Ted L. Anderson, MD, PhD

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"What is the hardest of all to do? To see with our eyes what our eyes lay before us. (Paraphrased, with apologies from Goethe) That essentially is the message of the innovative efforts of Ms. Deborah Bush, Chairperson of the New Zealand Endometriosis Foundation. She has developed an interactive Menstrual Health and Endometriosis Education Program that has been presented to over 40,000 young women (ages 15-24), educators and clinicians. There has been an overwhelmingly positive response as this population gained better knowledge of what is "normal" and how to recognize the symptoms of endometriosis. Of note, anecdotal reports show this program has resulted in increased referrals to gynecologists and increased early diagnosis and treatment. Hopefully, such early intervention will mitigate the long-term sequellae of adhesions, pain and infertility. On the other hand, it is too often that we dismiss endometriosis as a source of pelvic and rectal pain, especially in young women and after hysterectomy and salpingo-oophorectomy.
 
 However, infiltrative endometriosis involving the apical vaginal wall, the anterior rectal wall and the soft tissues of the cul-de-sac are not uncommon. This is the advice from Dr. Ray Garry and his colleagues from WEL Foundation, South Cleveland Hospital, Middleborough, UK. Using his techniques of radical laparoscopic excision, he excises the tissue bounded by the uterosacral ligaments laterally, the anterior rectal wall posteriorly and the posterior cervix. Then he removes the tissue en bloc. This technique offers relief from dysmenorrhea, dyspareunia, rectal pain and general pelvic pain in over 80% of his patients as measured by a standardized questionnaire. They have not examined the potential added benefit of hormonal suppressive therapy pre or post-operatively. Despite excellent results in this difficult patient population, this group continues to follow long-term success, as will we, with great interest."
 
 The patient with pelvic pain continues to be one of the greatest therapeutic challenges to gynaecologists. There have been few developments in recent years that will impact treatment success in these patients, as we will likely see with conscious laparoscopy and pain mapping. This was illustrated beautifully in an excellent workshop on pelvic pain, moderated by Dr. Christopher Sutton (The Guilford Nuffield Hospital, Surrey, UK). Our concepts of pain aetiologies were challenged by Dr. FM. Howard (Rochester General Hospital, NY, USA), who provided evidence that endometriosis lesions accounted for only 1/3 of pain described by patients during conscious pain mapping, with adhesions accounting for another 1/3. This group called into question the routine use of postoperative GnRH agonists in this patient population. Dr. John Steege (University of North Carolina, USA), demonstrated the power of pain mapping by showing a procedure without sound in a post-hysterectomy patient with adhesions involving the pelvic sidewall and vaginal cuff, as well as an ovarian remnant. After an audience poll of operative options, he replayed the tape with audio feedback from the patient during the procedure. Much to our surprise, this experience changed the opinion of appropriate operative intervention in a substantial number of participants. Dr. Lawrence Demco (University of Calgary, Canada), illustrated his techniques of pain mapping through multiple video clips. Interestingly, many patients described pain with touching of peritoneal surfaces up to 2.5 cm away from visible endometriotic lesions. Additionally, he demonstrated that the pain perceived by the patient frequently does not correlate with the position of lesions or pain elicited during mapping. For example, touching visible endometriosis on the left pelvic sidewall often correlated with right-sided pelvic pain experienced by the patient. Using these techniques to guide subsequent operative interventions, he has described greater than 80% of patients remain pain free at 6 months follow-up. Dr. Sutton presented his prospective randomized double-blinded study that demonstrated the efficacy of operative treatment for stage I-III endometriosis compared with no treatment. Not surprisingly, there was increasing benefit of surgical treatment with advancing endometriosis stage. Additionally, he presented the results of a study showing no additional benefit of LUNA when endometriosis is ablated surgically. Certainly the message we can learn from this workshop will continue to guide our ability to understand and treat pelvic pain.     

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"What is the hardest of all to do? To see with our eyes what our eyes lay before us. (Paraphrased, with apologies from Goethe) That essentially is the message of the innovative efforts of Ms. Deborah Bush, Chairperson of the New Zealand Endometriosis Foundation. She has developed an interactive Menstrual Health and Endometriosis Education Program that has been presented to over 40,000 young women (ages 15-24), educators and clinicians.

