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Uterus is transfixed
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Laparoscopy and Hysterectomy — 357
Figure 13.1.31. The uterus has beentransfixedwith the CURTinstrument. With the classic intrafascialsupracervical hysterectomy procedure, the inner part of the cervix is excised by clockwise rotation of the cutting cylinder
of the CURT instrument. The instrument has perforated the fundus.
The inner portion of the
cervical body is excised
by clockwise rotation of
the cutting cylinder in
the CURT instrument
Figure 13.1.32. The cutting cylinder has removed a portion of the cervix.
358 — Farr Nezhat and Jyoti Yadav
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A
Roeder loop
is tightened
B
Figure 13.1.33. (A) After the uterus has been mobilized, the Roeder loop is placed around the lower uterine
segment. (B) The loop is tightened around the cervix as the metal cylinder is removed.
Laparoscopy and Hysterectomy — 359
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shorter meanhospital stay (2.1days) and convalescence (28 days)
than abdominal hysterectomy (4.1 days and 38.0 days, respectively). There were no important differences in mean hospital
charges, blood loss, or intraoperative complication rates between
the study groups. A higher incidence of wound complications in
the abdominal hysterectomy group was noted. Slightly less optimistic experience with laparoscopic hysterectomy was reported
by Bruhat and coauthors [22] in a series of 36 patients. Twentyseven (75%) were treated successfully by laparoscopy, whereas
nine (25%)wereconvertedto laparotomy. Gynecologists haddifficulty achieving hemostasis (six patients) and locating anatomic
landmarks (three patients) because of large uteri, myomas, or a
long cervix. Nevertheless, the authors concluded that LAVH is
an alternative to abdominal hysterectomy in properly selected
patients. Recent studies have reported a conversion rate of
10%.[46]
The opposite is true when LAVH is compared with standard
vaginal hysterectomy, as reported by Summitand colleagues.[19]
Among 56 women scheduled to undergo vaginal hysterectomy
in an outpatient setting, 29 were randomized to LAVH and
27 to standard vaginal hysterectomy. In the latter group, all
surgical procedures were completed and the patients were discharged within 12 hours of admission. In the LAVH group, one
patient had a bladder laceration repaired, and the hysterectomy
was completed endoscopically. A second patient experienced
bleeding from the inferior epigastric vessels. It was not controlled endoscopically, and she underwent exploratory laparotomy with abdominal hysterectomy. When the two groups were
compared, the LAVH group required more pain medication,
experienced greater blood loss and more intraoperative complications, and incurred higher surgical expenses – a mean of
$7905 compared with $4891 forthe standard vaginal group. Similar outcomes have been demonstrated in several randomized
Table 13.1.3: Type of Laparoscopic Hysterectomy
Procedures, no.
Types of Hysterectomy BSO RSO LSO
Laparoscopically assisted vaginal
hysterectomy
Vaginally assisted laparoscopic
hysterectomy
Total laparoscopic hysterectomy 176 114 15 29
Subtotal laparoscopic hysterectomy 13 6 0 1
Total 361 228 29 46
BSO, bilateral salpingo-oophorectomy; LSO, left salpingooophorectomy; RSO, right salpingo-oophorectomy.
Source: Nezhat et al. [51]
24 14 2 3
148 94 12 13
comparisons.[47–49] A large retrospective review of 10,110 hysterectomies from Europe reported a higher complication rate,
specifically infectious morbidity and bowel injury, blood loss,
hospital stay,and recovery,following vaginal hysterectomyversus
laparoscopic hysterectomy.[50] Notably,the number of hysterectomies performed vaginally (n = 1801) was the least of all the
approaches (abdominal hysterectomy, n = 5875; laparoscopic
hysterectomy, n = 2434), indicating a relative lack of experience with vaginal surgery, which may account for the findings of
the study. Overall, there are strong data to support the recommendation that LAVH should replace abdominal, not vaginal,
hysterectomy.
Nezhat et al. [51] reported on 361 women who fulfilled
the criteria for abdominal hysterectomy but underwent LAVH
Three Roeder loops
tightened around
the cervix
Figure 13.1.34. The corpus is amputated above the suture using an electrosurgical knife.
