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Uterine Fibroid Embolization — 337
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the existing fibroid, presenceof extrauterine blood supply,growth
of new fibroids, or etiologies other than myomas.
Resolution of dysmenorrhea and bulk-related symptoms has
been reported to be in the 80% to 90% range. The potential reasons for lack of complete response in these patients are discussed
below.
In a recent study of 2112 eligible patients, a change in symptom severity and health-related quality of life among patients
treated with UFE was reported.[10] At 12 months, symptom
improvement was observed in 94.53% of patients, with the mean
symptom score improving from 58.61 to 19.23 (P ≤ 0.001). The
mean health-related quality-of-life score improved from 46.95 to
86.68 (P ≤ 0.001). Hysterectomy was required in only 2.9% of
patients in the first 12 months.
Reduction in the volume of the fibroids depends on the
tumors’ initial size, vascularity, and presence or absence of previous spontaneous infarcts. It averages around 50% to 60%
decrease in volume and is continuous over time, with the maximum rate of shrinkage occurring in the first 6 to 12 months
post embolization.[8] The degree of reduction in the volume of
leiomyomas after UFE is unpredictable and cannot be guaranteed in any one patient. For this reason, we recommend surgery
to women who seek cosmetic relief from fibroids. Despite the
emphasis of many physicians and patients on the size of fibroids,
there appears to be no correlation between reduction in fibroid
volume and degree of relief from symptoms after UFE.
Studies addressing the long-term efficacy of UFE have confirmed the durability of this procedure in patients with symptomatic fibroids. Spies et al. [11] followed 200 consecutive
patients who had undergone UFE. Of the 182 patients with complete follow-up data, 73% remained symptom-free at 5 years.
Although UFE results in a decrease in fibroidsizeandstopsthe
pathologic preferential flow away from the muscle of the uterus,
its role in the treatment of fibroid-related infertility has not been
comprehensively studied to date. For this reason, UFE is not recommended for treatment of infertility until more data become
available.
the point anastomosis. Fibroid devascularization is hence unaffected. Disruption of flow at any point proximal to these anastomoses, which may occur with uterine artery ligation, will not
cause fibroid infarction and lasting symptom relief in women
with this type of anastomosis.
In type II anastomosis, direct parasitization of the flow from
the ovarian arteries to the fibroids occurs. Although connections
to the intramural uterine artery may exist, flow to the fibroid
is anatomically independent of uterine artery. This occurs in
approximately 8% of women and may be an important cause
of procedural failure after UFE.[12]
Conversely, in type III anastomosis, the ovarian supply is
mainly from the uterine artery through the tubal arteries. Independent ovarian arteries are not seen. At angiography, the
observed flow is therefore toward the ovary. This pattern of flow
has been observed in approximately 6% of arteries. This pattern
of flow will not change the efficacy of fibroid devascularization
but may be a cause of ovarian failure.
UFE VERSUS SURGERY
Several studies have compared UFE with surgery, either abdominal myomectomyor hysterectomy. Inthe first suchstudy, the outcomes of two uterine-sparing procedures (UFE and abdominal
myomectomy) were retrospectively compared in 111 patients.[9]
Efficacy,complication, and recovery periods were the main study
outcome measures of this analysis. Results are summarized in
Tables 12.2.1 and 12.2.2.
Statistical analysis of these results revealed that UFE is significantly better than myomectomy in relieving menorrhagia, with
both procedures being equallyeffective in controlling pelvicpain.
There was a trend toward better improvement in symptoms of
mass effect, such as urinary frequency and constipation, after
myomectomy.
Comparison of other outcome measures, such as postprocedural pain, recovery period, and complications, all favored UFE
CAUSES OF UFE FAILURE
Clinical failure of UFE occurs in a relatively small number of
patients. There are several causes for failure, including coexistence of other pelvic pathologies not responding to UFE, unrealistic patient expectations, and inadequate embolization leading to suboptimal fibroid infarction, which may be the result of
extrauterine arterial flow to the fibroids. Ovarian arteries are the
most important source of such collateral flow.
