Isterectomia laparoscopica

ISTERECTOMIA SUB-TOTALE o intrafasciale sec. Semm: è detta anche intrafasciale perché lascia intatti  i legamenti cardinali, la fascia endopelvica, la vagina e i tessuti circostanti, i nervi pericervicali, le aa. uterine e la topografia del pavimento pelvico. Introdotta da Semm nel 1960 trova indicazione nelle neoplasie benigne dell’utero.

L’utero viene manipolato con una lunga asta metallica che perfora a tutto spessore il fondo dell’utero, l’asta di Curt. Si applicano tre cappi (endoloop) che serrano l’utero a livello istmico.  L’asta del CURT funge da supporto per un cilindro metallico a sua volta posto all’interno di un morcellatore che isola un cilindro del canale cervicale e del corpo uterino. Una volta estratto il cilindro di tessuto per via vaginale, si stringe per via laparoscopico il primo dei tre lacci posti a livello istmico per assicurare l’emostasi dei vasi uterini. Dopo aver serrato il cappio, si seziona il corpo uterino con forbici o elettrodo monopolare o laser.  Segue la peritoneizzazione del tratto compresso fra i due annessi con punti o con colla di fibrina.  Alcuni AA. applicano, a scopo cautelativo,   due punti sulle aa. cervicali oppure un cerchiaggio di Mc Donald che viene stretto subito dopo aver asportato il cilindro cervicale e rimosso dopo 24 ore per assicurarsi contro eventuali emorragie.

 LSH (laparoscopic supracervical hysterectomy) è l’approccio principalmente utilizzato per indicazioni benigne. La tecnica inizia come per la LAVH, ma procede con l’incisione cervicale dopo il trattamento dei vasi e legamenti. L’utero viene quindi rimosso attraverso una via addominale di 12 mm.  Questo approccio elimina incisioni vaginali e addominali ed i rischi di lesioni dell’arteria uterina o dell’uretere sono ridotti al minimo. I tempi operativi (30-60 minuti) e la degenza ospedaliera (2-3 giorni) più brevi e minor numero di complicanze rispetto a quelli sottoposte ad intervento di isterectomia totale. In caso di prolasso genitale la cervice viene fissata all’osso sacro con o senza uso di mesh. La sospensione della cervice (spessore di 2-3 cm) è più sicura e duratura di quella della volta vaginale (spessore 2-3 mm).

Le pazienti devono attenersi ad un preciso protocollo di monitoraggio della portio con controlli citologici almeno ogni anno.

Indicazioni per LSH

• desiderio di mantenere la cervice uterina (Pap-test normale)
• prolasso genitale
• Incontinenza urinaria
• Miomi – utero miomatoso
• Endometriosi
• Dolore pelvico
• Aderenze
• Menometrorragia

Enjoy this exciting new issue and stay tuned for more!  

We value your opinion and are receptive to comments and suggestions.

Yours faithfully,  

dr. Enzo Volpicelli

References list:

1. Reich H., De Caprio J., McGlynn F., 1989. Laparoscopic Hysterectomy. J. Gynecolo Surg, 5:213-216

2. Dequesne J., Waddel G. 1990. Indications et Complications de l’hystérectomie par laparoscopie. Congrès Suisse de Gynécologie. Interlaken

3. Donnez J., Nisolle M. 1993. Annual Endoscopic Meeting Hôpital St-Luc

4. Semm K., 1992. Total Uterus Mucosal Ablation (TUMA)- CURT anstelle endometrium Ablation. Geburtsch Frauenheilk, 52:773-77

5. Donnez J., Nisolle M 1993. LASH: laparoscopic supracervical (subtotal) hysterectomy. J. Gynecol Surgery, 1993;9:91-94

6. Reich H. 1990. Laparoscopic extrafascial hysterectomy with bilateral salpingo-oophorectomy using stapling techniques for endometrial adenocarcinoma. AAGL 19th Annual Meeting Orlando, Florida, November 14-18

7. Reich  H., McGLynn F., Wilkie W. 1990. Laparoscopic management of Stage I ovarian cancer. J. Reprod., 35: 601-5

8. Bruhat A., Canis M., Mage G., Wattiez A., Pouly J.-L. et all. 1990. Does endoscopic surgery have a role in radical surgery of cancer of the cervix uteri ? J. Gynecol Obstet Biol Reprod 19: 921

