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Editorial JULY 2007
Picking Up All
The Pieces
Veronica Ravnikar, MD
The advent of laparoscopic techniques for hysterectomy has made
a significant difference in the impact of this procedure. A number
of multicenter studies show that such techniques are associated
with shorter operative times and quicker recovery/hospital discharge.1,2 There are differences among laparoscopic techniques as well; for
example, the laparoscopic supracervical hysterectomy (LSH) with
uterine morcellation is considered superior to the laparoscopic
assisted vaginal hysterectomy (LAVH) in terms of shorter operative
time, less blood loss and postoperative morbidity, and better quality
of life.3-5 Indeed, LSH is emerging as the procedure of choice
today, and appears to be safer and more efficient—eg, lower complication
rates and shorter surgical times compared with LVAH and total abdominal
hysterectomy via laparotomy. Insurance providers also favor any
procedure that cuts hospital costs.
But how much do we really know about all of the potential outcomes
of LSH, especially given that one of its main benefits is speed?
For example, there are anecdotal reports of pieces of myometrium
left behind in women whose uteri were morcellated, leading to implanted
myometrial tissue causing pain and bowel problems.6,7 Some of these
cases developed years after the LSH procedure was performed, and
so were omitted from initial analyses of outcomes. Surgical correction
of these problems is complex because such tissue can cause bowel
obstruction, and the retained pieces are more than likely retroperitonealized.7 The
published cases involved women with adenomyotic uteri who underwent
LSH, suggesting that this form of endometriosis may confer a
greater risk of becoming parasitic. Additionally, what about
the potential for releasing endometriotic fragments when an ovary
with undetected endometriosis is morcellated? And what is the
risk of retained ovary syndrome? How will we handle the incidental
finding of undiagnosed endometrial cancer in a morcellated uterus?
Finally, morcellation certainly creates problems for pathologic
evaluation, as the specimen cannot
be “oriented.”
Department policies should clearly specify patient criteria
for LSH, together with the necessary minimal preoperative work-up.
In general, conditions treated effectively by LSH include symptomatic/enlarging
fibroids, therapy-resistant abnormal uterine bleeding, and chronic
pelvic pain. The patient must have confirmed normal cervical
cytology and continue to follow Papanicolaou screening guidelines,
and intrauterine/ovarian malignancy must be excluded.
However, the concern remains that the pathologist may still
not detect microscopic cancer, or that a known fibroid may be
a sarcoma. Furthermore, morcellated fragments can still be left
behind inadvertently due to haste, or to the presumption that
such fragments will become necrotic.
These procedures must be performed in the right patients, by
qualified surgeons, and with the appropriate biopsies. The LSH
learning curve for a qualified gynecologist is not long, but
varies according to surgical skills and uterine contour/mass.
The hospital should clearly define the guidelines for credentialing;
centers with large databases suggest that a surgeon needs 80
cases to get the operative time below 90 minutes.4 The complication
rate for a specific surgeon does not correlate with the number
of cases performed,1-5 so the emphasis should be on caution,
not speed. Finally, if there is any suspicion of an abnormality
that was not detected beforehand—eg, apparent ovarian endometrioma
or dermoid—the procedure should be converted to removal in an
endobag, or to an LAVH if the uterine surface is suspicious.
In any case, the surgeon should always take the time to pick
up all the pieces.
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References
- Ewen SP, Sutton CJ. Initial experience with supracervical laparoscopic hysterectomy and removal of the cervical transformation zone. Br
J Obstet Gynaecol. 1994;101(3):
225-228.
- Hoffman CP, Kennedy J, Borschel L, Burchette R, Kidd A. Laparoscopic hysterectomy; the Kaiser Permanente San Diego experience. J
Minim Invasive Gynecol. 2005; 12(1):16-24.
- El-Mowafi D, Madkour W, Lall C, Wenger JM. Laparoscopic supracervical hysterectomy versus laparoscopic assisted vaginal hysterectomy. J
Am Assoc Gynecol Laparosc. 2004;11(2):175-180.
- Bojahr B, Raatz D, Schonleber G, Abri C, Ohlinger R. Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique. J
Minim Invasive Gynecol. 2006;13(3):183-189.
- Sarmini OR, Lefholz K, Froeschke HP. A comparison of laparoscopic supracervical hysterectomy and total abdominal hysterectomy outcomes. J
Minim invasive Gynecol. 2005;12(2):121-124.
- Lieng M, Istre O, Busund B,
Qvigstad E. Severe complications caused by retained tissue in laparoscopic supracervical
hysterectomy. J Minim Invasive Gynecol. 2006;13(3):231-233.
- Donnez O, Squifflet J, Leconte I, Jadoul P, Donnez J. Posthysterectomy pelvic adenomyotic masses observed in 8 cases out of a series of 1405 laparoscopic subtotal hysterectomies. J
Minim Invasive Gynecol. 2007;14(2):156-160.
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