The majority of vascular communications between theuterus
and ovary aretoosmall to be visualized atangiography and do not
affect the outcome of UFE.However, threemain types ofovarianto-uterine artery anastomosis that are of prognostic significance
have been described at angiography.[12]
The most common anastomosis is type I, which occurs in
approximately 28% of women with symptomatic fibroids. The
ovarian artery connects to the intramural uterine artery via the
tubal segment, with flows toward the uterus. Type I anastomosis is a substantial source of collateral flow to the uterus and
fibroids. In this type, ovarian artery supply is not a likely source
of UFE failure because the embolization typically occurs distal to
Table 12.2.1: Percent Response after Abdominal Myomectomy (AM) and UFE
Menor- Pain Mass Effect
rhagia, % Number,% Number,%
Response Category AM UFE AM UFE AM UFE
6 (resolved) 27 60 38.5 29.5 65 19
5 (significantly
improved)
4 (moderately
improved)
3 (no change) 9 2 4 3 0 5
2 (moderately worse) 4.5 0 4 0 0 0
1 (significantly worse) 0 0 0 0 0 0
% Improvement 86.5 98 92 97 100 95
Adapted from Razavi MK, et al. [9].
36 32 15.5 44 26 57
23 6 38 23.5 9 19
338 — Mahmood K. Razavi
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Table 12.2.2: Comparison of Other Outcome Measures
AM, mean
(range)
Inpatient hospital days 2.9 (2–7) 0 ≤ 0.05
Days on pain medications 8.7 (2–47) 5.1 (1–21) ≤ 0.05
Days to normal activity 36 (7–120) 8 (1–49) ≤ 0.05
Secondary interventions,% 10 8 NS
Estimated blood loss, mL 376
(50–2000)
Complications,% 25 10 ≤ 0.5
NS, not significant.
Adapted from Razavi MK, et al. [9]
UFE, mean
(range) P value
Minimal
(Table 12.2.2). The need for secondary interventions during the
study period was similar in both groups.
The complications included nonautologous blood transfusion (n =3), wound infection (n = 2), adhesion (n = 2), readmission for ileus (n = 1), and chronic pelvic pain (n =2)
among the myomectomy patients. Complications in the fibroid
embolization group included endometritis requiring readmission for intravenous antibiotics (n = 1), readmission for pelvic
pain (n = 1), and menopause (n = 4). All those who experienced menopause after fibroid embolization were older than
46 years.
In a prospective randomized study of 63 women with intramural fibroids larger than 4 cm who desired future fertility, Mara
et al. [13] compared UFE to myomectomy. Similar to the study
by Razavi et al. [9], UFE was associated with fewer hospital days,
procedure time, blood loss, and disability period. Complication
rate and follicle-stimulating hormone (FSH) levels were similar
at 6 months, although the UFE group reported a lower rate of
symptom relief.
UFE has also been compared with hysterectomy. Pinto et al.
[14] conducted a prospectiveanalysis of hysterectomyversusUFE
in 60 patients. UFE was associated with fewer complications and
a shorter hospital stay.Spies etal. [15],in a prospectivemulticenter trial of UFE versus hysterectomy, reported similar results. In
this study, pain relief was more common among those with hysterectomy, with both groups experiencing marked improvement
in other symptoms and quality-of life-scores, with no difference
between them. Complications were more frequent in the hysterectomy group (50% vs. 27.5%).
In a cost-effectiveness analysis, Beinfeld et al. [16] developed
a decision model to compare the costs and effectiveness of UFE
and hysterectomy. They concluded that UFE is less expensive and
more effective than hysterectomy. In their model, however, when
the quality-of-life adjustmentwas eliminated, the twoprocedures
were equally effective.
UFE AND PREGNANCY
The issue of pregnancy after UFE has been addressed in only a
small number of studies. Kim et al. [17] reviewed their experi-
ence in 94 patients and concluded that UFE with PVA particles
does not seem to affect fertility among women who do not use
contraception.
Based on their study of 671 women who underwent UFE,
Carpenter et al. [18] observed no increased obstetric-associated
risk, with the exception of the number of patients who underwent cesarean section. In a similar large multicenter clinical registry of 555 patients with a mean age of 43 years, the enrolled
women were followed prospectively.[19] Thirty-one percent of
the patients were younger than 40 years. Although it is unclear
as to what fraction of women who were trying to get pregnant
actually did, 24 pregnancies were reported in women who were
an average age of 34 years. There were four spontaneous abortions and four preterm deliveries. Abnormal placentation was
seen in three women. The authors concluded “women are able to
achieve pregnancies after uterine artery embolization, and most
resulted in term deliveries and appropriately grown newborns.”
Close monitoring of placental status, however,wasrecommended
in this study.
In comparison with myomectomy, McLucas et al. [20]
and Goldberg et al. [21] reached opposite conclusions. The
McLucas group observed no difference in pregnancy outcome
between those who underwent UFE versus those who had
myomectomy, whereas the Goldberg group reported a higher
incidence of complications in UFE patients. It should be noted
that both these studies suffer from major methodologic flaws,
and their results should be interpreted with caution.