9. Stovall TG, Ling FW, Henry LC, Woodruff MR. 1991. A randomized trial evaluating leuprolide acetate before hysterectomy as treatment for leiomyomas. Am J. Obstet Gynecol, 164: 1420-25

10. SCHLAFF W.D., ZERHOUNI E.A., HUTH J.A., CHEN J., DAMEWOOD M.D., ROCK J.A. 1989. A placebo-controlled trial of a depot gonadotropin-releasing hormone analogue (leuprolide) in the treatment of uterine leiomyomata. Obstet Gynecol, 74: 856-62

11. SCHLAFF W.D. ZERHOUNI E.A:, HUTH J.A., CHEN J., DAMEWOOD M.D., ROCK J.A. 1989. A placebo-controlled trial of a depot gonadotrophin-releasing hormone analogue (leuprolide) in the treatment of uterine leiomyomata. Obstet Gynecol, 74: 856-862

12. DEQUESNE J., LACHAT R. May 1992. Utilization and complication of Automatic Stapling during laparoscopic hysterectomy

13. HULKA J.F., PETERSON H.B., PHILIPPS M.D., SURREY M.W. 1993. Operative Laparoscopy. American Association of Gynecologic Laparoscopists 1991. Membership Survey. J. reprod. Med. 38:569-571
14. AMIRIKIA H., EVANS T.N., 1979. Ten years review of hysterectomies trends. Indications and risks. Am. J. Obstet. Gynecol. 134: 431-437
15. DARGENT D., 1986. Répertoire de chirurgie gynécologique par voie vaginale. Eduprim. Lyon, 698 pages
16. DICKER R.C., GREENSPAN J.R., STRAUSS L.T. COWART M.R., SCALLY M.J., PETERSON H.B., DESTEFANO F., RUBIN G.L., ORY H.W. 1982. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The collaborative Review of Sterilization. Am. J. Obstet. Gynecol. 144: 841-848
17. PERINEAU M., MONROZIES X., REME J.M. 1992. Complications des hystérectomies. Rev. Fr. Gynécol. Obstét. 87: 120-125
18. Cardone A., Zarcone R., Giardiello M.: “Confronto di 100 casi isterectomia laparoscopica vs 100 casi isterectomia laparotomica”. Minerva Ginecologica 2010 Giugno;62(3):171-7
19. Donnez O et al, BJOG 2009; 116: 492-500
20. Brolmann HA, Bongers MY, Bremer GL, van der Salm PC. A randomised comparison and economic evaluation in laparoscopic assisted hysterectomy and abdominal hysterectomy. BJOG. 2002 Dec;109(12):1427-8
21. Campbell ES, Xiao H, Smith MK. Types of hysterectomy. Comparison of characteristics, hospital costs, utilization and outcomes. J Reprod Med. 2003 Dec;48(12):943-9.
22. Canis MJ, Wattiez A, Mage G, Bruhat MA. Results of eVALuate study of hysterectomy techniques: laparoscopic hysterectomy may yet have a bright future. BMJ. 2004 Mar 13;328(7440):642-3.
23. Chang WC, Lee CC, Wu HC, Yeh LS. Laparoscopy-assisted vaginal hysterectomy clinical pathway. A multivariate analysis of impact on costs and quality of care. Gynecol Obstet Invest. 2003;55(4):231-4.
24. Chang WC, Li TC, Lin CC. The effect of physician experience on costs and clinical outcomes of laparoscopic-assisted vaginal hysterectomy: a multivariate analysis. J Am Assoc Gynecol Laparosc. 2003 lug;10(3):356-9.
25. Chang WC, Tsai WC, Lin CC. Physician experience affects costs and clinical outcomes in laparoscopy-assisted vaginal hysterectomy. Int J Gynaecol Obstet. 2002 Oct;79(1):39-41.
26. Chapron C, Dubuisson JB, Ansquer Y. Total laparoscopic hysterectomy. Indications, results, and complications. Ann N Y Acad Sci. 1997 Sep 26;828:341-51. Review.
27. Chapron C, Dubuisson JB. Total hysterectomy: laparoscopy or vaginal route? Arguments in favor of laparoscopy Gynecol Obstet Fertil. 2000 Sep;28(9):672-8.
28. Chapron C, Dubuisson JB. Ureteral injuries after laparoscopic hysterectomy. Hum Reprod. 2000 Mar;15(3):733-4.
