ISTERECTOMIA MINIINVASIVA

Massimo LuertiDipartimento Materno Infantile

Unità Operativa di Ostetricia e Ginecologia 1A.O. della Provincia di LodiOspedale Maggiore di Lodi

massimo.luerti@ao.lodi.it

ALTERNATIVE TECNICHE ALTERNATIVE TECNICHE ATTUALI PER L’ISTERECTOMIAATTUALI PER L’ISTERECTOMIA

•Isterectomia totale- laparotomica tradizionale- minilaparotomica- vaginale- laparoscopica

•Isterectomia subtotale- addominale

- minilaparotomica- laparoscopica- vaginale

Perioperative Pain Management

“The era of managed care and shorter hospital stays has focused physicians and, in particular, surgeons on elements of patient care that can be addressed and improved. Reducing or eliminating postoperative pain without excessive sedation promotes rapid mobilization and return to self-care”.

Levy BS, Carpenter R, J Am Assoc Gynecol Laparosc. 1995 Aug;2(4):381-7

“Minimizing tissue traumais the key to good

(and rapid ) recovery”

- every professor of surgery I’ve ever had

Mehra S Gynaecol Endosc 1999

•VH has the lowest complication rate and the quickest recovery•Total AH has the highest patient morbidity and longest convalescence.

The post-operative rates of morbidity and complications are lower with the vaginal approach than with any other methods

Rates of complications associated with hysterectomy range from

• 24 percent for the vaginal approach to• 43 percent for an abdominal approach

CLINICAL PRACTICE GUIDELINES FOR HYSTERECTOMYCommittee of the Society of Obstetricians and Gynaecologists of Canada, 1995

“The only controindication for a vaginal hysterectomy is if a vaginal hysterectomy has been perfomed….”

Steven Cruikshank, MDCertified Vaginal Zealot

LIMITI DELLA VH• Sindrome dolorosa pelvica che richiede esplorazione pelvica o specifici trattamenti

• Sospetta o accertata endometriosi

• Pregressa chirurgia pelvica-addominale ad alto rischio di aderenze

• Utero largo e grosso:esperienza per la riduzione

• Insufficiente approccio vaginale

• Presenza di patologia annessiale non sospetta

TUTTI I LIMITI DELLA VH, TRANNE L’UTERO LARGO E GROSSO POSSONO CONSIDERARSI INDICAZIONI

PER LA ISTERECTOMIA LAPAROSCOPICA

LA LAPAROSCOPIA DEVE QUINDI AFFIANCARSI ALLA VIA VAGINALE

E NON SOSTITUIRLA

Dipendentemente dalle indicazioni, dal training

del chirurgo e dall’ esperienza, la laparoscopia

puo’ essere utilizzata per assistere una

isterectomia che puo’ concludersi per via

vaginale (LAVH) o per una isterectomia totale o

sopracervicale

HYSTERECTOMY % HYSTERECTOMY % via VAGINAL ROUTEvia VAGINAL ROUTE

Brown DA & Frazer MI/Australia medicare 79/19

Summit RI /USA 77/25

Kovac SR/USA 89/25

Querleu D 77

Sheth SS 82

Sweden 11

In most countries the percentage of uteri removed abdominally is above 50%

Finnish national survey (1998) 93%

United Kingdom (1998) 74%

Dutch Hospitals (1998) 54%

ANNESSIECTOMIA IN CORSO DI ISTERECTOMIA VAGINALE

USA: 1.700.000 isterectomie 1988-1990

10.3Vaginale

68Addominale

%Via

Wilcox LS Obstet Gynecol 1994

ANNESSIECTOMIA IN CORSO DI ISTERECTOMIA VAGINALE

Una inchiesta tra gli iscritti alla British Society of Gynacological Endoscopy evidenzia che, su un totale di 147 risposte (46% del campione), il 57% sceglieva solo una isterectomia per via addominale se aveva in programma anche una annessiectomia, e solo il 7% effettuava direttamente una isterectomia vaginale.

