectomy in Finland,
1987-1989. Int. J. Epidemiol, 1994. 23(2): p. 348-58.
[6] Boukerrou, M., et al., [Hysterectomy for benign lesions: what remains for the
abdominal route?]. J. Gynecol. Obstet. Biol. Reprod (Paris), 2001. 30(6): p. 584-9.
[7] Debodinance, P., [Hysterectomy for benign lesions in the north of France:
epidemiology and postoperative events]. J. Gynecol. Obstet. Biol. Reprod. (Paris),
2001. 30(2): p. 151-9.
[8] Sandberg, S.I., et al., Elective hysterectomy. Benefits, risks, and costs. Med. Care,
1985. 23(9): p. 1067-85.
[9] Kolata, G., Rate of Hysterectomies Puzzles Experts. The New York Times, 1988: p. 1.
[10] Farquhar, C.M. and C.A. Steiner, Hysterectomy rates in the United States 1990-1997.
Obstet. Gynecol, 2002. 99(2): p. 229-34.
[11] Rate of hysterectomies increases from 602/100,000 in 1970 to 727/100,000 in 1975.
Ob. Gyn. News, 1977. 12(4): p. 2, 50.
[12] Redburn, J.C. and M.F. Murphy, Hysterectomy prevalence and adjusted cervical and
uterine cancer rates in England and Wales. BJOG, 2001. 108(4): p. 388-95.
[13] McCracken, G. and G.G. Lefebvre, Vaginal hysterectomy: dispelling the myths. J.
Obstet. Gynaecol. Can. 2007. 29(5): p. 424-8.
[14] Garry, R., The future of hysterectomy. BJOG, 2005. 112(2): p. 133-9.
[15] Lundholm, C., et al., Hysterectomy on benign indications in Sweden 1987-2003: a
nationwide trend analysis. Acta. Obstet. Gynecol. Scand, 2009. 88(1): p. 52-8.
[16] Vuorma, S., et al., Hysterectomy trends in Finland in 1987-1995--a register based
analysis. Acta. Obstet. Gynecol. Scand, 1998. 77(7): p. 770-6.
[17] Backe, B. and S. Lilleeng, [Hysterectomy in Norway. Quality of data and clinical
practice]. Tidsskr Nor Laegeforen, 1993. 113(8): p. 971-4.
[18] Fischer, B. and J. Rehm, Illicit opioid use and treatment for opioid dependence:
challenges for Canada and beyond. Can. J. Psychiatry, 2006. 51(10): p. 621-3.
[19] Health, U.D.o., Annual Report 2005: The Chief Medical Officer on the state of public
health.
[20] Wu, J.M., et al., Hysterectomy rates in the United States, 2003. Obstet. Gynecol, 2007.
110(5): p. 1091-5.
[21] Kay, V.J., et al., Current practice of hysterectomy and oophorectomy in the United
Kingdom and Republic of Ireland. J. Obstet. Gynaecol, 2002. 22(6): p. 672-80.
The Hysterectomy Crossroads 165
[22] David-Montefiore, E., et al., Surgical routes and complications of hysterectomy for
benign disorders: a prospective observational study in French university hospitals.
Hum. Reprod, 2007. 22(1): p. 260-5.
[23] Makinen, J., et al., Morbidity of 10 110 hysterectomies by type of approach. Hum.
Reprod, 2001. 16(7): p. 1473-8.
[24] Johnson, N., et al., Surgical approach to hysterectomy for benign gynaecological
disease. Cochrane Database Syst. Rev, 2005(1): p. CD003677.
[25] Mittapalli, R., et al., Cost-effectiveness analysis of the treatment of large leiomyomas:
laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy. Am. J.
Obstet. Gynecol, 2007. 196(5): p. e19-21.
[26] Brill, A., et al., The effects of laparoscopic cholecystectomy, hysterectomy, and
appendectomy on nosocomial infection risks. Surg. Endosc, 2008. 22(4): p. 1112-8.
[27] Gunnarsson, C., J.A. Rizzo, and L. Hochheiser, The Effects of Laparoscopic Surgery
and Nosocomial Infections on the Cost of Care: Evidence from Three Common
Surgical Procedures. Value Health, 2008.
[28] Bijen, C.B., et al., Costs and effects of abdominal versus laparoscopic hysterectomy:
systematic review of controlled trials. PLoS One, 2009. 4(10): p. e7340.
[29] Carter, J.E., J. Ryoo, and A. Katz, Laparoscopic-Assisted Vaginal Hysterectomy: A
Case Control Comparative Study with Abdominal Hysterectomy. J. Am. Assoc.
Gynecol. Laparosc, 1994. 1(4, Part 2): p. S7.
[30] Garry, R., Various approaches to laparoscopic hysterectomy. Curr. Opin. Obstet.
Gynecol, 1994. 6(3): p. 215-22.
[31] Irico, G., et al., [Laparoscopic hysterectomy. Results in 80 cases]. Rev. Fac. Cien. Med.
Univ. Nac. Cordoba, 1994. 52(2): p. 17-24.
[32] Raju, K.S. and B.J. Auld, A randomised prospective study of laparoscopic vaginal
hysterectomy versus abdominal hysterectomy each with bilateral salpingo-
oophorectomy. Br. J. Obstet. Gynaecol, 1994. 101(12): p. 1068-71.
[33] Morelli, M., et al., [Total laparoscopic hysterectomy versus vaginal hysterectomy: a
prospective randomized trial]. Minerva Ginecol, 2007. 59(2): p. 99-105.
[34] Claerhout, F. and J. Deprest, Laparoscopic hysterectomy for benign diseases. Best Pract
Res. Clin. Obstet. Gynaecol, 2005. 19(3): p. 357-75.
[35] Ottosen, C., G. Lingman, and L. Ottosen, Three methods for hysterectomy: a
randomised, prospective study of short term outcome. BJOG, 2000. 107(11): p. 1380-5.
[36] Grunberger, W., [Laparoscopic interventions in gynecology]. Wien Klin Wochenschr,
1995. 107(2): p. 77-82.
[37] Lumsden, M.A., et al., A randomised comparison and economic evaluation of
laparoscopic-assisted hysterectomy and abdominal hysterectomy. BJOG, 2000.
107(11): p. 1386-91.
[38] Tietz, C.A., Laparoscopic-assisted hysterectomy in a rural Minnesota hospital. Minn.
Med, 1995. 78(12): p. 31-2, 52-3.
[39] Meikle, S.F., E.W. Nugent, and M. Orleans, Complications and recovery from
laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal
hysterectomy. Obstet. Gynecol, 1997. 89(2): p. 304-11.
[40] Hercz, P., [Laparoscopic surgery in gynecology. Surgical reform of mere luxury?
(Physiologic and economic effects of laparoscopic surgery)]. Orv. Hetil, 1997. 138(5):
p. 271-4.
[41] Reed, P., Hysterectomy - Medical Disability Guidelines, in MDGuidelines. 2009.

[42] Walid, M.S. and R.L. Heaton, Total laparoscopic hysterectomy Arch Gynecol Obstet.
2010 Jun;281(6):1077-8.
[43] Walid, M.S. and R.L. Heaton, Laparoscopic extirpation of a 3-kg uterus. Arch.
Gynecol. Obstet, 2009. 279(4): p. 607-8.
[44] Walid, M.S. and R.L. Heaton, Total laparoscopic hysterectomy JSLS. 2010 Apr-
Jun;14(2):178-82.
[45] Walid, M.S. and R.L. Heaton, An intention-to-treat study of total laparoscopic
hysterectomy Int J Gynaecol Obstet. 2010 Oct;111(1):57-61.
Chapter 13
Interrupted Muney Stitch versus