29. Chapron C, Fernandez B, Dubuisson JB. Total hysterectomy for benign pathologies: direct costs comparison between laparoscopic and abdominal hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2000 Apr;89(2):141-7.
30. Chapron C, Laforest L, Ansquer Y, Fauconnier A, Fernandez B, Breart G, Dubuisson JB. Hysterectomy techniques used for benign pathologies: results of a French multicentre study. Hum Reprod. 1999 Oct;14(10):2464-70.
31. Cosson M, Lambaudie E, Boukerrou M, Querleu D, Crepin G. Vaginal, laparoscopic, or abdominal hysterectomies for benign disorders: immediate and early postoperative complications. Eur J Obstet Gynecol Reprod Biol. 2001 Oct;98(2):231-6.
32. Cravello L, Agostini A, Bretelle F, Blanc B. Total hysterectomy: laparoscopy or vaginal route? Arguments in favor of the vaginal route Gynecol Obstet Fertil. 2000 Sep;28(9):678-82.
33. Davies A, Hart R, Magos A, Hadad E, Morris R. Hysterectomy: surgical route and complications. Eur J Obstet Gynecol Reprod Biol. 2002 Sep 10;104(2):148-51.
34. Donnez J, Squifflet J, Jadoul P, Smets M. Results of eVALuate study of hysterectomy techniques: high rate of complications needs explanation. BMJ. 2004 Mar 13;328(7440):643.
35. Ellstrom M, Ferraz-Nunes J, Hahlin M, Olsson JH. A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol. 1998 Jan;91(1):30-4.
36. Erian M, McLaren GR, Buck RJ, Wright G. Reducing costs of laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 1999 Nov;6(4):471-5.
37. Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol. 1999 Apr;180(4):955-62.
38. Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, Clayton R, Phillips G, Whittaker M, Lilford R, Bridgman S, Brown J. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004 Jan 17;328(7432):129. Epub 2004 Jan 07. Erratum in: BMJ. 2004 Feb 28;328(7438):494.
39. Garry R. A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy. BJOG. 2002 Dec;109(12):1428.
40. Harkki P, Kurki T, Sjoberg J, Tiitinen A. Safety aspects of laparoscopic hysterectomy. Acta Obstet Gynecol Scand. 2001 May;80(5):383-91. Review.
41. Harkki-Siren P, Sjoberg J, Toivonen J, Tiitinen A. Clinical outcome and tissue trauma after laparoscopic and abdominal hysterectomy: a randomized controlled study. Acta Obstet Gynecol Scand. 2000 Oct;79(10):866-71.
42. Holub Z, Jabor A, Kliment L Jr, Voracek J, Lukac J. Comparison of two procedures for laparovaginal hysterectomy: a randomized trial. Eur J Obstet Gynecol Reprod Biol. 2000 May;90(1):31-6.
43. Horng SG, Huang KG, Lo TS, Soong YK. Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH. J Am Assoc Gynecol Laparosc. 2004 Feb;11(1):42-6.
44. Hwang JL, Seow KM, Tsai YL, Huang LW, Hsieh BC, Lee C. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study. Acta Obstet Gynecol Scand. 2002 Dec;81(12):1132-8.
45. Ikhena SE, Oni M, Naftalin NJ, Konje JC. The effect of the learning curve on the duration and peri-operative complications of laparoscopically assisted vaginal hysterectomy. Acta Obstet Gynecol Scand. 1999 Aug;78(7):632-5.
46. Kim DH, Bae DH, Hur M, Kim SH. Comparison of classic intrafascial supracervical hysterectomy with total laparoscopic and laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc. 1998 Aug;5(3):253-60.
47. Kohler C, Hasenbein K, Klemm P, Tozzi R, Schneider A. Laparoscopic-assisted vaginal hysterectomy with lateral transsection of the uterine vessels. Surg Endosc. 2003 Mar;17(3):485-90. Epub 2002 Nov 06.
48. Kovac SR, Barhan S, Lister M, Tucker L, Bishop M, Das A. Guidelines or the selection of the route of hysterectomy: application in a resident clinic population. Am J Obstet Gynecol. 2002 Dec;187(6):1521-7.
