Original Article

Reverse Hysterectomy: Another Technique for Performing a Laparoscopic Hysterectomy

Pietro Litta, MD, Carlo Saccardi, MD, PhD*, Lorena Conte, MD, and Pasquale Florio, MD, PhD
From the Department of Womens and Childrens Health, Obstetrics and Gynecology Clinic, University of Padova, Padova, Italy (Drs. Litta, Saccardi, and Conte), and Department of Paediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynecology, University of Siena, Siena, Italy (Dr. Florio).

ABSTRACT Study Objective: To show and evaluate outcomes of a modied laparoscopic hysterectomy technique (total reverse laparoscopic hysterectomy). Design: Observational study (Canadian Task Force classication II-2). Setting: Department of Womens and Childrens Health, Obstetrics and Gynecology Clinic, University of Padova, Padova, Italy. Patients: One hundred one women underwent total reverse laparoscopic hysterectomy for benign disease. Indications for surgery, patient characteristics, surgical data, complications, and patient satisfaction were recorded. Interventions: Total reverse laparoscopic hysterectomy. Measurements and Main Results: The modied procedure was performed starting with the incision of the vesicouterine fold and the pubocervical fascia followed by the dissection of only the anterior layer of the broad ligament, thus preserving the integrity of the posterior leaf (retrograde hysterectomy). This technique permits identication of the ureter until the cross with the uterine artery, creating a safe triangle for closure of the uterine vessels. The remaining surgical time did not differ from the standard technique. The average operating time was 112.1 6 35.6 minutes, and the average intraoperative mean blood loss was 79.5 6 138.4 mL. Ninety-one (90%) patients were very satised after surgery. No injuries to the ureter or bladder occurred in any patients. No other major complications were recorded. Conclusion: Reverse hysterectomy is another technique for performing laparoscopic hysterectomy, and it has been proven to be safe and efcient. Journal of Minimally Invasive Gynecology (2013) 20, 631636 2013 AAGL. All rights reserved.
Keywords: Complications; Laparoscopic hysterectomy; Surgical technique
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Laparoscopic hysterectomy (LH) was rst described by Reich et al in 1989 [1], and within the last 2 decades, it has become a widely performed procedure. The laparoscopic approach to hysterectomy can be technically demanding, especially in case of a large uterus, and sometimes it takes a long time to complete [2,3]. Benets associated with the
The authors declare that they have no conict of interest. Corresponding author: Carlo Saccardi, MD, PhD, Department of Womens and Childrens Health, Obstetrics and Gynecology Clinic, University of Padova, Via Giustiniani, 3-35128 Padova, Italy. E-mail: carlo.saccardi@unipd.it Submitted February 26, 2013. Accepted for publication April 9, 2013. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter 2013 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2013.04.004

laparoscopic technique include a short recovery time, less postoperative discomfort, improved patient outcomes, and increased cost-effectiveness [4,5]. LH is a procedure that requires meticulous dissection, safe anatomic exposure, and effective hemostasis to avoid peri- and postoperative complications. Severe hemorrhage and ureteral injuries remain major challenges for gynecologic surgeons and are the most serious events related to LH. As a consequence, the method used to secure the blood vessel pedicles inuences the rate of complications [18]. Recently, a Cochrane review showed that LH has a greater risk of damaging the bladder or ureters [9], but the most recent works have shown that the risk of complications for the laparoscopic approach could be signicantly reduced by using

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specic techniques [10,11]. Education and training of the surgeons, knowledge of electrosurgical principles, correct execution technique, and proper selection of patients are important factors in safely performing hysterectomy. Alternative approaches have been proposed, such as supracervical hysterectomy [9], as well as the use of new devices [1214] or the validation of a standard technique [1517] to ensure protection of the ureteres (fenestration of the right and left broad ligaments) and to control occlusion of the uterine pedicles (through ligatures or clip application). It is commonly accepted that to avoid complications, it is important to consider a series of basic precautions, including isolation of the uterine artery before coagulation, development of the paravesical space, use of a uterine manipulator to stretch the uterine pedicle, and especially restoration of the normal anatomy in case of deeply inltrating endometriosis and/or in the presence of severe adhesions [1820]. A safe and effective surgical technique is crucial, particularly for technically demanding situations in which the risk of complications could lead the gynecologist to choose laparotomy rather than laparoscopy. In the present study, we report on the technique and clinical outcomes associated with LH performed using a modied laparoscopic approach. Materials and Methods One hundred one women underwent total reverse LH in the Department of Womens and Childrens Health, Obstetrics and Gynecology Clinic, University of Padova, Padova, Italy. The preoperative workup consisted of pelvic gynecologic examination; transvaginal ultrasound; Papanicolaou smear; outpatient diagnostic hysteroscopy with endometrial biopsy; and urinary and blood analysis including hemochrome, prothombin time, partial thromboplastin time, and electrocardiography. Prior informed consent was obtained from all patients. The main indications for hysterectomy were abnormal uterine bleeding caused by uterine bromatosis, chronic pelvic pain, nonatypical endometrial hyperplasia, or benign adnexal masses in postmenopausal women. The exclusion criteria were the following: preneoplastic or neoplastic genital disease, anesthetic contraindications to laparoscopy, and prior pelvic or abdominal radiation therapy. All the procedures were performed by the same 2 surgeons (P.L. and C.S), who are both skilled and experienced in the LH procedure. Surgical Procedures The surgery was performed under general anesthesia with nasogastric tube insertion and a bladder catheter placed immediately before the operation. All patients underwent antibiotic prophylaxis with 2 g cefazolin (Cefamezin; Pzer Italia Srl, Rome, Italy) 30 minutes before surgery. Hysterectomies were performed with a 10-mm telescope (Karl Storz, Tuttlingen, Germany) through 1 optic trocar located in the