360 — Farr Nezhat and Jyoti Yadav
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Table 13.1.4: Summary of Women Who Underwent LAVH,
TLH, or SLH
Mean age, years (range) 42.5 (25–72)
Gravidity, no. of pregnancies (range) 1.6 (0–7)
Parity, no. of live births (range) 1.3 (0–5)
Mean duration of procedure (range) 2.3 hours (55
minutes–6.5 hours)
Uterine size, weeks’ gestation 4–26
Mean uterine weight, g (range) 178.38 (36–1530)
Average blood loss, mL (range) 73 (50–800)
Average hospitalization duration (range)
Time to full recovery post operation
†
(range)
Length of time postoperative pain
medication was needed, days (range)
∗
From termination of procedure until discharge from hospital.
†
This information was obtained from office visits, written question-
naires, and telephone interviews.
‡
After the patient was discharged from the hospital.
∗
21 hours (20 hours–5
days)
3.3 weeks (3 days–13
weeks)
3.3 days (0–21 days)
‡
Table 13.1.6: Additional Procedures Carried Out with
Hysterectomy
Procedure Patients, no.
Treatment of mild to extensive endometriosis 212
Lysis of mild to extensive abdominal 189
and/or pelvic adhesions
Ureterolysis 129
Appendectomy 47
Marshall–Marchetti–Krantz or 43
Burch procedure
Moschcowitz procedure 88
Bowel resection 11
Cystocele repair 13
Rectocele repair 24
Enterocele repair 6
Vaginal sacral colposuspension 2
Cholecystectomy 2
Removal of ovarian remnant 4
Removal of pelvic abscess 1
Table 13.1.5: Inoperative and Pathologic Findings in 361
Women
Finding Patients, no.
Mild to extensive endometriosis 212
Mild to extensive adhesions 189
Uterine fibroids (uterine size 8–26 weeks’ size) 116
Uterine adenomyosis 119
Endometriomas (5–15 cm in diameter) 22
Endometrial polyp 13
Endometrial hyperplasia 2
Cervical dysplasia 4
Large cornual pregnancy 1
Hydrosalpinx 7
Pelvic abscess 1
Asherman’s syndrome 2
Benign cystic teratoma 3
Serous cyst 2
Mucinous cyst 2
Para-ovarian cyst 2
Source: Nezhat et al.[51]
Table 13.1.7: Complications after Hysterectomy in 361
Women
Complications, Incidence per
Complication, Type no. 100 Women
Mortality 0 0.00
Intraoperative
Vascular
Inferior epigastric vessel injury 3 0.83
Hemorrhage requiring
transfusion
Major blood vessel injury 0 0.00
Gastrointestinal
Small bowel injury 1 0.27
2 0.55
Source: Nezhat et al.[51]
Source: Nezhat et al.[15]
Laparoscopy and Hysterectomy — 361
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(172), TLH (176), or SLH (13) from July 1987 through July
1993 (Table 13.1.3). Bipolar forceps and the CO
laser were used
2
for hemostasis and cutting, respectively. Patients who required
suturing, staples, or clips for hemostasis or had malignancy
were excluded from the study. Preoperative indications for hysterectomy included chronic pelvic pain (116 women), chronic
pelvic painwith abnormal uterine bleeding (148women), abnormal uterine bleeding (40 women), and enlarging leiomyoma
(28 women). Other indications were endometrial hyperplasia, cervical dysplasia, pelvic abscess, ectopic pregnancy, and
pelvic relaxation. The demographic, surgical, and postoperative characteristics of women who underwent hysterectomy are
listed in Table 13.1.4. There were no conversions to laparotomy, although one patient with bowel endometriosis and stricture underwent laparotomy for bowel resection and anastomosis. Intraoperative and pathologic findings are summarized in
Table 13.1.5. Most patients underwent one or more additional
procedures (Table 13.1.6), and the complication rate was 10%
(Table 13.1.7).
