A new approach to hysterectomy without colpotomy: pelviscopic intrafascial hysterectomy

Abstract

Objective: Total abdominal and vaginal hysterectomies have been performed by extrafascial enucleation of the uterus with amputation of the upper vagina. Our new method, which is limited to an intrafascial cylindriform enucleation of the cervix, leaves intact the highly vascularized extrafascial cervical tissue, the corresponding nerves, and the topography of the ureters.

Study design: From December 1991 to December 1992, 60 patients underwent an intrafascial hysterectomy by pelviscopy and two patients by laparotomy for leiomyomas, endometriosis, and other intractable bleeding disorders and for a variety of additional benign gynecologic diseases. Uterine extirpation was performed in the classic manner with grasping forceps, scissors, ligatures, and sutures. No electrosurgical equipment, stapling devices, or lasers were used.

Results: We analyzed our cases according to intraoperative, immediate postoperative, and late postoperative complications. We had no major complications. Average operating time is compatible with that of conventional total abdominal or vaginal and laparoscopy-assisted vaginal hysterectomy. Blood loss was minimal (average drop of hemoglobin 1.8 gm). Average hospitalization was 50.6 hours.

Conclusion: There has never been an indication for the removal of the normal cervix at hysterectomy, other than for cancer prophylaxis. The synthesis of supracervical extirpation of the uterus, conization of the cervix, and operative laparoscopy (pelviscopy) enables us to perform a truly laparoscopic hysterectomy without colpotomy. Pelvic floor support is maintained and transvaginal sexual sensation is less likely to be impaired because of the preservation of the cardinal and uterosacral ligaments. With the serrated-edge macromorcellator, morcellated cylinders of cervical and uterine body tissue guarantee a thorough histologic examination and interpretation. Physical stress to the patient is minimized. There are no abdominal or vaginal incisions. The abdominal space remains practically unopened. Pelviscopic intrafascial hysterectomy equates with minimally invasive and organ-preserving surgery. It may be sufficient for cervical and endometrial cancer prophylaxis.