James F. Daniell, MD

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 The growth of managed care and the influence of third party payers in the medical decision making process have served to diminish the ability of physicians to direct the care of patients; physicians, however, still continue to be held accountable for the management of care. In the case of gynecologists performing hysterectomy, this care extends well beyond the actual operation with the global costs related to recovery and time off from work. The physician's ultimate goal is the best possible operation for each patient with minimal intraoperative and postoperative complications. As a result, even though the physician now has diminished control, he has responsibility and increased pressure to reduce global costs.
 
 In America, hysterectomy is one of the most frequently performed operations and has a long, controversial history. The true impact on the advent of laparoscopic hysterectomy is not yet clear in America. As the millennium approaches, we are entering an interesting period in healthcare, and physicians are now with trying to contain health care costs associated with hysterectomy, and with providing quality health care to patients while minimizing costs and enhancing recovery. In certain situations, laparoscopic hysterectomies may fulfill all these goals. 
 
 


 
 With the first one being done in humans in the first decade of the 20th century in Germany, laparoscopy is not new a procedure. It was not until after the Second World War that laparoscopy became popular, when it was widely used in France for laparoscopic sterilization. The first book on laparoscopy published in English was only in 1967 by Patrick Steptoe,

 who later became famous for having the first successful in-vitro fertilization pregnancy. Furthermore, the first American book on laparoscopy was not published until 1970 by Melvin Cohen of Michael Reese Hospital in Chicago.

 
 
 In the 1980s, however, several events rapidly propelled laparoscopy forward. 
 
 1.

. The television industry developed cameras that became suitable for laparoscopy. Miniaturization through the use of a silicon chip was combined with greater light sensitivity. These developments led to the adoption of television in surgery, first as an operative recording device and then as a monitor for both the surgeon and the assistant to view while operating. The magnification made possible by bringing the laparoscope lens close up to the surgical field compensated for the loss of detail in the electronic image. By multiplying the eyes and hands involved in laparoscopy, "videoendoscopy" made possible more complex and extensive surgery through the laparoscope. Furthermore, more importantly, videotaping allowed physicians to share their techniques with other M.D.s and finally to the public.
 
 2. 

 Laser surgery increased the new enthusiasm for laparoscopic surgery, allowing safe dissection in close areas in the abdomen. Manufacturers promoted its use both to patients and physicians and added glamor to the word laparoscopy by prefixing it with LASER!! Suddenly, the public thought laparoscopy was high tech. To be or to have a laser surgeon became a status symbol to both physicians and patients. Eventually, however, surgeons realized that lasers were just another tool to be used wisely and safely but were not the "holy grail" of surgery.
 
 3. 

 Manufacturers expanded the availability of laparoscopic hemostatic clips, stapling devices, and suturing equipment. Reich showed that hemostasis was practical by occluding and desiccating (now termed coaptating) large vessels with bipolar electrosurgery.

 All these new tools have made possible extirpative surgery on structures such as ovaries, uteri, appendix, kidneys, and gallbladders.
 
 

The General Surgery "Discovery" of Laparoscopy


 
 In the summer of 1987 in Lyons, France, a watershed event occurred in laparoscopy when Phillipe Mouret and colleagues successfully performed the first laparoscopic cholecystectomy, an event that revolutionized general surgery.

 In the United States, Eddie Joe Reddick and Douglas Olsen worked to refine "lap chole" and to develop cholangiography. These two general surgeons developed and first offered laser laparoscopic cholecystectomy with cholangiography and developed the first "hands-on" animal training courses in our animal lab at Centennial Medical Center here in Nashville. We co-authored the first report on "lap chole" in English in 1989.

 Our videotapes shown at USA national surgical meetings at that time led to the explosion in the USA of extensive publicity over "lap-chole." As they say, "the rest is history." Surgeons then rushed to learn laparoscopy supported by laparoscopic instrument manufacturers such as U.S. Surgical's Autosuture or Johnson & Johnson's Ethicon EndoSurgery. Thus began the multibillion dollar disposable laparoscopic instrument industry.
 
 Not to be outdone by their aggressive general surgeon friends who so rapidly embraced "new" laparoscopy, gynecologists who had much more experience over years of performing basic laparoscopy followed their competitive instincts and used the improved laparoscopic equipment to perform more extensive gynecologic laparoscopic procedures, e.g. the various types of laparoscopic hysterectomies available today in most American operating rooms.
 
 


 
 Hysterectomies have a long history, with the first vaginal hysterectomy reported in 1813, and the first elective abdominal hysterectomies in 1863.

 These two operations were constantly refined over the remainder of the 19th century and by the mid portion of the 20th century, had become established as the classic techniques. Since the middle of this century, however, there were no substantial changes in the classic techniques of either abdominal or vaginal hysterectomy until 1989, when the first reported laparoscopic hysterectomy was reported.


 
 Each gynecologist believes that he or she is aware of the correct indications for performing each type of hysterectomy, and when each should be performed. The actual percentages of abdominal or vaginal hysterectomies vary from country to country and from region to region of the United States. A few expert vaginal surgeons are capable of removing the majority of uteruses by vaginal hysterectomy. Kovac

 reported that in a series of 617 patients he was able to perform vaginal hysterectomy in 89%. However, in contrast to these individual reports, a national survey of every hysterectomy performed in Finland in 1995 indicated that 93% of cases were performed by the abdominal route.


 
 The varying proportions of abdominal and vaginal hysterectomies reported indicates that after more than one hundred years of experience with the most commonly performed major surgical operation in the world (hysterectomy), the gynecological profession as a whole has no clear indication of the optimum method by which to perform a hysterectomy in differing situations! The choice of method of the operation depends more upon experience and personal bias of the surgeon than upon a critical evaluation of the operative and outcome data. 
 
 Now, with ten years of experience with laparoscopic hysterectomy, a third variable has been introduced. Alan Johns, in a review on the medical and economic impact of laparoscopic hysterectomy in Fort Worth, Texas, stated "the route of hysterectomy is usually determined by the skill, experience, and preferences of the operating gynecologist. Few other parameters matter."


 
 Another important development in the history of intelligent medical care is the concept of evidence-based medicine. Various authors point out that all clinical data does not appear to be of equal importance when assessing the worth of a technique. Individual case series are of least value, non- randomized controlled trials and case controlled studies are of somewhat greater value, and randomized controlled trials (RCT) are of even more value. Perhaps of greatest value, however, is the meta analysis of a number of good RCTs. Many scientific and funding bodies are now insisting that evidence be categorized according to the quality. 
 
 In the real world, the problem with evidence based medicine is that even though you have evidence which is based on scientific data, it is difficult to convince practitioners that this evidence should lead to changes in daily practice. Changes can cause physicians considerable discomfort and inconvenience. To be effective as surgeons, it is essential that physicians believe that whatever operation they recommend to their patients is the best available. If they doubt the superiority of their selection and their techniques, then physicians may be compromising their patient care.
 
