Comparison of Total and Supracervical Laparoscopic Hysterectomy for Benign Disease in a Collective of 200 Patients

Abstract

Objective: The purpose of this study was to compare total laparoscopic hysterectomy (TLH) and laparoscopic supracervical hysterectomy (LASH) for benign disease, in terms of pre-, intra-, and postoperative findings and complications as well as necessary concomitant operative procedures. Design: This study was a retrospective review of 200 women who underwent LASH or TLH between September 2009 and April 2011. Materials and Methods: Statistical analysis and comparison of medical records were performed. Main outcome measures were patient characteristics, operating time, blood loss, uterine weight, concomitant procedures, length of stay, and intra- and postoperative complications. Results: TLH was performed in 108 cases, and 92 patients underwent LASH. The mean follow-up times were 12.5±5.4 months for TLH and 13.4±5.7 months for LASH. Suspected benign tumors of the uterus were the most frequent indication for both TLH and LASH (78% of all cases). The operating time for TLH was significantly longer than the time needed for LASH (p=0.004). The blood losses did not significantly differ. Concomitant operative procedures were necessary in 73% of all cases, mostly for the lysis of adhesions and the treatment of ovarian pathologies. Laparoconversion rate was 0.5%. The rate of wound healing problems was significantly higher in the group of patients who underwent TLH than in the group who underwent LASH (p=0.027). The groups did not differ in the rate of stationary readmission and repeat operation (p=0.531). Conclusions: Both procedures can be performed with a minimal rate of intra- and postoperative complications, even though removal of the cervix is associated with a higher rate of postoperative vaginal cuff wound healing problems. (J GYNECOL SURG 28:333)

Introduction

The ancient history of hysterectomy goes back to 2000-year-old Greek manuscripts, which describe the necessity of hysterectomy when a prolapsed uterus “has become black.”¹ Since then, especially since the nineteenth century, new operating techniques for both total and subtotal removal of the uterus have continuously evolved and been improved. Today, hysterectomy is still one of the most frequently performed surgical procedures in the world.²

There are many different approaches to the removal of the uterus for benign disease, including abdominal (AH), vaginal (VH), laparoscopically assisted vaginal (LAVH), total (TLH), and subtotal (STLH/LASH) laparoscopic hysterectomy (LH).³ It is widely accepted that of all these approaches, AH is associated with the longest hospital stay, the highest rate of infections, and the longest time to return to normal activities,⁴ and that AH should be avoided whenever possible. Since the late 1980s and early 1990s, more and more hysterectomies are performed laparoscopically.⁵ Laparoscopy enables the surgeon to inspect the peritoneal cavity and to perform concomitant procedures such as lysis of adhesions or treatment of endometriosis.⁶ Mueller et al. showed in a recent retrospective study that TLH and LASH reduce the length of hospital stay and the amount of blood loss compared with LAVH and VH.⁷ Moreover, LH seems to necessitate significantly fewer repeat operations than AH or VH.⁸ However, a Cochrane review in 2009 found no evidence of benefits for LH versus VH, considering that the rate of substantial bleeding is lower and the operating time is shorter for VH.⁴ In spite of this, there is still a lack of randomized controlled studies comparing the vaginal with the laparoscopic approach.

There has been a controversy over the removal of the cervix, given that the Papanicolaou smear test results are normal at the time of operation. For both TLH and LASH, there are method-specific problems that one should take into consideration. On the one hand, when leaving the cervix in situ, persistent bothersome menstrual bleeding may require secondary removal of the cervical stump. The risk of cervical carcinomas is low, with a rate of only 0.1% when leaving the cervix in place.⁶ On the other hand, when removing the cervix and suturing the vaginal stump, vaginal cuff dehiscence may occur.

In this study, a closer look was taken at TLH and LASH. The characteristics and diagnoses of the patients selected for either TLH or LASH were compared, as were those approaches regarding necessary concomitant operative procedures, which had not yet been done in previous studies. In other studies, many of the concomitant procedures were excluded or not mentioned for the comparison of TLH to LASH for benign disease. Finally, an attempt was made to determine whether leaving the cervix in situ might promote or reduce any complications in the first months after surgery.

Materials and Methods

The study included all women who underwent TLH or LASH for benign disease at the Department for Obstetrics and Gynecology of the Saarland University Hospital between September 2009 and April 2011. Patients with suspected malignant diseases were excluded, whereas precancerosis of the cervix was not considered to be an exclusion criterion.

