Background: The Emergence of Laparoscopy
Most gynecologists believe that they know the correct indications for performing vaginal versus abdominal hysterectomy. But after more than 100 years of experience, there is still no consensus in the field. Some gynecologists perform up to 100 percent of their hysterectomies by the single “classic,” open-surgery method. According to U.S. surveys, individual surgeons report more than 70 percent of their hysterectomies being done vaginally. Most data from around the world suggest that more than 70 percent of hysterectomies are abdominal, even in the absence of structural pathology.
Amazingly, vaginal and abdominal hysterectomy have never been subjected to a single class-A evidence study (randomized controlled trial), and have not attracted comparative studies until the recent introduction of LH. Most published studies are single-center retrospective covering many years (class C: personal series by experts).1 After a century of experience with the world’s most commonly performed major operation, the gynecological profession as a whole still has no clear indication of the optimal method to perform it in differing situations. The standard-of-care is that abdominal hysterectomy can be used for every indication.
The first LH, defined as laparoscopic ligation of the blood supply to the uterus, was performed in January, 1988 using bipolar desiccation for ligation.2 The first LH using staples was performed in August, 1990 using the EndoGIA. During the ten years before 1998, we had extensive experience in most laparoscopic operations including what U.S. Surgical Corporation later named LAVH (upper uterine pedicle ligation prior to vaginal hysterectomy) as they felt that the “real” LH operation was too difficult for most gynecologists to master. It was in the late 1970's that Harry Reich conceptualized the original idea that bipolar electrosurgical desiccation could be used for large vessel hemostasis, an idea which was rejected by medical journals until 1986, when Reich's abstract on the first series of laparoscopic bipolar desiccation oophorectomies was published.3 (Oophorectomy is the removal of the ovary or ovaries.)
Before 1988, laparoscopy was almost exclusively the domain of the gynecologist. It is ironic that, although laparoscopic hysterectomy (LH) was introduced at the same time as laparoscopic cholecystectomy (surgical removal of the gall bladder), it is currently performed far less worldwide. Rapid acceptance of LH by surgeons did not occur probably because most gynecologists are not surgeons, and thus, have not exerted the effort to master advanced laparoscopic techniques as a part of their current skills. In addition, most patients continue with the gynecologist who delivered their children for their gynecological operations. Contrary to the general surgeon’s experience, gynecologists do not feel any economic pressure to change even though there are significant advantages for the patient.
LH stimulated a much greater interest in proper scientific evaluation of all forms of hysterectomy. From the time of its invention, LH was considered a substitute for abdominal hysterectomy and not for vaginal hysterectomy. Yet unfavorable reports were published comparing laparoscopic hysterectomy to vaginal hysterectomy to further academic careers and hinder the acceptance of LH in the U.S. Laparoscopic surgery has never been indicated for hysterectomy if the operation is feasible quickly and under good conditions via the vaginal route.
Laparoscopically assisted hysterectomy is a cost-effective procedure when performed with reusable instruments. It is a safe procedure, even when performed by various gynecologists with different skill levels, and its adoption can decrease abdominal incision hysterectomies.4 However, the use of LH has reached a plateau because most managed care plans reimburse poorly for a laparoscopic approach relative to laparotomy, and discourage both hospital administrators and surgeons from promoting short hospital-stay laparoscopic surgery instead of traditional, open laparotomy.
There are many surgical advantages to laparoscopy, particularly visual magnification of anatomy and pathology, easy access to the vagina and rectum, and the ability to achieve complete hemostasis and clot evacuation during underwater examination. Most hysterectomies which require an abdominal approach, rather than vaginal, may be performed with laparoscopic dissection of all or part of the abdominal portion followed by vaginal removal of the specimen. Advantages for the patient are many, and are related to the avoidance of a painful abdominal incision. Benefits include reduced duration of hospitalization and recuperation, along with an extremely low rate of infection and ileus.
One of the goals of vaginal hysterectomy, LAVH, and LH should be to achieve the operational objective while safely avoiding an abdominal wall incision. The surgeon must remember, if it is more appropriate to do vaginal hysterectomy after ligating the ovarian or uteroovarian vessels, then a vaginal hysterectomy should be done. Laparoscopic hysterectomy is not indicated when vaginal hysterectomy is possible. Even so, laparoscopic inspection at the end of the procedure still enables the surgeon to control bleeding and evacuate clots.
Surgical skill is paramount for LH. Ambidexterity separates the laparoscopic surgeon from those trained traditionally, as the surgeon must often hold the camera with the dominant hand. No surgical procedure should not be performed with the surgeon's preoccupation with developing new surgical skills.