49. Kovac SR. Guidelines to determine the role of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol. 1998 Jun;178(6):1257-63. Review.
50. Kreiker GL, Bertoldi A, Larcher JS, Orrico GR, Chapron C. Prospective evaluation of the learning curve of laparoscopic-assisted vaginal hysterectomy in a university hospital. J Am Assoc Gynecol Laparosc. 2004 May;11(2):229-35.
51. Lee YS. Benefits of high epigastric port placement for removing the very large uterus. J Am Assoc Gynecol Laparosc. 2001 Aug;8(3):425-8.
52. Lipscomb GH. Laparoscopic-assisted hysterectomy: is it ever indicated? Clin Obstet Gynecol. 1997 Dec;40(4):895-902. Review.
53. Lowell L, Kessler AA. Laparoscopically assisted vaginal hysterectomy. A suitable substitute for abdominal hysterectomy? J Reprod Med. 2000 Sep;45(9):738-42.
54. Lumsden MA, Twaddle S, Hawthorn R, Traynor I, Gilmore D, Davis J, Deeny M, Cameron IT, Walker JJ. A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy. BJOG. 2000 Nov;107(11):1386-91.
55. Makinen J, Johansson J, Tomas C, Tomas E, Heinonen PK, Laatikainen T, Kauko M, Heikkinen AM, Sjoberg J. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod. 2001 Jul;16(7):1473-8.
56. Malzoni M, Perniola G, Hannuna K, Iuele T, Fruscella ML, Basili R, Ebano V, Marziani R. A review of 445 cases of laparoscopic Hysterectomy: benefits and outcome Clin Ter. 2004 Jan;155(1):9-12.
57. Malzoni M, Perniola G, Perniola F, Imperato F. Optimizing the total laparoscopic hysterectomy procedure for benign uterine pathology. J Am Assoc Gynecol Laparosc. 2004 May;11(2):211-8.
58. Meeks GR, Harris RL. Surgical approach to hysterectomy: abdominal, laparoscopy-assisted, or vaginal. Clin Obstet Gynecol. 1997 Dec;40(4):886-94. Review.
59. Miskry T, Davies A, Magos AL. Laparoscopically assisted vaginal hysterectomy compared with total abdominal hysterectomy. Am J Obstet Gynecol. 1999 Dec;181(6):1580-1.
60. Nazah I, Robin F, Jais JP, Jeffry L, Lelievre L, Camatte S, Taurelle R, Lecuru F. Comparison between bisection/morcellation and myometrial coring for reducing large uteri during vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy: results of a randomized prospective study. Acta Obstet Gynecol Scand. 2003 Nov;82(11):1037-42.
61. Olive DL, Parker WH, Cooper JM, Levine RL. The AAGL classification system for laparoscopic hysterectomy. Classification committee of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc. 2000 Feb;7(1):9-15.
62. O’Shea RT, Cook JR, Seman EI. Total laparoscopic hysterectomy: a new option for removal of the large myomatous uterus. Aust N Z J Obstet Gynaecol. 2002 Aug;42(3):282-4.
63. Ottosen C, Lingman G, Ottosen L. Three methods for hysterectomy: a randomised, prospective study of short term outcome. BJOG. 2000 Nov;107(11):1380-5.
64. Parker WH, Cooper JM, Levine RL, Olive DL. The AAGL classification system for laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 2000 Aug;7(3):439-40.
65. Parker WH. Total laparoscopic hysterectomy. Obstet Gynecol Clin North Am. 2000 Jun;27(2):431-40. Review.
66. Patsner B. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol. 1999 Jan;93(1):160.
67. Perino A, Cucinella G, Venezia R, Castelli A, Cittadini E. Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study. Hum Reprod. 1999 Dec;14(12):2996-9.
68. Reisner JG, Miollis M. Laparoscopically assisted vaginal hysterectomy in a community hospital. J Reprod Med. 1997 Sep;42(9):542-6.