(Clark TJ 2001)

ISTERECTOMIA VAGINALE

Revisione critica di una casistica di 500 isterectomie consecutive (68.4% AH, 19.2% VH), da parte degli stessi operatori (A. Magos e coll.):

353 (70,6%) proponibili per una isterectomia vaginale, ma solo 1/3 ha evitato la laparotomia

la via vaginale è proposta in modo variabile dagli operatori (da 9.9 a 100%)

le variabili principali all’indicazione sono: dimensioni dell’utero abilità del chirurgo

VANTAGGI DELL’ISTERECTOMIA LAPAROSCOPICA RISPETTO

ALL’ISTERECTOMIA ADDOMINALE

•Perdita ematica minore•Minore dolore postoperatorio•Minore durata della degenza•Più precoce recupero postoperatorio•Maggiore facilità di annessiectomia•Possibilità di adesiolisi•Migliore emostasi della trancia vaginale e toilette•Minore quantità di tessuto necrotico

J.H. Olsson et al. BMJ,1995;103:345-350R.I. Summit et al. Obst & Gyn,1998;92:321-326

FIHYST 1996FIHYST 1996AH VH LH

cases 5875 1801 2434

OVERALL COMPLICATIONSOVERALL COMPLICATIONS 17.2%17.2% 23.3%23.3% 19.0%19.0%

Infections 10.5% 13.0% 9.0%

Hemorrhagic events 2.1% 3.1% 2.7%

Bowel injuries 0.2% 0.5% 0.4%

Ureter injuries 0.2% 0 1.1%

Bladder injuries 0.5% 0.2% 1.2%

Makinen, 2001

COMPLICANZE PER TIPO DI ISTERECTOMIA

9.7% (*)10.9%20.1%

THLVHAH

*-Chapron. 235 pz ,1999

RUOLO DELLA CURVA DI APPRENDIMENTO NELLE COMPLICANZE DELL’ISTERECTOMIA

LAPAROSCOPICA (A. Wattiez, 2002)

1989-1995 1996-1999(n=695) (n=952)

Trasfusioni 15 (2.2) 1 (0.1)Danni vescicali 11 (1.6) 6 (0.6)Danni ureterali 4 (0.6) 2 (0.2)Fistola vescicovaginale 1 (0.1) 1 (0.1)Danni intestinali 1 (0.1) 0Reinterventi 9 (1.3) 3 (0.3)Ematoma parietale 10 5Ematoma cupola vaginale 3 4Iperpiressia 14 4Infezione cupola vaginale 4 0Infezione della parete 2 0

VH is superior in terms of operative time and

immediate inflammatory response when compared

with TAH and LH, and therefore it should be the

first option for hysterectomy.

LH should be the preferred option when the vaginal approach is unfeasible, showing clear advantages over TAH.

A randomized study of total abdominal, vaginal and laparoscopic hysterectomyS.C. Ribeiro, International Journal of Gynecology and Obstetrics 83 (2003) 37–43

CLINICAL PRACTICE GUIDELINES FOR HYSTERECTOMYClinical Practice Guidelines – Gynaecology,Committee of the Society of Obstetricians and

Gynaecologists of Canada, December, 1995.

•Any patient requiring a hysterectomy should be offered the vaginal approach as the morbidity and post-operative complications are less. •Laparoscopic assisted vaginal hysterectomy may be used instead of an abdominal hysterectomy, but is of no advantage where a vaginal hysterectomy can be performed.

