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Intrafascial Hysterectomy
Another Option of Hysterectormy
Introduction:
Approximately, 600,000 hysterectomies are performed in the United States annually. Vast majority of these hysterectomies are done for benign medical reasons. Hysterectomies may be performed using an abdominal, vaginal or laparoscopic approach. Using the abdominal or laparoscopic technique, the hysterectomy can be divided into two categories; total hysterectomy and subtotal hysterectomy. There is no indication for removal of cervix in most total Hysterectomies. Total hysterectomy is preferred over Subtotal Hysterectomy for prevention for future cervical cancer and cyclic bleeding. laparoscopic Intrafascial hysterectomy will give physicians an option to remove inner Cervix and Subtotal hysterectomy giving the physicians benefits of both total and Subtotal Hysterectomy.
Historic Background of Hysterectomy:
The first hysterectomy was performed by Charles Clay in November 1843. This hysterectomy was performed due to a large myomatous uterus. The operation was successful, however, the patient died on the fifteenth postoperative day. The first patient to survive a hysterectomy was in 1853, it was performed by Walter Burnham. Out of his subsequent 15 patients, three patients did not survive. These early hysterectomies were all subtotal hysterectomies. In 1929, Dr. Richardson performed the world’s first total hysterectomy. He recommended the excision of the cervix, for prevention of a future carcinoma. The incidence of a cervical carcinoma during that time was 0.4%. Despite Dr. Richardson’s recommendation, subtotal hysterectomy remained the preferred surgical technique until the late 1940's. Prior to 1950, about 95 percent of the hysterectomies were supracervical. Supracervical hysterectomies were preferred for prevention of peritoneal contamination with vaginal bacterial flora and for prevention of peritonitis. However, in the 1950's, when penicillin and other antibiotics became available, Dr. Richardson’s technique of total abdominal hysterectomy started to become popular. Once again, the focus was on prevention of a future carcinoma of the cervical stump. During subsequent decades in the 1950's and 1960's when various antibiotics became available and infectious morbidity had decreased, total abdominal hysterectomy became the standard of care.
In 1991, Dr. Kurt Semm published his technique known as, Classic Intrafascial Semm Hysterectomy, or CISH procedure. His technique involved coring out the entire transformation zone and the endocervical canal, followed by laparoscopic ligation of vascular pedicles. The uterus was then morcellated and removed through laparoscopic incision sites. Dr. Kurt Semm removed the inner cervix using a manual CURT (Calibrated Uterine Resection Tool) device. Various studies showed that Semm hysterectomies had various benefits over traditional hysterectomies. These benefits included shorter recovery time, lower complication rates and less destruction to the pelvic anatomy. However, in spite of these benefits, the Semm hysterectomy never became popular due to long learning curve and technical challenges. Our Laparoscopic Intrafascial hysterectomy (LIH) is similar with Semm hysterectomy except here “Endocervical Electrode” is used instead of CURT device for removal of inner cervix making LIH an easier procedure with shorter learning curve.
Present Options for Hysterectomies :
The hysterectomies can be performed with abdominal total or subtotal, vaginal or laparoscopic approach. Total abdominal hysterectomy is the standard of care today. In the vast majority of the hysterectomies performed, there is no need for removal of the cervix in vast majority cases; however, total hysterectomy is performed as standard of care for the prevention of future cervical diseases and menstrual bleeding. Subtotal Hysterectomy is mostly performed for difficult surgical cases and is criticized for future risk of cervical diseases & carcinoma and cost of its preventive care. During supracervical hysterectomy physicians tried to destroy the cervical canal using electrocautery needle or cone biopsy electrode for prevention of cyclic bleeding. However the procedures are never uniform and results are variable. Total hysterectomy continued to be the standard of care for benign medical conditions. Total hysterectomy has increased risk for ureter injury, longer recovery period, and increased risk for vaginal cuff hematoma, abscess, distortion and prolapse. The supracervical hysterectomy has shorter recovery time, reduced or no risk for ureter injuries. However, supracervical hysterectomy has increased risk of future cervical diseases, and menstrual bleeding.
