Hysterectomies are one of the most common surgical procedures in the world, with greater than 600,000 performed each year. For decades, abdominal and vaginal approaches accounted for the vast majority of hysterectomies. The advent of better laparoscopic technology resulted in the first Total Laparoscopic Hysterectomy (TLH) in 1989.
The need of Total Laparoscopic Hysterectomy (TLH) has heightened in the past 20 years. Total Laparoscopic Hysterectomy accounted for 9.9% of all hysterectomies in 1997 and 11.8% in 2003.
The total laparoscopic hysterectomy (TLH) offers women an option that is far less invasive than other surgical approaches. The need for a hysterectomy is an important and difficult decision.
The laparoscopic ligation of the ovarian arteries and veins with the deletion of the uterus vaginally along with laparoscopic closure of the vaginal cuff is known as Total Laparoscopic Hysterectomy. This is in contrast to other methods of removing the uterus, fallopian tubes, and ovaries.
The removal of the uterus by surgery can be lifesaving for those which are suffering from gynecological cancers or the severe pain and heavy bleeding due to fibroids or endometriosis.
A laparoscopic supra cervical hysterectomy is completed in a similar fashion, with the exception that the cervix is amputated after occluding the ascending vascular pedicles. A laparoscopic-assisted hysterectomy (LAVH) is a way to secure the ovarian and uterine vasculature via laparoscopy.
The laparoscope is often re-inserted after closure of the vaginal cuff to inspect the abdomen and vaginal cuff for adequate hemostasis at the end of the procedure. Total Laparoscopic Hysterectomy requires adequate uterine descent to safely complete the vaginal portion of the procedure.
Laparoscopic radical hysterectomy has emerged as an alternative to abdominal radical hysterectomy for patients with stage I cervical cancer. The new advancements of the technology include robotic-assisted laparoscopic hysterectomy, single-incision laparoscopy, and laparoscopic pelvic reconstruction surgery.
The advantages of Total Laparoscopic Hysterectomy compared to abdominal hysterectomy have been well documented. Visualization of pelvic anatomy and the ability to minimize blood loss is superior with Total Laparoscopic Hysterectomy. Substantial and dynamic access to the uterine vessels, vagina and rectum is possible from many angles, especially after introduction of the uterine manipulator in 1995.
The advantages of Total Laparoscopic Hysterectomy have been firmly established to include reduced short-term morbidity (less blood loss, wound infections, and postoperative pain), shorter hospital stay, and faster resumption of normal activities when compared with abdominal hysterectomy. The main focus of this chapter is to review the indications, surgical technique, and advantages of Total Laparoscopic Hysterectomy for women who are candidates for a hysterectomy.
Potential benefits of Total Laparoscopic Hysterectomy include shorter hospital stays, quicker return to normal activities, and less use of postoperative pain medications in comparison to TAH.
A comparison of TVH and Total Laparoscopic Hysterectomy outcomes demonstrate similar length of hospital stays and level of post-operative pain. Surgical outcomes, although not the primary outcome measure for this study, also favored laparoscopic hysterectomy. Operative times were 5 minutes longer for the laparoscopic cases, and similar rates of conversion to laparotomy, intra-operative complications, and intra-operative blood loss existed.
After completing a pelvic examination under anesthesia, the first step is to properly position and drape the patient as previously described. The patient is placed in the modified position during the placement of uterine manipulator. Currently, several manipulators are marketed.
The manufacturer's directions for assembly and application should be reviewed prior to use. Correct application of the uterine manipulator is the key to a successful Total Laparoscopic Hysterectomy, as many of these manipulators facilitate identification of important anatomical structures.
After the surgery, patients are willing to have a much quicker recovery they are usually going home the same day or stay one overnight in the hospital. Often, patients are able to return to their normal routine in one to two weeks.
Patients revert less pain, minimal post-surgical narcotic pain medication use and a faster recovery time than women undergoing abdominal hysterectomies who usually require a three to four day hospitalization and lengthy recovery time of usually six to eight weeks.