COMPLICATIONS OF UFE
Serious complications after UFE are rare. In a large prospective
multicenter study of 3160 patients enrolled in 72 sites, major inhospital complications occurred in 0.66% of patients.[22] The
30-day complication rate was 4.8%, with no reported deaths.
The most common complication was inadequate pain control requiring a hospital visit by 2.4% of patients. One percent required additional surgical procedures within the first 30
days, with 0.1% undergoing hysterectomy. Multivariate analysis
showed modest increased odds for an adverse event for African
Americans, smokers, and those with prior leiomyoma procedures.[22]
Endometritis has been reported to occur in 1% to 4% of
patients after UFE. The most common risk factors for infection
are the presence of large submucosal fibroids or preexistence of
an undetected or incompletely treated pelvis infection. In these
patients, aggressive therapy with antibiotics is warranted to prevent further progression, which may lead to sepsis and/or hysterectomy.
A long-term complication of UFE is ovarian failure and early
menopause. The risk of ovarian failure is age dependent and
highest in women over the age of 45. Review of the literature
reveals that less than 1% of women under the age of 40 develop
menopause after UFE. This risk increases to 15% for those older
than 45 years.[12,23]
Other, less common complications occurring in less than 1%
of patients include vessel injury, deep vein thrombosis, and pulmonary embolism.
Uterine Fibroid Embolization — 339
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POSTPROCEDURAL CARE AND FOLLOW-UP
As mentioned above, the most common reason for postprocedural physician visits after UFE is inadequate pain control.
Because of the less invasive nature of UFE, occasionally the treating physicians have a tendency to underprescribe pain medications. According to the published studies, women will experience
pelvic discomfort for an average of 3 to 4 days after the procedure
and may require oral analgesics. Thedegree of pain is highly variable, with no reliable preprocedural indicator. Rarely, pain may
last longer, but persistent pelvic discomfort for a period longer
than 3 weeks or recurrence of pain after an initial abatement
requires evaluation.
Postembolization syndrome is a constellation of symptoms
including nausea, low-grade fever, and malaise and is common
after UFE. This syndromemay last for 4 to 7 days post procedure,
and the treatment is supportive, including the use of antiemetic
and anti-inflammatory medications.
A self-limiting vaginal spotting with a brownish discharge
is also a common finding and may occur for several weeks after
embolization. In fewer than10% of women,the discharge may be
associated with passing of tissue and clot,which have been shown
histologically to be fibroid fragments. Transcervical expulsion of
leiomyomas may occur in 1% to 2% of patients and is associated with pain and bleeding. These are typically submucosal
fibroids, which detach into the uterine cavity about 4 to 12 weeks
after embolization. Incomplete passage is associated with a high
risk of infection andmay require hospitalization and intravenous
antibiotics. Delayed passage of leiomyomas for up to a year after
UFE has also been reported.[24]
After the initial postprocedural follow-up, patients are seen
in follow-up approximately 3 months later. Follow-up MRI is
obtained 6 to 12 months later.
Temporary amenorrhea occurs in approximately 5% to 8%
of women during the first 3 months following the procedure.
Menses resumes in the majority of these women, with no permanent sequela. No specific therapy is prescribed in these patients.
If amenorrhea persists, a serum FSH may be obtained to evaluate
for menopause.
SUMMARY
UFE is auterine-sparing alternative to hysterectomythathas been
shown to be an effective therapy for women with fibroids. By
permanently eliminating the blood flow to the fibroids, UFE alleviates symptoms and reduces fibroid volume and uterine size.
Advantages include the elimination of surgical risks, treatment
of the entire fibroid burden with one therapy, preservation of
fertility, and reduction of hospitalization and recovery times.
Although the role of UFE in the treatment algorithm for leiomyomas remains controversial, it should be offered to women who
do not desire surgery or those who have failed medical or less
invasive surgical therapies before hysterectomy is advised.
REFERENCES
1. Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE,
Miller FJ Jr. Uncontrollable postpartum bleeding: a new approach
to hemostasis through angiographic arterial embolization. Obstet
Gynecol. 1979;54(3):361–365.
2. Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery
embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol. 1997;176(4):938–948.
3. Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial
embolisation to treat myomata. Lancet. 1995;346:671–672.