New Concepts in Diagnosis and Treatment Summarized from ISGE 8th Annual Congress

Drs. Anderson, Lindsay and Daniell practice gynecology at

Centennial Medical Center in affiliation with the Women's

Health Research and Education Foundation, both in

Nashville, Tenn. They also serve on the clinical faculty of

Vanderbilt University Medical Center's Department of

he forces that drive the development and refinement of surgical technique are multifocal. Physicians value effective procedures that combine safety, simplicity, and reproducibility. Third-party payers seek techniques that are cost effective, require shorter hospital stays, and result in less morbidity. Patients flock to physicians who are able to perform procedures that entail less discomfort, shorter recovery times, better cosmetic results, and also preserve or improve the equality of their lives. Such has been the case with the evolution of laparoscopic hysterectomy.

Multiple variations of laparoscopic hysterectomy has been described since the procedure first was reported by Reich in 1989.

One that continues to inspire considerable controversy is laparoscopic supracervical hysterectomy (LSH), which was first described in 1991 by Semm.

 Several authors have since reported their experience with various methods for LSH, 

The main concern of gynecologist who are opposed to LSH is the potential for subsequent cervical disease, a possibility that would be moot if the cervix had been removed.

 However, multiple studies provide evidence to refute these concerns and have been reviewed elsewhere.

Furthermore, give the widespread use of Pap smears, office colposcopy, biopsy, and LEEP to detect and treat cervical disease, the argument for routinely removing the cervix to eliminate the risk of cervical cancer seems all but archaic.

It is time to rethink our reasons for taking this step.

Meanwhile, many patients want to retain their cervix because they believe it contributes to increased sexual satisfaction and preservation of pelvic support postoperatively. While factors contributing to sexual satisfaction usually are quite subjective, studies have failed to demonstrate a clear role for the cervix in sexual response.

Conversely, there is strong evidence that patients without pre-existing pelvic relaxation enjoy better pelvic support after supracervical hysterectomy than after a total hysterectomy.

As such, patients who exhibit significant descensus or pelvic floor defects preoperatively may not receive maximal benefit from LSH.

Clearly, LSH is enjoying increasing acceptance among both patients and gynecologists in the industrialized world. Indeed, it has been called "..a reprise of the oldest hysterectomy technique using the newest laparoscopic methods, which results in a product that is highly satisfactory to the patient."

We discuss here our experience with laparoscopic supracervical hysterectomy, including clinical considerations in patient selection, evaluation, and operative technique.

advise the surgeon should inform the pathologist that tissue will be received as

multiple cores, such as these specimens morcellated that were removed with the

Patient selection, preoperative evaluation

All patients being considered for LSH should meet the same criteria applied to abdominal and vaginal hysterectomy. Once suitability for hysterectomy has been established, additional factors must be considered in evaluating the appropriateness of LSH.

Foremost, we recommend that all candidates have a documented normal Pap smear within three months of the scheduled surgery. We maintain that the option of supracervical hysterectomy should be limited to patients who have a normal cervix and no history of significant abnormal Pap smears. However, a single previous reactive atypia or ASCUS with subsequent normal Pap smears should not preclude consideration for LSH. Additionally, all patients should be counseled regarding the need for lifetime annual Pap smears following surgery.

When tissue morcellation is involved, there is always a concern that architectural disruption may preclude the pathologist from adequately evaluating invasion in malignant neoplasms. Consequently, special attention should be paid to rule out malignancies during the preoperative evaluation. The endometrium should be evaluated by ultrasound and, if clinically indicated, by endometrial biopsy. Suspected fibroids or other masses should be evaluated fully using appropriate diagnostic modalities. Additionally, we recommend discussing tissue morcellation with the pathologist before undertaking its use; the pathologist needs to be aware that the tissue will be received as multiple cores. Clearly, the morcellator should be used only on masses that the operator is confident are benign. If there is 

 suspicion of malignancy, the patient should not be considered a candidate for laparoscopic supracervical hysterectomy.

Operating time and the use of disposable materials

 are among the greatest direct contributors to the cost of any procedure. intraoperative and postoperative complications also contribute to overall cost. Keeping these issues in mind, our selection of equipment and instruments has evolved as newer technologies have become available.

It is our practice to use only metal reusable trocars. We prefer the operative ports from Mahe (

which employ a reusable trocar that is shielded in a manner similar to the disposable brands. Further, the sheath's blunt distal end decreases the risk of inadvertent bowel or other injury compared with the beveled edge that marks many other brands. With the exception of the 12-mm port needed for the morcellator, we use only 5-mm trocars, even for the umbilical camera port. This choice minimizes the risk of incisional hernia. For an optic system, we prefer the Olympus 5-mm laparoscopy 

 which employs autofocus and autoiris technologies, and provides lighting and field of view comparable to most 10-mm scopes.

