European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 97–101

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Retroperitoneal and retrograde total laparoscopic hysterectomy as astandard treatment in a community hospital

Eugenio Volpi *, Luca Bernardini, Moira Angeloni, Stefano Cosma 1, Paolo Mannella

Department of Obstetrics and Gynecology, Sant’ Andrea Hospital – ASL n 5, Via Vittorio Veneto 197, 19100 La Spezia, Italy

A R T I C L E I N F O

Article history:

Received 18 May 2013

Received in revised form 10 September 2013

Accepted 9 October 2013

Keywords:

Total laparoscopic hysterectomy

Retrograde hysterectomy

Retroperitoneal hysterectomy

A B S T R A C T

Objective: To report our experience with a modified procedure for total laparoscopic hysterectomy based

on a retrograde and retroperitoneal technique. This surgical approach is analyzed on a consecutive series

of patients in a community hospital and theoretical educational advantages are proposed.

Study design: All patients undergoing hysterectomy from January 2012 to April 2013 were included in

the study. A detailed description of the technique is given. As main outcome measures we evaluated: the

number and rate of patients excluded from laparoscopic approach, the rate of late complications need

readmission, the rate of transfusions, the rate of conversion to laparotomy and the number of minor

complications. The main concern of the study was ureteral complications.

Results: Overall 174 patients underwent hysterectomy in our unit. The rate of patients submitted to

laparoscopic hysterectomy was 97.5%. The number of complications needing re-admission was three

(2%). The rate of conversion was 2.7%. In the study period, two (1.2%) ureteral complications were

observed (late fistulae). There were four bladder lesions but the patients were released on the same day

as the patients with no lesion.

Conclusions: Opening the retroperitoneum allows rapid control of the main uterine vessels by

coagulation, and constant checks on the ureter. Difficult benign situations can be managed. Even in a

non-referral center about 94% of hysterectomies can be performed by laparoscopic surgery. This

approach is helpful and may be reproducible in gynecological procedures.

� 2013 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology andReproductive Biology

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Copia1. Introduction

The exponential growth achieved in the last decade in the fieldof endoscopic surgery has allowed a tremendous diffusion of totallaparoscopic hysterectomy (TLH). Minimally invasive approacheshave been applied with success to an increasing number ofgynecological procedures. While in the USA robotics has spread tomany referral centers, setting the state of the art in minimallyinvasive gynecological procedures [1], in Europe, on the contrary,laparoscopic surgery is much more widely distributed, beingactually the main alternative to abdominal hysterectomy (TAH)[2]. TLH is associated with less blood loss, shorter hospital stay andextremely low rates of infection and ileus [3]. Patients avoid apainful abdominal incision and return more quickly to theiractivities [3].

* Corresponding author.

E-mail address: eugenio.volpi@hotmail.com (E. Volpi).1 Department of Obstetrics and Gynecology, SS Antonio e Biagio e Cesare Arrigo

Hospital, Via Venezia 16, 15100 Alessandria, Italy.

0301-2115/$ – see front matter � 2013 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ejogrb.2013.10.013

The most widespread technique for TLH involves intrafascialdissection of vascular pedicles and the use of a manipulator for themobilization of the uterus and the cervix. With some minorchanges from one place to another, most TLHs are nowadaysperformed according to the original studies reported by the Frenchand Finnish schools [2–5]. In these laparoscopic procedures thetransection of the uterine vessels is performed close to the uterus,medially to the ureter, repeating the steps of a conventional TAH.Coagulation or dissection of the ascending and descendingbranches may be sometimes difficult, however, due to a widevariety of anatomical conditions such as endometriosis, intra-ligamentary fibroids or sequelae of infections. In addition, whencoagulation is extensively done, there is increased risk of ureterallesions [6–8].

In this paper, we present a modified procedure for retroperito-neal (dissection of the uterine arteries) and retrograde (dissectionof the bladder and of the vagina) TLH with the aim of providingoptimal control of the ureter and against post-operative hemor-rhage. With this aim, we have adopted a combination of theretroperitoneal laparoscopic approach as originally described byKohler et al. [9] and Roman et al. [10], with that of retrogradeculdotomy reported a long time ago by Delle Piane [11], Hudson

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Fig. 1. Opening the pararectal space above the m. psoas and creating a medial leaf of

peritoneum with the ureter.

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and Chir [12], and more recently by Bristow et al. [13]. We alsowant to analyze our experience in a community hospital and not areferral center.