4. Spies JB, Ascher SA, Roth AR, Kim J, Levy EB,Gomez-JorgeJ. Uterine artery embolization for uterine leiomyomata. Obstet Gynecol.
2001;98:29–34.
5. Goodwin SC, McLucas B, LeeM, et al.Uterineartery embolization
for the treatment of uterine leiomyomata: midterm results. J Vasc
Interv Radiol. 1999;10:1159–1165.
6. Worthington-KirschRL, Popky GL,Hutchins FLJr.Uterine arterial
embolization for the management of leiomyomas: quality-of-life
assessment and clinical response. Radiology. 1998;208:625–629.
7. Hutchins FL Jr, Worthington-Kirsch R. Embolotherapy for
myoma-induced menorrhagia. Obstet Gynecol Clin North Am.
2000;27:397–405.
8. Spies JB, Roth AR, JhaRC, et al. Leiomyomata treated with uterine
artery embolization: factors associated with successful symptom
and imaging outcome. Radiology. 2002;222:45–52.
9. Razavi MK, Hwang G, Jahed A, Modanloo S, Chen B. Abdominal myomectomy versus uterine fibroid embolization in the treatment of symptomatic uterine leiomyomas. AJR Am J Roentgenol.
2003;180(6):1571–1575.
10. Spies JB, Myers ER, Worthington-Kirsch R, Mulgund J, Goodwin
S, Mauro M; the FIBROID Registry Investigators. The FIBROID
Registry: symptom and quality-of-life status 1 year after therapy.
Obstet Gynecol. 2005;106(6):1309–1318.
11. Spies JB, Bruno J, Czeyda-Pommersheim F, Magee ST, Ascher
SA, Jha RC. Long-term outcome of uterine artery embolization
of leiomyomata. Obstet Gynecol. 2005;106(5):933–939.
12. Razavi MK, Wolanske K, Hwang G, Sze D, Kee S, Dake M. Angiographic classification of ovarian to uterine artery anastomoses:
incidence and significance in UFE. Radiology. 2002;294:707–712.
13. Mara M, Fucikova Z, Maskova J, Kuzel D, Haakova L. Uterine
fibroid embolization versus myomectomy in women wishing to
preserve fertility: preliminary results of a randomized controlled
trial. Eur J Obstet Gynecol Reprod Biol. 2006;126(2):226–233.
14. Pinto I, Chimeno P, Romo A, et al. Uterine fibroids: uterine artery
embolization versus abdominal hysterectomy for treatment – a
prospective, randomized, and controlled clinical trial. Radiology.
2003;226(2):425–431.
15. Spies JB, CooperJM, Worthington-Kirsch R, Lipman JC, MillsBB,
Benenati JF. Outcome of uterine embolization and hysterectomy
for leiomyomas:resultsofamulticenterstudy.Am J Obstet Gynecol.
2004;191(1):22–31.
16. Beinfeld MT,BoschJL,IsaacsonKB,GazelleGS.Cost-effectiveness
of uterine artery embolization and hysterectomy for uterine
fibroids. Radiology. 2004;230(1):207–213.
17. Kim MD, Kim NK, Kim HJ, Lee MH. Pregnancy following uterine
artery embolization with polyvinyl alcohol particles for patients
with uterine fibroid or adenomyosis. Cardiovasc Intervent Radiol.
2005;28(5):611–615.
18. Carpenter TT, Walker WJ. Pregnancy following uterine artery
embolisation for symptomatic fibroids: a series of 26 completed
pregnancies. Br J Obstet Gynaecol. 2005;112(3):321–325.
19. Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L; Ontario UFE Collaborative Group. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter
trial. Obstet Gynecol. 2005;105(1):67–76.
20. McLucas B, Goodwin S, Adler L, Rappaport A, Reed R, Perrella R.
Pregnancy following uterine fibroid embolization. Int J Gynaecol
Obstet. 2001;74(1):1–7.
340 — Mahmood K. Razavi
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21. Goldberg J, Pereira L, Berghella V, et al. Pregnancy outcomes after
treatment for fibromyomata:uterineartery embolization versuslaparoscopic myomectomy. Am J Obstet Gynecol. 2004;191(1):
18–21.
22. Worthington-Kirsch R, Spies JB, Myers ER, et al.; FIBROID Investigators. The Fibroid Registry for outcomes data (FIBROID)
for uterine embolization: short-term outcomes. Obstet Gynecol.
2005;106(1):52–59.
23. Chrisman HB, Sakter MB, Ryu RK, et al. The impact of uterine
fibroid embolization on resumption of menses and ovarian function. J Vasc Interv Radiol. 2000;11:699–703.