Continuous Baseball-Like Suture
for Abdominal Myomectomy
Ozgul Muneyyirci-Delale (Muney)*, Ibrahim Joulak

and Hans von Gizycki
Department of Obstetrics and Gynecology, SUNY Downstate Medical Center,
Brooklyn, New York USA
Muney vs. Baseball-like Suture for Myomectomy
Abstract
Objective: To compare interrupted Muney Stitch with a continuous baseball-like suture
for abdominal myomectomy.
Methods: Retrospective review of patient records who underwent abdominal
myomectomy at the same time, subserosal layer closed with interrupted Muney Stitch (Group
1) or continuous baseball-like suture (Group 2). Twenty patients had Muney Stitch and 20
patients had baseball-like suture.
Results: Both groups were equivalent across several critical factors such as age, uterine
size and duration of surgery. When post-op fever was compared between the groups, only
25% of patients who received Muney suture developed fever while 60% of the patients with
baseball-like suture developed post-op fever (p=0.025). The odds of developing this
complication was estimated to be 4.5 (95% C1, 1.16-17.37 p=0.029) higher using the
baseball-like suture when compared to the Muney Stitch. Two different suture methods
produced different amount of blood loss during surgery. These significant differences were
attributable to suture type (p=.011) but not for suture position (p=0.066). A significant
*
SUNY Downstate Medical Center, 450 Clarkson Avenue, Box # 24, Brooklyn, New York 11203, Phone: 718-270-
2101, Fax: 718-270-2067, E-mail: ozgul.muneyyirci-delale@downstate.edu
168 Ozgul Muneyyirci-Delale (Muney), Ibrahim Joulak and Hans von Gizycki
correlation between incision type and suture type was found (p=0.029). Patients who had
Muney suturing of the posterior uterine wall had less blood loss.
Conclusion: Muney Stitch produces less post-op fever and blood loss in a posterior
uterine incision.
Introduction
It is a commonly held opinion that myomectomies carry more morbidity than
hysterectomies.[1] Myomectomies generally produce more bleeding than hysterectomies[2]
thus making an unintentional hysterectomy due to uncontrollable bleeding during
myomectomy necessary in 1% - 8% of cases.[3,4]
Post-operative adhesion formation is the second major cause of post-myomectomy
morbidity. Gehbach et al reported 68% of patients undergoing surgery following previous
myomectomy had adhesions.[5,6] Ninety seven percent of patients with previous
myomectomy through a posterior uterine incision and 56% with anterior incision showed
adhesions at a subsequent laparoscopy.[6] Use of seprafilm membrane did not eliminate post-
myomectomy adhesions in 65% of patients.[7] Peritoneal adhesions often cause infertility,
recurrent pelvic pain, small bowel obstruction and may make subsequent operative
procedures technically difficult.[6-9] Concern about operative complications associated with
myomectomy is one of the reasons why hysterectomy continues to be the first choice for
operative management of leiomyomata.[10] Currently in the United States, hysterectomy is
done nine times more frequently than myomectomy for leiomyomata.[1,11]
It is generally believed that the major cause of adhesions is a continuous oozing from the
uterine incision.[12-16] It appears, therefore, that the improved hemostasis at the
myomectomy incision should be an important step in reducing adhesion formation. A number
of surgical techniques have been described in textbooks and specialty journals for closure of
myomectomy or cesarean section uterine incisions. Recommended techniques for closure of
serosal and subserosal layers are: continuous ―baseball,‖[17] running imbricating,[12,18]
running locked,[13] running inverting,[14] continuous running,[19] interrupted suture[20] or
subserosal continuous suture.21 We retrospectively reviewed the charts of patients who
underwent myomectomies at SUNY Downstate at the same time who had either Muney or
baseball stitches to close serosa and subserosal layer of uterus.[22] The Muney stitch was
compared with the most commonly used suture method which is baseball-like suture to close
subserosal layers of the uterus.
Material and Methods

IRB approval was obtained prior to review of charts of patients who underwent
abdominal myomectomy at the same time at SUNY Downstate Medical Center. Twenty
women had the Muney Stitch to close subserosal layer of the uterus and 20 women had
continuous baseball-like suture.
Age, size of uterus, duration of surgery, post-op fever (12 hours or more of fever of 100.4
or over), uterine incision (anterior, posterior or anterior and posterior combined), and blood
Interrupted Muney Stitch versus Continuous Baseball-Like Suture … 169
loss was compared. The uterus was closed in layer with interrupted layers of figure of eight of
0 vicyl.
For the Muney interrupted suture 0-Vicyl was used in this study and 3-0 Vicyl was used
for the baseball-like suture. The person who reviewed the charts was not involved in the
surgeries. Blood loss was estimated by anesthesiologist.
The patients who had more than one operation (lysis of adhesions, cystectomy), had
previous procedures and had additional conditions (extensive adenomyosis, extensive
endometriosis adhesions) were excluded.
Statistical Method
Since there was no random selection for assignment of suture groups it was assessed if
both groups were equivalent across several factors using t-tests. Pearson chi-square tests were
used when comparing post-op fever. ANOVA was to find out if two different suture methods
produced different amounts of blood loss during surgery. (SPSS)
Results
Both groups were equivalent across several critical factors such as age, uterine size and
duration of surgery (Table 1). Using the Muney suture technique 25% of the patients
developed post-op fever (12 hours or more) while using the standard (baseball-like suture)
approach 60% of the patients developed post-op fever. These findings were statistically
significant (p=.025). Additionally it was observed that the odds of developing post-op fever
was estimated to be 4.5 (95%CI, 1.16-17.37, p=.029) times higher using the baseball-like
suture method when compared to the Muney method. Both these results suggest that the
Muney method produces less post-op fever.
Table 1.
Muney Stitch Baseball-like Suture

Mean 95% CI 95%CI Mean 95% CI 95%CI P
Duration of Surgery 171.32 144.39 198.24 146.9 128.08 165.72 0.150
Uterus Size 13.58 11.69 15.46 15.45 13.87 17.03 0.143
Age 36.6 34.41 38.56 36.6 34.41 38.78 0.868
Using ANOVA, we examined if the two different suture methods produced different
amounts of blood loss during surgery. (Figure 1) Significant difference was found for suture
type (p=.011) but not for suture position (p=0.66). A significant correlation between incision
type and suture type was found (p=.027).
Additionally, the presence or absence of complications and the interactions between this
blood loss and suture type were also assessed. In order to localize the source of interaction
effect post hoc analysis performed. Pair-wise comparison between the suture types for each of
three incision types (anterior, posterior, and anterior and posterior) demonstrated that there
was a significant difference between the two suture types only for the posterior incision
(p=.027) and no significant difference for the other two incision locations. (Figure 1)
Figure 1. Location of incisions and blood loss.
Discussion
Suturing techniques in reference 1-8 might not prevent blood loss during and following
the surgery or prevent hematoma formation for abdominal myomectomy and classical
cesarean section, a different suturing technique is needed. After the Muney Stitch there is no
oozing from the surface of the uterus and the uterus remains the same size (no hematoma
formation).
Even though, age, parity, duration of surgery and size of uterus were not different
between groups, when comparing post-op fever 12 hours and more, fewer patients developed
fever with the Muney Stitch. The odds of developing post-op fever were estimated to be 4.5
times higher using baseball-like than Muney suture. We suspect that decreased oozing from
incision site and produce less hematoma formations in uterus resulting in fewer patients with
post-op fever.
Pair-wise comparison between suture types and for three incision types (anterior,
posterior and anterior and posterior combination) demonstrated that there was a significant
difference between the two suture types only for the posterior incision. The advantage of
suturing with the Muney Stitch is that it reduces continuous loss of blood from serosa and
thus might decrease the chance of having hematoma, infectious morbidity, hysterectomy and
adhesions. In literature, Ninety seven percent of patients with previous myomectomy through
a posterior incision and 56% with anterior incision showed adhesions at a subsequent
laparoscopy.[6] It is generally believed that the major cause of adhesions is a continuous
oozing from the uterine incision.[11-13,15,18] It appears, therefore, that the improved
Interrupted Muney Stitch versus Continuous Baseball-Like Suture … 171
hematosis at the myomectomy incision should be an important step in reducing adhesion