All of the operations were performed with the patient under general anesthesia, and patients stayed in the hospital for at least 3 days after the surgical intervention. The hysterectomies, TLH or LASH respectively, were performed using standardized surgical techniques that have already been described previously in detail elsewhere.⁹ Vaginal cuff closure was performed by the laparoscopic route with figure-of-eight sutures.

The following data were collected pre-, intra-, and postoperatively: medical condition, diagnoses, weight, height, age, date of the procedure, blood loss during the operation (estimated by the surgeon from the amount of blood collected in the suction device), blood transfusions, operating time (time from the first incision or invasive procedure, respectively, to the last stitch), weight of the uterus tissue that was removed, concomitant procedures, length of hospital stay, readmission and repeat operation, as well as other relevant intra- and postoperative complications that occurred until July 2011. Wound healing problems of the vaginal cuff or cervical stump, respectively, were defined as infection and/or strong pain at the vaginal pole and/or bothersome polypous granulation tissue and/or bleeding of the operation site with an at least menstruation-like flow.

Statistical analysis

After obtaining an approval from the institutional review board, statistical analysis of the data was conducted by using SPSS 15.0 for Windows (SPSS Inc., Chicago, IL). Because none of the continuous variables approximated a normal distribution, the Mann–Whitney U test was used to evaluate significant differences. The categorical variables were evaluated with the χ² test with Yates correction. When >20% of the expected values in our contingency tables were <5, the z-test with Yates correction was used instead. A p-value<0.05 was considered to be statistically significant.

Results

During the study period, 108 women received TLH, whereas LASH was performed in 92 cases. The mean follow-up times were 12.5 months for TLH (SD 5.4) and 13.4 months for LASH (SD 5.7).

Only 1 procedure had to be converted from TLH to laparotomy because of the large uterus size (2649 g). That case was excluded for the evaluation of operating time, blood loss, uterine weight, and length of hospital stay.

Pre- and perioperative findings

An overview of the pre- and perioperative findings is shown in Table 1. The patients selected for TLH did not differ significantly from those selected for LASH in age, weight, or body mass index (BMI). The age range of the women selected for TLH (28.0–81.6 years) was higher than the age range of the women selected for LASH (31.2–68.4 years). The skin to skin operating time for TLH was significantly longer than the time needed to perform LASH (p=0.004). The estimated blood losses in the two groups were low, ranging to a maximum of only 300 mL. The mean hospitalization time turned out not to be significantly shorter for LASH, but it is noticeable that the range of the length of hospital stay was greater for patients undergoing TLH than the range evaluated for those who underwent LASH (3–10 days for LASH vs. 3–19 days for TLH). The weight of the uterine tissue that was removed was slightly lower in the TLH group, but there was no statistically relevant difference to the uterine weights excised by LASH.

Table 1.

Pre- and Perioperative Findings

	LASH (n=92)	TLH (n=108)	p value
Age (years)	46.4±6.5 (range 31.2–68.4)	46.0±9.0 (range 28.0–81.6)	0.186
BMI (kg/m²)	26.4±5.9 (range 16.8–42.6)	27.2±6.5 (range 17.1–48.4)	0.385
Operating time (min)^a	126.4±53.9 (range 63–352)	145.7±58.9 (range 55–380)	0.004
Estimated blood loss (mL)^a	71.6±64.3 (range 20–300)	81.9±75.9 (range 20–300)	0.618
Length of hospital stay (days)^a	5.7±1.6 (range 3–10)	6.3±2.3 (range 3–19)	0.131
Uterine weight (g)^a	216.0±231.8 (range 36–1111)	202.8±193.6 (range 38.5–1365)	0.439

Data presented as mean±standard deviation.

One case excluded because of conversion to laparotomy.

LASH, laparoscopic supracervical hysterectomy; TLH, total laparoscopic hysterectomy; BMI, body mass index.

Primary indications for surgery

Table 2 gives an overview of the findings and symptoms that physicians considered to be indications for surgery, after taking the medical histories and examining the patients in the clinic.

Table 2.

Primary Indications for Surgery

	LASH (n=92)	TLH (n=108)	p value
Suspicion of uterine leiomyomas and/or adenomyosis uteri	85.9% (79)	71.3% (77)	0.021
Menstrual bleeding disorders^a	67.4% (62)	54.6% (59)	0.090
Abnormal Papanicolaou	-	18.5% (20)	-
Postmenopausal uterine bleeding	2.2% (2)	2.8% (3)	0.855
Other^b	33.7% (31)	34.3% (37)	0.947

Total numbers of patients in parentheses. Summations >100% because of comorbidity.