 


 
 It is accepted that abdominal hysterectomy can be used for every indication and can be considered to be the "default" operation. That is, when a procedure cannot be carried out vaginally or via laparoscopy, it can always be done by the abdominal route: "If we have trouble with a laparoscopy, we can always open you up." Amazingly, the two approaches to the most common major operation in the world had never been subjected to a single formal prospective randomized trial until the recent introduction of laparoscopic hysterectomy. In the past, most studies were retrospective studies, and those before 1970 generally found vaginal hysterectomy to be associated with more morbidity than abdominal hysterectomy, particularly fever and infections in the vagina.
 
 

Facts Concerning Complications of Abdominal and Vaginal Hysterectomy

There is a higher incidence of bleeding complications after vaginal hysterectomy.

Overall blood transfusion rate has fallen in the last eighteen years, but is 	still higher with abdominal hysterectomy.

Abdominal hysterectomy probably still has a higher rate of unexplained infection 	than vaginal, but the rate of urinary tract infection seems to be similar for both groups.

There is a greater risk of bladder injury after a vaginal hysterectomy, and the 	more difficult the procedure, the higher the incidence of bladder injury with vaginal surgery.

Injuries to the ureter appear to be more common after abdominal hysterectomy. 	These conclusions are based on our review of sixty-five series of complications reported after abdominal or vaginal 	hysterectomy since the CREST study was published in 1982.


 The lack of relevant data concerning abdominal and vaginal hysterectomy makes it difficult to compare data in the first decade for laparoscopic hysterectomy. Since physicians are just finishing the first decade of laparoscopic hysterectomy, gynecologists are still modifying their techniques and are still early in their learning curve. Thus the number of complications in some of the initial series has been higher than it will be in the future as clinicians gain further experience and develop a more skilled operative team and define more reliable and safer operative techniques.
 
 

What About The Safety and Efficacy of Laparoscopic Hysterectomy?


 
 There have now been at least six randomized controlled studies comparing laparoscopic and abdominal hysterectomy. These all show quicker recovery, less complications, and less patient discomfort with the laparoscopic approach. At the same time, there have been two small randomized controlled trials comparing vaginal hysterectomy to laparoscopic hysterectomy. Both show similar pain with reduced costs from vaginal hysterectomy. This would clearly be expected, since there is minimal equipment required for vaginal hysterectomy when compared to that required for laparoscopic hysterectomy. 
 
 Our conclusion from a careful review of the literature is that after the first decade of laparoscopic hysterectomy, clearly there is more rapid recovery, with no greater risk of complications in the hands of physicians who have experience with laparoscopic hysterectomy of various types. Postoperative pain is less severe compared to abdominal hysterectomy and recovery is clearly more rapid than with either vaginal or abdominal procedures.
 
 

Laparoscopic Hysterectomy - The First Decade


 
 Clearly, as more physicians have become comfortable doing laparoscopic hysterectomies, it has increased the numbers of vaginal hysterectomies which they perform without laparoscopy. This has reduced the overall numbers of abdominal hysterectomies being performed. The reasons for this are clear if one is active in surgery. As a physician begins to do laparoscopic hysterectomy, he gains more confidence and skill at vaginal surgery. There is nothing like having a laparoscope in the abdomen looking from above while trying to do difficult vaginal surgery. This enhances visibility, improves safety, and encourages the surgeon to be more aggressive.
 
 Initially, the concerns of the critics of laparoscopic hysterectomy were that laparoscopic hysterectomy would be used to replace vaginal hysterectomy. This was never the thought, as the initial article by Reich stated that careful investigation of laparoscopic hysterectomy should be undertaken to possibly replace some abdominal hysterectomies. It was never the intent of any of the early physicians doing laparoscopic hysterectomies to "compete" with vaginal hysterectomies. Clearly, from the patient's standpoint, if a vaginal hysterectomy is indicated and if the gynecologist feels comfortable with that approach, then this should be the treatment of choice, as it is most cost effective, and is a tried and true procedure. However, the outcome is based on the skills of the surgeon as well as the pathology involved and the condition of the patient.
 
 

Various Types of Laparoscopic Hysterectomy - Confusing Terms to Us All


 
 The generic term laparoscopic hysterectomy covers several types of procedures. It can be confusing sometimes because the terminology has not yet been well defined or standardized. The first term used was LAVH, which stands for Laparoscopically Assisted Vaginal Hysterectomy. Surgery begins by laparoscopy, and then is completed vaginally, with the uterus being removed through the vagina, but with laparoscopic observation from above. Total laparoscopic hysterectomy involves doing the entire procedure through the laparoscope. Subtotal or laparoscopic supracervical hysterectomy (LSH) is similar to open subtotal hysterectomy done earlier in this century, in which the uterus is amputated between the cervix and the fundus. In this case, the vagina is not opened, and the entire body of the uterus, tubes, and ovaries, if indicated, are removed by laparoscopy through small abdominal incisions. The first laparoscopic subtotal hysterectomy was reported in Germany in 1991.

 Since that time, several large series have been reported, including 500 cases from Belgium with no complications and very rapid recovery.

Table 1- Laparoscopic Hysterectomy Various Terms

The concept of leaving the cervix is somewhat controversial, particularly among older gynecologists in America, who have been trained to "always remove the cervix." Many physicians do not feel comfortable with laparoscopic supracervical hysterectomy because of biases from their previous training. On the other hand, many women seek out this procedure because it potentially gives better postoperative sexual function while minimizing the complications and costs associated with laparoscopic hysterectomy.

we have found operating time (time is money in the operating room) to be much shorter with laparoscopic subtotal hysterectomy compared to total laparoscopic hysterectomy. Our patients have been very happy with the procedure and we have been able to reduce our global operating costs significantly compared to 1992 costs with LAVH.

The bottom line global health care costs associated with LSH are less than with other forms of laparoscopic hysterectomy. Since the patient can return to work or full activities much sooner, this reduces costs to the employer and society. The average time to return to work for our patients who have undergone subtotal laparoscopic hysterectomy is three weeks, compared to four weeks for those undergoing laparoscopic assisted vaginal hysterectomy, six weeks for vaginal hysterectomy, and approximately eight weeks for total abdominal hysterectomy.

So Why Should Hospitals Embrace Laparoscopic Hysterectomy?

Global costs are reduced, thus benefitting all parties

Hospitals Maximize use of high income areas of hospital, e.g. surgery, recovery 	room, short stay facility

Enhances reputation of the hospital as a "Center of Excellence"

Attracts desirable payer mix with high pay insurance plans (working patients 	who want rapid recovery to return to work)

With proper cost containment efforts can still be profitable in capitated systems

Why Most Hospitals Currently Don't Promote Laparoscopic Hysterectomy

Because they lose money on the procedure!!!

Poorly motivated or trained GYN staff = high costs and complication rates with 	prolonged operating times

Excess waste of intraoperative equipment by using disposable equipment unnecessarily

Early data that suggested procedure costs exceed payor reimbursements

Ignorance, inertia or disinterest of surgical and administrative staff

Inadequate O.R. equipment and support = long operating times, higher complication 	rates, frustrated surgeons, excessive turn-over time between cases

What is the Secret to Profiting with LAVH Today?


 
 There is a clear need for hospitals to offer hysterectomy in a cost effective manner to survive in today's healthcare environment. 
 
 

How Can A Hospital Profit From An Active Hysterectomy Program in Today's Health Care Environment?