formation.
With continuous baseball-like suture, suture material passes over serosal surface;
therefore, the foreign material exposes to other organs and can increase the chance of
adhesion formation. In the Muney Stitch,[21] the suture material is cut under serosal layer,
and is not transferred over the surface. The Muney Stitch after myomectomy shown by
Muneyyirci-Delale and Sauma[21] and video presentation appeared at American Society for
Reproductive Medicine (ASRM) meeting in 2008.[23]
References
[1] Barbieri RL: Ambulatory management of uterine leiomyomata. Clin. Obstet. and
Gynecol 1999;42(2):196-205.
[2] Farrer-Brown G, Beilby JO, Tarbit MH: The vascular patterns in myomatous uteri. J.
Obstet. Gynaecol. Br. Commonw. 1970;77:967-975.
[3] Myers ER, Barber MD, Gustilo-Ashby T, Couchman G, Matchar DB, McCrory DC:
Management of uterine leiomyomata: What do we really know? Obstet. Gynecol. 2002;
100:8-17.
[4] LaMorte AI, Lalwani S, Diamond MP: Morbidity associated with abdominal
myomectomy. Obstet. Gynecol. 1993;82:897-900.
[5] Gehlbach DL, Sousa RC, Carpenter SE, Rock JA: Abdominal myomectomy in the
treatment of infertility. Intl. J. Gynecol. Obstet. 1993;40:45-50.
[6] Tulandi T, Murray C, Guralnick M: Adhesion formation and reproductive outcome
after myomectomy and second-look laparoscopy. Obstet. Gynecol. 1993;82:213-215.
[7] Diamond MP: Reduction of adhesions by seprafilm membrane (HAL-F): A Blinded,
prospective, randomized, multicenter clinical study. The Seprafilm Adhesions Study
Group. Fertil. Steril. 1996;66:904-910.
[8] Diamond MP: Surgical Aspects of Infertility. In Gynecology and Obstetrics, Vol. 5,
Philadelphia, PA, Harper and Rowe, 1988:1-23.
[9] DiZegre GS, Rogers KE: Peritoneum. New York, Springer-Verlag, 1992.
[10] Boyd ME: Myomectomy. The Canadian J. Surg. 1986;29:161-163.
[11] Iverson RE Jr, Chelmow D, Strohbehn K, Waldman L, Evantash EG: Relative
leiomyomas. Obstet. Gynecol. 1996;88:415-419.
[12] West CP: Hysterectomy and myomectomy by laparotomy. Baillieres Clinical
Obstetrics and Gynaecology, 1998;12:317-335.
[13] Stringer NH, McMillen MA, Jones RL, Nezhat A, Park E: Uterine closure with the
endo stitch 10 mm laparoscopic suturing device a review of 50 laparoscopic
myomectomies. Intl J of Fertil and Women’s Med 1997;42(5):288-296.
[14] Buttram VC Jr, Reiter RC: Uterine leiomyomata: etiology, symptomatology, and
management. Fertil. Steril. 1981;36:433.
[15] Berkeley AS, DeCherney AH, Polar ML: Abdominal myomectomy and subsequent
fertility. Surg. Gynecol Obstet. 1983;156:319-322.
[16] Hemminki E, Graubard BI, Hoffman HJ, Mosher WD, Fetterly K: Cesarean section and
subsequent fertility: result of the 1982 National Survey of Family Growth. Fertil. Steril.
1985;43(4):520-528.
[17] Thompson JD, Rock JA: Leiomyomata Uteri and Myomectomy. In Te Linde‘s
Operative Gynecology, 8th ed. Philadelphia and New York City, Lippincott-Raven
Publishers, 1997;731-763.
[18] Sanz LE, Hayne PM: Gynecologic Surgery. Luis E. Sanz (ed.). Oredell NJ, Medical
Economics Books, 1988.
[19] Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC (eds.): Williams
Obstetrics, 19th Edition, Norwalk, CT, Appleton and Lance, 1993:603.
[20] Jones HW Jr, Rock JA: A Reparative and Constructive Surgery of Female Generative
Tract. Baltimore, MD, Williams and Wilkins, 1983.
[21] Mukhopadlaya N, DeSilva C, Manyonda T: Conventional myomectomy. Best Prac Res.
Clin. Obst Gynecol, 2008;22:677-705.
[22] Muneyyirci-Delale O, Sauma A: Interrupted and continuous Muney stitch for
abdominal myomectomy and classical cesarean section. (submitted for publication)
[23] Muneyyirci-Delale O: Muney Stitch for Subserosal Closure During Myomectomy.
Video Presentation at American Society for Reproductive Medicine 64th Annual
Meeting, October 2008.
Chapter 14
Interrupted and Continuous Muney

Stitch for Abdominal Myomectomy
and Classical Cesarean Section
Ozgul Muneyyirci-Delale (Muney)1,3* and Amy Sauma,2

1
Division of Reproductive Endocrinology,
2
Department of Obstetrics and Gynecology
3
SUNY Downstate Medical Center and Kings County Hospital Center,
Brooklyn, New York USA
Muney Stitch for Myomectomy and Classical

Cesarean Section
Abstract
During abdominal myomectomy and classical cesarean section, the serosal and
subserosal layer of the uterus are approximated with a continuous baseball-like suture,[1]
running suture utilized to imbriate the serosa,[2,3] running locked suture,[4] continuous
inverting suture,[5] continuous running suture,[6] or interrupted.[7] These techniques do
not always control bleeding arising from congested and dilated subserosal veins,[2] and
reduce unintentional hysterectomy, adhesion formation and infertility after myomectomy
and classical cesarean section. To prevent continuous blood loss during and following the
surgery and to prevent hematoma formation in the uterus, a different suturing technique is
needed to control congested and dilated vessels in subserosal regions.[2]
In a very vascular uterus, an interrupted overlapping Muney Stitch provides good
homeostasis, and approximates the serosal layers without tension. In addition, the suture
does not pass through the surface of the uterus and thus reduces foreign body reactions
and possible adhesion formation. In case of a smaller incision with less vascular uterus a
continuous Muney Stitch can be used.
*
SUNY Downstate Medical Center, 450 Clarkson Avenue, Box # 24, Brooklyn, New York 11203, Phone: 718-270-
2101, Fax: 718-270-2067, E-mail: ozgul.muneyyirci-delale@downstate.edu
174 Ozgul Muneyyirci-Delale (Muney) and Amy Sauma
Introduction
It is a commonly held opinion that myomectomies carry more morbidity than
hysterectomies.[8] Myomectomies generally produce more bleeding than hysterectomies[9]
thus making an unintentional hysterectomy due to uncontrollable bleeding during
myomectomy necessary in 1% - 8% of cases.[10,11]
Post-operative adhesion formation is the second major cause of post-myomectomy
morbidity. Gehbach et al reported 68% of patients undergoing surgery following previous
myomectomy had adhesions.[12]
Ninety seven percent of patients with previous myomectomy through a posterior uterine
incision and 56% with anterior incision showed adhesions at a subsequent laparoscopy.[13]
Use of seprafilm membrane did not eliminate post-myomectomy adhesions in 65% of
patients.[14]
Peritoneal adhesions often cause infertility, recurrent pelvic pain, small bowel obstruction
and may make subsequent operative procedures technically difficult.[13-16] Concern about
operative complications associated with myomectomy is one of the reasons why
hysterectomy continues to be the first choice for operative management of leiomyomata.[17]
Currently in the United States, hysterectomy is done nine times more frequently than
myomectomy for leiomyomata.[8,18]
It is generally believed that the major cause of adhesions is a continuous oozing from the
uterine incision.[2,4,5,19,20] It appears, therefore, that the improved hemostasis at the
myomectomy incision should be an important step in reducing adhesion formation.
A number of surgical techniques have been described in textbooks and specialty journals
for closure of myomectomy or cesarean section uterine incisions.
Recommended techniques for closure of serosal and subserosal layers are: continuous
―baseball,‖[1] running imbricating,[2,3] running locked,[4] running inverting,[5] continuous
running,[6] interrupted suture,[7] or subserosal continuous suture.[8]
The Muney Stitch, devised by the author 17 years ago offers improved hemostasis
without increasing the suture tension.
Extensive library (Downstate Medical Center, Brooklyn, NY), Medline, Index Medicus
(1913-1999) surgical textbooks (Obstetrics and Gynecology) and Melloni Medical
Dictionary[21] research failed to discover any previous reference to a similar technique.
Surgical Technique
We use synthetic absorbable suture - Vicryl, Polysorb, Dexon, size 0 to 3-0 (smaller than
3-0 thread may cut through the myomectrium). The needle size varies with the length of
uterine incision. The larger incision requires larger needle size.
The needle is placed perpendicular to the needle holder jaws, 3.0 mm from the needle
swage hole. At the apex of incision, a horizontal subserosal bite is taken 1.5 - 2 mm below the
uterine surface through the superficial myometrium, deep enough to prevent suture cutting
through the tissue and to secure adequate hemostasis.
Similar bite is taken through the opposite side and suture is tied without tension. A secure
four-throw square knot is constructed to secure suture.
Interrupted and Continuous Muney Stitch for Abdominal Myomectomy… 175
The ends of the suture should be cut flush with serosa to prevent peritoneal irritation that
may lead to adhesion formation. Overlap bites are carried out to close the layer as in figures
1a, 1b.
In case of bleeding from apex, the interrupted suture starts at above the apex as in figure
1a.
Video presentation at American Society Reproductive Medicine (ASRM) in 2008 shows
appearance of Muney stitch when a patient underwent myomectomy. There is no suture above
serosal layer. This layer approximated closely with minimal gape.
Figure 1. Interrupted Muney Stitch.
Figure 2. Continuous Muney Stitch.

In case of a smaller incision with less vascular uterus a continuous stitch can be used. The
needle is held as for interrupted Muney Stitch (figure 2). The interrupted suture starts at the
apex through myometrium horizontal to serosa layer existing 3-4 mm above apex, then
reentering through the same hole to bury suture under serosa and finally exiting at the
opposite side of incision.
A secure four-throw square knot is constructed to secure the suture. After cutting the ear
attached to the knot, the next subserosal bite is taken as in interrupted suture and the opposite
side bite should be one half size of the first bite. These bites are repeated until the end of the
incision. The suture loop is then cut flush with the knot.
Discussion
Figure 3. shows normal subserosal vessels. However, Farrer-Brown et al.[9] study
provides radiographic evidence by which leiomyomata arising in various sites may cause
congestion and dilatation of venous plexi by impinging on the arcuate and radial veins which
course through the intramural and subserosal region of the myometrium since suturing
techniques in references 1-8 might not prevent blood loss during and following the surgery
and to prevent hematoma formation. Therefore, unintentional hysterectomy due to
uncontrollable bleeding during myomectomy becomes necessary in 1-8% of cases. For
abdominal myomectomy and classical cesarean section, a different suturing technique is
needed. Another concern is the risk of post-operative adhesions subsequently impairing
fertility after myomectomy and classical cesarean section.[19,20] In the incision site, there is
no oozing and when uterus is held between two hands and squeezed, no blood escapes from
the incision. Other suture techniques do not provide this.
Figure 3. Normal Subserosal Vessels.