umbilicus and lateral trocars placed fairly high (at 2 ngers above the anterosuperior iliac spines and lateral to the rectus abdominal muscles). The trocar position varied according to the uterine size. In all cases, the left trocar was 10 to 12 mm in size to allow the insertion of the morcellator to partially reduce the uterus, which was then removed through the vagina. The central and right lateral trocars were 5 mm in size. A Breisky-like vaginal valve was used in place of the uterine manipulator, pointing out of the anterior vaginal fornix. All surgical times were performed with a Harmonic scalpel (Ultracision, Ethicon Endo-Surgery, Rome, Italy), but the same technique can be performed either with mono- or bipolar energies or by securing the uterine artery with a suture. Coagulation of the vessels was performed using level 2 of the microprocessor of the Ultracision, whereas dissection was performed using the 5 microprocessor variation. After exploration of the peritoneal cavity, the procedure was performed as follows: 1. The anterior vaginal fornix was visualized and stretched using the Breisky valve, which was gently pushed through the vagina with its convex side upward. We then proceeded to the incision of the vesicouterine fold and the subsequent 2-cm transverse incision of the pubocervical fascia (Ultracision power level 5) beginning in the middle. This incision represents the rst cervical landmark to perform the reverse laparoscopic hysterectomy (Fig. 1). 2. Coagulation and incision of the round ligament was performed followed by the dissection of only the anterior layer of the broad ligament (Ultracision power level 5). This procedure allows for easy and quick detection of the ureter, which is adherent to the posterior leaf of the broad ligament that is preserved, and enables the surgeon to follow the ureter until it crosses the uterine artery. The

Fig. 1
The rst cervical landmark: the vesicouterine folder and pubocervical fascia are resected transversely for approximately 2 cm.

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opening of the anterior leaf of the broad ligament represents the second landmark (Fig. 2). The maintenance of the posterior leaf of the broad ligament allows the exposure of a triangular area whose sides are represented medially by the uterine vessels (ascending branch) and laterally by the ureter. The apex points downward and corresponds to the crossing of the ureter and the uterine artery (Littas triangle) (Fig. 3). The advantage of exposing this triangle is to reduce the risk of damaging the ureter as well as to better and safely control possible bleeding from the uterine vessels. The skeletonization of the uterine vessels on the posterior leaf of the broad ligament allows the exposure and visualization of the uterine pedicle (Ultracision power level 5) up to the cervical landmark. This step is relevant because it provides complete isolation and coagulation of the uterine vessels and, at the same time, allows a constant check for bleeding, thus reducing the risk of damage to local structures (ureter and bladder). The coagulation of the uterine vessels (Ultracision power level 2) was performed at least 1 cm above the incision of the pubocervical fascia, pushing the uterus cranially (Fig. 4). In cases of preservation of the adnexa, dissection of the fallopian tubes, and utero-ovarian ligaments, mesosalpinx was performed, and, if necessary, removal of the adnexa was performed by coagulation and dissection of the infundibulopelvic ligament (Ultracision power level 2). Steps 1 to 5 were performed contralaterally. Circular colpotomy after exposure of the anterior vaginal fornix (Ultracision level 3) was performed.