CONCLUSION
Currently, 25% of hysterectomies are done vaginally, the least
traumatic, safest, and most cost-effective way to remove the
uterus. Seventy-five percent of hysterectomies are conducted
abdominally. Laparoscopically assisted hysterectomy is an excellent alternative when the standard vaginal approach seems difficult. Laparoscopicically assisted hysterectomyoffersmanyadvantages and will become an integral part of gynecologic surgery,
replacing the abdominal hysterectomy. Therefore, efforts no
longer should be directed toward validating such surgery but
toward providing gynecologists with more opportunities for
training. In five reports [51–55], the complication rate was less
than 10% (Table 13.1.8) and was lower than those from abdominal and vaginal hysterectomy. Mostof thesecomplicationsinvolve
ureteral and bladder injuries.[50,56] Therefore, particular attention should be paid to identifying and localizing the ureters and
dissecting the bladder during an LAVH or laparoscopic hysterectomy. The rate of complications is directly related to the level
of expertise and experience of the surgeon. Wattiez et al. [27]
reported adeclineinmajorcomplicationsfrom5.6%to1.3%with
increasing operator experience. Though hard to determine, several studies have attempted to define the number of cases needed
to attain proficiency and a low complication rate with LAVH and
Table 13.1.8: Complications of Laparoscopic Hysterectomy
Author(s) Cases, no. Complications, no. (%)
Nezhat et al. [51] 361 40 (11.0)
Hill et al. [52] 220 35 (15.9)
Liu [53] 518 30 (5.8)
Jones [54] 252 18 (7.1)
Chapron et al. [55] 210 21 (10.0)
Total 1561 144 (9.2)
laparoscopic hysterectomy. A large Finnish study with more than
2400 laparoscopic hysterectomiesdemonstratedastatistically significant drop in all complications after 30 procedures.[50] Similar
experiences have been reported by others.[57]
Although laparoscopically assisted hysterectomytakeslonger,
this approach tends to result in less postoperative pain, requires
shorter hospitalization, and allows a more rapid recovery. Specific indications and contraindications for LAVH and laparoscopic hysterectomy must be established on the basis of outcome data. Such information is essential for the gynecologist
to ascertain the best method for removal of the uterus in each
instance. The authors recommend that the use of laparoscopic
assistance during hysterectomy be considered in cases in which
intra-abdominal pathology or adnexal pathology is suspected, as
in cases of endometriosis, adhesions, or an adnexal mass. The
extent of laparoscopic dissection should be determined based
on the surgeon’s experience and comfort with laparoscopic and
vaginal procedures.
REFERENCES
1. Selwood T, Wood C. Incidence of hysterectomy in Australia. Med
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2. VanKeepPA, Wildemeersch D, Lehert P. Hysterectomy in six European countries. Maturitas. 1983;5:69.
3. Porkas R, Hufnagel VG. Hysterectomy in the United States, 1964–
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4. Bachmann GA. Hysterectomy: a critical review. JReprodMed.
1990;35:839.
5. Dicker RC, Scally MJ, Greenspan JR, et al. Hysterectomy among
womenofreproductiveage.JAMA. 1982;248:323.
6. White SC, Wartel LJ, Wade ME. Comparison of abdominal and
vaginal hysterectomy: a review of 600 operations. Obstet Gynecol.
1971;37:530.
7. Wingo PA, Huezo CM, Rubin GL, et al. The mortality risk associated with hysterectomy. Am J Obstet Gynecol. 1985;152:803.
8. Lee NC, Dicker RC, Rubin GL, et al.Confirmationof the preoperativediagnosesforhysterectomy. AmJ ObstetGynecol.1984;150:283.
9. Semm K. Operationslehre f¨ur endoskopische Abdominalchirugie–
operative Pelviskopie. Stuttgart, Germany: Schattauer; 1984.
10. Semm K. Operative Manual for Endoscopic Abdominal Surgery.
Friedrich ER, trans. Chicago: Year Book Medical Publishers; 1987.
11. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J
Gynecol Surg. 1989;5:213.
12. Nezhat C, Nezhat F, Silfen SL. Laparoscopic hysterectomy and
bilateral salpingo-oophorectomy using multifire GIA surgical stapler. J Gynecol Surg. 1990;6:185.
13. Kovac RS, Cruishank SH, Retto HF. Laparoscopy-assisted vaginal
hysterectomy. J Gynecol Surg. 1990;6:185.