Recruit or educate and train GYN staff MDs to become "expert" surgeons 	- "Best of the Best" doctors have best outcomes

Provide MDs with cost profiles of hysterectomy to enhance MD's incentive to reduce 	costs - No doctor wants to be the high cost provider

Promote vaginal hysterectomy or laparoscopic hysterectomy over total abdominal 	hysterectomy

Inservice to staff to support excellent efficient operations

Provide incentive to MDs with extra payment for LH or Vag Hyst over TAH

Provide excellent reusable cost effective equipment and encourage MDs to use 	them

By merely going back to safe effective use of reusable laparoscopic tools, a hysterectomy program can become profitable.
 
 A recent widely read 1997 editorial in the prestigious journal Fertility and Sterility addressed this issue with a catchy title - "There's a Hole in My Bucket: The cost of Disposable Instruments."

Bowel injuries with disposable trocars appear to be three times more common (complications 	= cost)

There is no evidence reusable laparoscopic instruments increase infections

Savings per case is significant with reusables

Several peer review articles have now reported significant cost savings with laparoscopy by use of reusable instrumentation. Here are some quotes.

"When actual costs have been analyzed, it appears that the cost per case 	of disposable instruments is approximately seven times that of the reusable version."       

"The cost of the disposable cannula per use was higher than that of the 	nondisposable cannula, $63.71 and $1.35, respectively, and thus increased hospital costs for laparoscopic procedures. 	Furthermore, although the charge to patients reflects a significant mark-up from the hospital costs for disposable 	cannulas, capitation agreements eliminate any possibility of a real hospital profit with the use of these cannulas."       

"The routine use of disposable equipment and automatic disposable staplers 	for laparoscopic hysterectomies is very debatable as the considerable increase in cost is not accompanied by any 	benefit for patients or society." 

"At current costs to our hospital, over $2,000 is saved per operation with 	our conversion to reusable instrumentation where possible. This has occurred with reduced operating times and no 	increase in complications." 

What Is The Quickest, Easiest Way To Implement An Effectuve Laparoscopic Hysterectomy Reusable Instrument Program?

. We practice at Columbia Centennial Medical Center (CMC), the "home office" facility in Nashville for America's largest hospital chain. In spite of years of expertise in all types of laparoscopic operations, CMC recently contracted with an innovative local company, American Endoscopy Services (AES), with the experience to solve this problem. The information in the box below is taken directly from AES promotional information provided to our hospital O.R. staff, and clearly defines the problem and their solution. Since we have implemented this simple outsourcing solution, we have rapid turnover time between cases and a high number of our laparoscopists are switching to reusable equipment with no problems or complaints. 
 
 This is now a win-win situation for all of us at CMC. Our hospital profits; we doctors have safe, clean tools; and patients receive the clear benefits of minimally invasive surgery with low risk of complications.
 
 

American Endoscopy Services (AES) - Nashville, Tennessee (Direct quotes from company literature)


 
 "In today's rapidly changing healthcare environment, hospitals face extraordinary pressure to reduce operating expenses and improve patient care. AES offers a unique solution through our comprehensive surgical support program. In addition to reducing laparoscopic procedure costs by an average of 30%, our technical support improves patient care at no capital expense to the hospital."
 
 

"The AES program offers two principle services for one per-procedure charge:"

"1. We provide all new state-of-the art reusable instrumentation and video equipment for rigid-scope endoscopy surgery. The products we provide are based on the preferences of your staff and surgeons. AES works with your staff and surgeons personally to educate them on the safety and cost-reducing benefits of the most modern reusable instruments for rigid-scope endoscopy. AES is responsible for all instrument care, cleaning, and maintenance."
 
 "2. We provide highly trained AES surgical technicians on site to assist your staff in every laparoscopic, thoracoscopic, and hysteroscopic procedure. Our technicians assist with preoperative room set up, intraoperative technical assistance, and postoperative room turnover."

How Laparoscopic Hysterectomy Can Help Reduce Employer Health Care Costs
 by Jim Astuto - Regional Healthcare Manager, GTE Corporation


 
 Many employers don't understand the total overall economic benefits that can be realized when laparoscopic hysterectomy (LH) is performed instead of total abdominal hysterectomy (TAH). However, GTE Corporation, the telecommunications giant, is not one of them because GTE's healthcare cost management strategy is focused on the quality of care rather than strictly the cost of care. GTE realizes that the best care is always the least costly, especially when it is delivered by high quality cost effective providers.
 
 Laparoscopic hysterectomy is a perfect example of how the best care can help reduce an employee's total overall healthcare cost. While the sum of physician and hospital fees for laparoscopic hysterectomy can sometimes be more than that of total abdominal hysterectomy, GTE beneficiaries having an LH are able to return to normal activities much sooner than those who have a TAH. This allows them to return to work earlier thus reducing disability, replacement worker and lost productivity costs for GTE. These cost savings will more than offset the occasionally high additional direct medical costs of laparoscopic hysterectomy in GTE's view.
 
 So what has stopped LH from becoming the standard of care? One of the main problems is that health plans don't require it instead of TAH because they are only concerned about the direct medical cost associated with a hysterectomy and are not accountable for the total costs of the procedure to the employer. As long as they continue to be measured only on direct medical costs ( and LH cost more than TAH), it will not be in their financial interest to encourage network providers to perform LH instead of TAH. While the health plans don't have a financial interest in the cost of disability, productivity or the other non-medical costs associated with hysterectomy, employers like GTE do and they want global costs to be as low as possible. Thus, if LH is going to be a tool that helps better manage the total costs associated with hysterectomy, employers must demand it from their health plans and healthcare providers. We want the best care by the best doctors for our employees and feel cost effective LH performed by "expert" experienced gynecologic surgeons clearly is better for the GTE patient when a hysterectomy is necessary.
 
 The reporting of LH under the frequency of procedures section in the 1998 HEDIS data that will be reported by health plans in 1999 will be one of the first steps to measure the actual utilization of LH in managed care plans. With this information available for the first time, interested employers like GTE will be able to demand improvement from health plans providers in this area. - James Astuto, Regional Healthcare Manager, GTE
 
 


 
 Hysterectomy will always be necessary.It is time that we all focus on the real reason to be in the health care business - to deliver quality care to sick patients with minimal risk or discomfort and quick recovery in the most cost effective manner possible. We conclude that appropriately performed laparoscopic hysterectomy is a cost effective operation that meets all our common goals for the women of America. Major abdominal surgery can be avoided. Women recover quicker with less pain. Payors (such as GTE) benefit with cost savings and healthier employees; insurance companies save money, and finally, hospitals which are well run can survive and profit as well. Thus have we created a win-win situation.
 
 Remember the "Right Stuff" movie. The "right" patient with the "right" doctor, in the "right" operating room and with the "right" tools = successful avoidance of abdominal hysterectomy.

1. Sutton C. Hysterectomy: a historical perspective. BalliÃ¨re's Clinical Obstetrics and Gynaecology 1997;11:1-22.

2. Reich H, Decaprio J, McGlynn F. Laparoscopic Hysterectomy. Journal of Gynecologic Surgery 1989;5:213-16.

3. Kovac SR. Guidelines to determine the route of hysterectomy. Obstetrics and Gynecology 1995;85:18-23.

4. Harkki-Siren P, Sjoberg J, Titinen A. Urinary tract injuries after hysterectomy. Obstetrics and Gynecology 1998;92:113-8.