Hypermenorrhea, dysmenorrhea, polymenorrhea, menorrhagia, metrorrhagia, menometrorrhagia.

Other indications: cancerophobia, benign ovarian cysts, endometriosis, pelvic organ prolapse.

LASH, laparoscopic supracervical hysterectomy; TLH, total laparoscopic hysterectomy.

Suspected benign tumors of the uterus were by far the most frequent indication for both TLH and LASH, although those patients were significantly more often planned for LASH (p=0.021). In women with suspected adenomyosis uteri and/or uterine leiomyoma, menstrual bleeding anomalies were comorbid in 58.3% of the cases. In total, bleeding anomalies were present in 67% (53) of the cases designated for supracervical hysterectomy and in 50.6% (79) of the cases planned for total hysterectomy (p=0.090). Patients with cervical precancerosis were planned for TLH.

Concomitant operations and procedures

A detailed overview of concomitant operations and procedures can be found in Table 3. In addition to the hysterectomy, other surgical interventions were necessary in 73% of all cases. Adhesiolysis, neurolysis, and ureterolysis were the most frequent concomitant procedures (necessary in as often as 44.5% of all cases), followed by the removal of ovarian cysts, and colposuspension. Although not statistically different, it is noticeable that adnexectomy was performed more often with TLH than with supracervical hysterectomy (p=0.070).

Table 3.

Concomitant Operations and Procedures

	LASH (n=92)	TLH (n=108)	p value
Total of concomitant procedures	70.7% (65)	75% (81)	0.265
Adhesiolysis, ureterolysis, neurolysis	46.7% (43)	42.6% (46)	0.656
Excision of ovarian cysts or hydatids	17.3% (16)	18.5% (20)	0.982
Colposuspension	18.5% (17)	12% (13)	0.283
Adnexectomy	6.5% (6)	15.7% (17)	0.070
Excision of endometriosis	12% (11)	7.4% (8)	0.394
Salpingectomy	5.4% (5)	8.3% (9)	0.601
Other^a	16.3% (15)	20.4% (22)	0.579

Parentheses show total number of patients.

Other: hysteroscopy, cystoscopy, scar revision, dilatation and curettage (D&C), laser ablation of genital warts.

LASH, laparoscopic supracervical hysterectomy; TLH, total laparoscopic hysterectomy.

Intra- and postoperative complications

During the study period, none of the patients died as a result of intra- or postoperative complications. No iatrogenic injuries to the intestine, urinary tract, or vessels occurred. Only one operation (0.5%) had to be converted from laparoscopy to laparotomy, because of the large uterus size (2649 g). That patient lost ∼1500 mL of blood during the hysterectomy (hemoglobin [Hb] 6.7 g/dL) and received two blood transfusions after the operation. That case was excluded for the statistical evaluation of postoperative complications. No other remarkable intraoperative complications occurred in this series of 200 laparoscopies.

Table 4 gives an overview of the postoperative complications. The rate of wound healing problems was significantly higher in the group of patients who underwent TLH than in the group who underwent LASH (p=0.027). However, the groups did not differ in the rate of serious complications that required stationary readmission and repeat operation (p=0.531). Secondary removal of the cervical stump because of troublesome, persistent menstrual bleeding, had to be performed after 2.2% of all supracervical hysterectomies during the follow-up period, something that was method specific for LASH.

Table 4.

Postoperative Complications

	LASH (n=92)	TLH (n=107)^a	p value
Total of postoperative complications requiring stationary readmission and repeat operation	4.4% (4)	7.5% (8)	0.531
Total of wound healing problems	3.3% (3)	13.1% (14)	0.027
• Wound healing problems of the cervical stump or vaginal cuff respectively^b	Ambulatory manageable: 1.1% (1)	Ambulatory manageable: 10.3% (11)
		Requiring repeat operation: 1.9% (2)
• Wound dehiscences and hematomata at trocar sites	2.2% (2)	0.9% (1)
Postoperative functional abdominal pain and dyspareunia^c	2.2% (2)	5.6% (6)	0.393
Peritoneal adhesions and pseudocysts requiring operative revision	2.2% (2)	3.7% (4)	0.840
Secondary removal of the cervix because of persistent vaginal bleeding	2.2% (2)	-	-
Postoperative detection of endometrial cancer as a secondary finding, requiring repeat operation and radiation therapy^d	0	0.9% (1)	0.911
Postoperative abdominal bleeding requiring revision and blood transfusion	0	0.9% (1)	0.911

Total numbers of patients in parentheses.