14. Nezhat C, Nezhat F, Gordon S, et al. Laparoscopic versus abdominal hysterectomy. JReprodMed. 1992;37:247.
15. Nezhat C, Nezhat F, Silfen SL. Laparoscopic hysterectomy and
bilateral salpingo-oophorectomy using multifire GIA with standard vaginal hysterectomyin an outpatient setting.Obstet Gynecol.
1992;80:895.
16. Nezhat C, Burrell MO, Nezhat FR, et al. Laparoscopic radical hysterectomywith para-aortic and pelvic nodedissection. AmJ Obstet
Gynecol. 1992;166:864.
17. Nezhat CR, Nezhat FR, Ramirez CE, et al. Laparoscopic radical
hysterectomy and laparoscopic assisted vaginal radical hysterectomy with pelvic and paraaortic node dissection. J Gynecol Surg.
1993;9:105.
362 — Farr Nezhat and Jyoti Yadav
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18. Nezhat C, NezhatF, Burrell M. Laparoscopicallyassisted hysterectomy for the management of a borderline ovarian tumor: a case
report. J Laparoendosc Surg. 1992;2:167.
19. Summit RL, Stovall TG, Lipscomb GH, et al. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatientsetting. Obstet Gynecol.
1992;80:895.
20. Nezhat C, Nezhat F, Nezhat C. Operative laparoscopy (minimally
invasive surgery): state of the art. J Gynecol Surg. 1992;8:111.
21. Nezhat F, Nezhat C, Levy JS. A report of laparoscopic injuries and
complications over a 10-year period. Presented at: 41st Annual
Clinical Meeting of the American College of Obstetricians and
Gynecologists; May 3–6, 1993; Washington, DC.
22. Bruhat MA, Mage G, Pouly JL, et al. Laparoscopic Hysterectomy in
Operative Laparoscopy. New York: McGraw-Hill; 1992.
23. Nezhat C, Nezhat F, Winer W. Salpingectomy via laparoscopy: a
new surgical approach. J Laparosc Surg. 1991;1:91.
24. Nezhat C, Nezhat F, Bess O, et al. Injuries associated with the use
of a linear stapler during operative laparoscopy: review, diagnosis,
management, and prevention. J Gynecol Surg. 1993;3:145.
25. Wattiez A, Soriano D, Fiaccavento A, et al. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc.
2002;9(2):125–130.
26. Seracchioli R, Venturoli S, Vianello F, et al. Total laparoscopic hysterectomycomparedwith abdominal hysterectomyin the presence
of alarge uterus. J Am Assosc GynecolLaparosc. 2002;9(3):333–338.
27. Wattiez A, Soriano D, Cohen SB, et al. The learning curve of total
laparoscopic hysterectomy: comparative analysis of 1647 cases. J
Am Assoc Gynecol Laparosc. 2002;9(3):339–345.
28. Lee PI. Total laparoscopic intrafascial hysterectomy. J Am Assoc
Gynecol Laparosc. 1996;3(suppl 4):S25.
29. Scott JR, Sharp HT, Dodson MK, et al. Subtotal hysterectomy
in modern gynecology: a decision analysis. Am J Obstet Gynecol.
1997;176:1186.
30. Munro MG. Supracervical hysterectomy: a time for reappraisal.
Obstet Gynecol. 1997;89:133–139.
31. Learmen LA, Summitt RL, Varner RE, et al.; Total or Supracervical
Hysterectomy (TOSH) Reasearch Group. A randomized comparison of total or supracervical hysterectomy: surgical complications
and clinical outcomes. Obstet Gynecol.2003;102(3):453–462.
32. Richards SR, Simpkins S. Laparoscopic supracervical hysterectomy versus laparoscopic assisted vaginal hysterectomy.J Am Assoc
Gynecol Laparosc. 1995;2(4):431–435.
33. Lalonde CJ, Daniell JF. Early outcomes of laparoscopic-assisted
vaginal hysterectomy versus laparoscopic supracervical hysterectomy. J Am Assoc Gynecol Laparosc. 1996;3(2):251–256.
34. Milad MP, Morrison K, Sokol A, Miller D, Kirkpatrick L. A comparison of laparoscopic supracervical hysterectomy vs laparoscopically assisted vaginal hysterectomy. SurgEndosc. 2001;15:286–288.