We avoid monopolar electrical energy whenever possible. We're concerned about the associated risk of collateral thermal damage to adjacent tissues through arcing. Also, monopolar energy carries an increased risk for unrecognized tissue damage outside the operative field of view through capacitance coupling. In the past, we have used bipolar coagulating forceps alternating with separate curved blunt 5-mm scissors to secure and dissect adnexal tissue. However, it now is our practice to use the 5-mm BiCoag bipolar cutting device from Everest Medical 

. This is the only disposable instrument we use. We believe the rapidity with which this device permits securing coagulating, and transecting pedicles and vascular structures justifies its relatively modest cost. Further, the use of the instrument eliminates potential injury for repetitive insertion of the separate coagulation and cutting instruments. As an added safety feature, we recommend the use of an amp meter to note when tissue is completely desiccated and can be transected safely.

We have found that the Marlow PumpVac device 

for combined irrigation and aspiration offers many benefits. The irrigation is controlled at variable pressures through a spring-loaded autorefilling syringe, while the aspiration tube can be connected to the low-pressure hose suction. The tubing for both functions is connected to a single nipple through a "Y" connector, which can be attached to the insufflation stopcock of any operative port. During the operation, it should be attached to the port through which the bipolar cutting forceps are being used. This step allows effective irrigation of the operative field as the flow of heparinized lactated Ringer's solution follows the path of the instrument and also permits evacuation of smoke.

The amputated uterus and adnexae can be retrieved using a variety of techniques, including a minilaparotomy incision through which the intact or quartered specimen can be passed. We routinely use the Steiner electromechanical morcellator 

(Karl Storz Endoscopy, Culver City, Calif.,).

 This device, which is passed through a 12-mm suprapubic operative port, contains a rapidly circulation, hollow 10-mm cylindrical blade. The blade can turn clockwise, counterclockwise, or rotate back and forth, and is controlled by a foot switch. A 10-mm grasper is passed through the hollow blade and used to advance the specimen for cutting cores of tissue.

After general endotracheal anesthesia has taken effect, a pelvic exam is performed to confirm preoperative findings. The patient then is prepped and draped in the low lithotomy position, with a Foley catheter in place for continuous bladder drainage. Catheterization offers the added advantage of providing a mechanism for filling the bladder intraoperatively, if needed, to identify the limits of the vesico-uterine fold.

Next, a uterine manipulator is placed; we usually find that a Hulka tenaculum is adequate for all but the largest of uteri. We routinely use a four-puncture laparoscopic technique, with a 5-mm camera placed through the umbilicus and a second 5-mm camera placed through the umbilicus and a second 5-mm port placed 2 cm to 3 cm above the symphysis pubis in the midline. Left and right lower abdominal 5-mm ports are placed lateral to the rectus muscles and well above the inferior epigastric vessels, sufficiently high to give a good "angle of attack" into the pelvis.

As with any pelvic surgical procedure, care should be taken during the initial laparoscopic inspection of the abdomen and pelvis to identify the course of the ureters to ensure that they are not in the path of the intended operative field. If the adnexae are to be removed, any adhesions that limit their mobility should be lysed first. With traction and countertraction for adequate exposure, 50 watts of bipolar electrosurgical energy are used to desiccate and then transect the round ligaments, followed by the infundibulopelvic (IP) ligaments (when the adnexae are being removed) or proximal fallopian tubes and utero-ovarian ligaments (when the adnexae are being preserved).

Once the upper portion of the fundus has been separated from its lateral attachments, we turn our attention to the anterior uterus to identify the utero-cervical junction. We do not dissect the bladder peritoneum off the anterior portion of the cervix, but merely coagulate the serosa transversely with bipolar forceps just above the level of the vesico-uterine fold. This line provides a helpful guide for determining the limit of subsequent dissection of the parametrial tissue and transection of the uterus from the cervix. The superior portion of the broad ligaments are coagulated and transected sequentially. taking care to include both anterior and posterior reflections of the broad ligament in the bipolar device, and to remain as close to the lateral uterine aspect as possible.

As dissection approaches the previously marked vesico-uterine fold, the ascending branches of the uterine vessels are identified, coagulated using the bipolar forceps, and cut. Care must be taken to identify the main uterine artery, recognizing that the ureter passes under this visibly pulsating structure. (Also, keep in mind that, with bipolar coagulation, temperatures exceeding 50°C may extend up to 1 cm lateral to the edge of the coagulation device. Thus, it is imperative to monitor placement of the instrument tips before applying bipolar energy.)

