Laparoscopic hysterectomy for large uteri: Outcomes and techniques

Abstract

Aim: The aim of this study was to analyse our data of laparoscopic hysterectomy for large uteri (>16 weeks size) regarding their perioperative outcomes and possible factors for conversions to open surgery over 5 years. It also describes our techniques for the feasibility of performing such hysterectomies by the minimally invasive way.

Materials and methods: A five-year retrospective chart review was performed at the Minimal Access and Robotic Surgery Unit of the Department of Gynecology at Apollo Hospital, Hyderabad. Demographic and pre-operative and post-operative data were recorded. Clinical assessment including bimanual examination and surgery was made by a single senior surgeon. Intra-operative conversions, complications and post-operative complications were recorded.

Results: A total of 128 women were included in this study, 5 patients underwent robotic-assisted hysterectomy. The average age was 44.4, body mass index - was 27.6 and size of the uterus was 17.5 weeks. The most common diagnosis was leiomyoma. The median Operating room (OR) time was 107 min. There was a need for myomectomy in 39.8%, extensive adhesiolysis in 33.6% and dense bladder adhesion in 26.6%. The average drop in haemoglobin was 1.72 g%, and hospital stay was 2 days. The specimen was removed by vaginal morcellation (2 cases via an umbilical port). Conversion to open surgery was required in 10.9% of cases. The conversion was significantly correlated with excessive haemorrhage and bladder injury but not with difficult hysterectomy, difficult bladder dissection or adhesions. There were 3 cases of bladder injury detected and managed intraoperatively.

Conclusion: Laparoscopic hysterectomy is technically feasible and safe procedure for large uteri. The learning curve is about 50 cases and can be performed by experienced surgeons regardless of the size, number or location of the myomas without much morbidity.

Keywords: Conversion; feasibility; fibroid; hysterectomy; laparoscopic; outcomes; robotic; techniques.

Figure 1

(a) Clinical picture showing the size of uterus of 22 weeks included in study. (b) Laparoscopic view of the same case (22 weeks) before starting the laparoscopic hysterectomy

Figure 2

Depicts the number of cases, need for supra pubic incisions, haemorrhage and blood transfusions over 5 years

Figure 3

(a) Intra-operative myomectomy being performed before hysterectomy in a case with large right lower uterine myoma extending into broad ligament. (b) 30° degree, 10 mm telescope camera skilfully rotated to visualize the left uterine artery from the left lateral aspect. (c) Myoma screw being used for manipulation and cranial traction during laparoscopic hysterectomy. (d) Vaginal vault opened posteriorly without any colpotomiser. This is then extended both sides to severe cervix from vault. (e) Port placement; 10 mm primary port at upper border of umbilicus, two 5 mm ports on the left side and one 5 mm port on the right side of abdomen. (f) Morcellated specimen depicting the technique to convert a globular specimen to longitudinal one