Alternative Options for Hysterectomy:
Intrafascial Hysterectomy using Endocervical Electrode:
- Laparoscopic Intrafascial hysterectomy (LIH)
- Abdominal Intrafascial hysterectomy (AIH)
Laparoscopic Intrafascial hysterectomy (LIH) :
Steps of Laparoscopic Intrafascial hysterectomy are: excision of entire cervical canal and transformation Zone is using “Endocervical electrode”, approximation of Cervical Stump, Laparoscopic suracervical hysterectomy and Morcellation of Uterus. Food and Drug Administration approved “Endocervical Electrode” for excision of the inner cervix during supracervical hysterectomy. This “Endocervical Electrode” has Parallel wire and is used for uniform cylindrical excision of entire cervical Canal and Transformation Zone. All the benefits of Electrosurgical Electrode technology developed in 1980s, for removal of abnormal cervical tissue, as an alternative to cone biopsy, cryotreatment and laser treatment to the cervix, is used here. The safety of the electrode technology is well established during the last 20 years of use.
As first Step a cylindrical Inner Cervix is removed Using Endocervical Electrode. Cervix is exposed using a Coated speculum. Suction device is attached to the speculum. Appropriate size of Endocervical Electerode is attached to the Pencil handpiece. Always foot switch should be used for uniform non-stop 360 degree excision. Use High power between 100 to 150 watts for drag free excision. Cervix must be approximated for faster healing, prevention of bleeding and infection. We recommend two layers of approximation. First layer as McDonald type circular absorbable suture near internal Os. Second layer as figure of 8 suture at external Os. This excision of inner cervix will take only few minutes and will reduce significant operating time and bleeding compared to total hysterectomy. This procedure will preserve all the peripheral cervical tissue with all ligament attachment and neurovascular supply.
Subsequently Laparoscopic supracervical hysterectomy is performed in the usual way. The uterus is now amputated at the level of internal Os. We used Wire Loops for this step. The uterus is then removed preferably using a trans abdominal or trans-cervical morcellation. If transcervical morcellation is preferred, Inner Cervix is closed at the end of the procedure.. This mini cervical stump usually heals within two to three weeks. Risks for cervical stump hematoma, infection, prolapse or distortion is very rare compared to vaginal cuff healing in total hysterctomy.
Abdominal Intrafascial hysterectomy (AIH) :
Steps of Abdominal Intrafascial hysterectomy are: excision of entire cervical canal and transformation Zone is using “Endocervical electrode”, approximation of Cervical Stump, Abdominal suracervical hysterectomy of Uterus. This “Endocervical Electrode” has Parallel wire and is used for uniform cylindrical excision of entire cervical Canal and Transformation Zone.
We again recommend that inner cervix be removed first. Cervix is exposed using a Coated speculum. Suction device is attached to the speculum. Appropriate size of Endocervical Electerode is attached to the Pencil handpiece. Always foot switch should be used for uniform non-stop 360 degree excision. Use High power between 100 to 150 watts for drag free excision. Cervix must be approximated for faster healing, prevention of bleeding and infection. We recommend two layers of approximation. First layer as McDonald type circular absorbable suture near internal Os. Second layer as figure of 8 suture at external Os. This excision of inner cervix will take only few minutes and will reduce significant operating time and bleeding compared to total hysterectomy. This procedure will preserve all the peripheral cervical tissue with all ligament attachment and neurovascular supply.
Subsequently Abdominal supracervical hysterectomy is performed in the usual way. The uterus is now amputated at the level of internal Os.
