Journal of obstetrics and women's diseasesJournal of obstetrics and women's diseases1684-04611683-9366Eco-Vector8722610.17816/JOWD87226Review ArticleTotal laparoscopic hysterectomy in the grossly enlarged uterusBotchorishviliR.<p>Department of Obstetrics and Gynecology</p>info@eco-vector.comRabischongB.<p>Department of Obstetrics and Gynecology</p>info@eco-vector.comJardonК.<p>Department of Obstetrics and Gynecology</p>info@eco-vector.comPoulyJ. L.<p>Department of Obstetrics and Gynecology</p>info@eco-vector.comMageG.<p>Department of Obstetrics and Gynecology</p>info@eco-vector.comWattiezА.<p>Department of Obstetrics and Gynecology</p>info@eco-vector.comCanisМ.<p>Department of Obstetrics and Gynecology</p>info@eco-vector.comPolyclinique de L’Hotel-Dieu, BD Leon MalfreytC.H.U. Hautepierre15112005545S15112005Copyright © 2005, Eсо-Vector2005<p><strong>Introduction: </strong>Avoiding laparotomy by performing laparoscopic hysterectomy, of various types, has been shown to be beneficial in a number of ways. Shorter recovery times, shorter length of hospital stay and convalescence period, and earlier return to work than after abdominal hysterectomy are some of the positive factors cited. However, it is often considered that there is a size limitation of 14-16 weeks gestation to the feasibility of laparoscopic hysterectomy. Whilst a number of studies have shown that the laparoscopic-assisted vaginal hysterectomy (LAVH) successfully manages the large uterus, little has been published regarding a total laparoscopic approach.</p>total laparoscopic hysterectomyenlarged uterusтотальная лапароскопическая гистерэктомияувеличенная матка<p><strong>Introduction: </strong>Avoiding laparotomy by performing laparoscopic hysterectomy, of various types, has been shown to be beneficial in a number of ways. Shorter recovery times, shorter length of hospital stay and convalescence period, and earlier return to work than after abdominal hysterectomy are some of the positive factors cited. However, it is often considered that there is a size limitation of 14-16 weeks gestation to the feasibility of laparoscopic hysterectomy. Whilst a number of studies have shown that the laparoscopic-assisted vaginal hysterectomy (LAVH) successfully manages the large uterus, little has been published regarding a total laparoscopic approach.</p>
<p><strong>Objective. </strong>To examine the practice and feasibility of total laparoscopic hysterectomy (TLH) for uteri weighing 500g or more compared to other total laparoscopic hysterectomies performed for the management of benign gynecological diseases.</p>
<p><strong>Patients: </strong>All patients who underwent total laparoscopic hysterectomy during the period January 2000 to December 2003 were included. Inclusion criteria included all women with benign uterine conditions. Malignant pathologies were excluded from the assess</p>
<p>ment. Patients who had pelvic floor prolapse treated laparoscopically concurrently with laparoscopic hysterectomy were also excluded. Sixty-nine patients with uterus 500g were compared to 537 patients with uterus 500g.</p>
<p></p>
<table style="height: 321px;" width="487">
<tbody>
<tr>
<td style="width: 177.715px;">
<p><strong>Characteristics</strong></p>
</td>
<td style="width: 150.547px;">
<p><strong>Uterus 500g </strong></p>
<p><strong>N=69</strong></p>
</td>
<td style="width: 137.754px;">
<p><strong>Uterus 500g</strong></p>
<p><strong>N=537</strong></p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>Mean age</p>
</td>
<td style="width: 150.547px;">
<p>47.1 4.7</p>
</td>
<td style="width: 137.754px;">
<p>48.6 6.7*</p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>% C/S</p>
</td>
<td style="width: 150.547px;">
<p>10.1%</p>
</td>
<td style="width: 137.754px;">
<p>14.1%</p>
</td>
</tr>
<tr>
<td style="width: 477.5px;" colspan="3">
<p><strong>Prior surgery</strong></p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>- Laparoscopic surgery</p>
</td>
<td style="width: 150.547px;">
<p>17.4%</p>
</td>
<td style="width: 137.754px;">
<p>25.1%</p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>- Pelvic surgery</p>
</td>
<td style="width: 150.547px;">
<p>22.6</p>
</td>
<td style="width: 137.754px;">
<p>29.7</p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>Endometriosis</p>
</td>
<td style="width: 150.547px;">
<p>1.5%</p>
</td>
<td style="width: 137.754px;">
<p>6.0%</p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>Mean BMI</p>
</td>
<td style="width: 150.547px;">
<p>25.0</p>
</td>
<td style="width: 137.754px;">
<p>23.7*</p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>Post-menopausal</p>