2. Material and methods

From January 9th 2012 to April 30th 2013, 174 patientsunderwent hysterectomy overall in the unit. The patients’characteristics and indications are shown in Table 1. Their medianage was 48 years (range 37–80) and mean body mass index (BMI)was 22.41 (range 18.16–39.64). Inclusion criteria were all patientsneeding an abdominal hysterectomy according to the policy of theunit where the vaginal approach is reserved for prolapsed uterus.Two types of indication were excluded from TLH: uterine sizelarger than the first supraumbilical transverse line in benigndiseases and endometrial cancer in which morcellation wasforeseen. Patients over the age of 45 are offered bilateraladnexectomy, but the patient’s choice to keep or remove theadnexa was respected. Prophylactic removal of the salpinges wasnot suggested to the patients.

Informed consent was obtained for all patients about risks ofanesthesia, hysterectomy, laparoscopy and risk of conversion tolaparotomy. All patients underwent general anesthesia andendotracheal intubation. Urinary catheterization was performedjust before the beginning of the procedure and kept in place for thefirst night after intervention. On the day of surgery, i.v. cefazolin 2 gwas administered. Prophylactic anticoagulant therapy was givenfor up to 28 days.

As the main outcome measures we considered: the number andrate of patients excluded from the laparoscopic approach, the rateof late complications needing readmission, the rate of transfusions,the rate of conversion to laparotomy and the number of minorcomplications. Minor complications were defined as complicationsnot needing readmission nor having an impact on the clinicalcourse and the release of the patient.

The critical steps of the procedure are the following:

(1) Patients are placed in the dorsal lithotomy position with legsapart and semiflexed, and the arms tucked at the sides. Themonitor is placed between the patient legs or on her left foot ifmorcellation is foreseen, facing the two surgeons to facilitatean ergonomic working position. Simplified equipment is usedincluding a scissors, two grasping forceps, a washing-aspirationcannula, and a 5-mm bipolar coagulation forceps. Recently, theLigasure 5 mm–37 cm (Covidien LF1537) forceps was added tothe instrumentation avoiding the use of disposable scissors. Nouterine manipulator is placed in situ. No monopolar currentshave ever been used in the procedures.

(2) Access to the peritoneum is obtained through direct trocarinsertion as reported elsewhere [14]. Only patients withprevious surgery are accessed via the Palmer point and a

Table 1Patients’ characteristics of the group undergoing hysterectomy.

# Range

Total 174

TLH 169

TAH 5

Age 48 37–80

BMI 22.41 18.16–39.64

Previous cesarean 42

Main indications

Fibroids/adenomyosis 95 (56.2%)

Metrorraghia 9(5.3%)

Endometriosis 22 (13.0%)

Endometrial cancer/hyperplasia 39 (23.0%)

H-SIL 4 (2.3%)

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trocars are placed in the lower abdomen under direct vision, inthe usual diamond-shaped positions. Variations may be due tothe uterine size.

(3) The first surgical step is isolation of the ureter and of theuterine artery. The second operator moves the utero-ovarianligament medially to stretch the broad ligament. The incision ismade up to where the broad ligament overlies the iliac vesselsthus allowing entry into the pararectal space. The peritoneumis opened parallel to the infundibulo-pelvic ligament above thecrossing with the external iliac artery at the pelvic brim, takingcare to move the ureter on the medial sheet of the peritoneum(Fig. 1). The ureter is then followed to the crossing with theuterine artery. The peritoneum and all the structures are nowsevered by the Ligasure forceps. Previously and in the case ofdissections needing sharp instruments, disposable scissors areopened and used. After dissection, the uterine artery iscoagulated at its origin from the internal iliac artery (Fig. 2).Often the uterine veins are grasped and coagulated altogether.No transection of the uterine vessels is performed. Because theinfundibulo-pelvic ligament is not divided, the medial leaf isentirely pulled medially thus avoiding any bowel interferenceduring the operation. The same steps are performed on theother side.

Fig. 2. The left uterine artery as it appears after bipolar coagulation at its origin.

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Fig. 3. Blunt dissection of the paravescical space beneath the anterior leaf of the

broad ligament.

Fig. 4. Relationship between the resection line on the vagina and ureteral course in

retrograde hysterectomy.

Table 2Complications of TLH.

Early

Conversion 5a (2.9%)

Lesion of the epigastric artery 1

Bladder lesion 4 (2.3%)

Late

Ureteral fistula 2 (1.2%)

Transfusion 1

Vaginal vault dehiscence 1

a Conversion may not be considered a complication.

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(4) The round ligament may or may not be divided at this time atthe crossing with the umbilical artery, generally using theLigasure forceps. Blunt dissection of the vesico-vaginal fascia isperformed from the lateral side medially (Fig. 3). The vesico-uterine peritoneal fold is left aside and retrograde dissectioninitiated just distal to the uterine arteries. Dissection is stoppedwhen the white vaginal fornix is reached. At the end of thisstep, transection of the round ligament is completed bydividing all the anterior leaf down to the vesico-uterineperitoneal fold. This is finally mobilized from connections tothe lower uterine segment. The infundibulo-pelvic or theutero-ovarian ligaments are coagulated and dissected afterfenestration of the broad ligament, watching the ureter.