LAVH is “to assist in the performance of a vaginal hysterectomy in situations in which an abdominal approach might otherwise be indicated”

American College of Obstetricians and Gynecologists (ACOG), 1995

CLASSIFICAZIONE DELLE ISTERECTOMIE CON TEMPO LAPAROSCOPICO

•LAVH (Laparoscopic Assisted Vaginal Hysterectomy)

con tempo laparoscopico che arriva fino ai vasi uterini esclusi

•LH (Laparoscopic Hysterectomy)

con vasi uterini affrontati per via laparoscopica mentre i legamenti utero-sacrali e cardinali e la parete vaginale possono essere affrontati come si vuole: sutura vaginale dal basso

•TLH (Total Laparoscopic Hysterectomy)

con totale dissezione del pezzo operatorio e la sutura della parete vaginale per via laparoscopica

AAGL ABBREVIATED CLASSIFICATION SYSTEM FOR AAGL ABBREVIATED CLASSIFICATION SYSTEM FOR LAPAROSCOPIC HYSTERECTOMY LAPAROSCOPIC HYSTERECTOMY

J Am Assoc Gynecol Laparosc 7(1):9-15,2000

Type 0: Laparoscopic-directed preparation for vaginal hysterectomyType I: Occlusion and division of at least one ovarian pedicle, but not including uterine artery(es)Type II: Type I plus occlusion and division of the uterine artery, unilateral or bilateralType III: Type II plus a portion of the cardinal-uterosacral ligament complex, unilateral or bilateralType IV: Complete detachment of cardinal-uterosacral ligament complex, unilateral or bilateral, with or without entry into the vagina

BIPOLAR VESSEL SEALING

•Conventional bipolar electrosurgery

•Ultrasonic and laser-based systems

•Pulsed plasma kinetic electrosurgical

•Feedback-controlled, radiofrequency-based bipolar devices

•Can effectively seal vessels and vascular bundles up to 7mm in diameter. •Application of mechanical energy or pressure in conjunction with the delivery of electrical energy•Electrosurgical generator measures both voltage and current to monitor tissue response: as tissue impedance changes because of resistive heating, voltage and current will vary accordingly.•When tissue response indicates a successful seal, a cool cycle is entered, during which time the device position is maintained and no power is delivered. After the cooling period, the generator emits an audible tone to indicate cycle completion. On average, the entire sealing and cooling cycle takes approximately 5 seconds.

Randomized Trial of Suture Versus ElectrosurgicalBipolar Vessel Sealing in Vaginal HysterectomyBarbara Levy, MD, and Laura Emery

VOL. 102, NO. 1, JULY 2003OBSTETRICS & GYNECOLOGY

ELECTROSURGICAL BIPOLAR VESSEL SEALER

.005126.7 113.3100

(25–600)

68.9 51.650.0

(20–200)

Estimated bloodloss (mL)

.01460.3 27.955.5

(37–160)

48.0 26.842.0

(22–93)

Total proceduretime* (min)

.00353.6 26.747

(37–160)

39.1 17.736

(22–93)Proceduretime (min)

StatisticalSignificance

(P)

Suture(n 30)

EBVS(n 30)

Randomized Trial of Suture Versus Electrosurgical Bipolar Vessel Sealing in Vaginal Hysterectomy

Barbara Levy, MD, and Laura Emery, VOL. 102, NO. 1, JULY 2003, OBSTETRICS & GYNECOLOGY

ELECTROSURGICAL BIPOLAR VESSEL SEALING IN VAGINAL HYSTERECTOMY

TECNICA TECNICA ISTERECTOMIA ISTERECTOMIA

LAPAROSCOPICALAPAROSCOPICA

OPERAZIONI PRELIMINARI

•Posizionamento della paziente

•Posizionamento dei trocars

•Posizionamento del mobilizzatore uterino

+++++++++Tenuta del gas

++++++++++Maneggevolezza

++++++++++Facilità d’uso

+++-++++++++Movimenti indipendenti

+++++++++++++Identificazione fornici

+++++++++Movimenti d’elevazione

++++++++++Movimenti laterali

++++++++++++Movimenti anti-retroversione

nopartiallyYesYes Poliuso

VcareRumiClermont FerrandHourcabie

                                                                                                      