Fig. 3
The safe triangle: the apex of the cross between the urethra and the uterine artery; the lateral side is represented by the ureter, and the medial side is represented by the ascending branch of the uterine vessels.

extraction through the lateral port or through the vagina. Vaginal vault suture was performed in all cases with 2-0 polydioxanone (PDS; Ethycon SpA, Pomezia, Italy) interrupted sutures and intracorporeal knots, and the vaginal vault was suspended to the pubocervical fascia and the residual uterosacral ligaments. Main Outcome Measures Demographic characteristics, surgical history, and intraand postoperative ndings were recorded for all patients. Details related to the operative time (from the insertion of trocars to closure), uterine weight (measured by the pathologist after dehydration in formaldehyde), estimated blood loss (performed at the conclusion of the surgical procedure), length of the hospital stay, and the time needed to return to normal activity and to work were recorded. Patients satisfaction with surgery was evaluated subjectively 1 month after discharge with the use of a visual analog scale (VAS), which varied linearly from 1 (low satisfaction) to 10 (high satisfaction). Early and late complications were recorded by a clinical evaluation of the patients between 7 and 30 days after surgery. Results Total reverse laparoscopic hysterectomy was performed because of abnormal uterine bleeding caused by uterine bromatosis in 78 (77.2%) women, for chronic pelvic pain in 9 (8.9%) women, and for complex endometrial hyperplasia in 14 (13.9%) women. In 34 (33.7%) women, benign adnexal cysts were also cured. The mean age of the patients at surgery was 52.8 6 8 years. Twelve of the 101 (11.9%) were nulliparous, and 40 (39.6%) women were postmenopausal (Table 1).

Depending on its volume, the uterus was removed by uterine morcellation (1215 mm Morcellator Steinert Multidrive; Karl-Storz Endoscope, Tuttlingen, Germany) and

Fig. 2
Second landmark: the only anterior layer of the broad ligament is dissected starting from the round ligament. The posterior leaf of the broad ligament, in which the ureter rests, is preserved.

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Fig. 4
Skeletonization and coagulation of uterine vessels: (A) the left side with bipolar energy and (B) the right side with Harmonic scalpel.

Surgical Outcomes The mean duration of surgery was 112.1 6 35.6 minutes, and the mean uterine weight was 266.9 6 199.7 g. Forty-one patients (40.6%) underwent bilateral adnexectomy, and 12 (11.8%) had signicant adhesiolysis. Intraoperative mean blood loss was 79.5 6 138.4 mL. Surgical data and complications are presented in Table 2. In our sample, 36 (35.6%) patients had a large uterus (uterine weight R300 g), and 47 (46.5%) patients had undergone a previous abdominal surgery, of which 24 (51%) were uterine surgery (Table 1). The mean recovery time was 2.17 6 1.8 days. Within 2 days of surgery, 5 (4.9%) patients experienced fever (temperature over 38 C on 2 occasions at least 4 hours apart), which was successfully treated with antibiotics. At 7 days after surgery, no major complications were recorded. In 5 women (4.9%), a slight subfascial hematoma was present at the ancillary level, mainly (n 5 4) on the left access, and 3 patients (2.9%) experienced cystitis. Patients returned to normal activities 6.18 6 2.89 days after surgery and to work 12.57 6 4.08 days after hysterectomy. With regard to patient satisfaction, the mean VAS was 8.47 6 1.48; 91 (90%) patients were very satised after surgery (VAS ranging from to 10 to 7), 9 (9%) indicated a VAS ranging from to 6 to 4, and 1 (1%) was not satised with the procedure (VAS of 3). Table 1
Anthropometric characteristics and surgical history of 101 patients Patients characteristics Age (yr) Parity BMI (kg/m2) Menopause (n, %) Previous pelvic surgery (n, %) Previous uterine gynecologic surgery (n, %) Previous cesarean section (n, %)
BMI 5 body mass index.

Discussion It is well known that laparoscopy compared with open surgery offers advantages to both the patient and the surgeon. Laparoscopy provides a magnication of the operative eld, facilitates accurate dissection, reduces blood loss and postoperative pain, and permits faster recovery, but compared with abdominal or vaginal hysterectomy, it is still associated with a higher incidence of major intra- and postoperative complications [4,6,7,9]. According to the literature, the incidence of ureteral injuries in total abdominal hysterectomy ranges from 0.04% to 0.4% [21], whereas in LH it ranges from 0.65% to 1.39% [4]. Indeed, the true rate of urinary tract injuries is not easy to quantify because there are many different factors that can interfere with the surgical steps. In a study by Ribeiro et al [22], with the help of cystoscopy examination performed at the time of the procedure, overall ureteral injuries were reported in 3.4% of patients. However, this high percentage of ureteral damage was supposed by others authors to be

Table 2
Surgical outcomes of patients who underwent total laparoscopic reverse hysterectomy Operative data Uterine weight (g) Large uterus (weight R300 g) (%) Duration of surgery (min) Intraoperative blood loss (mL) Recovery time (d) Major complication Bladder injury Urethral injury Bowel injury Hemorrhage (needing transfusion) Minor complication (%) Fever (needing antibiotic therapy) Subfascial hematoma Urinary tract infection Values 266.9 6 199.7 36 (35.6) 112.1 6 35.6 79 6 138.4 2.17 6 1.8 0 0 0 0 5 (4.9) 5 (4.9) 3 (2.9)