One case excluded because of conversion to laparotomy.

Defined as infection and/or strong pain at the vaginal pole and/or bothersome polypous granulation tissue and/or bleeding of the operation site with an at least menstruation-like flow.

Peritoneal adhesions requiring operative revision or pathologies of the vaginal cuff or cervix excluded.

See “Results” section for a detailed description of the case.

LASH, laparoscopic supracervical hysterectomy; TLH, total laparoscopic hysterectomy.

As a secondary finding, endometrial cancer was detected by the pathologist after the operation in 1 case in the TLH group (finally pT1a pN0 V1 G2). The patient was 59.5 years old and postoperative muscle vein thrombosis was diagnosed 1 day after surgery. The diagnosis necessitated secondary pelvic and para-aortal lymphonodectomy as well as local radiation therapy. That case was not excluded for the evaluation of postoperative complications because that diagnosis had not been expected when planning the hysterectomy, as the case history and ultrasound findings were unremarkable.

Discussion

In this study, TLH was compared with LASH for benign disease.

The patient collectives selected for TLH or LASH did not differ significantly in age, weight, or BMI. Those patient characteristics were very similar to other collectives recently reported for the assessment of the same subject.^9–11

This study confirms the experience of Mueller et al. and Boosz et al., who described that weights of uteri excised using the LASH technique tend to be a little bit higher, despite the uterine weights in the current study being lower than theirs. We also think that this might be a result of the nonrandomized, retrospective design of the current studies.^9,10

The skin to skin operating time in this study was a little higher than that reported by some other authors,^5,9,12 which may be caused by the fact that this study did not exclude concomitant procedures. This study appears to be the first published detailed comparison of the concomitant procedures that are necessary during TLH and LASH for benign uterine disease. In other studies, many of the concomitant procedures were excluded or not mentioned for the comparison of TLH with LASH. That is why the operating time reported in this study may be closer to reality. The rate of other procedures performed during laparoscopic hysterectomy was very high. This may have three main causes. First, the surgeon can select patients with comorbid pathologies (e.g., cysts of the ovaries) for the laparoscopic approach. When laparoscopy is performed, access to the peritoneal cavity can be used to treat such a comorbid pathology. Second, during laparoscopy, unexpected pathologies can be visualized and treated. Third, adhesiolysis may be necessary to visualize and access the operation site. Adhesiolysis, ureterolysis and/or neurolysis were by far the most common concomitant procedures in this collective and needed to be performed in 44.5% of all cases. This is almost double the adhesiolysis rate that Chopin et al. reported for a collective of 1460 patients who underwent TLH.¹³ The difference may be partially explained by this study's inclusion of ureterolysis and neurolysis. The second reason for concomitant procedures was the existence of ovarian pathologies, whereas adnexectomy was performed more often with TLH than with LASH (not statistically significant, p=0.070). This might be one reason for the operating time observed here being significantly longer for TLH than for LASH (p=0.004); in addition the total rate of concomitant procedures was slightly higher in the TLH group (75% vs. 70.7% in the LASH group).

A total laparoconversion rate of only 0.5% was observed in this series of 200 laparoscopic hysterectomies (0.93% in the TLH group, no cases in the LASH group). That rate is very low when compared with the conversion rates observed by Harmanli et al. in a collective of >1000 patients (4.1% for LASH and 5.8% for TLH).¹¹ The reason for their conversion rates being so high might be that a total of 48 gynecologists contributed to their study sample and that the number of cases per surgeon varied exorbitantly. In our study, the operations were performed by only a few well-experienced laparoscopists. Park et al. recently reported a conversion rate of 8% in a collective of 288 patients who underwent TLH.¹⁴ They identified pelvic adhesions as a main risk factor for laparoconversion in their clinic. Considering that this study's rate of adhesiolysis was extremely high and the conversion rate was 16-fold lower, it is questionable how their conversion rates can be explained. This study bears out the experience of other authors that conversion rates can be low when using standardized procdures and well-trained surgeons.^9,15 No other intraoperative complications occurred, especially no iatrogenic injuries to the bowel or urinary tract.