35. van der Stege JG, van Beek JJ. Problems related to the cervical
stump at follow-up in laparoscopic supracervical hysterectomy.
JSLS. 1999;3(1):5–7.
36. Okaro EO, Jones KD, Sutton C. Long term outcome following laparoscopic supracervical hysterectomy. BJOG. 2001;108(10):
1017–1020.
37. Semm K. Hysterectomy via laparotomy or pelviscopy: a new
CISH method without colpotomy. Geburtshilfe Frauenheilkd.
1991;51:996.
38. Semm K. Endoscopic subtotal hysterectomy without colpotomy:
classic intrafascial SEMMhysterectomy:anew method of hysterec-
tomy by pelviscopy,laparotomy,per vagina orfunctionally by total
uterine mucosal ablation. Int Surg. 1996;81:362.
39. Mettler L, Semm K, Lehmann-Willenbrock L, et al. Comparative evaluation of classical intrafascial–supracervical hysterectomy (CISH) with transuterine mucosal resection as performed
by pelviscopy and laparotomy – our first 200 cases. Surg Endosc.
1995;9:418.
40. Kim DH, Lee JC, Bae DH. Clinical analysis of pelviscopic classic
intrafascial SEMM hysterectomy. J Am Assoc Gynecol Laparosc.
1995;2:289.
41. Kim DH, Bae DH, Hur M, et al. Comparison of classic intrafascial supracervical hysterectomy with total laparoscopic and
laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol
Laparosc. 1998;5:253.
42. Marana R, Busacca M,ZupiE, Garcea N, Paparella P, CatalanoGF.
Laparoscopicallyassistedvaginalhysterectomyversustotal abdominal hysterectomy: a prospective, randomized, multicenter study.
Am J Obstet Gynecol. 1999;180(2 pt 1):270–275.
43. Falcone T, Paraiso MF,Mascha E. Prospective randomizedclinical
trial of laparoscopically assisted vaginal hysterectomy versus total
abdominal hysterectomy. Am J Obstet Gynecol. 1999;180(4):955–
962.
44. Olsson J, Ellstrom M, Hahlin M. A randomized prospective trial
comparing laparoscopic and abdominal hysterectomy. Br J Obstet
Gynaecol. 1999;180:270–275.
45. Summitt RL Jr, StovallTG,Steege JF, Lipscomb GH.A multicenter
randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol. 1998;92:321.
46. Cristofororni PM, Palmieri A, Gerbaldo D, Montz FJ. Frequency
and cause of aborted laparoscopic-assisted vaginal hysterectomy.
J Am Assosc Gynecol Laparosc. 1995;3(1):33–37.
47. Ottosen C, Lingman G, Ottosen L. Three methods for hysterectomy: a randomised, prospective study of short term outcome.
BJOG. 2000;107(11):1380–1385.
48. Kovac SR. Hysterectomy outcomes in patients with similar indications. Obstet Gynecol. 2000;95(6 pt 1):787–793.
49. Soriano D, Goldstein A, Lecuru F, Darai E. Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal
hysterectomy: a prospective, randomized, multicenter study. Acta
Obstet Gynecol Scand. 2001;80(4):337–341.
50. Makinen J, Johansson J, Tomas C, et al. Morbidity of 10,110 hysterectomies by type of approach. Hum Reprod . 2001;13:431–436.
51. Nezhat F, Nezhat CH, Admon D, et al. Complications and results
of 361 hysterectomies performed at laparoscopy. JAmCollSurg.
1995;180:307.
52. Hill D, Maher PJ, Wood CE, et al. Complications of laparoscopic
hysterectomy. J Am Assoc Gynecol Laparosc. 1994;1:159.
53. Liu CY. Complications of total laparoscopic hysterectomy in 518
cases. Gynecol Endosc. 1994;3:203.
54. Jones RA. Complications of laparoscopic hysterectomy: 250 cases.
Gynecol Endosc 1995;4:95.
55. Chapron CM, Dubuisson JB, Ansquer Y. Is total laparoscopic hysterectomyasafeprocedure?Hum Reprod. 1996;11:2422.
56. Meikle SF, Nugent EW, Orleans M. Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared
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1997;89(2):304–311.