Interrupted and Continuous Muney Stitch for Abdominal Myomectomy… 177
In other suture techniques, suture material passes over the serosal surface; therefore, the
foreign material is exposed to other organs and can increase the chance of adhesion
formation. In the Muney Stitch, the suture material is cut under serosal layer, and is not
transferred over the surface. The advantages of suturing with the Muney Stitch is that it may
reduce continuous loss of blood from the serosa and subsequently decreases the chance of
having blood transfusions, hematoma, hysterectomy, infectious morbidity, and adhesions.
The drawbacks of the Muney Stitch in comparison to others include more time that it might
take to perform the interrupted Muney Stitch.
Acknowledgments
I want to thank my father, Gabriel Muneyyirci, for introducing me to sewing and
designing. Also, we want to thank Dr. Alexander Sedlis and Cassandra Charles for their
comments and editorial assistance, and Mrs. Jessie Walsh for her secretarial assistance.
References
[1] Thompson JD, Rock JA. Leiomyomata Uteri and Myomectomy. In Te Linde's
Operative Gynecology, 8th ed. Philadelphia and New York City, Lippincott-Raven
Publishers, 1997;731-763.
[2] West CP. Hysterectomy and myomectomy by laparotomy. Baillieres Clinical
Obstetrics and Gynaecology, 1998;12:317-335.
[3] Sanz LE, Hayne PM: Gynecologic Surgery. Luis E. Sanz (ed.). Oredell, NJ, Medical
Economics Books, 1988.
[4] Stringer NH, McMillen MA, Jones RL, Nezhat A, Park E: Uterine closure with the
endo stitch 10 mm laparoscopic suturing device a review of 50 laparoscopic
myomectomies. Intl. J. of Fertil Women’s Med 1997;42(5):288-296.
[5] Buttram VC Jr, Reiter RC: Uterine leiomyomata: etiology, symptomatology, and
management. Fertil Steril 1981;36:433-.
[6] Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC (eds.): Williams
Obstetrics, 19th Edition, Norwalk, CT, Appleton and Lance, 1993:603.
[7] Jones HW Jr, Rock JA: A Reparative and Constructive Surgery of Female Generative
Tract. Baltimore, MD, Williams and Wilkins, 1983.
[8] Barbieri RL: Ambulatory management of uterine leiomyomata. Clin Obstet Gynecol
1999;42(2):196-205.
[9] Farer-Brown G, Beilby JO, Tarbit MH: The vascular patterns in myomatous uteri. J
Obstet Gynaecol Br Commonw 1970;77:967-975.
[10] Myers ER, Barber MD, Gustilo-Ashby T, Couchman G, Matchar DB, McCrory DC:
Management of uterine leiomyomata: What do we really know? Obstet Gynecol 2002;
100:8-17.
[11] LaMorte AI, Lalwani S, Diamond MP: Morbidity associated with abdominal
myomectomy. Obstet Gynecol, 1993;82:897-900.
[12] Gehlbach DL, Sousa RC, Carpenter SE, Rock JA: Abdominal myomectomy in the
treatment of infertility. Intl. J. Gynecol. and Obstet. 1993;40:45-50, 1993.
[13] Tulandi T, Murray C, Guralnick M: Adhesion formation and reproductive outcome
after myomectomy and second-look laparoscopy. Obstet Gynecol 1993;82:213-215.
[14] Diamond MP: Reduction of adhesions by seprafilm membrane (HAL-F): A blinded,
prospective, randomized, multicenter clinical study. The Seprafilm Adhesions Study
Group. Fertil and Steril 1996;66:904-910.
[15] Diamond MP: Surgical Aspects of Infertility. In Gynecology and Obstetrics, Vol.5,
Philadelphia, PA, Harper and Rowe, 1988;1-23.
[16] DiZegre GS, Rogers KE: Peritoneum. New York, Springer-Verlag, 1992.
[17] Boyd ME: Myomectomy. The Canadian J. Surg. 1986;29:161-163.
[18] Iverson RE Jr, Chelmow D, Strohbehn K, Waldman L, Evantash EG: Relative
leiomyomas. Obstet Gynecol 1996;88:415-419.
[19] Berkeley AS, DeCherney AH, Polar ML: Abdominal myomectomy and subsequent
fertility. Surg Gynecol. and Obstet. 1983;156:319-322.
[20] Hemminki E, Graubard BI, Hoffman HJ, Mosher WD, Fetterly K: Cesarean section and
subsequent fertility: result of the 1982 National Survey of Family Growth. Fert. and
Steril. 1985;43(4):520-528.
[21] Melloni’ s Illustrated Medical Dictionary. 3rd Edition. Cox, IG, Melloni BJ, Ridnrt GM.
The Parthenon Publishing Group Inc., 1993.
[22] Muneyyirci-Delale O: Muney Stitch for Subserosal Closure During Myomectomy.
Video Presentation at American Society for Reproductive Medicine 64th Annual
Meeting, October 2008.
Chapter 15
Minilaparotomy for Repair of Bowel

Injury at Initial Trocar Placement

Heart of Georgia Women‘s Center,
209 Green Street, Warner Robins, GA 31099 - USA
Abstract
Bowel injury can happen during insertion of the direct view trocar for laparoscopy,
irrelevant to the surgeon‘s experience. We explain how to repair the bowel injury via a
minilaparotomy and continue the laparoscopic procedure as planned.
Keywords: laparoscopy; bowel injury; enterotomy; minilaparotomy.
Enterotomies (bowel injuries) sometimes happen during therapeutic or diagnostic