(5) The posterior aspect of the broad ligament is incised toward theposterior vaginal apex and recto-vaginal septum. The uterineartery is now coagulated and dissected, checking the ureteralcourse which is directly visible. The parametria and uterosacralligaments may be severed at this time, but normally arecontrolled by retrograde resection. By means of a ring forceps,the anterior fornix is exposed by a third operator or by a nurse.This is incised on the bulging of the rings and opened by meansof a grasping and the Ligasure forceps. Alternatively scissorscan be used. A vaginal plug is then used to stop gas loss. Whilstthe second operator grasps and elevates the distal margin ofthe vagina, the first operator moves the cervical margin of thevagina proximally and starts the retrograde incision of thevagina. This is facilitated by strongly pulling the cervixcranially. Vagina, parametrium and utero-sacral ligamentsare severed, moving from the anterior aspect to the posteriorand from the vagina toward the cervix, parallel to the ureteralcourse. Classic vaginal morcellation to extract the uterus isperformed. In the case of very restricted vaginal access, theremoval of the uterus is performed by abdominal morcellation(Fig. 4).

(6) Finally, the vagina is closed laparoscopically by a runningsuture using a 2–0 tapered needle V-Lock suture (Covidien) orCaprosyn (Ethicon).

3. Results

Out of 174 procedures, 5 patients were excluded from TLH, 3 foruterine size and 2 with endometrial cancer (2.8%).

The mean operative time was 125 � 49 min, but after excludingendometrial cancer, the mean operative time dropped significantly to66 � 15 min. Duration of steps 2 and 3 including identification and

adisolation of ureter, opening the pararectal space, identification andcoagulation of the uterine artery, averaged 5 min per side.

The median uterine weight was 120 g (range 40–870).Five of the 169 procedures were converted to laparotomy

(2.9%), three for difficulties during hysterectomy for benigncondition, one for hematoma of the epigastric vessel in anendometrial cancer and one for uterine size in endometrialcancer. Thus in total 5.7% of the patients underwent laparotomy(10/174).

Complications are reported in Table 2. The total complicationrate was 4.7% (8/169). Three patients needed readmission, two forureteral fistula and one because of vaginal vault dehiscence (1.7%).Only one patient needed transfusion, because of a hematoma of theabdominal wall, and was released on day 7. The mean drop inhemoglobin level was 1.5 � 1 g%. Median hospital stay was 2 days(range 1–7).

4. Comment

We report our experience in a community hospital using amodified technique for TLH based on the combination of lateralcoagulation of the uterine artery and a retrograde approach to thelower structures of the pelvis. In fact, the retrograde vesicaldissection and the retrograde culdotomy have been previouslydescribed specifically only for abdominal laparotomies in surgicaloncology [11–13], while the retroperitoneal approach has beenemphasized mainly as a strategy during vaginally assistedlaparoscopic hysterectomies [9,10,15–17]. To date, there is onlyone study reporting the application of a retroperitoneal approachfor TLH in cases of enlarged uteri [10].

In the present series about 94% of hysterectomies could beperformed laparoscopically, although a limitation in size of theuterus is admitted. We observed a low rate of complications (4.7%).The main problems were the two ureteral fistulas. The first fistula

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was a complication of too wide a dissection of the ureter due to avery large (12 cm) infraligamentary fibroid, and was managed byreimplantation. In that case, the pelvic ureter was much longerthan usual and so dissection resulted in excessive devasculariza-tion. The second is difficult to explain since dissection was easy andno coagulation was performed near the ureter managed bystenting. Both complications were late and appeared at 10–15days from surgical procedure. The results of this series based onabout 170 cases are comparable to those reported by most centerswhere laparoscopic hysterectomy is routinely performed accord-ing to a completely different principle (intrafascial dissection andconstant use of uterine manipulator) [9,10,18,19]. Remarkably, therate of urologic complications (1.2%) observed in this experiencemay be also justified by the absence of selection of the patientsexcept for uterine size and is in agreement to that reported bysimilar studies using a retroperitoneal approach [8–10,19–23].Four patients had bladder perforation. The lesion was suturedlaparoscopically and the patients released on the 3rd day with thecatheter in situ. When the patients came back for check-up as usualthe catheter was removed.