57. Altgassen C, Michels W, Schneider A. Learning laparoscopicassisted hysterectomy. Obstet Gynecol 2004;104(2):308–313.
Section 13.2. Laparoscopic Excision of a Rudimentary
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Uterine Horn
Togas Tulandi
During embryogenesis, complete atresia of one of the two mullerian ducts results in the development of one of the uterine horns
only (unicornuate uterus), whereas partial development of the
mullerian duct results in a rudimentary horn.
The American Society for Reproductive Medicine classified
unicornuate uterus as type II.[1] It is further divided into four
subcategories. Types IIa and IIb are unicornuate uteri with and
without a communicating rudimentary horn, respectively; type
IIc is a unicornuate uterus with a noncavitated uterine horn; and
type IId is a unicornuate uterus without a rudimentary horn
(Figure 13.2.1).
In most cases, thereisno communication between the uterine
cavity proper and the cavity of the rudimentary horn (Figure
13.2.2, type IIb). As a result, menstrual blood will accumulate in
the rudimentary horn (hematometra), causing cyclic abdominal
pain. It also predisposes to the development of endometriosis.
Approximately 25% of unicornuate uteri are associated with a
cavitated noncommunicating rudimentary uterine horn.[2] The
rudimentary horn may be separated fromthe unicornuate uterus
by fibrous tissue (Figure 13.2.2), or the horn may be adherent to
the uterus.
As with the normal uterus, polyps, fibroids, or adenomyosis
may be found in the rudimentary uterine horn (Figure 13.2.3).
Pregnancy may be located in the rudimentary uterine horn.
Its incidence isestimated to bebetween one in100,000 and onein
140,000 pregnancies.[3] It occurs as the result of transperitoneal
migration of a fertilized ovum or spermatozoa. Although most
reported casesof pregnancy have beenin thenoncommunicating
rudimentary horn, pregnancy in the communicating horn has
also been reported.[4] In anyevent,pregnancyintherudimentary
horn, whether communicating or noncommunicating, carries
the risk of uterine rupture.[5–9]
(MRKH) syndrome. Other associated findings of MRKH syndrome are urinary tract abnormalities and endometriosis.
TREATMENT
The noncavitated rudimentary uterine horn isasymptomatic and
does not require treatment. In contrast, excision of a cavitated
uterine horn is recommended because of the symptoms of cyclic
abdominal pain, the need to reduce possible endometriosis, and
more importantly, the possibility of pregnancy in the horn with
functional endometrium. Because of the high risk of uterine rupture, early discovery of a pregnancy in the uterine horn is best
terminated with methotrexate and local injection of potassium
chloride. Laparoscopic removal of the rudimentary horn may be
performed several months later.
Fedele et al. [2] reported a series of 10 women with unicornuate uterus associated with a cavitated uterine horn. They and
others [10–16] demonstrated that excision of a uterine horn by
laparoscopy is effective.
DIAGNOSIS
The most common symptom of a cavitated rudimentary uterine horn is primary dysmenorrhea, sometimes associated with
dyspareunia. The diagnosis is best established by magnetic resonance imaging (MRI). However, a noncavitated rudimentary
horn may be misinterpreted as a pedunculated uterine fibroid.
Another important imaging technique is ultrasound. The best
time to perform ultrasound is in the second half of the cycle,
when the endometrium is thick and echogenic. A cavitated uterine horn can be easily identified.
Concomitant findings of a blind vagina and a rudimentary
uterine horn are found in Mayer–Rokitansky–K¨uster–Hauser
Figure 13.2.1. The American Society for Reproductive Medicine classifications of unicornuate uterus.
363
364 — Togas Tulandi
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Figure 13.2.2. The most common type of rudimentary uterine horn
(cavitated and noncommunicating). The horn is separated from the
unicornuate uterus by a fibrous band. This case is unusual. The two
horns are seperated by a long fibrous band.
SURGICAL TECHNIQUE
Standard laparoscopy is performed with one primary trocar for
the laparoscope andtwo secondary trocars.A thorough examination of the abdominal cavity should be performed. The presence
of endometriosis might distort the anatomy,including the course
of the ureter.Inanyevent,theureteripsilateraltotherudimentary
horn is often located higher than the opposite side.