Values 52.8 6 8.0 1.1 6 0.7 26.2 6 2.4 40 (39.6) 47 (46.5) 13 (12.8) 11 (10.8)

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correlated to patient selection (many patients with endometriosis and with a large uterus) and to the technique of uterine artery closure (suture rather than bipolar electrocoagulation) [23]. The incidence of bladder injury ranges from 0.2% to 1.8%, and according to recent studies, it reached rates similar to those of patients undergoing abdominal hysterectomy [24]. Bladder injury appears to be signicantly associated with previous laparotomy; adhesiolysis; and, in particular, previous cesarean section [24]. Ureteral injury is strongly associated with thermal spread from coagulation devices or with suture ligation during uterine artery occlusion and vaginal cuff closure [25]. Although bladder damage is easier to recognize and repair, ureteral injury is more insidious, and many efforts have been made to reduce this complication. Some authors suggest that dissection and isolation of the ureter during surgery is necessary to prevent ureteral injury, but this technique extends operative time, increases the risk of bleeding, and requires a long learning curve [18,26]. Koh et al [26], in a series of laparoscopic-assisted vaginal hysterectomies, proposed to create windows over both sides of the broad ligament and to push away inferolaterally the posterior broad ligament in which the ureter and uterine vessels are embedded. To reduce complications, favorable opinions were expressed with regard to opening the anterior page of the broad ligament in front of the round ligament to safely coagulate the uterine artery [27] and with regard to performing hemostatic suture at the level of the uterine artery as a referential lateral point, beyond which thermal devices should not be used [10]. Some surgeons suggest that laparoscopic subtotal hysterectomy or laparoscopic-assisted vaginal hysterectomy should be performed whenever possible, but in a recent study the rate of major complications, including bladder, ureteral, and bowel injury, was not statistically signicantly different among the 3 laparoscopic techniques [28]. The complications after laparoscopic hysterectomy are inuenced by the surgeons experience. Tan et al [29] showed that after a decade of surgical experience, the overall complication rate during total LH was signicantly reduced from 4.5% (LH between 1994 and 2001) to 1.5% (LH between 2001 and 2007) [29]. It appears that at least 30 procedures are necessary to achieve a signicant decrease in bladder and ureter injury [30]. In the present preliminary observational study, we refer to the surgical technique and outcomes related to a modied approach for LH that we called total reverse laparoscopic hysterectomy. The name was derived from the steps, the rst of which is the dissection of the vesicouterine fold and pubocervical fascia followed by the coagulation and incision of the round ligament. The second step is the opening of the anterior fold of the broad ligament between the lateral (round ligament incision) and central (pubocervical fascia incision) landmarks. This way better visualization of the uterine vascular pedicle is obtained, and a real plane, represented by the posterior layer of the broad ligament, is created that permits the identication of the ureter until it crosses the uterine artery, thus creating a safe triangle. The consecutive coagulation and dissection of uterine vessels, at least

1 cm above the anterior incision of the pubocervical fascia (rst landmark), is of relevance for the management of potential bleeding. In other words, the uterine pedicle is resected, leaving a sufcient caudal part that can be easily seen and quickly identied, and in the case of bleeding or retraction after the dissection, this area can be immediately and safely sealed without injuring the ureter. Coagulating the uterine vessels 1 cm above the pubocervical fascia is already well away from the ureter. However, in the classic technique, the broad ligament is entirely dissected or fenestrated. Thus, in case of bleeding while dissecting the uterine vessels, the course of the ureter must be detected to safely execute the hemostasis, and this can be accomplished by pulling the posterior dissected broad ligament. The time required could result in a delay of hemostasis and thus increase the risk of direct (thermal or mechanic by suture) and/or indirect (thermal spread) ureteral injuries. Data obtained from 101 patients who underwent total reverse laparoscopic hysterectomy show that this technique is associated with low blood loss and similar operative times to those reported in the literature for the standard technique [9,24,30], even among patients with a large uterus (R300 g) or previous uterine surgery. In our study, the 36 patients with a large uterus and the 24 patients with previous uterine surgery (gynecologic and obstetric) presented similar operative times and surgical outcomes to the overall sample. No cases of bladder or ureter injuries were reported. It is not always necessary to identify or isolate the ureter during a simple hysterectomy. We believe that this alternative approach to LH could be proposed, especially in cases of abnormal pelvic anatomy, such as large uteri, severe endometriosis, and previous gynecologic or pelvic surgery. References
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