5. Johns DA, Carrera B, Jones J, DeLeon F, Vincent R, Safely C. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. American Journal of Obstetrics and Gynecology 1995;172:1709-15.

6. Harris WJ, Daniell JF. Early complications of laparoscopic hysterectomy. Obstetrical and Gynecological Surgery 1996;51:559-67.

7. Semm K. Hysterectomy via laparotomy or pelviscopy. A new CASH method without colpotomy. Geburtshilfe und Frauenheilkunde 1991;51:996-1003.

8. Donnez J, Nisolle M, Smets M, Polet R, Bassil S. Laparoscopic supracervical (subtotal) hysterectomy: a first series of 500 cases. Gynaecological Endoscopy 1997;6:73-6.

9. Lalonde CJ, Daniell JF. Early outcomes of laparoscopic assisted vaginal hysterectomy versus laparoscopic supracervical hysterectomy. Journal of the American Association of Gynecologic Laparoscopists 1996;3:251-6.

10. Daniell JF, Channell C, Lindsay J, Staggs S, Henry T. Early evaluation of an electromechanical morcellator for laparoscopic supracervical hysterectomy. Gynaecological Endoscopy 1999;7:1999 (in press)

11. Daniell JF, Kurtz BR, McTavish G, et al. Laparoscopically assisted vaginal hysterectomy: the initial Nashville experience. Journal of Reproductive Medicine 1993;38:537-42.

12. Steptoe PC. Laparoscopy in Gynaecology. Edinburgh, Livingstone 1967.

13. Cohen M. Laparoscopy, Culdoscopy and Gynecography: Technique and Atlas.Philadelphia, WB Saunders, 1970.

14. Reich H. Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tubo-ovarian disease. International Journal of Fertility 1987;32:233-6.

15. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparoscopic cholecystectomy. American Journal of Surgery 1991;161:385-7.

16. Reddick EJ, Olsen DO, Daniell JF. Laparoscopic laser cholecystectomy. Laser Med Surg News Adv 1989;Feb:38-40.

17. Hurd WW, Diamond MP. There's a hole in my bucket: the cost of disposable instruments. Fertil Steril 1997; 67:13-5.

18. Schaer GN, Koechli OR, Haller U. Single-use versus reusable laparoscopic surgical instruments: a comparative cost analysis. Am J Obstet Gynecol 1995;173:1812-5.

Articles

Laparoscopic Hysterectomy and Health Care in America -Finding the Balance Between Costs and Outcomes

Laparoscopic Hysterectomy and Health Care in America

 To evaluate the effectiveness, safety, and cost effectiveness of electromechanical morcellation of the uterus and adnexae to enhance laparoscopic supracervical hysterectomy (LSH).


 Forty-one consecutive cases of LSH with and without adnexectomy were reviewed. Each case utilized an electromechanical morcellator to accomplish laparoscopic removal of the uterus and adnexae.


 Private gynecologic practice in a full service hospital
 Interventions: LSH


 The mean uterine weight was 146 g (60-569 g). The mean operating time was 94 minutes (60-225 min.). Actual morcellation time was available in 19 cases by reviewing videotape with an average morcellation time of 11.8 minutes (4-23 min.). Average blood loss was 125 cc (20-600 cc) with one case of late postoperative bleeding requiring operative intervention. The average cost for the procedure was $7,998 ($6,989 - $11,581). Thirty-six patients were discharged within 23 hours from the time of admission and all patients were discharged within 48 hours of the time of admission.


 LSH is a safe and effective method of managing patients that lack cervical pathology or pelvic relaxation. Electromechanical morcellation can enhance the performance of LSH by decreasing operative time.




 All variations of laparoscopic hysterectomy (LH) have been much discussed since first reported by Reich in 1989.

 One particularly controversial form of laparoscopic hysterectomy is subtotal hysterectomy (LSH). LSH was first described by Semm.

 Since that report, several authors have reported their initial experience with various methods for LSH.

 One recent report from Belgium has also reviewed 500 cases of LSH..

 recent clinical commentary by Munro discussed the pros and cons of LSH in an editorial entitled 

"Supracervical Hysterectomy: A Time for Reappraisal"

 We recently published our initial experience with laparoscopic subtotal hysterectomy.

 In this article, we report our initial experiences with an electromechanical morcellator designed for laparoscopy and describe and discuss in detail our other modifications of LSH that we feel simplifies the procedure, and reduces operative time and intraoperative and postoperative complications.




 From January, 1996 through January, 1997 we reviewed 41 consecutive cases of laparoscopic subtotal hysterectomy performed by our group in Nashville. All operations were performed by the senior author (JFD) with the assistance of one of the co-authors. The office records and hospital charts for these 41 women were reviewed to determine indications, clinical parameters, operating times, blood loss, length of hospitalization, and complications. All patients were interviewed at least six weeks following discharge from the hospital. Pathology reports were reviewed to obtain uterine weights and final pathologic diagnosis. With our institution of use in January 1996 of the electromechanical surgical morcellator (Karl Storz Endoscopy, Culver City, CA), operating times were monitored for both total operative times and the actual time necessary for laparoscopic morcellation and removal of the fundus of the uterus and/or adnexae. In nineteen cases real time videotapes were available for review and analysis so that exact operative and morcellation times could be obtained for accurate reporting. Findings in these 41 patients were then compared with 20 previous patients who had undergone LSH by the senior author (JFD) without the morcellator between January 1993 and December 1994.


 All women underwent preoperative approval for hysterectomy through their insurance carriers, and none were deemed inappropriate candidates for surgery. Postoperatively, when hospital tissue review committees reviewed the charts, no procedures were considered 

. All patients were either private patients of the authors or had been referred to the senior author for consideration specifically for laparoscopic subtotal hysterectomy because of desire for retention of the cervix. The patients were all counseled preoperatively concerning the risks versus benefits of subtotal hysterectomy with retention of the cervix. The option of supracervical hysterectomy was offered only to patients who had a normal cervix and no history of any abnormal cervical pathology on Papanicolaou smears. Patients with uterine descensus or cervicitis were not offered this procedure. All patients were informed of the need for and consented to lifetime follow-up Papanicolaou smears following surgery. Indications for hysterectomy included symptomatic uterine fibroids, chronic pelvic pain, chronic menometrorrhagia 

 with hormonal therapy, or endometriosis.




 All patients had a preoperative Papnicolaou smear within three months of the scheduled surgery. Patients over 35 had an endometrial biopsy and ultrasound if clinically indicated. Patients were given the opportunity to bank autologous blood prior to surgery, and were pre-treated with oral iron prophylactically. Ten patients with fibroids and anemia secondary to menorrhagia were pretreated with GnRh analogs for three months preoperatively.




 As with our recent clinical practice, we used the most cost effective methods for LSH whenever possible. Lateral 5 mm ports were used and reusable instruments, including all four trocars and sheaths and reusable scissors and Verres needles were used in all cases. After general anesthesia with endotracheal anesthesia, pelvic exam was performed on the patients to confirm the preoperative findings. A reusable uterine manipulator was placed using either a polyp forceps taped to a single toothed tenaculum, or in certain cases with a small uterus, a Hulka tenaculum was inserted. Continuous bladder drainage with a Foley catheter was used intraoperatively. A four-puncture technique was used with a 10 mm reusable cannula infraumbilically and two lateral 5 mm cannulas laterally in each lower quadrant.