24. Spies JB, Spector A, Roth AR, Baker CM, Mauro L, MurphySkrynarz K. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol. 2002;100(5 pt 1):873–
880.
13 HYSTERECTOMY
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Section 13.1. Laparoscopy and Hysterectomy
Farr Nezhat and Jyoti Yadav
The number of hysterectomies, a frequently practiced major surgical procedure, varies between different regions and cultures of
the world. It reflects differencesin health caresystems, education,
and psychosocial attitudes. The highest rates of hysterectomy are
found in the United States and Australia (36% and 40%, respectively) and the lowest in Italy (15.5%) and France (8.5%).[1–3]
INDICATIONS
Most hysterectomies are performed for leiomyomas,uterine prolapse, endometriosis, and gynecologic cancer.[4] The number
of hysterectomies for endometriosis doubled between 1965 and
1984, exceeding the increase observed for any other indication
and probably reflecting an increased recognition of endometriosis. Other indicationsareabnormal uterine bleeding, pelvicinfection and its sequelae,ovarian tumors,and complications of pregnancy. These indications account for 15% to 21% of all hysterectomies.
About 75% of all hysterectomies are done abdominally and
25% vaginally.[4,5] The vaginal approach is primarily used for
uterine prolapse. Abdominal hysterectomy is usually done for
women with significant pelvic disease, such as endometriosis
or pelvic adhesions, which can make a vaginal removal more
difficult (Table 13.1.1).[6] Compared to those having a vaginal
hysterectomy, women having an abdominal operation have more
febrile morbidity, receivemore blood transfusions [5,7],andhave
a longerpostoperativehospitalization and convalescence. If more
women had a vaginal ratherthanan abdominal approach for their
hysterectomy, therapeutic, economic, and social benefits would
result.[8]
The route selected depends on the clinical assessment of the
pelvic disorder, which is based on the medical history, pelvic
examination, ultrasound studies, review of prior operative notes,
and the surgeon’s experience in vaginal surgery.[8]
The role of the laparoscope in assisting vaginal hysterectomy has been described by Semm since 1984.[9,10] Laparoscopic hysterectomy using bipolar electrocautery and the endoscopic stapler was first described in 1989 [11] and 1990 [12],
respectively. Kovac and coworkers [13] performed diagnostic
laparoscopy in 46 patients scheduled for abdominal hysterectomy who, on the basis of clinical indicators, were thought to
have a serious pelvic abnormality that contraindicated vaginal
hysterectomy. Based on the laparoscopic findings, 42 of the 46
women (91%) were candidates for vaginal hysterectomy, which
was done under the same anesthesia. Because clinical assessment
of pelvic disease may not be accurate, laparoscopy can reveal
whether a vaginal approach is appropriate. For these women,
diagnostic or operative laparoscopy provided the benefits of
both vaginal and abdominal approaches without their disadvantages (Table 13.1.2). A comparison of the results of abdominal
hysterectomy versus laparoscopic hysterectomy in 20 cases was
reported by Nezhat et al. in 1992.[14] That report established the
validity oflaparoscopicallyassistedvaginal hysterectomy(LAVH)
and suggested that it could replace most abdominal hysterectomies for benign lesions. The indications for laparoscopically
assisted hysterectomy in this series were similar to those listed
for abdominal rather than vaginal hysterectomy. All hysterectomies were completed successfully endoscopically without significant complications. Patients had reduced morbidity, blood
loss, postoperative discomfort, hospitalization, and recovery
time.
A review of the literature reveals many definitions of a
laparoscopically assisted hysterectomy. A suggested classification
follows:
1. Total laparoscopic hysterectomy (TLH). The hysterectomy is
done laparoscopically; the vaginal cuff may be closed laparo-
scopically or vaginally.
2. Subtotal laparoscopic hysterectomy (SLH). A supracervical
hysterectomy is done laparoscopically.
3. LAVH. The hysterectomy starts laparoscopically, but most
steps, especially the uterosacral and cardinal ligaments, are
done vaginally.