69. Ribeiro SC, Ribeiro RM, Santos NC, Pinotti JA. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynaecol Obstet. 2003 Oct;83(1):37-43.
70. Robertson EA, de Blok S. Decrease in the number of abdominal hysterectomies after introduction of laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 2000 Nov;7(4):523-5.
71. Salmanli N, Maher P. Laparoscopically-assisted vaginal hysterectomy for fibroid uteri weighing at least 500 grammes. Aust N Z J Obstet Gynaecol. 1999 May;39(2):182-4.
72. Saunders SM. Results of eVALuate study of hysterectomy techniques: degree of pain cannot be commented on. BMJ. 2004 Mar 13;328(7440):642.
73. Schutz K, Possover M, Merker A, Michels W, Schneider A. Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200 g. Surg Endosc. 2002 Jan;16(1):121-5. Epub 2001 Sep 04.
74. Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ. 2004 Jan 17;328(7432):134. Epub 2004 Jan 07.
75. Seracchioli R, Venturoli S, Vianello F, Govoni F, Cantarelli M, Gualerzi B, Colombo FM. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):333-8.
76. Shalowitz RJ, Jaenisch JB, Algre P. Should laparoscopic hysterectomy replace vaginal hysterectomy? J Am Assoc Gynecol Laparosc. 1999 Nov;6(4):522.
77. Shen CC, Wu MP, Kung FT, Huang FJ, Hsieh CH, Lan KC, Huang EY, Hsu TY, Chang SY. Major complications associated with laparoscopic-assisted vaginal hysterectomy: ten-year experience. J Am Assoc Gynecol Laparosc. 2003 May;10(2):147-53.
78. Simon NV, Laveran RL, Cavanaugh S, Gerlach DH, Jackson JR. Laparoscopic supracervical hysterectomy vs. abdominal hysterectomy in a community hospital. A cost comparison. J Reprod Med. 1999 Apr;44(4):339-45.
79. Soriano D, Goldstein A, Lecuru F, Darai E. Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy: a prospective, randomized, multicenter study. Acta Obstet Gynecol Scand. 2001 Apr;80(4):337-41.
80. Spellacy WN. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol. 1999 Jan;93(1):160-1.
81. Summitt RL Jr, Stovall TG, Steege JF, Lipscomb GH. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol. 1998 Sep;92(3):321-6.
82. Visco AG, Barber MD, Myers ER. Early physician experience with laparoscopically assisted vaginal hysterectomy and rates of surgical complications and conversion to laparotomy. Am J Obstet Gynecol. 2002 Oct;187(4):1008-12.
83. Wattiez A, Cohen SB, Selvaggi L. Laparoscopic hysterectomy. Curr Opin Obstet Gynecol. 2002 Aug;14(4):417-22. Review.
84. Wattiez A, Goldchmit R, Durruty G, Mage G, Canis M, Cucinella G, Pouly JL, Bruhat MA. Minilaparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 1999 Feb;6(1):97-100.
85. Wattiez A, Soriano D, Cohen SB, Nervo P, Canis M, Botchorishvili R, Mage G, Pouly JL, Mille P, Bruhat MA. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc. 2002. Aug;9(3):339-45.
86. Wattiez A, Soriano D, Fiaccavento A, Canis M, Botchorishvili R, Pouly J, Mage G, Bruhat MA. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc. 2002 May;9(2):125-30.
87. Pellegrino A.,  Villa A., Fruscio R., Signorelli M., Meroni M., Iedà N., Vitobello D.: “Total Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy in Early Stage Cervical Cancer”. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques: October  2008 – Volume 18 – Issue 5 – pp 474-478
88. Lyons T. Laparoscopic supracervical hysterectomy: a procedure whose time has come. OB/GYN News. June 1, 2004.
89. Keshavarz H, Hillis SD, Kieke BA, Marchbanks  PA, Hysterectomy Surveillance — United States, 1994-1999. Morb Mortal Wkly Rep CDC Surveill Summ. 2002; 51 (SS05): 1-8