 These were placed under direct visualization and were placed lateral to the rectus muscle and up out of the pelvis well above the inferior epigastric vessels. This gave a good angle of attack into the pelvis and reduced the risk of bothersome bleeding from the abdominal wall puncture. Another 5 mm reusable cannula was placed suprapubically in the midline approximately 3 cm above the pubic symphysis. A video camera was attached with two videos being made, one edited tape for the patient and one real-time copy of the procedure with sound which could be later reviewed and for timing purposes to monitor the exact time of surgery and morcellation with the electromechanical morcellator. After initial laparoscopic inspection of the pelvis and entire abdomen and an intraoperative phone consultation with the family, the procedure was then commenced.

 For tissue separation, bipolar coagulation was applied at 50 watts with 5 mm instruments. Initially a 5 mm disposable Maryland dissector (Everest Medical, Minneapolis, MN) was used for coagulation and dissection during the LSH with 5 mm reusable scissors for transection. For the last 20 cases, a 5 mm combined coagulating and transecting bipolar forceps (Everest Medical, Minneapolis, MN) was used. 

 With traction and countertraction for adequate exposure, the bipolar coagulating device was used to coagulate and then transect the round ligaments and the infundibulopelvic (IP) ligaments (whenever the adnexae were being removed). Whenever the adnexae were being retained, the same techniques were used to coagulate and transect the round ligaments, proximal fallopian tubes, and ovarian ligaments.

Once the upper portions of the fundus had been separated from its lateral attachments, the anterior cervical uterine junction was identified. We did not dissect the bladder peritoneum off of the anterior portion of the cervix, but merely coagulated the serosa transversely with bipolar coagulation forceps just above the level of the vesico uterine fold. In addition, the main branches of the uterine artery and the ureters were not dissected unless adnexal adhesions required this for adequate exposure and to facilitate removal of the adnexae. After coagulating and transecting the upper portions of the broad ligaments, the ascending branches of the uterine vessels were identified and coagulated using the bipolar coagulating forceps and then cut. At all times, care was taken to identify the main branch of the uterine artery and to know that the ureter passes under this visibly pulsing structure.

Since bipolar coagulation was being used, we were aware that temperatures above 50 degrees Centigrade could be reached as far as 1 cm lateral to the edge of any bipolar coagulating device. Thus, we always carefully monitored placement of the tips of the instruments before applying the bipolar energy. We used an amp meter at all times to note when tissue desiccation was completed and when it was thus safe to cut tissue. By using the 5 mm bipolar coagulating multifunction device, we eliminated the problems of cutting with scissors past the tip of the coagulated zone, since the cutting blade could not pass beyond the area of coagulation.

Once the ascending branches of the uterine vessels have been coagulated close to the isthmus of the uterus, the uterus would become discolored from reduced blood supply. Dilute pitressin (20 units diluted in 50 cc of saline) was then injected via a long spinal needle placed directly through the lower abdominal wall into the anterior uterine fundus to reduce cervical small vessel bleeding with separation of the uterus. This was done with the approval and vigilance of the anesthesiologist because of the potential for bradycardia or hypertension with systemic absorption. Whenever possible, the posterior peritoneum over the back of the lower uterine isthmus was coagulated with the bipolar forceps to mark the intended area for transection of the low posterior fundus. At this point, the lateral third of the isthmus just above the cervical uterine junction was transected using 50 watts cutting current with reusable 5 mm unipolar scissors incorporating active electrode monitoring via an integrated electrode (Electroscope, Boulder, CO) to reduce the potential for accidental electrosurgical injuries such as capacitive coupling.

After transecting both lateral thirds of the isthmus, the uterine manipulating device was removed, but the tenaculum was maintained on the cervix for downward traction. Then with traction and counter-traction, the isthmus of the uterus was transected just above the level of the cervical junction, trying to maintain a transverse plane whenever possible. Once the body of the uterus was cut away from the cervix, the cervical stump was coagulated with the bipolar forceps for hemostasis. The endocervical canal was then coagulated by placing the blunt 5 mm coagulating forceps into the cervical canal, making certain the jaws of the forceps were open and then applying bipolar energy and slowly rotating the forceps so that the entire cervical canal can be thermally coagulated from above with electrosurgery. This was done to hopefully destroy all the endocervical tissue which might lead to later bothersome persistent vaginal spotting.

In the past, we have used various methods for transecting the fundus from the cervix, including a bipolar needle, a harmonic scalpel blade, laser energy, blunt scissors, a 5 mm knife, and unipolar electrosurgical energy with scissors. We found that the 5 mm shielded reusable scissors with unipolar current (50 watts cutting blend 1) gave us the most rapid effective transection of the dense cervical tissue. Care was taken to stay just above the level of the cervix when cutting with the scissors so as not to remove the lateral cervical stroma containing the uterine vessels. Careful coagulation of the exposed ascending branches of the uterine vessels in each lateral cervix was then performed and any small oozing vessels from the cervical body were coagulated with the bipolar coagulating forceps. At this point, the lower 5 mm suprapubic site was converted to a 12 mm reusable sheath through which the electromechanical morcellator was introduced

The electromechanical morcellator allows a rapidly circulating sharp 10 mm cylinder to be used for tissue coring with a foot control switch. Through this instrument, the uterus and adnexae were grabbed with a 10 mm claw grasper. The tip of the rotating electromechanical morcellator was always kept close to the trocar sheath in the lower abdominal wall and not allowed to "wander" into the abdominal cavity. The tissue was pulled up into the jaws of the rotating sharp cylinder, but the cylinder was not pushed inwards. In this fashion, we were able to minimize the potential for intra abdominal accidents from the sharp rotating blade of the electromechanical morcellator. The long 10 mm cores of tissue were then pulled up out through the 12 mm port and deposited into a sterile pan. When removed, the adnexae were morcellated in a similar fashion.

After the larger portions of the tissue were removed, a 10 mm spoon forceps was introduced and used to pick up the small remaining pieces that may have fragmented during the manipulations. The patient was taken out of Trendelenburg so that any accumulated intraperitoneal fluids would pool in the lower pelvis. These fluids were aspirated and replaced with fresh heparinized Ringers (5,000 units of heparin per 1 L of lactated Ringers). Approximately 200 to 300 cc of fluid containing 2 cc of polymixin, bacitracin, and neomycin was instilled to remain intraperitoneally. Nu-Knit (Johnson & Johnson Medical, Arlington, TX) was then introduced into the abdomen with the spoon forceps through the lower 12 mm trocar sheath and placed over the cervical stump.

