1. Laparoscopic Hysterectomy: Total, supracervical, robotic, single port ? Tommaso Falcone, M.D. Professor an Chair

2. Learning Objectives Select patients appropriately for Laparoscopic hysterectomy Understand the advantages and limitations of different surgical approaches Understand the advantages and limitations of robotic hysterectomy

3. DUB 20% (120,000/year) Fibroids 30% Endometriosis/ Adenomyosis 20% (Pre) cancer 10% Chronic pelvic pain 10% Prolapse 15% Hysterectomy in the US for DUB

4. Procedure of Choice Johnson N, Barlow D, Lethaby, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev 2006; CD 003677. This review included 3643 patients from 27 randomized trials. Vaginal hysterectomy is the procedure of choice

5. Preoperative Considerations Prophylactic oophorectomy in women without risk –A decision analysis by Parker et al suggested that the age for prophylactic oophorectomy should be closer to 65 years (Obstet Gynec 2005). – Vitonis et al Obstet Gynecol May 2011 Risk: Jewish ethnicity, less than 1 year of OCs, nulliparity, no breastfeeding, no tubal ligation, endometriosis, PCOS or obesity, talc use 0-1 score lifetime risk 1.2 % 5 or more 6.6%

6. Total vs. Supracervical Hysterectomy Learman et al Obstet Gynecol 2003 (RCT 135 patients) No difference –Complications –Length of stay –Postoperative pain –Total convalescence –Reduction of preoperative symptoms (including urinary symptoms) –In urinary symptoms or incontinence at 24 months

7. Readmissions Readmissions: TAH 6% & SCH 12% (NS) Post-supracervical hysterectomy cyclic vaginal bleeding: 5%

8. RCT: Thakar et al NEJM 2002 No difference in outcome –Sexual function, urinary symptoms all improved More blood loss in TAH ( 422mL) vs. SCH (320mL); no difference in blood transfusion Time difference: 11 minutes Postoperative complications –Pyrexia higher TAH group –Cyclic vaginal bleeding or cervical prolapse: 7%

9. Post-hysterectomy bleeding Danish study- N=136 19 % experienced bleeding but only 2 patients required a trachelectomy British study-N= 140 7 % bleeding & 2 % had prolapse American study N=68 5 % bleeding only 1 patient required a trachelectomy

10. Quality of Life Einarsson et al 2011 –Prospective trial TLH vs. TSH QOL scores better with TSH No difference in postoperative pain, nausea, use of opoids, or return to daily activity

11. Patients want choices Decisions are a partnership between doctor & patient

12. Patients want choices Evidence based medicine does not imply giving one option-the one with the highest Odds Ratio in the Cochrane reviews

13. Impact of Hysterectomy Emotional and perceptional impact of hysterectomy

14. Patient resources Web sites –Attest to the “damage” of hysterectomy Amazon.com –Myriad of books

15. Supracervical hysterectomy Perceived as a “hysterectomy alternative” Allows preservation of what is perceived to be the most important part of the organ

16. Patient Selection Exclusion of malignancy or pre-malignant state Realistic expectations –Do they want 100 % guarantee of amenorrhea? –24 % had residual endometrium in the stump Endometriosis patients –23 % who had a trachelectomy had endometriosis Prolapse ?

17. How to convert an abdominal hysterectomy into a less invasive procedure Supracervical is far less complex than a laparoscopic or LAVH Supracervical is technically easier and faster

18. Injury Cochrane database-Urinary Tract injury –LAVH associated with more injury than abdominal hysterectomy Related to the dissection required around the paracervical area –Supracervical is probably associated with less urinary tract injury The RCT were not powered to assess injury To detect a 2 % difference- 2000 subjects randomized

19. Abdominal Hysterectomy Laparoscopic Hysterectomy Vaginal Hysterectomy Laparoscopic Hysterectomy At least one complication 6.2 % 7.2 % 5.4 % 6.7 % Conversion to laparotomy 3.9 % 4.2 % 2.7 % Major hemorrhage 1 2.4 % 4.6%2.9%5.1% Bowel injury 1%0.2%0%0% Ureter injury 0%0.9%0%0.3% Bladder injury 1%2.1%1.2%0.9% Other 2 2.1% 2.4 % 1.8 % 3.9 %

20. Perioperative Considerations Prophylactic antibiotics initiated within one hour of incision Use of first or second generation cephalosporins Discontinuing prophylactic antibiotics within 24 hours

21. VTE prophylaxis unfractionated heparin (5000 units every 12 hours) or low molecular weight heparin (ex.enoxaparin 40 mg or 2500 units of dalteparin) or intermittent pneumatic compression device Patients over 40 years of age or those under 40 years of age who have risk factors (such as obesity)- unfractionated heparin (5000 units every 8 hours) or low molecular weight heparin ( 5000 units of dalteparin or similar dose of enoxaparin 40 mg).

28. 5mm vessel sealing devices 4-5mmvesselsClipHSPKPTRxLSFT Mean burst (mmHg ) 9403906472959271261884 Mean seal (Sec)----3.9444.556.817.23 % failures 022%41%48%000

48. LESS ( Single Site) Hysterectomy

49. LESS Hysterectomy

51. Less Tips for Promoting Ergonomics and Efficiency The surgeon should handle both operating instruments The assistant should operate the scope If using a rigid scope, use a bariatric length with an angled light cord adapter Stand on a step-up to have better leverage and control with “in-line” operation of instruments

52. Optics

53. Instrumentation

54. Gynecologic Oncology

55. RCT: Conventional vs. Single Port Hysterectomy Chen et al April 2011 Obstet Gynecol –N=100 –Uterine weight 284 grams –OR time 122-127 minutes –Cuff closed through the vagina –Pain score at 24 hours & 48 hours was significantly different ( 3.6 vs. 5.1; 1.9 vs. 2.8) –Total Meperidine dose difference 25 mg

56. Laparoendoscopic single-site (LESS) surgery in patients with benign adnexal disease Bedaiwy and Escobar F&S 2010

57. LESS Dermoid Cystectomy

61. Women’s Preferences in Minimally Invasive Incisions Bush et al JMIG 2011 Preference was traditional 4 puncture configuration over single site and robotic 5 puncture techniques.