No differences were observed between TLH and LASH in terms of stationary readmission and reoperation (p=0.531). However, there was a high rate of wound healing disorders of the vaginal cuff in the TLH group that occurred in as many as 12.2% of all women, whereas 1.9% of all TLH patients needed resuturing of the vaginal pole. The vaginal cuff complication rate in this study was comparable to the rate recently reported by Hwang et al. for a collective of 471 patients.⁵ In contrast, the total number of wound healing problems in the LASH group was significantly lower (p=0.027). Vaginal cuff dehiscence has been extensively discussed in the literature, and sexual intercourse before complete healing seems to be the main trigger event in young patients.^{16, 17} It remains unclear why the risk of cuff dehiscence after LH is higher than with AH, and there is no consensus about the best stump-suturing technique.¹⁸ Method-specific for LASH, secondary removal of the cervical stump was necessary in 2.2% of all cases during this study's follow-up time. No other statistically relevant differences between TLH and LASH were found.

Conclusions

Both total and subtotal LH can be performed safely, with a minimal rate of intra- and postoperative complications, as long as the patients are selected carefully and the surgeons are experienced and welltrained.

However, when deciding between LASH and TLH, the patient and the surgeon should consider that leaving the cervix in situ might reduce postoperative wound healing problems of the vaginal cuff.

Footnotes

Acknowledgments

We thank Kirsten Weber from Nevada, IA for polishing the language in this article. The costs associated with the provision of this study were funded solely by the Department of Obstetrics and Gynecology of the Saarland University Clinic.

Disclosure Statement

No competing financial conflicts exist.

References

Baskett

. Hysterectomy: Evolution and trends. Best Pract Res Clin Obstet Gynaecol, 2005; 19:295.

Baggish

. Total and subtotal abdominal hysterectomy. Best Pract Res Clin Obstet Gynaecol, 2005; 19:333.

Papadopoulos

, Tolikas

, Miliaras

. Hysterectomy: Current methods and alternatives for benign indications. Obstet Gynecol Int 2010, 2010; 356740Epub 2010 Jul 28.

Nieboer

, Johnson

, Lethaby

et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev, 2009; 3:CD003677.

Hwang

, Lee

. Vaginal cuff closure: A comparison between the vaginal route and laparoscopic suture in patients undergoing total laparoscopic hysterectomy. Gynecol Obstet Invest, 2011; 71:163.

Sokol

, Green

. Laparoscopic hysterectomy. Clin Obstet Gynecol, 2009; 52:304.

Mueller

, Thiel

, Renner

et al. Hysterectomy: A comparison of approaches. Dtsch Arztebl Int, 2010; 107:353.

Doganay

, Yildiz

, Tonguc

et al. Abdominal, vaginal and total laparoscopic hysterectomy: perioperative morbidity. Arch Gynecol Obstet, 2011; 284:385.

Mueller

, Renner

, Haeberle

et al. Comparison of total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma. Eur J Obstet Gynecol Reprod Biol, 2009; 144:76.

10.

Boosz

, Lermann

, Mehlhorn

et al.

Comparison of re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH)

Eur J Obstet Gynecol Reprod Biol, 2011; 158:269.

11.

Harmanli

, Tunitsky

, Esin

, Citil

, Knee

. A comparison of short-term outcomes between laparoscopic supracervical and total hysterectomy. Am J Obstet Gynecol, 2009; 201:536e1.

12.

Cipullo

, De Paoli

, Fasolino

. Laparoscopic supracervical hysterectomy compared to total hysterectomy. JSLS, 2009; 13:370.

13.

Chopin

, Malaret

, Lafay-Pillet

et al. Total laparoscopic hysterectomy for benign uterine pathologies: Obesity does not increase the risk of complications. Hum Reprod, 2009; 24:3057.

14.

Park

, Cho

, Kim

. Factors determining conversion to laparotomy in patients undergoing total laparoscopic hysterectomy. Gynecol Obstet Invest, 2011; 71:193.

15.

Bojahr

, Tchartchian

, Ohlinger

. Laparoscopic supracervical hysterectomy: A retrospective analysis of 1000 cases. JSLS, 2009; 13:129.

16.

Agdi

, Al-Ghafri

, Antolin

et al. Vaginal vault dehiscence after hysterectomy. J Minim Invasive Gynecol, 2009; 16:313.

17.

Iaco

, Ceccaroni

, Alboni

et al.

Transvaginal evisceration after hysterectomy: Is vaginal cuff closure associated with a reduced risk?

Eur J Obstet Gynecol Reprod Biol, 2006; 125:134.

18.

Jeung

, Baek

, Park

et al. A prospective comparison of vaginal stump suturing techniques during total laparoscopic hysterectomy. Arch Gynecol Obstet, 2010; 282:631.