Minimally Invasive Hysterectomy

Reasons for Minimally Invasive Hysterectomies

Hysterectomy means to surgically remove the uterus, leaving the ovaries and tubes. Typical reasons for hysterectomy include: disabling menstrual pain or flow, uterine fibroid tumors producing abnormal bleeding, pain or pressure symptoms or pelvic floor relaxation.

Types of Minimally Invasive Techniques

1. Supracervical vs. Full Hysterectomy

Removing the cervix with the uterus is the traditional approach for hysterectomy. It was thought to be a good preventative measure with little extra risk or time expended. However in the last 10 years, the benefits of leaving the cervix have been better appreciated. The cervix is tightly integrated into the support structure of the pelvic floor. Removing it disrupts this support and can contribute to later problems with pelvic floor prolapse and bladder dysfunction. Removing the cervix also opens up the vagina, exposing the surgery to vaginal bacteria, increasing the risk for infection. The open vagina also needs to be sutured closed, causing more pain in recovery and risking either short term or long term failure of the vaginal defect to stay closed. In addition, with the prevalent use of Pap smears and HPV testing, advanced cervical cancer is now rare, reducing the preventative value of removing the cervix. If vaginal hysterectomy cannot be done or there is a specific reason to remove the cervix, such as a precancerous condition or other cervical pathology, supracervical hysterectomy is a better option.

2. Laparoscopic vs. Vaginal

Laparoscopy is a surgical technique utilizing small incisions through the abdominal wall, anywhere from 3 to 12 mm, and then using carbon dioxide gas to expand the abdominal cavity and pelvis. This allows surgeons using specialized instruments, micro cameras and high resolution video screens to perform precise and complicated surgery. The carbon dioxide gas is not able to be completely removed and must absorb over the first few days after the surgery. This gas can cause abdominal discomfort and referred back pain until it is absorbed. Minimally invasive hysterectomies can be done purely by laparoscope, purely vaginally or by combination of the two. Proponents of the vaginal approach argue that there are no abdominal incisions or post operative gas pains to recover from. They also point out that studies have shown vaginal hysterectomies have less blood loss, less overall complication rates and faster surgery and recovery times when compared to any other type of hysterectomy. For easier recovery and low surgical risks, laparoscopic supracervical hysterectomy (LSH) is very close to vaginal hysterectomy . The proponents for LSH state that because there is no vaginal suturing, recovery pain is actually better than the vaginal hysterectomy patients and long term complications such as pelvic prolapse and bladder dysfunction are less likely. Which approach would be best depends on the individual with consideration of uterine size, prior surgeries and the existing level of pelvic floor relaxation. We would encourage you to have a good discussion about these options with your surgeon, because the best outcome and recovery will come with your understanding of the process and the options.

3. Laparoscopic Single Site

Single site laparoscopy utilizes only one incision for the surgery. Three or four instruments can utilize the same incision simultaneously. The incision is at the belly button, which is naturally the thinnest point of the abdominal wall and the point of least discomfort when healing. The incision is a bit larger than other laparoscopic incisions at about 25mm, but it is easily hidden in the belly button. The second large advantage of using the single site technique is that allows the surgeon to manually remove tissue directly through the open incision without the laparoscopic instruments. Utilizing a technique similar to peeling an apple, the surgeon can remove even large uteruses very efficiently and safely. This technique is referred to as manual morcellation which is faster and likely safer than the laparoscopic technique referred to as power morcellation.

4. Robotic

Robotic surgery is a form of laparoscopic surgery. The laparoscopic instruments are connected to a robotic device and the surgeon uses a console to instruct the robot to use the instruments. The camera used allow 3-D visualization and the instruments can articulate in 3 dimensions as well. The robotic technique is ergonomically easier on the surgeon and allows surgeons to do more complicated laparoscopic surgery. However, it adds both time and expense to the surgery. Generally, if the surgery can be done by laparoscopic technique, the robot does not offer an advantage to the patient.

Morcellation Controversy

A uterus can grow to be as big as a cantaloupe or bigger. For this reason, the need to reduce the uterus into smaller parts in order to remove it through laparscopic surgical incisions has always been a concern. The process of cutting the uterus into smaller parts is called morcellation. With minimally invasive incisions, the need for morcellation occurs often, but not always.

One of the advances in surgical technology was the development of "power morcellators". The power morcellator is a 1 cm diameter tube with a sharp edge, which rotates. The surgeon grasps the tissue with a laparoscopic instrument going through the tube. As the surgeon draws the tissue into the tube, a cylinder of tissue is cut out of the specimen. As this process is repeated, the specimen develops a Swiss cheese appearance. Small fragments of the specimen can fall off and be left behind. In rare cases, these fragments left behind have re-established by blood flow in the body and have grown multiple fibroids, or even caused the spread of unsuspected cancers. For this reason, the use of power morcellators has been called into question. In 2014, the FDA and the American College of Obstetricians and Gynecologists have both published concerns about the use of power morcellators.

Surgeons who perform manual morcellation, such as in vaginal hysterectomies or single site laparoscopic hysterectomies have less risk of leaving tissue behind. With single site, the uterus is morcellated extra corporally, or "outside the body". It is cut into only as it is brought through the incision. There are also containment bags into which the specimen can be placed during morcellation to remove any risk of contamination. Women who undergo minimally invasive surgery should discuss with their surgeon what type of morcellation process he or she uses.