Arch Gynecol Obstet (2012) 285:13531361

DOI 10.1007/s00404-011-2140-2

GENERAL GYNECOLOGY

Comparative analysis of different laparoscopic hysterectomy

procedures
Deslyn T. G. Hobson Anthony N. Imudia
Zain A. Al-Safi George Shade Michael Kruger
Michael P. Diamond Awoniyi O. Awonuga

Received: 29 May 2011 / Accepted: 4 November 2011 / Published online: 29 November 2011
Springer-Verlag 2011

Abstract
Purpose To compare the antecedent gynecological characteristics, indications for, and complications associated
with, the different laparoscopic approaches to hysterectomy, in women with benign gynecological conditions.
Methods A retrospective cohort study of 957 patients
who underwent laparoscopic supracervical (LSH), total
(TLH), and assisted vaginal (LAVH) hysterectomies
between January 2003 and December 2009.
Results Among 957 LH, 799 (83.5%) were LSH, 62
(6.4%) TLH, and 96 (10.1%) LAVH. Demographic characteristics were not different among the groups. Antecedent
gynecologic conditions that were associated with the type
of laparoscopic hysterectomy (LH) performed were: postmenopausal bleeding [LAVH vs. LSH, odds ratio (OR)
2.20; 95% confidence interval (CI) 1.044.65], previous
pelvic surgery (TLH vs. LSH, OR 1.92; CI 1.053.52),
previous cesarean delivery (LAVH vs. LSH, OR 0.39; CI
D. T. G. Hobson (&)  Z. A. Al-Safi  G. Shade 
M. P. Diamond  A. O. Awonuga
Department of Obstetrics and Gynecology, Wayne State
University School of Medicine/Detroit Medical Center,
3990 John R Street, Detroit, MI 48201, USA
e-mail: hdeslyn@hotmail.com
A. N. Imudia
Division of Reproductive Medicine and IVF, Massachusetts
General Hospital, Boston, MA, USA
M. Kruger
CS Mott Center for Human Growth and Development, Wayne
State University School of Medicine, Detroit, MI, USA
M. P. Diamond  A. O. Awonuga
Division of Reproductive Endocrinology and Infertility, Wayne
State University School of Medicine/Detroit Medical Center,
Detroit, MI, USA

0.210.76), and prior hysteroscopy (LAVH vs. LSH, OR

0.29; CI 0.160.50). Preoperative diagnoses that were
associated with the choice of LH were: menometrorrhagia
(LAVH vs. LSH, OR 0.23; CI 0.140.38; TLH vs. LSH,
OR 0.50; CI 0.260.98), uterine fibroids (LAVH vs. LSH,
OR 0.25; CI 0.150.41), endometrial hyperplasia (TLH vs.
LSH, OR 5.5; CI 2.0414.84), and cervical dysplasia (TLH
vs. LSH, OR 17.1; CI 6.8342.79; LAVH vs. LSH, OR
8.05; CI 3.0522.06). Estimated blood loss, operating time,
and length of hospital stay were significantly reduced with
LSH.
Conclusion Antecedent gynecological history and the
indications for surgery were associated with the type of LH
performed in our institution. LSH was the most common
approach and was associated with significantly less
morbidity.
Keywords Laparoscopic hysterectomy  Laparoscopic
supracervical hysterectomy  Total laparoscopic
hysterectomy  Laparoscopic-assisted vaginal hysterectomy

Introduction
Hysterectomy is the most common major gynecologic
surgery performed in women in the USA [1]. The open
hysterectomy approach, termed total abdominal hysterectomy (TAH), has remained the predominant route of hysterectomy, although the proportion of hysterectomies
performed laparoscopically increased from 0.3% in 1990 to
14% in 2005 [2, 3]. In 2003, Harry Reich et al. [4]
described three subcategories of laparoscopic hysterectomy
(LH): laparoscopic-assisted vaginal hysterectomy (LAVH),
laparoscopic supracervical hysterectomy (LSH), and total
laparoscopic hysterectomy (TLH).

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The most recent Cochrane review reported several

advantages including shorter duration of hospital stay and
faster return to normal activity when LH was compared to
TAH [5]. Similar to open hysterectomy, some authorities advocate for LSH and have justified this assertion with
the argument that LSH is easier and faster, and associated
with less blood loss, and fewer complications compared
with TLH and LAVH [68]. However, these putative
benefits remain unsubstantiated, and most of the recent
studies compared some or all of laparoscopic approaches
with the different approaches performed abdominally. In
addition, the extent to which the different laparoscopic
hysterectomy approaches are influenced by patients
demographics, antecedent gynecological characteristics
and indications for surgery is unclear. In this study, our
objective was to perform an analysis of the different laparoscopic hysterectomy approaches in women who underwent hysterectomy for benign gynecological conditions.
Knowledge of the intraoperative complications and the risk
conferred by the different laparoscopic approaches may be
helpful to both patients and their treating physicians in
making informed decisions about optimal surgical
approach in a given situation.