Once the ascending branches of the uterine vessels have been coagulated close to the isthmus of the uterus, the fundus becomes visibly discolored from reduced blood supply. A diluted solution of pitressin (20 units diluted in 50 cc of saline) then is injected into the uterine fundus via a long needle placed directly through the midline suprapubic operative post. This reduces cervical small vessel bleeding at amputation of the uterus. It is important to notify the anesthesiologist prior to injection because of the potential for bradycardia or hypertension with systemic absorption. When possible, the posterior peritoneum at the level of the lower uterine isthmus should be coagulated with the bipolar forceps to mark the intended area for transection of the uterus from the cervix.

We have used a variety of methods and devices for amputating the fundus from the cervix. These include: a unipolar needle, a harmonic scalpel blade, laser energy, 5-mm curved blunt scissors, a 5-mm knife, and unipolar electrosurgical energy with scissors.

Our current practice is to replace the 5-mm suprapubic port with a 12-mm port at this point in the procedure, and then amputate the uterus using 10-mm curved scissors. This is accomplished under direct visualization, with superior and anterior traction to avoid the potential for bowel injury. When cutting with the scissors, care is taken to stay at the superior margin of the cervix in the plane of the previously placed coagulation mark. This prevents extension into the lateral cervical stroma containing the uterine vessels and pelvic support ligaments.

Careful coagulation of the exposed ascending branches of the uterine vessels at the lateral margins of the cervix is then performed, and any small oozing vessels from the cervical body can be coagulated with the bipolar coagulating forceps. At some point during amputation of the uterus the Hulka tenaculum must be removed. Finally, the endocervix is coagulated by placing the coagulating forceps into the cervical canal, opening the jaws of the forceps, and applying bipolar energy while slowly rotating the forceps. In the manner, the entire endocervical canal can be thermally coagulated to destroy tissue that might later lead to bothersome, persistent vaginal spotting.

Once the uterus is amputated, and hemostasis of all pedicles and the cervical stump is ensured, the electromechanical morcellator is introduced through the 12-mm suprapubic port. The uterus and adnexae are secured with a 10-mm claw grasper passed through the blade. Morcellation requires careful coordination between the surgeon, the assistant, and the scrub nurse. The technique that we have developed keeps the 12-mm trocar sheath close to the abdominal wall and pulls the tissue up against the rotating blade, which is held under direct visualization just outside the tip of the sheath. This reduces the chances of inadvertent injury to bowel or other organs from the sharp rotating blade. By bringing the morcellator in through the lower suprapubic site, we avoid creating large trocar sites laterally in the abdomen and so also avoid the potential sequelae of bleeding, hernia defect, and poor cosmetic results.

We recommend morcellating dense fibroids first (while the blade is sharpest), before the less-dense uterine and adnexal tissues are removed. The long 10-mm cores of tissue then are pulled up and out through the 12-mm port and deposited into a sterile pan.

After the larger portions of tissue are removed, a 10-mm spoon forceps can be used to retrieve any small remaining pieces that may have fragmented during the manipulations. NuKnit 

(Johnson & Johnson Medical, Arlington, Tex.)

 is then placed over the cervical stump. This double thickness surgicel is designed specifically for laparoscopic application, and acts as a hemostatic agent to augment early postoperative hemostasis. Next, the patient is taken out of Trendelenburg positioning so that any accumulated fluid can be aspirated and replaced with 300 cc of fresh heparinized lactated Ringer's solution (5,000 units of heparin per 1L), containing 2 cc of polymixin, bacitracin, and neomycin. The pneumoperitoneum is evacuated to facilitate inspection of all the pedicles inspection of all the pedicles with reduced intraperitoneal CO

 pressure. Finally, the fascia and peritoneum of the 12-mm suprapubic incision are sutured using a Carter-Thompson fascial closure device 

In our experience, LSH with electromechanical tissue morcellation offers significant direct benefits to patients. This minimally invasive approach results in less perioperative morbidity, a better cosmetic results, and less recovery time than abdominal, vaginal, or laparoscopically assisted vaginal hysterectomy. Hospital stays rarely exceed the 23-hour extended recovery interval. Additionally, most patients have reported the ability to return to work or normal daily activities within 2 to 4 weeks. At the 6-week follow-up exam, all sexually active patients have reported satisfactory intercourse without significant dyspareunia. Finally, we have encountered no cases of postoperative morbidity from anemia. The mean blood loss is approximately 100 cc, and no patients have required transfusion.