laparoscopy irrelevant to the surgeon‘s experience. These injuries can also occur during laser
vaporization, excision of endometriosis and/or lysis of adhesions [1]. The rate of major
complications during trocar insertion is estimated at around 0.5% [2].
The lubricant protective function of the omentum usually prevents adhesions of the bowel
to the anterior abdominal wall. However, rare cases of bowel adhesions to the anterior
abdominal wall are encountered from time to time especially in patients with previous
abdominal surgery which can predispose to direct bowel injury during initial trocar insertion.
Kaali and Barad conducted a retrospective review of 4,532 outpatient laparoscopic procedures
to determine the frequency of dense bowel adhesions at the level of the umbilicus [3]. Four
bowel injuries were recorded [3]. Bowel adhesion to the insertion site was noted in one case
[3]. We believe, however, this incidence rate is artificially low as many laparoscopists
exclude high risk patients with prior midline incisions at or above the umbilicus, prior ventral
hernia repairs, prior ruptured appendix, prior generalized peritonitis, prior billiary peritonitis,
*
prior massive hemoperitoneum, prior abdominal gunshot wound, prior peritoneal dialysis,
Crohn‘s disease, ulcerative colitis and other conditions.
However, even with the above-mentioned conditions that can lead to bowel adherence to
the anterior abdominal wall there is usually a free window in the left upper quadrant that will
allow access with a direct view trocar except in cases of prior gastric surgery, splenectomy or
Nissen fundoplication. Trocar placement is done at the intersection of the costal margin and
the anterior axillary line. The advantage of direct view trocar placement is that tissue planes
are easily seen and if bowel entry occurs the trocar is not advanced any further. If a 5mm
penetrating trocar is utilized, the actual injury will be very small and unlikely to leak
significantly in the acute phase immediately after removal of the trocar. Besides, with
visualization of the penetrated planes and knowing that there is a single entry to the bowel,
full laparotomy and running of the bowel may be unnecessary, depending on each case
individually.
We had a 56 year-old, gravida 4, para 4, patient with history of hysterectomy and
sacrospinous suspension and chief complaint of deep dyspareunia. The patient was counseled
about her condition and diagnostic laparoscopy with bilateral salpigo-oophorectomy and left
uterosacral stump resection was planned based on her physical and anamnestic data. During
insertion of a 5 mm direct view trocar in the umbilicus and on going through the final layer of
tissue greenish fluid was noted. Under further inspection, we understood that we were in the
colon (which had undergone preoperative bowel preparation). The scope and trocar were
removed and a minilaparotomy was performed. The adherent transverse colon was dissected
free from the underlying abdominal wall and the loop of bowel pulled up through the
minilaparotomy. The patient had a double layer of interrupted silk suturing done which gave
excellent closure with no leakage on manipulation and good lumen palpation. The hole was
less than 5 mm in diameter. The area was rinsed thoroughly with cefazolin solution, as was
later the abdominal cavity (although no intraperitoneal spill occurred as the bowel was
adherent and stuck to the anterior abdominal wall right beneath the umbilicus). The fascial
part of the incision was closed with a running looped #1 Polydioxanone (PDS) and then the 5
mm trocar was replaced at the umbilicus and laparoscopy was resumed. The abdomen was
reinsufflated; punctures were performed lateral to the umbilicus on the left and in the right
lower and left lower quadrants. The patient had extensive lysis of adhesions of the omentum
from the anterior abdominal wall, from the left adnexa and from the pelvic floor. The sigmoid
was dissected free from the left pelvic sidewall and pelvic floor. Laparoscopic bilateral
salpingo-oophorectomy and laparoscopic resection of the left uterosacral ligament were
performed. Operative time was 76 minutes and estimated blood loss 50 cc. The patient was
discharged the next day as soon as she passed gas and started eating. The patient‘s deep
dyspareunia resolved postoperatively and remains resolved 2 years later.
The case shows that direct injury to an adherent bowel during initial trocar placement can
occur in a patient with a history of abdominal surgery. Such a case can be treated through a
minilaparotomy and lavage with an antibiotic solution then the laparoscopy can be resumed
as planned without the need to convert to a full laparotomy. A bowel injury should not be
missed as mortality and litigation risks substantially increase with delayed recognition of
these complications [4,5].
Minilaparotomy for Repair of Bowel Injury at Initial Trocar Placement 181
References
[1] Nezhat C, Nezhat F, Ambroze W, Pennington E. Laparoscopic repair of small bowel
and colon. A report of 26 cases. Surg Endosc. 1993 Mar-Apr;7(2):88-9.
[2] Jirecek S, Dräger M, Leitich H, Nagele F, Wenzl R. Direct visual or blind insertion of
the primary trocar. Surg Endosc. 2002 Apr;16(4):626-9.
[3] Kaali S G; Barad D H. Incidence of bowel injury due to dense adhesions at the sight of
direct trocar insertion. The Journal of reproductive medicine 1992;37(7):617-8.
[4] Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries provoking
litigation. J Am Assoc Gynecol Laparosc. 2001 Aug;8(3):341-7.
[5] Vilos GA. Laparoscopic bowel injuries: forty litigated gynaecological cases in Canada.
J Obstet Gynaecol Can. 2002 Mar;24(3):224-30.
Index
anuria, 113
A anus, 117
anxiety, 3, 81, 82, 84, 85, 88, 90
abortion, 139, 140, 141
aorta, 14, 111, 113
abortion rate, 139
aplasia, 143
absorption, 116
appendectomy, 165
accessibility, 5, 146, 158
appetite, 84
acid, 129
arousal, 85, 86
adaptation, 78, 79, 82, 86, 88, 89, 90
arteries, 8, 10, 12, 29, 31, 97, 145, 151
adenomyoma, 133
artery, 8, 10, 11, 36, 45, 46, 55, 59, 60, 95, 103, 113,
adenomyosis, xi, 48, 98, 109, 123, 129, 131, 133,
130, 133, 147, 149, 150, 151, 156
169
aspiration, 56
adhesion, 15, 30, 55, 58, 59, 62, 126, 139, 146, 168,
assessment, 63, 83, 104, 106, 130
171, 173, 174, 175, 177, 179
asymptomatic, xi, 25, 123, 136, 140
adhesions, 11, 15, 18, 27, 28, 30, 31, 49, 50, 56, 58,
atrophy, 36, 86, 104
60, 61, 62, 97, 98, 100, 110, 113, 114, 117, 137,
audits, 19
138, 139, 141, 142, 147, 151, 168, 169, 170, 171,
authorities, 16
174, 176, 177, 178, 179, 180, 181
autonomy, 105
adjustment, 6, 160
avoidance, 101, 152
advantages, 5, 6, 9, 15, 16, 24, 26, 29, 30, 31, 37, 48,
101, 127, 128, 135, 141, 153, 156, 177 B
African American women, 69, 80
African Americans, 69 back pain, 95
aging process, 90 bacteria, 156
agonist, 35, 129 barriers, 2, 4, 36
algorithm, 34, 37 beneficial effect, 77, 95
alternative energy, 9 benign, xii, 2, 3, 5, 16, 20, 21, 22, 23, 24, 28, 40, 41,
alternative treatments, xii, 82, 90, 96, 124 47, 48, 49, 51, 53, 54, 55, 61, 62, 63, 64, 67, 68,
amenorrhea, 34, 36, 136, 137 69, 70, 82, 95, 96, 98, 99, 100, 106, 107, 116,
analgesic, 25 119, 120, 124, 132, 146, 153, 155, 160, 161, 162,
anastomosis, 137, 143 163, 164, 165
anatomy, 3, 15, 20, 26, 29, 38, 48, 85, 87, 98, 101, bias, 53, 88, 158
102, 111, 114, 119, 146, 152 birth rate, 139, 140, 141
androgen, 86 births, 138
anemia, 56, 129 bleeding, xii, 12, 15, 27, 34, 37, 39, 43, 44, 45, 47,
anesthesiologist, 169 48, 56, 59, 64, 70, 82, 83, 85, 88, 90, 91, 92, 95,
anger, 85 97, 102, 103, 104, 105, 107, 111, 113, 124, 129,
angiography, 36 136, 146, 168, 173, 174, 175, 176
antibiotic, 180 blogs, 21
184 Index
blood clot, 51 closure, 4, 12, 82, 112, 113, 116, 118, 138, 150, 156,
blood flow, 36, 104 168, 171, 174, 177, 180
blood pressure, 86 cognitive representations, 68
blood supply, 29 collateral, 104
blood transfusion, 32, 51, 52, 56, 111, 129, 151, 163, colon, 113, 115, 117, 142, 180, 181
177 colon cancer, 117
blood transfusions, 177 color, 147
blood vessels, 13, 47 colostomy, 116, 151
BMI, 18, 49 common symptoms, 50
body image, 82, 85, 86, 87, 91 community, 49, 78
body mass index, 31 comorbidity, 98
bone, 34 complaints, 18, 19, 87, 88, 137, 140, 151
bowel, xii, 6, 8, 13, 14, 17, 19, 31, 32, 33, 47, 49, 50, complexity, 13, 15, 18, 55, 96, 109, 114
55, 56, 58, 64, 84, 97, 101, 109, 110, 113, 114, compliance, 139
115, 116, 117, 124, 137, 146, 147, 152, 168, 174, complications, xii, 2, 4, 6, 13, 15, 17, 18, 19, 20, 21,
179, 180, 181 24, 26, 29, 31, 32, 33, 34, 36, 43, 47, 48, 49, 50,
bowel obstruction, 168, 174 53, 54, 57, 59, 60, 61, 62, 63, 64, 65, 84, 90, 95,
bowel perforation, 55, 56, 84, 115, 117 101, 103, 104, 109, 110, 111, 112, 113, 114, 116,
brachial plexus, 118 119, 120, 124, 125, 138, 146, 153, 156, 158, 159,
Brazil, 95 160, 164, 168, 169, 174, 179, 180
composition, 86
C compression, 118, 146
computed tomography, 115, 136
caesarean section, 11, 28, 150, 151
condensation, 9
caliber, 116
conference, 83
cancer, 6, 25, 43, 48, 59, 68, 92, 95, 96, 97, 98, 102,
configuration, 101
103, 162
conflict, 37, 39
candidates, 39, 62, 153
confounding variables, 83
carbon, 125
consensus, 14, 17, 21, 24, 27, 45, 81, 83, 87, 110
carbon dioxide, 125
consent, 9
carcinoma, 27, 101
conservation, 40, 102
cardiac arrest, 103
constipation, 81, 82, 84
cardiovascular disease, 25, 38, 39, 102
contamination, 115
caregivers, 163
control group, 90
case study, 144
controlled trials, 16, 20, 41, 63, 85, 120, 132, 165
catheter, 9, 11, 36, 112, 117, 151
conversion rate, 17, 18, 20, 127, 156
Caucasians, 69
coordination, 4, 101
cauterization, 129
correlation, 75, 89, 168, 169
cefazolin, 180
correlations, 91
cellulitis, 47
cost, 3, 8, 24, 25, 28, 30, 35, 36, 37, 38, 39, 40, 46,
cervical cancer, 6, 98, 100
69, 96, 104, 119, 126, 155, 156, 157, 158, 159,
cervix, 7, 11, 15, 33, 43, 48, 82, 86, 95, 96, 98, 100,
163
101, 104, 111, 113, 136, 140, 143, 144, 150, 151
cost saving, 157
cesarean section, 48, 50, 53, 57, 58, 61, 62, 95, 96,
cost-benefit analysis, 157
100, 124, 138, 143, 145, 168, 170, 172, 173, 174,
counseling, 84
176
covering, 10
Chile, 79
cultural beliefs, 77
cholecystectomy, 23
cultural norms, 78
chronic diseases, 88
culture, 68, 78, 82, 83, 90
circulation, 86
curriculum, 120
City, 172, 177
cystectomy, 115, 169
class, 69
cystocele, 102
clinical trials, 2
cystoscopy, 9, 11, 13, 15, 21, 55, 63, 112, 113, 120
Index 185
cystotomy, 50, 54, 61, 63, 112 dyspareunia, 33, 50, 61, 82, 87, 89, 97, 162, 180
cystourethroscopy, 55
E
D
economic evaluation, 42, 106, 165
daily living, 146 ectopic pregnancy, 136
danger, 98, 100 educational background, 67, 77
database, 5, 18, 129 effluent, 13
deaths, 25, 103 electrocautery, 55, 56
decision-making process, 27, 38, 69, 96 electrolyte, 115
defects, 13, 116, 118, 124, 125, 156 emboli, 34, 36, 38, 45, 95, 97, 103, 130, 133
deficiency, 82, 118 embolism, 59, 110
dehiscence, 125 embolization, 34, 36, 38, 45, 95, 97, 103, 130, 133
dementia, 25 embryogenesis, 135, 136
demographic characteristics, 69 emotional distress, 159
demography, 44 emotional well-being, 90
deposits, 101 emphysema, 119
depression, 68, 69, 78, 81, 82, 84, 86, 89, 90, 97 employment, 39, 77, 103
deprivation, 129 employment status, 103
depth perception, 2, 3 endometrial carcinoma, 27
desiccation, 146, 151 endometrial hyperplasia, 34
destruction, 35, 45, 104 endometriosis, 6, 7, 8, 9, 10, 15, 25, 28, 30, 31, 50,
detachment, 8 55, 59, 61, 62, 95, 96, 97, 100, 101, 112, 113,
detection, 55, 112 114, 117, 136, 137, 138, 139, 146, 159, 162, 169,
devaluation, 71, 72, 73, 74, 75, 77, 78 179
developing countries, 24, 50 endoscope, 104
diabetes, 49 endurance, 112
diagnosis, 15, 88, 97, 111, 112, 114, 117, 120, 136, enemas, 115
138, 140, 142, 143 England, 24, 39, 96, 164
dialysis, 180 enlargement, 86
diaphragmatic hernia, 114 epidemiology, 60, 164
diet, 146, 163 episiotomy, 117
dilation, 86 epithelial ovarian cancer, 40
direct cost, 30, 35, 163 epithelium, 50
direct costs, 30, 35 equipment, 4, 18, 98
disability, 31, 157, 158, 160 estrogen, 86, 97, 102, 118
disadvantages, 31 ethnic background, 68, 69
disappointment, 79 ethnic groups, 69
discomfort, 24, 146 etiology, 102, 171, 177
displacement, 8 examinations, xi, 123
dissatisfaction, 68, 76, 85 excision, xii, 8, 31, 124, 129, 179
dissociation, 129 excitation, 88
distilled water, 58 expenditures, 159
distortion, 152 experiences, 48, 49, 69, 76, 79, 80
distortions, 152 expertise, 6, 16, 97, 119
disturbances, 25 exploration, 48
diversity, 24 exposure, 2, 3, 6, 8, 124, 136, 141, 146, 152
diverticulitis, 117, 121 expulsion, 36
doctors, 1, 87
dopamine, 85
F
drainage, 56
fallopian tubes, 96, 136
drawing, 105
family development, 85
drugs, 25
family relationships, 68
dysmenorrhea, xii, 34, 50, 124, 129, 136, 138
186 Index
fantasy, 85 health care professionals, 87