Materials and methods

Following approval from the Wayne State University IRB,
a retrospective cohort study of all consecutive 957 patients
who underwent LSH, TLH, and LAVH for benign gynecologic disease at Hutzel Womens Hospital and Sinai
Grace Hospital between January 2003 and December 2009
was conducted. Hutzel Womens Hospital and Sinai Grace
Hospital are the two largest hospitals providing gynecological services within the Detroit Medical Center (DMC)
group. The DMC is a Wayne State University affiliated
hospital system in Metropolitan Detroit, and one of the
largest health-care providers in southeast Michigan.
Hospital charts were abstracted for pertinent patient
information. Cases were analyzed based on: the different
patients demographic (age, gravidity, parity, and body
mass index) and antecedent gynecological characteristics
[postmenopausal bleeding, Depot-Lupron pretreatment,
prior cesarean delivery (CD), laparoscopy, hysteroscopy,
endometrial ablation, and laparotomy]; indications for the
procedure; operative variables as determined from the
operative report including operative (op) time (defined as
the time from skin incision to skin closure), estimated
blood loss (EBL), need for blood transfusion, and units of
blood transfused; intra- and postoperative complications;
surgical pathologic data; length of stay (LOS, calculated by
subtracting the admission date from the discharge date with
same-day stays coded as 0 days) and hospital readmissions.

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Perioperative complications were divided into two main

categories: major and minor. Major perioperative complications included deep venous thrombosis (DVT)/pulmonary embolism (PE), urologic, vascular and bowel injuries,
as well as hospital readmission for delayed complications
such as wound separations, pelvic hematoma, pelvic
abscess, vaginal cuff hematoma/separation/infection, and
urologic complications (ureteral transection, bladder
injury, or fistula). Minor perioperative complications
included fever (temperature C38C or 100.4F at least 6 h
apart, occurring after the first 24 h of surgery from any
source), urinary tract infection, respiratory tract infection,
cuff infection, and ileus.
All statistical analysis was performed using Statistical
Package for Social Sciences (SPSS, Version 18 for Windows; SPSS, Inc., Chicago, IL, USA). All tests were conducted using p value of 0.05 for statistical significance. The
data were expressed as mean standard deviation (SD)
and median (range) for continuous variables, and categorical variables as number of cases (n) and percentage of
occurrence (%). Between group differences were analyzed
with Chi-square test and Fishers exact for categorical data,
and KruskalWallis test and analysis of variance
(ANOVA) for continuous variables. When ANOVA test
revealed a difference within the three treatment groups, a
post hoc comparison using Bonferroni correction was done
to determine which means or medians were significantly
different from each other. Factors identified from the
antecedent gynecological history and indications for surgery that were associated with the outcomes of interest by
the univariable analyses were included in the multinomial
logistic regression analysis [9], based on a p \ 0.05.

Results
During the study period, 4,577 women underwent hysterectomy, of which 3,258 (71%) were TAH, 957 (21%) were
via the laparoscopic approach, and 362 (8%) were vaginal
hysterectomy (VH).
All 957 patients who underwent an LH procedure during
the 7-year study period were reviewed; 799 (83.5%), 62
(6.4%), and 96 (10.1%) underwent LSH, TLH, and LAVH,
respectively. The patient demographic characteristics
including age, gravidity, parity, and body mass index (BMI)
are displayed in Table 1. There were no significant differences among these parameters in the three LH approaches.
To determine whether antecedent gynecological history
and indications for surgery were associated with the choice
of the LH procedure, these parameters were compared in
relation to the different types of hysterectomy approaches
(Tables 2, 3). There were significant differences in the LH
approaches in patients with history of postmenopausal

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Table 1 Demographic characteristics of patients who underwent different laparoscopic hysterectomy procedures
Characteristics

LSH

TLH

LAVH

P value

Age (years)

796

43.2 6.4

61

43.7 10.6

96

42.9 11.4

0.81

Gravidity

798

3 (014)

62

3 (010)

96

3 (013)

0.74

Parity

798

2 (012)

62

2 (07)

96

2 (08)

0.69

BMI

796

31.4 7.6

62

29.5 7.3

95

30.7 7.5

0.14

Data are in mean standard deviation and median (range)