Our analysis demonstrates the fiscal benefits of LSH, as well. The mean total hospital cost is less than $8000, which is well below the average for hysterectomies of all types (these are data from Centennial Medical Center Women's Hospital, Nashville, Tenn.; total hospital costs do not include pathology, anesthesia, or surgeon fees, nor managed care discounts).

We believe that the factors contributing the most to cost containment are reliance on reusable equipment, decreased operating room time, and rapid recovery. Studies clearly indicate that disposable laparoscopic instruments can be up to seven times more costly to patients than reusable devices. 

 Our mean operating time is less than 90 minutes from initial trocar placement until closure of the 12-mm suprapubic fascial incision. We believe that use of the electromechanical morcellator contributes significantly to relatively short operative times. Using this device, the specimen usually can be removed in less than 12 minutes, resulting in a calculated savings of more than $500 per case in operating room time alone. There is the added benefit of eliminating colpotomy or a larger abdominal wall incision.

Numerous studies examining all variations of laparoscopic hysterectomy have demonstrated fewer surgical complications, reduced operative morbidity, and hastened recovery with these endoscopic procedures than with abdominal or vaginal hysterectomy.

 Such has been our experience, as well; indeed we have experienced only three complications. One patient had persistent pelvic pain with dyschezia and, at the time of repeat laparoscopy, was found to have bowel adhesions to the cervical stump. While adhesion formation certainly is a multifactorial process, this finding illustrates the importance of adhesive barrier placement.

A second patient had persistent postoperative cervical bleeding. She eventually underwent trachelectomy, at which time tissue necrosis from thermal injury was evident. This case, in which we had used monopolar scissors to amputate the uterus, illustrates the dangers of collateral injury using this type of electrical energy. Accordingly, it is now our practice to use bipolar electrical energy routinely. The third case involved a small ovarian remnant that was fragmented during tissue morcellation. It is now our practice to amputate the adnexae prior to morcellation so they can be retrieved independently from the uterus.

A commonly cited criticism of laparoscopically assisted vaginal hysterectomy is an increased incidence of bladder and ureteral injuries

relative to the abdominal approach. To date, we have encountered neither. Nor are we aware of other reports of ureteral or bladder injury following LSH. We feel this is because we do not dissect the bladder in any of our cases. We also did not dissect the ureter, although it is identified and traced to its passage under the uterine artery. Further, we take great care not to extend dissection too low or too lateral to the cervix, as we recognize that thermal damage can occur as much as 1 cm from the edge of the bipolar coagulation instrument. 

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

Although it has been proposed that prophylactic conization be performed at the time of LSH,

our limited experience with this practice has shown an increased blood loss from postoperative cervical bleeding. We think that patients instead should be followed carefully after LSH with annual Pap smears and, when clinically indicated, with office colposcopy, biopsy, and excisional procedures. After nearly 500 procedures over a five-year interval, we have had only one patient in our practice with an abnormal Pap smear after LSH; a biopsy revealed only minimal atypia.

While LSH continues to gain acceptance among physicians and patients as an attractive surgical option, each gynecologic surgeon much honestly assess his or her skills in endoscopic, vaginal, and abdominal surgery. This technique is not well suited for the inexperienced laparoscopist. Ultimately, the route chosen for hysterectomy must be cost effective, maximize benefits, and minimize risks. Much more clinical investigation is required to address the long-term benefits of LSH. Additionally, classifications and techniques need to be standardized in the interest of appropriate comparison of outcomes. Hopefully, in the near future, carefully designed prospective studies of LSH can address some of these critical concerns. Such scientific information will be invaluable as we continue to strive to develop the most effective, safe, and cost-conscious methods of managing disorders requiring hysterectomy.

Drs. Lindsay and Anderson have no financial relationships with the companies mentioned in the article. Dr. Daniell owns stock, purchased in the open market, in Everest Medical.

The forces that drive the development and refinement of surgical technique are multifocal. Physicians value effective procedures that combine safety, simplicity, and reproducibility. Third-party payers seek techniques that are cost effective, require shorter hospital stays, and result in less morbidity. Patients flock to physicians who are able to perform procedures that entail less discomfort, shorter recovery times, better cosmetic results, and also preserve or improve the equality of their lives. Such has been the case with the evolution of laparoscopic hysterectomy.

Author | Ted L. Anderson, MD, PhD

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