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LAPAROSCOPIC HYSTERECTOMY

Laparoscopic hysterectomy, either total or supracervical, may be feasible for women with uterine fibroids, with the benefits of less postoperative pain, shorter hospital stay, and faster recovery.

Laparoscopic hysterectomy compared with vaginal hysterectomy.

If a vaginal hysterectomy is technically feasible for a patient, there is no benefit in performing a laparoscopic hysterectomy. The ability to perform a vaginal hysterectomy on an outpatient basis with good patient acceptance has been established (96). A prospective, randomized study compared laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting (97). All patients had a mobile uterus of <16 weeks’ size and were believed to be candidates for outpatient surgery. An average of 55 minutes’ additional operating time was required for the patients operated on by laparoscopy-assisted vaginal hysterectomy. Added anesthesia time, in addition to the cost of disposable instruments, increased the cost of laparoscopic surgery by $3,000 when compared with standard vaginal hysterectomy. The outcomes of the two groups were otherwise comparable. Other studies have confirmed these findings (98, 99).

Laparoscopic hysterectomy compared with abdominal hysterectomy.

A prospective, randomized, multicenter study concluded that laparoscopic-assisted hysterectomy offered the benefits of less-invasive surgery without increased risk (100). Eighty women with uterine size of between 280 and 700 g (considered a contraindication to vaginal hysterectomy) were included in the study. Laparoscopy-assisted vaginal hysterectomies, with the laparoscopic portion of the procedure concluded before ligation of the uterine arteries (type I according to the Munro and Parker classification) were compared with the standard abdominal approach (101). Estimated blood loss, postoperative day 1 hemoglobin, postoperative pain (as measured by a visual analog scale), and postoperative hospital stay were all significantly better for the laparoscopy-assisted hysterectomy group. The abdominal hysterectomy group had seven postoperative complications: one woman with a cuff hematoma who required transfusion, one with delayed bleeding requiring reoperation and transfusion, and five other women with fevers. The only complications in the laparoscopic group were postoperative fevers in two women.

A retrospective cohort study compared laparoscopic hysterectomy for fibroids in 34 women who had uterine weights of >500 g (range, 500–1,230 g) with the case of 68 women who had uterine weights of <300 g (102). The investigators found no difference in complications rate, blood loss, hospital stay, or postoperative recovery, but operating times were significantly shorter in the women with smaller uteri. No patient required conversion to laparotomy. Therefore, in experienced hands, the benefits of laparoscopic hysterectomy may also be extended to women who have large fibroids.

Conservative surgery for uterine sarcoma

Hysterectomy is the treatment of choice when leiomyosarcoma is found. However, a small number of young women who desired to retain fertility have been offered uterine preservation when sarcoma was found incidentally at the time of a presumed myomectomy and when no evidence of residual disease was found on postoperative ultrasound, hysteroscopy, abdominal and pelvic magnetic resonance imaging (MRI) or computed tomography scan, or chest roentgenogram. In a review of the available data, including their own cases, Lissoni et al. (103) reported that 27 such sarcomas were managed by observation, with a mean follow-up of 42 months (range, 11–92 mo). Nine women had subsequent surgery, and 3 had evidence of residual disease. Among the 18 women who were observed, only 1 had a recurrence, and 9 women had subsequent pregnancies that went to term.