A laparoscopic approach allows the treatment of intraabdominal and pelvic disease and the dissection or removal
of adnexa. Patients who have suspected pelvic endometriosis
undergo a diagnostic laparoscopy to inspect the pelvis. Significant
pelvic diseaseis treated endoscopically,and if necessary, adnexectomy is performed. The hysterectomy is completed vaginally.[13]
Usually, a combined laparoscopic and vaginal approach is used
to dissect and remove uterine attachments.[15–19] The extent
of laparoscopic and vaginal dissection depends on the gynecologist’s preference and experience with laparoscopic and vaginal
operations. A more experienced endoscopist can do the entire
hysterectomy laparoscopically.[20] However, TLH may be time
consuming, especially if the uterus is more than 16 to 18 weeks’
gestational size. Laparoscopic hysterectomy is useful if the vagina
is small and narrow and significant infiltrative pelvic endometriosis is present, which would make a vaginal operation difficult.
Almost all abdominal hysterectomies for endometriosis can be
converted to LAVH.[21] Patients who have the indications for
traditional vaginal hysterectomy should not undergo LAVH, vaginally assisted laparoscopic hysterectomy, or laparoscopic hysterectomy.[22]
341
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Table 13.1.1: Indications for Hysterectomy
Abdominal Vaginal
Hysterectomy,% Hysterectomy,%
Leiomyomas 38 1
Uterine prolapse 1 76
Endometriosis 3 0
Abnormal bleeding 13 9
Adenomyosis 9 8
Pelv ic
pain/adhesions
Ovarian tumors 10 0
Uterine neoplasia 15 3
Source: Dicker et al.[5]
PREOPERATIVE EVALUATION
50
Routine preoperative tests include a complete blood count
with differential, serum electrolytes, bleeding time, and urinalysis. More comprehensive blood studies, thrombin time, partial
thrombin time, electrocardiography (ECG), chest radiography,
and endometrial biopsy are done as indicated. Amechanical and,
at times, anantibioticbowelpreparationisadvised.Consultations
with a urologist, colorectal surgeon, and oncologist are sought as
necessary. Appropriate informed consent is obtained from the
patient after a thorough explanation of the planned operation,
its potential risks and benefits, the possibility of laparotomy, and
therapeutic alternatives. After an overnight fast, the patient is
admitted to the ambulatory surgical unit the morning of her
operation.
TECHNIQUE
Laparoscopically Assisted Vaginal Hysterectomy
The patient’s initial position is the same as that for standard
laparoscopy. The 10-mm trocar is inserted transumbilically for
placement of the operativelaparoscope,andtwo to four accessory
trocars are positioned suprapubically.Forthevaginal portion, the
patient’s legs arereadjusted to allowvaginal access (Allen Universal stirrups, Allen Medical Systems). With an adjustment under
the drapes, the legs are flexed and abducted without redraping.
Some gynecologists prefer to place the patient’slegs in candy-cane
stirrups for the vaginal portion. Various types of uterine manipulators can be placed inside the uterus of facilitate manipulation
intraoperatively.
Every operative laparoscopy begins with exploration of the
abdominal and pelvic cavity to assess the extent of disease.
Anatomic landmarks, anomalies, distortions, and alterations are
identified. The locations of the bladder, ureters, colon, rectum,
and major blood vessels are noted. The omentumandsmallbowel
are evaluated for disease and checked for Veress needle or trocar
injury.
After the diagnostic portion, the operator uses the CO
2
laser
or othercutting instrument and hydrodissection to resect, ablate,
or coagulate implants of endometriosis. An electrocoagulator,
Table 13.1.2: Advantages and Disadvantages of Abdominal,
Vaginal,and LaparoscopicallyAssisted VaginalHysterectomy
(LAVH)
Abdominal Vaginal LAVH
Exposure Excellent Limited Excellent
Associated
pelvic disease
Incision Abdominal Vaginal Abdominal/vaginal
Hospitalization,
days
Cost Average Average More expensive
Morbidity, % 30 10 10
Surgical
expertise
Oophorectomy Easy ≤25% Easy
Easily
treated
3 2–3 1–2
Average
gynecologist
Reduced
access
Average
gynecologist
Easily treated
Experienced
endoscopist
clips, staplers, or Endoloops (Ethicon) are used to coagulate or
ligate large vessels. Monopolar electrodes, fiber lasers, or the harmonic scalpel maybeused for smallerbleeders.[23] Other instruments include bipolar forceps (middle port), suction–irrigator
probe (left), and grasping forceps (right).
The bowel is freedfrom the pelvicorgans to expose thepelvis.
Ovaries and tubes are dissected from the cul-de-sac or pelvic side
wall, and endometriosis or other abnormalities are treated.