Benefits Of Laparoscopic Intrafascial Hysterectomy (LIH) :
With laparoscopic Intrafascial hysterectomy 3 difficult and risky steps of TLH is avoided. These are Transection of Cardinal and Utero-sacral ligaments, Colpotomy and vaginal cuff aproximetion. However laparoscopic Intrafascial hysterectomy will have all the benefits of Total Laparoscopic Hysterectomy without most the risks associated with total Laparoscopic hysterectomy due to avoidance of the above difficult, risky and time consuming steps. At present all laparoscopic hysterectomy comprise about 12 to 15 percent of all hysterectomies. This is due to learning curve, technical challenges and high complication rates. As laparoscopic intrafascial hysterectomy have less learning curve, less technical challenges and expected to have lower complication rate, after appropriate training, many more physicians may consider LIH over traditional hysterectomies and increase share of laparoscipic hysterectomies.
Following advantages of Laparoscopic intrafascial hysterectomy are based on technical nature of the procedure similar Semm Hysterectomy (CISH):
- No or reduced risk for ureter injury as cardinal ligament is not transected.
- Reduced operating time and bleeding compared to total Laparoscopic hysterectomy.
- Preserves Pelvic support Ligaments.
- Preserves Pelvic neuro-vascular supply.
- Cervical healing in 2 to 3 weeks, compared to 6 to 8 weeks for cuff healing.
- No risk of cuff abscess hematoma distortion or prolapse.
- No cyclic bleeding, as with some supracervical hysterectomy.
- No, risk future cervical diseade or cancer, compared to subtotal hysterectomy.
- Less learning curve than TLH.
- Eliminates 3 difficult and risky steps of TLH; Transection of Cardinal ligament, Colpotomy & Cuff approximation.
In addition to above advantages during of Laparoscopic intrafascial hysterectomy, surgeons will have another advantage of using the trans-cervical morcellation of uterus instead of trans-abdominal morcellation of uterus using the cervical opening. Trans-cervical morcellation of uterus during Laparoscopic intrafascial hysterectomy avoids the need for larger abdominal incision.
Conclusion :
Physicians and patients will both welcome Laparoscopic Intrafascial hysterectomy, if the procedure is done correctly and as expected with reduced complications, improves patient recovery and eliminates difficult & risky steps of present Total Laparoscopic hysterectomy. Laparoscopic Intrafascial hysterectomy is a minimally invasive hysterectomy and has less learning curve and less risky compared to TLH., many physician will consider TLH fo theirir patients. Laparoscopic Intrafascial hysterectomy will give physicians another option during hysterectomies for benign medical conditions. laparoscopic Intrafascial hysterectomy gives all benefits total hysterectomy without some of its risks. We believe with these advantages, many physicians and patients will accept of laparoscopic intrafascial hysterectomy over the traditional abdominal hysterectomy, total laparoscopic hysterectomy, Laparoscopy assisted Vaginal Hysterectomy and laparoscopic supracervical hysterectomy.. Most physicians will need minimum training in using this “Endocervical Electrode” for laparoscopic Intrafascial hysterectomy, With over 20 years of experience with electrode technology. most physicians will feel quite comfortable in using this technology. As many more physicians are now looking for more minimally invasive technology during surgical procedures, laparoscopic Intrafascial hysterectomy will give physicians another option to consider.
Referance:
- JOHNS, A,. Clinical Obstetrics & Gynecology. Supracervical Versus Total Hysterectomy. 40(4):903-913, December 1997.
- Mettler L, Semm K. Subtotal versus total laparoscopic hysterectomy. Acta Obstet Gynecol Scand, 76: 88-93, 1997.
- Semm K, Int. Surg 1996 Oct-Dec: 81(4): 362-70. Classic intrafascial SEMM hysterectomy.
- Thakar RT, et al. (2002). Outcomes after total versus subtotal abdominal hysterectomy. New England Journal of Medicine, 347(17): 1318–1325.
- Learman LA, et al. (2003). A randomized comparison of total or supracervical hysterectomy: Surgical complications and clinical outcomes. Obstetrics and Gynecology, 102(3): 453–462.
- Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database of Systematic Reviews 2006, Issue 2., Obstetrics & Gynecology (2007) ; 110: 705-706
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