</td>
<td style="width: 150.547px;">
<p>13.0%</p>
</td>
<td style="width: 137.754px;">
<p>20.3%</p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>Preoperative analogues</p>
</td>
<td style="width: 150.547px;">
<p>60.9%</p>
</td>
<td style="width: 137.754px;">
<p>29.4%*</p>
</td>
</tr>
<tr>
<td style="width: 177.715px;">
<p>Mean uterine weight</p>
</td>
<td style="width: 150.547px;">
<p>677.9 (500-1500)</p>
</td>
<td style="width: 137.754px;">
<p>200.5 (11-498)*</p>
</td>
</tr>
</tbody>
</table>
<p><strong></strong></p>
<p><strong>Intervention. </strong>Total laparoscopic hysterectomy by the technic of Clermont-Ferrand.</p>
<p><strong>Results. </strong>Patients with enlarged uteri had higher operating times and conversion rates, similar haemoglobin levels pre and post</p>
<p>operativeli, similar hospital stays, and lover complications rates compared to patients with non-enlarged uteri.</p>
<p></p>
<p><strong>Procedures</strong></p>
<table style="height: 128px;" width="464">
<tbody>
<tr>
<td style="width: 200.176px;">
<p><strong>TLH</strong></p>
</td>
<td style="width: 121.406px;">
<p><strong>Uterus 500g</strong></p>
</td>
<td style="width: 121.426px;">
<p><strong>Uterus 500g</strong></p>
</td>
</tr>
<tr>
<td style="width: 200.176px;">
<p>+/- USO/BSO</p>
</td>
<td style="width: 121.406px;">
<p>88.4%</p>
</td>
<td style="width: 121.426px;">
<p>97.2%</p>
</td>
</tr>
<tr>
<td style="width: 200.176px;">
<p>- Adhesiolysis</p>
</td>
<td style="width: 121.406px;">
<p>20.3%</p>
</td>
<td style="width: 121.426px;">
<p>20.9%</p>
</td>
</tr>
<tr>
<td style="width: 200.176px;">
<p>- Other procedure</p>
</td>
<td style="width: 121.406px;">
<p>26.1%</p>
</td>
<td style="width: 121.426px;">
<p>29.8%</p>
</td>
</tr>
<tr>
<td style="width: 200.176px;">
<p>Mean hospital stay (days)</p>
</td>
<td style="width: 121.406px;">
<p>3.67</p>
</td>
<td style="width: 121.426px;">
<p>3.65</p>
</td>
</tr>
<tr>
<td style="width: 200.176px;">
<p>Mean surgical time (min)</p>
</td>
<td style="width: 121.406px;">
<p>135.8(60-280)</p>
</td>
<td style="width: 121.426px;">
<p>106.4 (40-330)</p>
</td>
</tr>
</tbody>
</table>
<p></p>
<p><strong>Conversion</strong></p>
<table width="312">
<tbody>
<tr>
<td width="179">
<p><strong>Reason for conversion</strong></p>
</td>
<td width="57">
<p><strong>500g</strong></p>
</td>
<td width="76">
<p><strong>500g</strong></p>
</td>
</tr>
<tr>
<td width="179">
<p>Excessive hemorrhage</p>
</td>
<td width="57">
<p>0</p>
</td>
<td width="76">
<p>2</p>
</td>
</tr>
<tr>
<td width="179">
<p>Anaesthetic problems</p>
</td>
<td width="57">
<p>1</p>
</td>
<td width="76">
<p>1</p>
</td>
</tr>
<tr>
<td width="179">
<p>Emphysema</p>
</td>
<td width="57">
<p>0</p>
</td>
<td width="76">
<p>0</p>
</td>
</tr>
<tr>
<td width="179">
<p>Urinary tract injury</p>
</td>
<td width="57">
<p>0</p>
</td>
<td width="76">
<p>1</p>
</td>
</tr>
<tr>
<td width="179">
<p>Bowel injury</p>
</td>
<td width="57">
<p>2</p>
</td>
<td width="76">
<p>0</p>
</td>
</tr>
<tr>
<td width="179">
<p>Access/exposure</p>
</td>
<td width="57">
<p>6</p>
</td>
<td width="76">
<p>13</p>
</td>
</tr>
<tr>
<td width="179">
<p>Conversions to laparotomy</p>
</td>
<td width="57">
<p>6</p>
</td>
<td width="76">
<p>7</p>
</td>
</tr>
<tr>
<td width="179">
<p>Converted to LAVH laparotomy</p>
</td>
<td width="57">
<p>0</p>
</td>
<td width="76">
<p>1</p>
</td>
</tr>
<tr>
<td width="179">
<p>Converted to LAVH only</p>
</td>
<td width="57">
<p>3</p>
</td>
<td width="76">
<p>9</p>
</td>
</tr>
<tr>
<td width="179">
<p>TLH (type 4)</p>
</td>
<td width="57">
<p>87.0%</p>
</td>
<td width="76">
<p>96.8%</p>
</td>
</tr>
</tbody>
</table>
<p><strong></strong></p>
<p><strong>Conclusion. </strong>A laparoscopic approach, by LAVH and TLH, is both feasible and beneficial in patients with enlarged uteri. The higher rate conversion may be as a result of cautiousness and extra vigilance with an operative case known to be of a greater degree of difficulty. Thus increased care with toilette and haemostasis may account for the lesser degree of complications in the group with enlarged uteri, particularly with regards to vault haematomas and infection. Most complicationscan be managed intraoperatively without reverting to laparotomy.</p>
<p>Total laparoscopic hysterectomy results in several advantages to patient - decreased hospital stay, and decreased convalescence. The longer learning curve is acknowledged. Once acquired, however, it can be seen from the data that it is safe and has low complication rates that are comparable to traditional laparotomic and vaginal approaches.</p>