This piece of double thickness surgicel is designed specifically for laparoscopic application as a hemostatic agent to augment early postoperative hemostasis. The pneumoperitoneum was evacuated from the abdomen and the laparoscope was then used to inspect all the pedicles with reduced intraperitoneal CO2 pressure. At this point, the lower 12 mm trocar was removed and a reusable Carter-Thompson fascial closure device (Inlet Medical, Eden Prairie, MN) was used to close the lower 12 mm peritoneum and fascia opening with an absorbable suture. The two lateral 5 mm ports were then removed and the puncture wounds inspected for any bleeding. Finally, the umbilical 10 mm reusable sheath was removed and all four skin incisions closed with subcuticular sutures. Postoperatively, the patients were seen four to six hours after surgery, at which time the catheter was removed. After ambulating, voiding and tolerating oral fluids, patients were discharged in the care of family members.

All patients were seen two and six weeks postoperatively and closely questioned concerning their recovery.. They were encouraged to resume their regular activities in two weeks, but to avoid intercourse for one week following surgery. Patients undergoing oophorectomy with no contraindications to estrogen replacement therapy were started on estrogen the day after surgery to help them avoid early postoperative estrogen deficiency symptoms. All patients were again counseled that they must have annual follow-up Pap smears, as well as their routine scheduled gynecologic exams.

Clinical indications for hysterectomy in this series are shown in

The age range of the patients was 26 to 59 years, with the mean age being 43. Only three patients were under 35 and the youngest patient had severe endometriosis and bilateral endometriomas. Nineteen of the women in this series were nulliparous, with 14 having had previous Cesarean section, but only 8 having experienced a vaginal delivery. Uterine weights ranged from 48 to 569 grams, with a mean weight of 146 grams. The 48 gram uterus was from an 80 pound woman with adenomyosis. Evaluation of hospital days revealed a mean stay of 1.04 days.

Thirty-seven patients were discharged within 23 hours, and the other four stayed 48 hours. Actual time of the operation was calculated from placement of the first trocar until the closure of the 12 mm fascial suture and recorded in each case. Mean operating time was 94 minutes, with the minimum time being 60 minutes and the maximum time 225 minutes. The patient with prolonged operative time reflected an extremely difficult operation. She had a 5 cm broad ligament fibroid and extensive adhesions from two previous open myomectomies which required significant dissection before the LSH could begin. In addition, the morcellator stopped working because of technical error in its assembly, and the majority of the morcellation was carried out with more tedious slower methods. Average blood loss was estimated as 125 cc with a maximum blood loss of 600 cc, and minimum blood loss of 20 cc. No patients received any blood transfusions in this series.

summarizes these outcome variables and compares them with our similar findings in our initial report on LSH from 1994. Representative mean hospital costs were calculated excluding surgical, anesthesiology, and pathological fees, and before managed care discounts were included. The mean actual cost for these procedures was $7,998 with a minimum of $6,989 and a maximum charge of $11,581. As expected, this highest charge occurred in the patient with 225 minutes of operative time.

On review of videotapes for this study, only 19 patients had actual real time video covering the full morcellation procedure. By viewing real-time videotapes of these operations it was possible to determine the actual time necessary to perform tissue removal with the electromechanical morcellator. Times for morcellation ranged from 4.2 minutes up to 23 minutes in this group of 19 patients with a mean time of 11.38 minutes.

illustrates this graphically comparing uterine weights to morcellation times for 19 of 41 patients and demonstrates the relationship between total operative anesthesia time and morcellation times previously described.

Complications in this study were few and included two patients with minimal postoperative cervical bleeding which stopped spontaneously within four months. One other patient who underwent bilateral adnexectomy with the LSH had persistent right lower quadrant pain following surgery and was thought to have probable postoperative adhesions. However, seven months post LSH, she underwent a diagnostic laparoscopy which revealed minimal postsurgical adhesions to the cervical stump and the left lower pelvic sidewall, but no adhesions in the area of her right lower quadrant pain and a normal appendix. With subsequent treatment for spastic colon syndrome, her symptoms resolved.

There was one significant postoperative complication that led to follow-up operative procedures. The patient with significant postoperative complications was a 32 year old 80 pound female with two previous Cesarean deliveries. She had a very small uterus (48 grams) and cervix with endometriosis, adenomyosis, and significant adhesions to the anterior cervix. During this LSH an upper portion of the small cervix on the left side was resected. Because of persistent mild cervical bleeding, a ball electrode was used transcervically three months after the LSH to coagulate the endocervical canal. This was done under laparoscopic visualization which revealed that the remaining left lateral cervix was very small with significant post-operative thermal necrosis. Ten days following this minor second operative procedure, the patient developed profuse cervical bleeding and underwent an emergency laparotomy with trachelectomy to remove a necrotic small residual cervix. At the emergency laparotomy done on a weekend night, the patient was noted to have a very small remaining portion of the left cervical tissue and it was theorized that the final bleeding episode occurred because of sloughing of the medial portions of the cervical branch of the uterine artery entering this area of thermal necrosis.

At six weeks follow-up exam and questioning, all sexually active patients reported satisfactory intercourse without significant dyspareunia. Since no pre-surgical questionnaires of sexual function were used in this study, no attempt was made to assess postoperative sexual function in this group. No patients developed any urinary tract infections or postoperative urinary dysfunction. There were no problems with trocar site hematomas, hernias, or wound healing in this series.

This short term retrospective study indicates that use of an electromechanical morcellator can enhance LSH. In the past, LSH required a colpotomy, a larger abdominal wall incision, or use of tedious mechanical methods to morcellate the fundus. This device first described by Steiner

 rapidly cores the uterus, removes the uterus and adnexae very rapidly, and reduces the operating times. In this study we reduced our average operating times for LSH by 16 minutes which in our operating room ($15/minute) results in a minimal cost savings alone of $240 per case. Actual dollar costs for LSH in this 1996 series were more than 1994 costs. However, our hospital reported to us annual inflation increases for all LAVH procedures of 8% per annum. Thus in 1994 dollars, costs for this series of operations were calculated to be $881 less per patient.

This method of LSH reduces operator fatigue and avoids colpotomy or larger abdominal wall incisions which can increase morbidity and give poor cosmetic results. Patients in this series were all appreciative of the fact that they only had two visible 5 mm trocar sites in each lateral lower quadrant. The 10 mm umbilical incision was hidden in the umbilicus since it was always made vertically deep down in the umbilicus, and the 12 mm suprapubic trocar site was always hidden in the pubic hair after full recovery from surgery. After personally viewing their videotapes, several patients commented on the fact that this actually was a

hysterectomy, since the only sutures used were subcuticular sutures in the abdominal wall and the one fascial closure stitch. No intraabdominal suturing was necessary, since bipolar coagulation was used for occluding all vascular pedicles.

The electromechanical morcellator requires careful coordination between the assistant, the scrub nurse, and the surgeon. The technique that we have developed for morcellator use keeps the 12 mm sheath close to the abdominal wall and pulls the tissue up against the rotating blade held high up in the lower abdomen just outside the tip of the 12 mm sheath. This reduces the chances for inadvertent injury from the sharp rotating blade. By bringing the morcellator in through the lower suprapubic site, we avoid introduction of large trocar sites laterally in the abdomen with the potential sequelae of bleeding, hernia defect or poor cosmetic results. When using the morcellator, it is appropriate to morcellate fibrotic tissue first while the blade is sharpest. In this fashion, dense fibroids can be morcellated before the less dense uterine and adnexal tissues are removed. One should discuss the use of this technique with hospital tissue committees and pathologists before undertaking to use the morcellator, since the pathologists need to be alert to the fact that tissue will be coming to them in long cylindrical cores and thus fragmented. For many years in our hospital we have done morcellation of fibroids using non-mechanical techniques and have yet to encounter any problems with anatomical final pathological diagnosis. The constant fear is that one will morcellate a leiomyosarcoma and the pathologists will be unable to reconstruct the exact location and depth of penetration of the lesion. Clearly, the morcellator should only be used on masses which the operator is confident are benign.