Ureteral Evaluation and Dissection
The direction and location of both ureters are identified from
the pelvic brim to the cardinal ligaments, where they are no
longer visible. This is undertaken early in the operation, before
pelvic side wall peritoneum becomes edematous or opaque and
ureteral peristalsis is inhibited due to irritation by the CO
pneu-
2
moperitoneum or hydrodissection. The course of the ureters is
marked superiorly with the laser or electrocoagulation so that
they can be identified while the broad ligament and adnexa are
dissected (Figure 13.1.1). For extensive endometriosis, very wide
dissection, as is done during radical hysterectomy, is sometimes
necessary.[16,17]To identifytheuretersatthe level of thecardinal
ligaments, the peritoneum is opened above or below the ureter
and hydrodissection is carried out. A peritoneal incision is made,
and the ureter is identified toward its course tothe bladder. Small
bleeding vessels are coagulated by laser or electrosurgery. If the
uterosacral ligaments are dissected, theureterisretracted laterally
and the uterosacral ligaments are dissected at their origin from
the cervix. The uterine vessels run superiorly. They are isolated
and safely coagulated. When the pelvic anatomy is distorted, it
may be saferto do acystoscopyand place catheters in both ureters
for better identification.
Upper Broad Ligament and Adnexa
If adnexectomy is indicated, after electrocoagulation and transection of the round ligaments 2 to 3 cm from the uterus,
the infundibulopelvic ligament is coagulated and cut. If the
endoscopic linear stapler is used, the appendage is grasped with
Hydrodissection
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in infundibulopelvic ligament
A
laser
CO
2
incising the
peritoneum
B
C
Figure 13.1.1. (A) After an opening is made above the ureter in the peritoneum, retroperitoneal hydrodissection is carried out. (B) Using the
suction–irrigator probe as a backstop, an opening is made above the ureter with the CO
the back of the bladder by using blunt hydrodissection.
Peritoneum
retracted to
expose ureter
laser. (C) The ureter is dissected from the pelvic brim to
2
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First application
of stapling device
(ENDOPATH ELC 35)
on infundibulopelvic
ligament
AB
Figure 13.1.2. (A) The linear stapler is applied across the infundibulopelvic ligament. Ureteral evaluation before transection of the ligament is
very important. (B) Second application of the stapler across the infundibulopelvic ligament. The round ligament may be included.
forceps. It is retracted medially and caudally to stretch and outline the infundibulopelvic ligament,whichis grasped andsecured
with the stapler.Auterinemanipulator(HUMI[CooperSurgical]
or other uterine manipulator) placed inside the uterus vaginally
is helpful in retracting the uterus in the opposite direction, facilitating the stretch on the infundibulopelvic ligament. The stapler is not fired until the contained tissue is identified and the
ureteral position is confirmed. Once it is transected, the staple
line is examined for placement and hemostasis. After infundibulopelvic ligament transection, the adnexa and uterine fundus are
retracted in the opposite direction. Tissue of the upper broad
ligament, including the round ligament, is grasped, secured, and
cut after safemargins have been established(Figure 13.1.2A). The
infundibulopelvic ligament and the round ligament occasionally
are cut with asingle staple application (Figure 13.1.2B).Any other
hemostatic cutting device (LigaSure, Valleylab; Harmonic ACE,
Ethicon Endo-Surgery) may be used in a similar fashion on all
vascular pedicles.
Development of the Bladder Flap
If the adnexa are preserved, the round ligament is coagulated
and cut approximately 3 cm from the uterus (Figure 13.1.3).
Using hydrodissection, the anterior leaf of the broad ligament
is opened toward the vesicouterine fold and the bladder flap is
developed (Figure 13.1.4).The anterior leaf ofthe broad ligament
is grasped with forceps, elevated, and dissected from the anterior
lower uterine segment with hydrodissection and the CO
2
laser,
monopolar scissors, or any harmonic device (Figure 13.1.5). The
utero-ovarian ligament, proximal tube, and mesosalpinxareelectrodesiccated and cut, andtheposterior leaf of thebroadligament
is opened (Figure 13.1.6). Similarly, the round ligament, fallop-
ian tube, andutero-ovarian ligament canbe grasped closeto their
insertion into the uterus with the endoscopic linear stapler and
then secured, stapled, and severed (Figure 13.1.7). The distal end
of the stapler or bipolar forceps must be kept free of the bladder
and ureter.
Electrodesiccation
of the round ligament
Uterus
Ovary
Figure 13.1.3. The round ligament is coagulated and cut 2 to 3 cm
lateral to the uterus.
Round
ligament
Fallopian
tube
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Foley catheter
in bladder
Bladder
Cut round
ligament
Fallopian tube
Hydrodissection develops
the bladder flap.