PRECAUZIONI PER EVITARE DANNI ELETTRICI ALL’URETERE

buona preparazione e scheletrizzazione del fascio vascolare scelta del punto di coagulazione, sulla branca ascendente dell’arteria uterina tempo di coagulazione, più breve possibile: coagulazioni

brevi e ripetute sono preferibili ad una coagulazione prolungata applicazione perpendicolare al fascio vascolare della pinza bipolare, introdotta dal trocar omolaterale forte laterodeviazione controlaterale dell’utero

CAUSE DI DIFFICOLTA’

• The presence of large uterus over 300 grams (or 12 weeks) with or without a poor vaginal access

• The presence of adhesions due to previous caesarean sections or previous pelvic surgeries (myomectomies)

• The presence of pelvic varicosities

• The presence of other pathologies like endometriosis

MEZZI PER SUPERARE LE DIFFICOLTA’

•Preoperative treatment with GnRH analogs

•Trocar placement and ergonomics •30° laparoscope •Securing uterine vessels and

decreasing the risk of hemorrhage

•Changing strategies •Morcellation

VARIANTE TECNICA

La chiusura dell’arteria uterina può essere effettuata come primo tempo operatorio, aprendo il legamento largo e andando a coagulare l’arteria alla sua emergenza dall’arteria ipogastrica

MINILAPAROTOMIA:MINILAPAROTOMIA:Un'alternativa miniinvasiva e meno dolorosa Un'alternativa miniinvasiva e meno dolorosa

per la chirurgia ginecologica maggioreper la chirurgia ginecologica maggiore

MINILAP PRINCIPLES• Smaller incisions are less traumatic

– Decreased post-op pain– Shorter hospital stay– Early ambulation– Earlier return to normal activities

• Vessels at same level regardless of uterine size• You only need to see what you’re cutting• Movement of uterus under incision allows access• Movement of incision to vascular pedicles• Minimal packing and bowel handling avoids ileus• Like doing a vaginal hysterectomy through the abdomen• Faster, easier to learn/teach, less costly than laparoscopy

Effects of presurgical local infiltration of bupivicaine in the surgical field on postsurgical wound pain in laparoscopic

gynecologic examinations: a possible preemptive analgesic effect

Kato J, Ogawa S, et al. Clin J Pain. 2000 Mar;16(1):12-17

• Incidence of wound pain significantly lower at 10 hrs. post op in treated vs control (p<.05)

• Mean visual analog pain intensity less in treated (p<.05)

• Patients requesting analgesics and who complained of sleep disturbance higher in control group (p<.05)

• Mean cumulative dose of diclofenac at 24 hrs signifcantly lower in treated vs controls (p<.05)

“Cruciate Incision” 4-8 cm transverse skin

incision6-8 cm. vertical fascial

incision

ISTERECTOMIA SUBTOTALE

The operation time and the blood loss were

significantly less in the subtotal abdominal hysterectomy group compared with total

abdominal hysterectomy

Helga Gimbel. BJOG.December 2003, Vol. 110, pp. 1088–1098

Laparoscopic supracervical hysterectomy has shorter

operating times, shorter length of stays, and less morbidity

than laparoscopically assisted vaginal hysterectomy

A Comparison of Laparoscopic Supracervical HysterectomyVersus Laparoscopically AssistedVaginal Hysterectomy

Andrew Sokol, MDObstetrics & Gynecology, VOL. 95, NO. 4 (SUPPLEMENT), APRIL 2000

TAH SCH

Intercourse frequency, orgasm frequency, and overall sexual satisfaction were all significantly related to type of procedure (P = 0.01, 0.03, and 0.03, respectively). Intercourse frequencyworse outcome 42% (n = 10) 15% (n = 5)

Decrease in the ability to achieve orgasm 43% (n = 9) 6% (n = 2)

Worsening of overall sexual satisfaction 33% (n = 8) 6% (n = 2)

Supracervical hysterectomy versus total abdominal hysterectomy: perceived effects on sexual function

Jyot SainiBMC Women's Health 2002, 2:1     doi:10.1186/1472-6874-2-1

CLINICAL PRACTICE GUIDELINES FOR HYSTERECTOMY

Committee of the Society of Obstetricians and Gynaecologists of Canada, 1995.