Complications in this study were limited to the cervical stump. In the past, we have used colpotomy on occasion to remove bulky uteri after LSH. With colpotomy, one introduces the potential for ascending infection, cuff cellulitis, and it prolongs the time postoperatively before a patient may have intercourse because of the vaginal sutures. In this series and our previously reported series, we had no bladder or ureteral injuries. This reflects the fact that we do not dissect the bladder in any of our cases. We also do not dissect the ureter, although the ureter is identified and traced in all cases down to where it passes under the uterine artery. If the thermal effect from bipolar cautery stays above the uterine artery, one is unlikely to produce any thermal damage to the ureter which passes beneath that structure.

Since the bladder peritoneum is not dissected anteriorly with our technique, we make no attempts to reperitonealize the cervical stump. We have elected to place Nu-Knit over the cervical stump, which we feel reduces any early minor postoperative oozing. Nu-Knit is double thickness Surgicel (J&J Medical, Arlington, Texas) packaged specifically for laparoscopic application for hemostasis. It dissolves within one hour into a gel similar to Surgicel. There are no studies in humans to suggest that Nu-Knit reduces postoperative adhesions, but theoretically, its hemostatic effects on the cervix should reduce postoperative bleeding and thus the potential for adhesions. We have recently had an opportunity to view the cervical stumps in three patients who had undergone laparoscopic subtotal hysterectomy prior to 1996. In all these patients, adnexal disease led to a repeat laparoscopy. In these patients, there was excellent reperitonealization over the cervix, with no adhesions present. To address the actual instance of adhesion formation after laparoscopic subtotal hysterectomy, one would have to perform second-look laparoscopy in every patient, and this is clearly not indicated.

The main concern of traditional gynecologists who are opposed to LSH is the potential for subsequent cervical disease that would not occur if the cervix had been removed at the primary operation.

 Clearly, in this study and in our group of patients in our previous report from 1994, it is too soon to address the question of subsequent abnormal cervical pathology. To date, we have only had one patient following an LSH in our practice who has developed an abnormal Pap smear. A colposcopy and office biopsy revealed minimal atypia in that patient. It has been proposed by others that a prophylactic cervical conization can be performed at the time of LSH.

The theoretical advantages are that the squamocolumnar junction is removed, and therefore the potential for subsequent abnormal cellular changes is hopefully eliminated. In our previous experience, in two patients in which we did prophylactic cervical conization with LSH, postoperative cervical bleeding occurred, most likely because of excess hyperemia of the cervix from the trauma of the LSH combined with the concomitant conization. In addition, our hospital tissue committee questioned our indications for doing conization in these two patients when there were only normal Pap smears and the final pathology report revealed normal cervical squamocolumnar epithelium. In the eyes of this committee, this was unnecessary and inappropriate surgery with unnecessary risks and costs to the patient. Thus, because of the potential complications of a prophylactic conization combined with the fact that it is unnecessary surgery on normal tissue, we think that elective prophylactic conization with LSH should be abandoned. Instead, patients should be carefully followed after LSH with annual Pap smears and office colposcopy, biopsy and excisional procedures only when clinically indicated. Clearly, patients who are not capable of or available for careful long term postoperative follow-up should not be given the opportunity to undergo LSH.

In the past, a comprehensive review of the early literature on laparoscopic hysterectomies of all types including LSH concluded that the surgical complications are less with all forms of laparoscopic hysterectomy than with abdominal or vaginal hysterectomy.

 Another review compared all LAVH types except LSH (3,112 operations) to abdominal hysterectomy (1,118 operations).

 This review of 34 reports noted a higher rate of bladder and ureter injuries with LAVH versus TAH. Hopefully our technique for LSH can reduce the risk of urinary tract injury. Recently, a countrywide study from Finland reported on over 70,000 laparoscopies, including both diagnostic and operative. 

 In that nationwide report, ureteral injuries were .3 per 1,000 and bladder injuries .3 per 1,000. All of those injuries except two occurred after total laparoscopic hysterectomy, but none occurred after LSH. To our knowledge, there has not yet been a report of a ureteral or bladder injury following a laparoscopic subtotal hysterectomy. Obviously, this is a possibility, particularly if bipolar cautery is used too low or too lateral to the cervix. The surgeons must always be aware that lateral thermal damage can occur as much as 1 cm from the edge of the bipolar coagulation instrument.

 Such thermal injuries usually present as a later complication after slow thermal necrosis.

Laparoscopic supracervical hysterectomy is a very controversial procedure. Munro recently stated in his excellent clinical summary that

"as a result, supracervical hysterectomy could be postulated to be associated with fewer short and long term complications and reduce direct costs of care."

We cannot draw any conclusions until prospective randomized blinded randomized studies have been performed comparing laparoscopic subtotal hysterectomy with other forms of hysterectomy. Such studies have been performed comparing vaginal hysterectomy with laparoscopic hysterectomy,

 and also comparing abdominal hysterectomy with laparoscopic assisted vaginal hysterectomy (LAVH).

 it would be very difficult in America to enroll patients for a randomized study of LSH versus LAVH or TAH. Patients who are coming to physicians seeking retention of the cervix and who are candidates for having the cervix retained, are not going to volunteer for a study in which they have a 50% chance of having their cervix removed. Because of this fact, any randomized prospective studies comparing LSH to LAVH will be impossible with our patient population.

Bladder function following LSH clearly needs further clinical evaluation. In the past, Kilkkue et al

 evaluated bladder function symptoms in a non-randomized study of 212 patients undergoing abdominal total or supracervical hysterectomy, and concluded that retaining the cervix reduced the postoperative bladder frequency symptoms. Lalos and Bjerle

 evaluated 22 patients equally divided between total abdominal and supracervical hysterectomy comparing objective symptoms and urodynamic studies. They found no differences in either group concerning the frequency of symptoms of incontinence or bladder dysfunction. However, this was a very small study and this subject clearly needs to be more carefully evaluated in the future.

Unfortunately, since Masters and Johnson, no new pioneer studies on sexual response have appeared in the modern gynecologic literature. The only data available to us is now over a decade old, and concerned patients undergoing abdominal subtotal versus total hysterectomy.

 It is clear that this available data, which was fully reviewed by Hasson5 fails to demonstrate any difference in sexual function in women undergoing total versus subtotal hysterectomy, either by the abdominal or laparoscopic approach. Problems in scientifically evaluating the complex physiology of the female sexual response will make it very difficult to construct proper studies, particularly if prospective randomized studies are to be employed. We do, however, encourage investigators in the field of female sexual response to consider trying to design and go forward with such studies to address the very important question of the role of the cervix in sexual activity and response.