fascia, 4, 12, 99, 119, 156 health care system, 1, 3, 158
fears, 67, 69, 77, 78, 79, 85, 87 health problems, 81, 82, 90
fecal impaction, 117 hematoma, 170, 173, 176, 177
feedback, 101 hematuria, 112
feelings, 69, 85 hemoglobin, 104, 125, 151
femininity, 67, 69, 71, 76, 77 hemorrhage, 51, 59, 97, 103, 106, 124, 138, 152
fertility, xii, 25, 34, 37, 44, 68, 95, 103, 104, 124, hemostasis, 128, 146, 156, 168, 174
129, 135, 138, 139, 141, 162, 171, 172, 176, 178 hernia, 33, 118, 156, 179
fertility rate, 135 hernia repair, 179
fertilization, 138 higher education, 77
fever, 47, 51, 109, 113, 115, 163, 167, 168, 169, 170 homeostasis, 56, 173
fibroids, xi, 27, 44, 59, 95, 97, 98, 102, 103, 104, hospitalization, 47, 98, 163
123, 133, 150, 163 husband, 78
fibula, 118 hyperplasia, 95
financial system, 20 hyperthermia, 6
Finland, 13, 21, 104, 163, 164 hypoplasia, 136, 137, 141, 142
first generation, 36 hysterectomy, 1, 2, 4, 5, 6, 12, 13, 15, 18, 19, 20, 21,
fistulas, 54, 117 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34,
flank, 113 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47,
flex, 7 48, 50, 51, 52, 53, 54, 55, 58, 60, 61, 62, 63, 64,
fluid, 51, 56, 163, 180 65, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78,
focus groups, 69 79,묈80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91,
Foley catheter, 112 92, 93, 95, 96, 97, 98, 100, 101, 102, 103, 104,
formula, 71 105, 106, 107, 109, 111, 112, 113, 116, 117, 119,
France, 50, 162, 164 120, 121, 124, 125, 127, 129, 131, 132, 138, 143,
freedom, 32 145, 146, 147, 150, 151, 152, 153, 154, 155, 156,
fusion, 136 157, 158,묈159, 160, 161, 162, 163, 164, 165,
G 166, 168, 170, 171, 173, 174, 176, 177, 178, 180
I
gallbladder, 97
gastrointestinal tract, 17, 117 iatrogenic, 7, 54, 109
gender identity, 76, 77, 79 ideal, 6, 7, 8, 14, 76, 124
general anesthesia, 31, 147 ideology, 80
general surgeon, 110 image, 9, 82, 86
general surgery, 57, 115 imagery, 85
genes, 130 images, 31, 101
genitourinary tract, 115 imbalances, 115
Georgia, 155, 161, 179 impacts, 1, 82, 106
Germany, 15 impairments, 87
gestation, 29, 146, 152 incidence, 16, 17, 21, 24, 25, 31, 32, 33, 44, 47, 48,
gland, xi, 123, 128 51, 52, 53, 54, 55, 56, 57, 59, 63, 98, 101, 111,
grades, 6 113, 118, 120, 138, 139, 164, 179
guidance, 16, 18, 21, 58 independence, 83
guidelines, 23, 26, 27, 29, 84, 92 India, 145
gynecologist, 101, 161, 162 industrialized countries, 96
H inferior vena cava, 111, 114
infertility, 50, 136, 137, 140, 141, 168, 171, 173,
haemostasis, 3, 6, 11, 30, 113 174, 178
haemostatic agent, 133 inflammation, 118
hair, 126, 127 inflation, 7
health care costs, 158 inguinal, 118, 119
Index 187
injections, 118 life changes, 77