When a hysterectomy is performed for benign disease, subtotal surgery may be preferable to a patient who has always had normal cytological findings and who believes sexual

relations may be affected by removal of the cervix

MINILAP SUPRACERVICAL HYSTERECTOMY

• Should only be considered when conservative therapy fails

• Is NOT a substitute for vaginal hysterectomy• Retention of the cervix is not an indication

– No scientific evidence that cervical retention prevents prolapse

– No convincing scientific evidence that cervix enhances sexuality

• Supracervical hysterectomy should be done since it is technically easier and there are fewer complications than total hysterectomy

Incidence of Cyclic Bleeding After Laparoscopic Supracervical Hysterectomy

• Prospective study of 67 LSH• Cervical stump biopsied at 12 and 6:00• All patients contacted 3-15 mos post- op• Overall bleeding incidence 19%• In group where biopsy showed endocervical

tissue, 17% experienced cyclic bleeding• Continuous variables (eg endometriosis,

adenomyosis, BMI, uterine wt) not significantGhomi A, Hantes J, Lotze EC. JMIG 2005 May/June; 12(3):201-205

MINILAP SUPRACERVICAL HYSTERECTOMY: TECHNIQUE

• Insert uterine manipulator

• Suprapubic transverse skin incision - 4 - 8 cm.

– Inject local prior to making incision

• 6 - 8 cm vertical facial incision (cruciate)

• Insert Mobius retractor and elevate uterus to ant abdominal wall

• Start at adnexae and work downward (like LAVH)

– Twist and deviate uterus with manipulator

– Use sutures, Hemalock clips, PK seal, Ligasure or PK short cutting forceps for control of pedicles

– Dissect bladder flap downward

– Clamp, cut and tie (clip or coagulate) uterine vessels

• Elevate lower segment and amputate at int. os

– Red Robinson catheter or penrose drain

• “Reverse Cone” endocervix

• Suture cervical stump

Minilap Supracervical Hysterectomy: Technique (cont)

• Morcellate fundus using #10 scalpel - Doyen “ ladder technique”

• Irrigate pelvis and incision with saline• Close subcutaneous “dead space” with sutures to avoid seroma• Subcuticular closure after injecting fascia and skin with local• Decadron 6-8 mg, Toradol 60 mg intraoperative• D/C Foley in OR – Void or Cath. Q 6-8 h.• Band-Aid and steristrips to incision, vertical pressure dressing

until discharge

•1 per 1000 women develops carcinoma in cervical stump.•Twenty-five percent of the patients continued to menstruate•10% had symptoms of discharge. •symptoms related to the cervical stump in 24% of patients, all requiring further operations•Adhesions, especially between the bowel and the cervical stump, endometriotic lesions, cervical pathologies (chronic cervicitis, SIL, mucocoeles), myomas and prolapse have been reported at long-term follow-ups

Myoma arising in a Cervical Stump. A. Rossetti, 2003

FATTORI CONDIZIONANTI LA SCELTA DEL TIPO DI ISTERECTOMIA

• Il chirurgo– Esperienza e predisposizione

• L’indicazione all’intervento– Patologia annessiale– Peso e disposizione volumetrica dell’utero– Sospetta endometriosi– Dolore pelvico cronico– Flogosi acuta o cronica in atto– Necessità di appendicectomia o annessiectomia

• Caratteristiche della paziente – BMI– Mobilità dell’utero– Accesso vaginale– Pregressa chirurgia pelvica