Several studies have now recently appeared in the literature which clearly show that LAVH of all types reduces operative morbidity, and hastens recovery compared to abdominal hysterectomy.

 No study yet has carefully evaluated the subgroup of laparoscopic hysterectomies performed by the laparoscopic subtotal approach. However, all of the initial reports of LSH compared to LAVH indicate shorter operating times for LSH, reduced blood loss, and a trend toward lower complication rates, particularly involving infectious processes from the cervical cuff and bladder or ureteral injury. Unfortunately, all of the initial studies involve single operators or groups extremely experienced in operative laparoscopy who are still constantly modifying their techniques.

lists and compares some of these initial studies.

Many techniques have now been described for laparoscopic subtotal hysterectomy. We feel as ours has evolved, it now combines safety, simplicity, reproducibility, and cost effectiveness. We minimize our use of disposable instruments and use bipolar electrosurgery extensively to allow use of smaller trocar sites and to save money. Our technique of four punctures allows good traction and counter traction during the procedure. Our method for evacuation of smoke and irrigation throughout surgery also allows us basically to utilize a five port technique since the port containing the bipolar device also allows active suction and irrigation at the same time via the trocar stop cock site. Thus, we can enhance the view while constantly irrigating throughout the procedure without wasting a port for constant placement of a suction aspiration device. In addition, the chore of suction of smoke and selected irrigation passes to the scrub nurse, thus freeing both hands of the surgeons. This enhances constant exposure by allowing use of two 5 mm graspers for traction and counter traction.

We all need to be constantly aware of the costs of the items we use in surgery, and whenever safe effective reusable means are available as alternatives to disposable means, we should incorporate those into our therapeutic regimen. This fact has clearly been addressed recently in an excellent editorial by Hurd and Diamond.

 clearly indicate that disposable laparoscopic instruments can be up to seven times more costly to patients yet show no safety advantages. In the past, the senior author (JFD) reported very high costs for early LAVH cases.

 In retrospect, these high costs reflected high usage of laparoscopic stapling devices and throw-away instruments.

illustrates our "old" instrument preferences compared with our "new" replacement reusable instruments. From this list one clearly sees where much money was wasted in the past. At current costs to our hospital over $2,000 is saved per operation with our conversion to reusable instrumentation where possible. This has occurred with reduced operating times and no increase in complications.

While costs are of concern, one must always put safety first with all patient care. One example when both safety and costs both are superior is by switching back to reusable 5 mm scissors. A recent study demonstrated in a controlled animal laboratory setting that reusable scissors with thicker insulation are safer for unipolar electrosurgical use at laparoscopy than disposable single use thinner insulated ones.

 Now even safer unipolar electrosurgery is possible at laparoscopy by using scissors or probes that incorporate active electrode monitoring to eliminate the rare but tragic complications from capacitive coupling.

 We advise all careful laparoscopists using unipolar electrosurgery to incorporate this safe feature analogous to automobile airbags into their personal laparoscopic armamentarium.

Clearly, supracervical hysterectomy is becoming more popular, both among patients and gynecologists in the industrialized world. We feel that with modern office screening and treatment of the cervix, that the argument for routine prophylactic removal of the cervix to eliminate the risk of cervical cancer has become archaic. Do we recommend prophylactic removal of the vagina in women undergoing hysterectomy because of the low theoretical risk of vaginal cancer? Clearly, not. Therefore, why do some physicians still insist on prophylactic removal of the cervix in women who are not at significant risk for cervical cancer and who are committed to careful lifetime follow-up. Many women who in the past have undergone endometrial ablation for treatment of dysfunctional uterine bleeding still have their uterus and cervix intact, leaving them at risk for subsequent cervical (and uterine) pathologies. Obviously, no one argues with this simple operation to minimize treatment for menorrhagia. We agree with Harry Hasson, who has said

"the cervix is not a useless organ and should not be removed during hysterectomy without a proper indication."

It is time to rethink our concepts of removing the cervix and to enhance our personal skills for laparoscopic surgery. Much more clinical investigation is required to address long term benefits of LSH. In addition, classifications of subtotal hysterectomies need to be standardized so that people will be comparing apples to apples when reporting outcomes. Hopefully, in the near future, carefully designed prospective studies of LSH can address some of these critical areas of concern. Such scientific information will be necessary as we continue to strive to develop the most effective, safe, and cost effective method to manage diseases which require hysterectomy among our patients.

The mean uterine weight was 146 g (60-569 g). The mean operating time was 94 minutes (60-225 min.). Actual morcellation time was available in 19 cases by reviewing videotape with an average morcellation time of 11.8 minutes (4-23 min.). Average blood loss was 125 cc (20-600 cc) with one case of late postoperative bleeding requiring operative intervention. The average cost for the procedure was $7,998 ($6,989 - $11,581). Thirty-six patients were discharged within 23 hours from the time of admission and all patients were discharged within 48 hours of the time of admission.

Early Evaluation Of An Electromechanical Morcellator For Laparoscopic Supracervical Hysterectomy

Click             here for Audio/Video Version

   “I’m Dr. Yap Lip Kee       the incoming President for the ISGE.  It’s a pleasure to be here  in Chicago.  We are looking at the newest things available to  gynecologists, gynecology, and endoscopists.  With me is Dr. James  Daniell, one of the pioneers in the field and he plans to tell us a bit  more about what is new.”
       
       

   “Dr. Yap, thank you very much.  It’s always a pleasure to get the chance  to be interviewed for OBGYN.net because it gives a wide dissemination  of information around the world.  The things that I’ve seen from walking  around the exhibits here today are interesting.  There’s some old,  there’s some new, there’s some borrowed, but there’s nothing blue here  today.  I think we’ve got about thirty-five exhibitors from many  countries.  One of the things that I saw that is most interesting is a  new safer way to use bipolar electro-surgery.  Everest Medical, which is  located here in the states, is coming out with a new generator from  England, which allows laparoscopic use of bipolar instrumentation with a  system of bipolar that they call “PK” generation.  This is really just  bipolar energy delivered in an intermittent pulse mode so that there’s  reduced thermo damage as your applying the electrosurgery.  As you and I  both know with laparoscopy, electricity can be very, very dangerous and  anything that can reduce the risk for collateral damage with  electricity, I think, will be a benefit for improved safety of surgery.   We’ve also done some animal studies with this PK generator in our lab  in Nashville, and we’ve been able to actually coagulate blood vessels as  large as 5 mm laparoscopically in animal model, which I think is very  impressive.  I think this is one of the things at this meeting here of  the ISGE that is very impressive in just coming on market here in the  states and will be a good addition to the armamentarium for all  laparoscopic surgeons that are dealing with large blood vessels during  either hysterectomy or adnexal removal.  Again, it’s my pleasure to sit  and talk with you here briefly and to talk about this for OBGYN.net.   Thank you.”
       
       

  “Thank you, Jim, for the quick updates.”     

OBGYN.net Conference CoverageFrom ISGE 2001 Congress - Chicago, Illinois, 2001

Author | James F. Daniell, MD

Articles

Laparoscopic Hysterectomy and Health Care in America

Early Evaluation Of An Electromechanical Morcellator For Laparoscopic Supracervical Hysterectomy

Safer Way to Use Bipolar Electro-Surgery