Laparoscopic hysterectomy for benign gynaecological diseases

Method and advantages

Traditionally, hysterectomy for benign gynaecological diseases was performed:

• Abdominal. Use of a mid-vertical or transverse incision, as in caesarean section surgery.
• Vaginal. Without the use of abdominal incisions.

What is laparoscopic hysterectomy?

Laparoscopic hysterectomy is the surgical removal of the uterus using small incisions (up to 1 cm) in the abdominal wall. The percentage of hysterectomies performed laparoscopically for benign gynaecological diseases has increased significantly in recent years.

Indications for laparoscopic hysterectomy

Indications include: fibroids (benign tumours that originate from the muscle wall of the uterus), endometriosis (a condition in which cells that normally cover the inner wall of the uterus grow elsewhere in the body), uterine prolapse, menstrual abnormalities, chronic pelvic pain and gynaecological cancers.

Types of hysterectomy for benign gynaecological diseases

There are different types of hysterectomy for benign gynaecological diseases:

• Total hysterectomy (with removal of the cervix)
• Hysterectomy (without removal of the cervix)
• Hysterectomy with removal of one or both fallopian tubes and ovaries

All three types of hysterectomy can be performed laparoscopically.

Method of laparoscopic hysterectomy

• For laparoscopic hysterectomy, the following is given general anaesthesia.
• Depending on the indication of the surgery and the surgeon's usual practice, 3 or 4 small abdominal incisions are needed.

• The surgeon uses a fine needle and fills the abdomen with carbon dioxide to expand the abdomen and reduce the risk of intra-abdominal organ injury.
• A small camera (laparoscope) is inserted through one of the incisions and allows us to see the organs in great detail and under magnification.
• The remaining incisions are used for the insertion of surgical instruments that enable the hysterectomy to be completed.
• The uterus (along with the fallopian tubes and ovaries, if their removal is indicated) is removed vaginally and the vagina is stitched laparoscopically using absorbable sutures.

Postoperative rehabilitation

Discharge and full recovery
Most patients are able to be discharged within 24 hours of surgery. In general, it takes 2 to 4 weeks for full recovery after laparoscopic hysterectomy.

Healing of surgical wounds 5 days after laparoscopic hysterectomy surgery

Postoperative pain

Postoperative pain is usually mild, lasts a few days and is controlled with simple analgesics. It is common to experience pain in the shoulder area due to irritation of the diaphragm by the carbon dioxide, which subsides soon after surgery.

Absorbable sutures

Incisions are closed using absorbable sutures or skin glue (they do not need to be removed). In the case of a total hysterectomy (removal of the cervix as well), absorbable sutures are also available inside the vagina.

Addressing the risk of thrombosis

To reduce the risk of blood clots in the veins of the lower limbs, plenty of fluids and quick mobilisation after surgery are needed. It is also likely that your gynaecologist will recommend the use of heparin (low molecular weight heparin) injections for at least a week after the operation.

Advantages of laparoscopic hysterectomy

Compared to abdominal hysterectomy, laparoscopic hysterectomy has:

• Significantly faster recovery
• Less postoperative pain
• Shorter length of stay in the clinic
• Less risk of surgical wound infection
• Better aesthetic result (due to the use of small incisions)

Laparoscopic hysterectomy may be associated with a longer duration of surgery and a slightly increased risk of injury to urinary tract organs (bladder, ureters). However, in the hands of a gynaecologist with considerable surgical experience, the duration of surgery and risk of complications is not significantly different from abdominal hysterectomy.

Η vaginal hysterectomy offers, in general, similar advantages to laparoscopic hysterectomy. However, it may not be feasible in the case of:

• No descent (prolapse) of the uterus
• adhesions from previous surgeries
• Large size of the uterus (e.g. in case of fibroids).
• Indications for removal of fallopian tubes and ovaries along with hysterectomy

In conclusion

The majority of hysterectomies for benign gynaecological diseases can be performed laparoscopically. Laparoscopic hysterectomy is associated with significant benefits and, in the hands of a gynecologist with significant surgical experience in this procedure, can be performed safely. The number of hysterectomies performed by this method is expected to increase further in the future.

Text:
George A. Grigoriadis, MRCOG (Member of The Royal College of Obstetricians and Gynaecologists U.K.)

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