The study by Kohler et al. [9] has been taken into particularconsideration. During laparoscopic assistance to 267 vaginalhysterectomies those authors were able to demonstrate full safetyand clinical advantages of an extraperitoneal technique properlyarranged for optimal isolation, coagulation and transection ofuterine artery and constant control of the ureter. In theirexperience, the interruption of blood supply in this way resultedin particular advantage during the vaginal removal of enlargeduteri (when bleeding generally is a problem in traditional vaginaloperations). Importantly, according to this article 70% of theoperations were performed by residents with only limitedexperience in hysterectomy and the use of non-disposableinstruments and no uterine manipulator allowed importantfinancial savings. Chang et al. [16] also reported minimal bloodloss (two patients had excessive hemorrhage, >500 mL) and lowcomplication rate (two patients had bladder laceration) among 225women with myomas or adenomyomas who underwent uterineartery ligation through retrograde tracking of the umbilicalligament in laparoscopic-assisted vaginal hysterectomy. Theaverage time from identification of the umbilical ligament toligation of the uterine artery was approximately 10 min andoperations were performed by residents with aid of the attendingphysician. In this experience, the technique to dissect the uterineartery is different, but the time is similar.

Laparoscopic hysterectomy of large uteri with uterine arterycoagulation at its origin was later reported also by Roman et al. inmore than 50 cases [10]. These authors could confirm that theretroperitoneal approach is feasible and reproducible by gyneco-logical surgeons avoiding the use of laparotomy in enlarged uteri.According to the authors the key to a successful procedure is theperformance of the uterine devascularization before initiatingfurther uterine surgical action. In their department one surgeonbegan using the technique and subsequently it was acquired andeasily reproduced by others. Other studies confirm this [15,16,20–22].

The technique we describe joins for the first time different stepsalready reported but not unified in a single procedure. First, theuterine vessels are not dissected but simply coagulated at theirorigin and the pararectal space is firstly created. Second,approaching the bladder from the lateral aspect helps a saferdissection particularly when anatomical difficulties are present.Third, the ureter is thoroughly checked through the wholeprocedure. Fourth, a retrograde circular colpotomy is done afterminimal preparation of the recto-vaginal septum with no use ofmanipulator and quite safely far from the ureter. This allows easycontrol of the final coagulation of the vaginal arteries. Lastly the

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whole procedure can be performed only with reusable instru-ments, decreasing the costs.

There may be doubts that the oncological preparation of thesurgical field as done during the creation of the Latzko’s procedure(preparation of the uterine arteries at their origin) might be excessivebut the post-operative course of the patients shows that it is verysimilar to traditional TLH. We believe, however, that this approachuses all the known advantages of laparoscopic surgery such asmagnification of the anatomy and pathology, access to the uterinevessels, vagina, rectum, lymph nodes, better exposure of ureter andachievement of clot drainage and hemostasis [23,24]. Furthermore,when experience is gained in isolating the ureters, this step does notincrease the time of operation. In this series, the average time toisolate the ureter, reach and coagulate the uterine artery was fiveminutes, but the operator was experienced in oncologic proceduresand has developed skill to deal with the retroperitoneum. Themedian time to complete hysterectomy was 66 min, which isacceptable and comparable to other experiences. The operating timeis also lessened by using the Ligasure forceps and the V-Lock suture.

The main advantage of not using the manipulator is that themovements of the uterus are free at the level of the isthmus and areguided by the first assistant, so exposure of the lateral aspect of theuterus is easier. The disadvantage with a larger uterus is that all themovements are dependent on the laparoscopic instruments and itmay need some skill. The lateral approach to the uterine arteriesand the retrograde resection of the vagina are independent of auterine manipulator, but it may be used in this same procedure. Inour opinion, it is in fact a cultural rather than a technical question.Despite facing, at the beginning, a more challenging hysterectomyit is possible to acquire progressively the right confidence withanatomic spaces and tissues of critical importance in the case ofmore complex pathology (treatment of endometriosis and cancer).It is well known that the retroperitoneal approach is mandatory forpelvic lymphadenectomy and advisable for preventive occlusion ofthe uterine arteries in cases of symptomatic fibroids and ovariancystectomies with severe adhesions [21,24]. For patients with afixed uterus or endometriosis, this alternative procedure of uterineartery coagulation through downstream ureter tracking in theretroperitoneum not only reduces the risks of massive bleedingand ureteral injury, but also shortens the operative time andminimizes the conversion rate to open laparotomy [17].

In conclusion, this experience shows that about 94% ofhysterectomies can be carried out by laparoscopic surgery in acommunity hospital. This modified technique of extraperitonealand retrograde laparoscopic hysterectomy, although at first it canappear challenging, allows a routine approach to almost allhysterectomies and can offer a great chance for ideal education ingynecological surgery.

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