The horn may be separated from the uterus or closely attached
to it with a poorly defined cleavage plane. To prevent the occurrenceoftubalectopicpregnancy, thefallopiantubeattachedtothe
rudimentary horn should be removed. Excision of the rudimentary horn is similar to that of hysterectomy. The round ligament,
proximal part of the fallopian tube, and ovarian ligament are
electrocoagulated and divided, allowing access to the retroperitoneal space and visualization of the uterine vessels. The bladder
Figure 13.2.4. Right rudimentary uterine horn in the same patient.
peritoneum anterior to the uterine horn is hydrodissected and
divided, and the bladder is dissected off the lower part of the
uterine horn.
Figures 13.2.4 through 13.2.6 show rudimentary uterine
horns in a patient with MRKH syndrome. The two horns are
completely separated witha long fibrous band.Inthis case, mobilization of the bladder was not required.
Separation of the horn from the uterus is easy when there is
merely a band of fibrous tissue between them. The fibrous band
can be simply coagulated and divided. The procedure is more
complex when the horn is closely attached to the uterus. Separation of the horn can be accomplished with sharp dissection at
the point where they join. Identification of the surgical plane can
be further enhanced by hysteroscopic illumination. Hemostasis
is achieved using bipolar coagulation, and the uterine defect is
closed with a few sutures.
The excised rudimentary horn is extracted intact either
through a colpotomy incision or an extended lateral port. This
will allow confirmation as to whether the horn is cavitated.
Figure 13.2.3. Left rudimentary uterine horn with a subserous fibroid
in a patient with Mayer–Rokitansky–K¨uster–Hauser syndrome.
Figure 13.2.5. Because of the wide separation of the two horns, in this
case the bladder does not need to be mobilized.
Figure 13.2.6. The cavitated rudimentary horns and the tube should
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be excised, leaving the fibrous bands that connected the two uterine
horns.
SUMMARY
The most common type of rudimentary uterine horn is communicating and cavitated uterine horn (type IIb of the American
Society for Reproductive Medicine classification). Pregnancy in
the rudimentary uterine horn, whether communicating or noncommunicating, carries the risk of uterine rupture. Because of
this risk and the symptoms of cyclic abdominal pain, excision of
a cavitated uterine horn is recommended. This can be achieved
effectively by laparoscopy.
REFERENCES
1. American Fertility Society. The American Fertility Society classifications of the adnexal adhesions, distal tubal occlusion, tubal
occlusion secondary to tubal ligation, tubal pregnancy, mullerian
anomalies and intrauterine adhesions. Fertil Steril. 1998;49:944–
955.
2. Fedele L, Bianchi S, Zanconato G, Berlanda N, Bergamini V.
Laparoscopic removal of the cavitated noncommunicating rudi-
Laparoscopic Excision of a Rudimentary Uterine Horn — 365
mentary uterine horn: surgical aspects in 10 cases. Fertil Steril.
2005;83:432–436.
3. Johansen K. Pregnancy in a rudimentary uterine horn. Obstet
Gynecol. 1983;61:565–567.
4. Elsayegh A, Nwosu EC. Rupture of pregnancy in the communicating rudimentary uterine horn at 34 weeks. Human Reprod.
1998;13:3566–3568.
5. Heinonen PK. Unicornuate uterus and rudimentary horn. Fertil
Steril. 1997;68:224–230.
6. Daskalakis G, Pilalis A, Lykeridou K, Antsaklis A. Rupture of
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14 PELVIC FLOOR
https://t.me/med1917
Section 14.1. Laparoscopic Burch Colposuspension
Jim W. Ross and Mark R. Preston
Retropubic Burch colposuspensionhas been considered by many
to be the “gold standard” procedure for the treatment of
female stress urinary incontinence for almost 40 years. Vancaillie and Schuessler [1] introduced the laparoscopic approach
to retropubic colposuspension in 1991. Numerous reports followed in subsequent years describing laparoscopic colposuspensions and their efficacy. Analysis of the outcomes of these various laparoscopic “Burch” colposuspensions is difficult because
many of the techniques are not true Burch procedures but rather
other modified retropubic colposuspensions. In this section,
we describe the laparoscopic Burch colposuspension, including
patient selection, preoperative evaluation, operative technique,
possible complications, and efficacy.We review theefficacy ofthe
laparoscopic Burch colposuspension studies that use the Burch–
Tanagho procedure and compare these techniques to other popular anti-incontinence procedures. The many modified laparoscopic retropubic procedures are not addressed.