insertion, 7, 14, 15, 36, 55, 57, 58, 110, 114, 115, life expectancy, 102
116, 147, 151, 179, 180, 181 life quality, xi, 123
insomnia, 84 life satisfaction, 83
intensive care unit, 158 ligament, 4, 7, 9, 10, 11, 27, 29, 59, 99, 113, 118,
interaction effect, 169 147, 148, 150, 180
intervention, 16, 24, 37, 38, 50, 58 liquids, 151
intestine, 55, 64, 116, 117 litigation, 13, 15, 18, 180, 181
intimacy, 83 liver, 9, 114
ipsilateral, 8, 36, 138 local anesthesia, 36
Ireland, 162, 164 localization, 111
irradiation, 112 low risk, 14, 16, 27, 127
irritability, 84 lumen, 115, 116, 180
ischemia, 36, 118, 156 luteinizing hormone, 85
Italy, 24, 39 lying, 128
lymph, 6, 27
J lymph node, 6, 27
lysis, 56, 169, 179, 180
Japan, 64, 98
M
K
Mackintosh, 60
kidney, 55, 112
magnetic resonance, 46, 142
kidneys, 13
magnetic resonance imaging, 142
knots, 11, 12
major decisions, 96
KOH, 7, 157
majority, xii, 3, 25, 28, 31, 68, 81, 82, 84, 87, 90, 98,
L 103, 114, 115, 118, 124, 157, 161, 163
malignancy, 27, 31, 38, 48, 50, 55, 98, 102
laceration, 14, 100 management, xii, 6, 15, 21, 30, 31, 33, 34, 35, 37,
laparoscope, 4, 9, 14 44, 45, 46, 64, 116, 124, 126, 127, 129, 131, 133,
laparoscopic cholecystectomy, 18, 165 135, 139, 140, 141, 143, 144, 146, 168, 171, 174,
laparoscopy, 1, 3, 4, 5, 12, 13, 17, 20, 21, 22, 24, 27, 177, 178
28, 30, 31, 32, 42, 47, 48, 49, 50, 51, 55, 56, 57, manipulation, 6, 7, 24, 127, 128, 147, 180
58, 61, 62, 63, 64, 65, 101, 109, 110, 111, 113, manufacturing, 2
114, 115, 118, 119, 120, 126, 127, 128, 129, 131, marriage, 68, 80
132, 135, 137, 140, 141, 143, 145, 152, 153, 156, masculinity, 78
160, 165,묈168, 170, 171, 174, 178, 179, 180 median, 127, 145, 151
laparotomy, 6, 13, 15, 17, 18, 22, 24, 31, 37, 39, 49, medication, 45, 129, 163
50, 53, 55, 57, 58, 59, 60, 62, 64, 65, 110, 111, memory, 79, 84, 88
112, 114, 115, 119, 124, 127, 128, 129, 131, 132, menarche, 137
135, 138, 140, 146, 152, 153, 171, 177, 180 menopause, 34, 68, 77, 86, 102
large intestine, 55, 114, 116 menorrhagia, xii, 33, 34, 35, 36, 38, 40, 44, 45, 95,
laser ablation, 35 103, 104, 107, 124, 129, 151, 163
LD, 64 menstruation, 95, 129, 138
leakage, 113, 114, 128, 180 mesenteric vessels, 14
learning, 2, 3, 4, 13, 17, 19, 21, 22, 26, 28, 30, 31, meta-analysis, 14, 16, 18, 20, 32, 41, 53, 54, 63, 103,
63, 155, 163 106, 120, 132
leiomyoma, 34, 44, 92, 95, 97, 130, 160 methodology, 78
leiomyomata, 44, 45, 46, 106, 133, 168, 171, 174, Mexico, 40, 67, 69, 77, 80
176, 177 middle class, 69
lens, 9 miscarriage, 135, 138, 139, 140, 141
lesions, 31, 47, 48, 110, 111, 147, 164 misconceptions, 4, 69, 77
level of education, 103 MLT, 126, 127, 128, 129
libido, 82, 86, 87 modernisation, 2
188 Index
modification, 57, 127 overweight, 19

morbidity, 5, 6, 13, 17, 26, 28, 32, 41, 44, 49, 51, 55, ownership, 39
56, 60, 83, 96, 97, 98, 109, 112, 124, 125, 127,
130, 131, 141, 146, 168, 170, 171, 174, 177, 178
P
mortality rate, 55, 60
pain, xii, 1, 2, 5, 19, 24, 25, 30, 31, 34, 36, 37, 40,
mortality risk, 82, 96
47, 50, 60, 61, 71, 82, 83, 84, 88, 90, 95, 96, 97,
MPI, 126
101, 113, 115, 118, 124, 125, 127, 128, 135, 136,
MRI, 36, 37, 136, 140
137, 138, 139, 141, 151, 156, 157, 158, 159, 162,
mucosa, 13, 112, 116
163, 168, 174
multidimensional, 83, 90
palpation, 27, 180
N parallel, 9, 10, 12, 21, 42, 51, 62, 71, 116, 125, 127,
159
narcotics, 26 paralytic ileus, 127
narratives, 79 parity, 6, 26, 170
nasogastric tube, 115 patents, 39
National Survey, 172, 178 pathogenesis, 130
nausea, 113, 115 pathologist, 116
necrosis, 37, 103, 113, 114 pathology, 6, 9, 10, 27, 28, 49, 57, 101, 106, 117,
negative attitudes, 67, 77, 79 120, 130, 146, 147
negative consequences, 90 Pearson correlations, 72
negative outcomes, 83 pelvic inflammatory disease, 15, 27, 50, 100, 114
neoplasm, 139 pelvic ultrasound, 146
nerve, 33, 86, 118 pelvis, 9, 10, 20, 24, 28, 30, 31, 32, 50, 81, 86, 103,
Netherlands, 13, 52 117, 139, 147, 156
neurohormonal, 86 perceived outcome, 69
New England, 39, 43 perforated bowel, 117
New Zealand, 45 perforation, 58, 109, 115, 117
next generation, 2, 4 performance, 28, 30, 45, 101, 142, 143, 144, 155
Nissen fundoplication, 180 perineum, 117
nodes, 6 peristalsis, 13, 59, 151
nodules, 9 peritoneal cavity, 4, 12, 13, 14, 100, 151
North America, 162 peritoneum, 6, 9, 10, 11, 28, 31, 101, 110, 119, 138,
Norway, 24, 39, 164 147
nulliparity, 6, 26, 98 peritonitis, 114, 115, 179
nurses, 18, 19, 87 permission, 158
nursing, 83, 84 permit, 29
nutrition, 117 physiology, 85
placebo, 45, 133
O placenta, 97
plexus, 83
obesity, 6, 7, 20, 31, 48, 49, 50, 59, 61, 112, 126
pneumonia, 158
objectivity, 90
polyvinyl alcohol, 36
obstruction, 117, 139, 159
positive correlation, 89
occlusion, 57, 127, 130, 132, 133
postmenopausal women, 72, 73, 75, 97
omentum, 111, 112, 179, 180
postoperative outcome, 128
oophorectomy, 11, 25, 29, 40, 41, 42, 86, 91, 102,
pregnancy, xii, 78, 83, 88, 96, 104, 124, 133, 135,
105, 153, 164, 180
136, 138, 139, 140, 141, 142, 143, 144
opiates, 36
preterm delivery, 136, 139, 141
organ, 32, 44, 57, 67, 68, 78, 113, 114, 116, 120
prevention, 21, 61, 65, 116
osteoporosis, 102
probe, 11, 35, 37, 115, 117
ovarian cancer, 25, 40, 102
productivity, 83, 157, 158, 159, 163
ovariectomy, 131
profit, 2, 157
ovaries, 11, 25, 38, 82, 86, 91, 96, 98, 101, 102, 150
progesterone, 86
Index 189
progestins, 36 responsiveness, 68
project, 72 revenue, 163
prolapse, 19, 25, 27, 33, 38, 41, 44, 55, 70, 102, 120 rings, 141
prolapsed, 98 risk factors, 22, 53, 54, 61, 65, 111, 112, 114, 153
prophylactic, 59, 105 risk management, 2
prophylaxis, 115, 146 ruptured appendix, 179
proposition, 117
psychiatric morbidity, 81, 90
S
psychological well-being, 91
sadness, 84
psychosocial factors, 83
salpingo-oophorectomy, 28, 39, 42, 67, 68, 70, 72,
public health, 164
73, 74, 75, 152, 153, 165, 180
pulmonary embolism, 158
savings, 157
puncture wounds, 116
scar tissue, 15, 86
PVA, 36
scars, 30, 31, 158
Q schooling, 69, 74
sciatica, 118
quadriceps, 118 screening, 13
qualitative research, 90 secretion, 117
quality of life, 3, 24, 35, 36, 37, 38, 44, 45, 68, 76, self-concept, 69
78, 79, 81, 82, 83, 91, 92, 93, 96, 119, 157 self-esteem, 85
quantitative research, 90 self-image, 82
sensation, xii, 31, 124
R sensitivity, 136
sepsis, 115
radiation, 112
septum, 139, 140, 144
radiation therapy, 112
serotonin, 85
reactions, 67, 70, 78, 92, 173
sex, 61, 69, 71, 85
reality, 28, 161, 162
sexual activities, 88
recall, 88
sexual activity, 85, 87
reception, 70
sexual behaviour, 84, 88
recognition, 13, 15, 110, 113, 180
sexual orientation, 68
recommendations, 5, 27, 40, 157
sexuality, 33, 67, 78, 80, 83, 85, 86, 87, 88, 91
reconstruction, 5, 139, 141, 142
shape, 27, 140
rectocele, 102
shock, 56
rectosigmoid, 114, 116
shrinkage, 87
rectum, 3, 33, 100, 102, 117
side effects, 34, 36
recurrence, 34, 44, 130
signals, 9
reflective practice, 17, 19
signs, 56, 112, 114, 115
relatives, 68
silk, 116, 180
reliability, 71, 90
Sinai, 106
religion, 83
skin, 13, 14, 37, 110, 117, 124, 126, 127, 137, 151
rent, 157
sleep disturbance, 83
repair, 13, 33, 44, 48, 54, 55, 63, 111, 112, 113, 115,
small intestine, 33, 55, 116
116, 117, 127, 128, 139, 179, 181
smooth muscle, 129
replacement, 70, 74, 81, 111
social construct, 78
reproduction, 107, 142
social norms, 88
reproductive age, xi, 50, 95, 105, 106, 123, 162
social relations, 83
reproductive organs, 68
societal cost, 54
resection, 35, 38, 40, 44, 45, 104, 116, 140, 180
socioeconomic status, 69, 77
resistance, 4, 17, 58
Spain, 23, 109, 135
resolution, 34, 36
spirituality, 83
resources, 21, 24, 163
splenomegaly, 15, 147
respiratory failure, 103
splinting, 14
190 Index
spontaneous abortion, 136, 138 training, 2, 4, 5, 6, 14, 19, 26, 28, 30, 48, 98, 112,
standardization, 130 125, 153, 155, 162
stent, 59, 159 transection, 7, 55
sterile, 117 transformation, 101, 130
sterilisation, 5, 40 transfusion, 6, 51, 151
steroids, 34 transverse colon, 180
stigma, 69 trauma, 2, 43, 103, 114, 116, 117, 146
stomach, 115, 116 trial, 14, 16, 18, 28, 36, 40, 41, 42, 43, 44, 45, 46, 51,
stressors, 90 53, 62, 64, 82, 91, 107, 120, 132, 152, 156, 159,
stretching, 7, 118 165
stroma, 50 tumor, xii, 124, 126, 127, 129, 130
subgroups, 135 tumors, xii, 46, 97, 124, 126, 127, 130, 162
success rate, 29, 35, 127 Turkey, 68, 79, 81, 91, 92
Sun, 106, 123, 133 turnover, 20
supervisors, 57
suprapubic, 9, 112, 125, 126, 127
U
surgical intervention, xii, 35, 36, 86, 124
ulcerative colitis, 117, 180
surveillance, 39, 63, 106, 164
ultrasonography, 142
survey, 20, 43, 70, 72
ultrasound, xi, 7, 27, 36, 37, 46, 97, 123, 142, 144
survival, 25, 38, 39, 111
ultrasound screening, 144
survival rate, 25, 38, 39
United Kingdom, 1, 26, 48, 82, 97, 162, 164
susceptibility, 118
ureter, 6, 7, 9, 10, 11, 12, 13, 15, 17, 28, 31, 47, 54,
suture, 11, 29, 31, 112, 114, 116, 124, 125, 131, 138,
55, 57, 59, 60, 98, 99, 100, 112, 113, 138, 152
146, 147, 150, 151, 152, 159, 167, 168, 169, 170,
ureters, 9, 11, 15, 48, 53, 111, 113, 147, 152
171, 173, 174, 175, 176, 177
urinary dysfunction, 19
Sweden, 78, 162, 164
urinary tract, 5, 9, 13, 15, 17, 21, 32, 47, 50, 54, 55,
sympathetic nervous system, 86
58, 63, 109, 111, 112, 117, 120, 146
symptoms, xi, xii, 9, 24, 33, 34, 36, 78, 79, 81, 82,
urinary tract infection, 47, 58
83, 84, 87, 88, 90, 92, 97, 101, 104, 105, 113,
urine, 13, 58, 112, 113
115, 119, 123, 124, 129, 130, 136, 137, 141, 151
urologist, 113
synthesis, 80
uterine cancer, 164
T uterine fibroids, 31, 42, 46, 95, 96, 97, 103, 105, 131
uterine prolapse, 48, 91, 95, 96, 97, 162
Taiwan, 43, 47, 64, 123, 131 uterus, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 24, 25, 26, 27,
target organs, 86 28, 31, 41, 43, 48, 51, 52, 54, 59, 60, 63, 67, 68,
temperature, 9, 35, 51, 58 71, 78, 81, 82, 86, 87, 90, 91, 96, 98, 99, 100,
tension, 6, 9, 11, 86, 125, 173, 174 101, 104, 105, 106, 107, 117, 124, 125, 129, 136,
testosterone, 82 137, 138, 139, 140, 141, 142, 143, 144, 145, 146,
textbooks, 168, 174 147,묈150, 151, 152, 155, 161, 162, 165, 168,
theatre, 19 170, 173, 176
therapeutic intervention, 106
therapy, 36, 37, 38, 44, 46, 70, 74, 81, 87, 97, 102, V
104, 130, 134
thrombophlebitis, 101 vagina, 3, 4, 7, 11, 12, 24, 26, 28, 29, 33, 86, 98,
thrombosis, 6 102, 113, 117, 136, 137, 143, 151, 156
thyroid, 126 Valencia, 23
time frame, 2 variations, 36, 39, 86, 90, 98, 136
tissue, xi, 2, 9, 10, 32, 35, 37, 43, 56, 58, 59, 83, 86, varimax rotation, 71
116, 117, 123, 127, 128, 138, 156, 174, 180 vasculature, 147
torsion, 138 vasomotor, 34
tourniquet, 129 vasopressin, 59, 129, 133
traditions, 95, 100 vein, 113
trainees, 2, 3, 20 ventilation, 6, 118
Index 191
vessels, 3, 4, 9, 10, 11, 12, 14, 15, 36, 48, 57, 99, Western countries, 24
104, 109, 111, 113, 114, 129, 146, 147, 150, 151, windows, 58
152, 173, 176 withdrawal, 15
video, 101, 125, 171 workload, 17
viscera, 115 wound infection, 32, 158
vision, 11, 13, 32, 57, 58, 101, 102, 110, 147, 150
visualization, 101, 111, 112, 147, 180
X
vomiting, 113, 115
xiphoid process, 125
W
Y
wages, 157, 163
young women, 96
Wales, 164
waste, 41 Z
weakness, 118
weight changes, 84 zygote, 142