Figure 13.1.4. While the anterior leaf of the broad ligament is elevated with hydrodissection, the anterior leaf
of the broad ligament is opened toward the vesicouterine fold.
Uterus
The uterovesical peritoneum is identified, grasped, and elevated with forceps while scissors, laser, or a harmonic device is
used to dissect the bladder off the cervix. The bladder pillars are
identified, coagulated, and cut. The bladder is dissected from the
uterus by pushing downward with the tip of a blunt probe along
the vesicocervical plane until the anterior cul-de-sac is exposed
completely (Figure 13.1.8).
In patients who have severe anterior cul-de-sac endometriosis
or adhesions or a history of previous cesarean deliveries, sharp
dissection of the vesicouterine fold often is necessary. Injecting 5
to 10 mL of indigo carmine in the patient’s intravenous line and
looking for its presence in the peritoneal cavity isone waytodetect
bladder trauma. However, the best method to identify bladder
injury is either by cystoscopyorbydistendingthebladder with300
to 400 mL of sterile milk and performing a careful laparoscopic
inspection for any leaks.
Uterine Vessels
After the bladder is dissected from the anterior cervix, the uterine
vessels are identified, desiccated, and cuttofree the lateral borders
of the uterus (Figure 13.1.9). If single clips or linear staplers are
used, the vessels are skeletonized to prevent slippage of the clips.
As the uterine vessels are grasped and cut, the safety and position
of the ureters should be checked. This can be done more easily if
they are marked, exposed, or catheterized at the beginning of the
procedure.The hysterectomy is completed vaginally orcontinued
laparoscopically.
The bladder flap is dissected down to the cervix.
Figure 13.1.5. The bladder is elevatedand further separated fromthe cervix. It ispushed downward using sharp
and blunt dissection and hydrodissection.
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Obliterated
hypogastric
artery
Round
ligament
as the width of the linear stapler is 12 mm. Because of the short
distance between the cervix and the ureter, the risk of ureteral
injury by the stapler increases. Using contralateral retraction of
the uterus, the cardinal ligament is dissected to identify tissue
planes, vessels, and the ureter. Once the ureter is displaced laterally,the cardinal ligamenttissue closest tothe cervix is coagulated
and transected(Figure 13.1.10). Alternatively,the linear stapler is
applied on both theuterinevesselsandthe cardinal ligament (Figure 13.1.11).The harmonic scalpel or LigaSure may be used as an
alternative.
Uterus
Coagulation and
dissection of the
ovarian ligament
and mesosalpinx
Figure 13.1.6. The proximal tube, mesosalpinx, and utero-ovarian ligament are coagulated and cut.
Cardinal Ligament
At the level of the cardinal ligaments, the ureter and the descending branches of the uterine artery are close to one another and
the cervix. Therefore, cardinal ligament dissection must be precise to prevent bleeding and ureteral injury. The linear stapler is
used only if the parametrium is dissected with ample margins
Anterior and Posterior Culdotomy
A folded wetgauzeinaspongeforcepsoronthetipofaright-angle
Heaney retractor marks the anterior or posterior vaginal fornix.
The vaginal wall is tented and transected horizontally (Figures
13.1.12, 13.1.13). Newer uterine manipulators on the market are
fitted with cups of varying sizes (KOH Colpotomizer, Cooper
Surgical) that fit onto the cervix anddelineate thevaginalfornices,
enabling easy transaction of the vaginal cuff. Additionally, they
are fitted with a balloon that maintains the pneumoperitoneum
once the vagina is opened.
Vaginal Portion of Hysterectomy
The laparoscopic portion temporarily ends before or after the
anterior or posterior culdotomy. Dissecting and resecting the
uterus are done vaginally using standard techniques. Once
the uterus is removed, the vaginal cuff is closed. To ensure support of the vaginal vault, the vaginal angles are attached to the
uterosacral and cardinal ligaments with absorbable sutures. The
vaginal cuff is closed transverselyor vertically, and any coexisting
cystocele or rectocele is repaired. Once the vaginal part is completed andthe cuff is closed, the laparoscopic procedure resumes.
First application of
linear stapler on the
upper portion of the
broad ligament
Right adnexa
has been
dissected
and removed
Application of stapler
on the upper portion
of the broad ligament
A B
Figure 13.1.7. (A) The linear stapler is applied on the upper portion of the broad ligament while preserving the adnexa. (B) The linear stapler is
applied on the upper broad ligament while removing the adnexa.
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