BURCH COLPOSUSPENSION: THE
EVOLUTION OF A PROCEDURE
In 1961, Burch [2] published the description of a new female
anti-incontinence procedure, based on a technique started in
1958. The technique involved entering the space of Retzius via
a paramedian incision. After clearing the periurethral tissue of
its overlying fat and areolar tissue, three 2-0 chromic sutures
were placed at the mid-urethra and the bladder neck and then
fixed to Cooper’s ligament. Burch [3] reported a subjective cure
rate of 92% in 143 patients with 10 to 60 months of followup.
Tanagho [4] suggested several refinements to increase the
cure rate and decrease complications for the Burch colposuspension (Table 14.1.1). He stressed the importance of the surgical
repair “is to preserve the initially intact sphincteric mechanism,
to restore its proper position and to provide it with adequate
support.” He stressed staying at least 2 cm lateral to the urethra and urethrovesical junction when removing overlying fat.
After placing absorbable sutures at the mid-urethra and lateral
to the urethra–vesical junction, the anterior vaginal wall is elevated by the surgeon. Each suture is placed through Cooper’s ligament and brought 2 cm below the ligament to be tied. Tanagho
stressed the formation of a “hammock” of support without compressing the urethra against the pubic bone. We feel the laparoscopic colposuspension must include the Burch–Tanagho gold
standard technique to be called a laparoscopic Burch colposuspension.
LAPAROSCOPIC COLPOSUSPENSIONS
The first reported retropubic surgery performed via the laparoscopic approach was described by Vancaillie and Schuessler
in 1991.[1] Their techniques resembled a Marshall–Marchetti–
Krantz (MMK) ratherthan a Burch colposuspension. Albalaet al.
[5] reported on a series of laparoscopic MMK and Burch colposuspensions. In subsequent years,larger caseseries werereported
by numerous authors.[6–8] One goal of this section is to show
that the laparoscopic Burch colposuspension, whenperformed in
a fashion identical to the open Burchwith good laparoscopic technique, is comparable to laparotomy and provides several advantages for patient care.
SELECTION, EVALUATION, AND ANATOMY
Patient Selection
Any patient with genuine stress incontinence (GSI)is a candidate
for laparoscopic colposuspension. Once the diagnosis is made,
the decision for surgery is made by the physician and patient
jointly, usually after a trial of more conservative treatment. Possible contraindications to the laparoscopic approach are history
of severe abdominal or pelvic adhesions, prior incontinence procedures, intrinsic sphincter deficiency, or the necessity of other
abdominal procedures requiring laparotomy. Many physicians
advocate treating only primary GSI with a retropubic Burch,
but we [9,10] and others [11] have successfully treated recurrent
GSI laparoscopically. Prior procedures, such as anterior vaginal
repair, needle suspensions, MMK, Burch, and bone anchor procedures, are not absolute contraindications. Laparoscopic Burch
has been used successfully in patients with low urethral closure
pressure and/or low Valsalva leak point pressure (VLPP) in conjunction with urethral hypermobility. Laparoscopic Burch is not
the surgery of choice for intrinsic sphincter deficiency (ISD) with
a fixed, frozen urethra.
Evaluation
The basic evaluation consists of a history and physical exam,
cough stress test (CST), urine culture and sensitivity, assessment
of postvoid residual volume, and 24-hour voiding diary. A basic
filling cystometrogram with VLPP is essential if multichannel
urodynamic testing is not available. Multichannel urodynamic
testing is considered necessary in patientswithprior incontinence
procedures and in the elderly. Quality-of-life (QOL) questionnaires, cystoscopy, and bladder neck ultrasound can also be used.
In the history, a detailed inquiry concerning urinary complaints
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