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OBSTETRICS AND GYNECOLOGY ADVANCES

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SURGERY - PROCEDURES, COMPLICATIONS

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NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

Hysterectomy : procedures, complications, and alternatives / editor, Deborah

Published by Nova Science Publishers, Inc. † New York

Chapter 10 Total Laparoscopic Hysterectomy for Large Uterus 145

menorrhagia, dysmenorrhea, and inter-menstrual bleeding, pressure symptoms, a bloated

Conclusion: Total laparoscopic hysterectomy is a technically feasible procedure. All the

Laparoscopic Hysterectomy: Its

Table 1. Laparoscopic associated hysterectomy classification

1. Diagnostic laparoscopy with vaginal hysterectomy

There are evidence-based recommendations suggesting that vaginal hysterectomy should

Urinary Tract Injuries

Ureteral or bladder injury in Laparoscopic Hysterectomy is one of the most troublesome

Bowel / Vascular Injury

the declining rates of hysterectomy due to hormonal intrauterine systems as well as

Obesity is sometimes considered a contraindication for LH but Chopin et al [10] showed

Long Term Complications

M. Gurrea*, S. Domingo and A. Pellicer

Keywords: hysterectomy, laparoscopic, vaginal, abdominal, guidelines, benign uterine

abdominal surgery. Many gynaecologic surgeons continue to perform hysterectomies by

Hysterectomy and Bilateral Salpingoophorectomy

This is another of the relevant factors in determining the route of a hysterectomy. A

In benign conditions, AH should be adopted only when pathological circumstances and

procedures that may need to be performed. Bilateral salpingo-oophorectomy is usually a

transcendental aspect is uterine mobility, as a fixed uterus is a challenge to the laparoscopic

Impact on Pelvis Floor Dysfunction

Levonorgestrel-Releasing Intrauterine Device

levonorgestrel over a period of 5 years through a rate-limiting membrane (20 µg/day). In

Uterine Artery Embolization

menorrhagia, for whom it offers an option of conservative management. Nevertheless, the

 Hysterectomy indications show a slow but continuous diminution thanks to more

Financial Disclosure / Acknowledgments

[67] Schutz K, Possover A, Merker A et al. Prospective randomized comparison on

[102] O‘Connor H, Broadbent J, Magos A, McPherson K. Medical research council

The Complications of Laparoscopic

Kok-Min Seow1, 2*, Yu-Hung Lin1,3 and Jiann-Loong Hwang1,4

Factors Associated with Increased Risk

3. Previous cesarean section: Cesarean section is the most commonly performed

Complications of Laparoscopic Hysterectomy

Intra-Operative Blood Loss

Table 1. Mean blood loss (ml) in three methods of hysterectomy

Study (years) TAH VH LAVH

Table 2. Bladder injuries in LAVH, TAH and VH

Studies LAVH/TLH TAH VH

in LH. Furthermore, surgeon experience is another important factor of increased bladder

Vaginal Colpotomy Wound Hemorrhage

occlusion by application of pressure of the pneumoperitoneum and placement of the patients

Major Vessels Injury

Methods to Reduce the Complications

[10] Kadar N, Lemmerling L. Urinary tract injuries during laparoscopically assisted

[28] Kataoka ML, Togashi K, Yamaoka T, Koyama T, Ueda H, Kobayashi H, Rahman M,

Beliefs, Attitudes and Psychological

Ma. Luisa Marván1 * and Rosa Lilia Castillo-López1,2

Table1. Sample characteristics (n = 94)

Data were collected using two surveys:

Some participants (39%) were recruited in a gynecological clinic waiting room. A