N number of patients, LSH laparoscopic supracervical hysterectomy, TLH total laparoscopic hysterectomy, LAVH laparoscopic-assisted vaginal
hysterectomy, BMI body mass index
P [ 0.05 not significant

bleeding, cesarean delivery, hysteroscopy, and other pelvic

surgery (pelvic floor surgery, loop electrosurgical excision
procedure, myomectomies, and uterine artery embolization)
(Table 2). Next, we examined the indications for the different laparoscopic procedures. The most common indications for LH regardless of approach were menometrorrhagia,
uterine fibroids, and chronic pelvic pain. Menometrorrhagia,
uterine fibroids, persistent cervical dysplasia (PCD), and
endometrial hyperplasia on postoperative specimen were
significantly likely to be associated with the choice of LH
performed (Table 3). The significant variables in the univariate analyses were then entered into a multinomial logistic
regression model built to examine the relationship between
the antecedent gynecological factors, indication for LH, and
the different laparoscopic approaches (Table 4).
A history of postmenopausal bleeding (PMB) was not
associated with the choice of the different laparoscopic
approaches. Women with history of previous hysteroscopy,
compared with those with no such a history, were 66% less

likely to undergo LAVH compared with LSH (OR 0.34; CI

0.180.63). Previous hysteroscopy did not influence the
choice between LSH and TLH. These findings held when
patients with a history of PMB were excluded from those
with a history of hysteroscopy. Those with such a history
were more likely to undergo LSH (38.3% vs. 15.1%, OR
3.49, 95% CI 1.906.40), and TLH (44.4% vs. 15.1%, OR
4.49, 95% CI 2.029.97), compared with LAVH. History
of hysteroscopy excluding women with PMB did not influence the choice between TLH and LSH.
History of previous pelvic surgery was not associated
with the choice of the laparoscopic approach performed.
Similarly, history of prior CD did not impact on the choice
between LSH and TLH. However, patients who had
undergone previous CD, compared with those with no such
history, were 58% less likely to undergo LAVH compared
with LSH (OR 0.42; CI 0.210.85).
Patients with menometrorrhagia compared with those
with no such diagnosis were 73% less likely to undergo

Table 2 Antecedent gynecologic characteristics in patients who underwent laparoscopic hysterectomy

Characteristics

LSH (%)
(n = 799)

TLH (%)
(n = 62)

LAVH (%)
(n = 96)

P value

Postmenopausal bleeding

47 (5.9)

8 (12.9)

10 (10.4)

0.04

Depot-Lupron use

62 (7.8)

5 (8.1)

10 (10.4)

0.66

Prior endometrial ablation

10 (16.1)

90 (11.3)

5 (5.3)

0.09

Prior cesarean section

205 (25.7)

Prior laparoscopy

284 (35.5)

Prior hysteroscopy

316 (39.5)*

Prior laparotomy

134 (16.8)

10 (16.1)

15 (15.6)

0.96

Other pelvic surgery

122 (15.3)

16 (25.8)

21 (21.9)

0.03

11 (17.7)

11 (11.5)

22 (35.5)

36 (37.5)

31 (50.0)*

16 (16.7)k

0.004
0.93

\0.0001

Numbers in n (percentage)
LSH laparoscopic supracervical hysterectomy, TLH total laparoscopic hysterectomy, LAVH laparoscopic-assisted vaginal hysterectomy
P [ 0.05 not significant
* [0.05

\0.05

0.01

0.001

\0.0001

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Table 3 Indications for laparoscopic hysterectomy procedures (Indications are not mutually exclusive)
Indications

LSH (%)
(n = 799)

TLH (%)
(n = 62)

LAVH (%)
(n = 96)

P value

Menometrorrhagia

687 (86.0)

45 (72.6)

45 (49.6)

\0.0001

\0.0001

Fibroids

646 (80.9)

Chronic pelvic pain

317 (39.7)

16 (25.8)*

36 (37.5)*

0.09

Adenomyosis

135 (16.9)

2 (3.2)*

5 (5.2)*

\0.0001

10 (1.3)

12 (19.4)*

11 (11.5)*

\0.0001

8 (8.3)*

\0.0001

PCD
Endometrial hyperplasia
NSAM

15 (1.9)

42 (67.7)

8 (12.9)

9 (1.1)

2 (3.2)

37 (38.5)

1 (1.0)

0.35

Numbers in n (percentage)
LSH laparoscopic supracervical hysterectomy, TLH total laparoscopic hysterectomy, LAVH laparoscopic assisted vaginal hysterectomy,
PCD Persistent cervical dysplasia, NSAM nonsuspicious adnexal mass, Combined indications endometriosis, uterine prolapse and risk reducing
salpingo-oophorectomy
P [ 0.05 not significant
* [ 0.05

\0.05

0.002

\0.0001

Table 4 Multinomial logistic regression model of antecedent gynecological characteristics and indication for surgery in patients who underwent
LSH compared with TLH and LAVH
P value
No postmenopausal bleeding
Postmenopausal bleeding

No prior cesarean
Prior cesarean

0.41
0.29

1.43 (0.742.79)

0.29

Referent
0.68 (0.341.38)
0.47 (0.211.06)

0.47

0.79 (0.411.51)

Persistent cervical dysplasia

\0.0001

16.2 (6.3441.33)

0.58

1.20 (0.632.27)

0.015

Referent
0.42 (0.210.85)

\0.0001

0.27 (0.150.47)

\0.0001

0.26 (0.150.43)

\0.0001

8.88 (3.0425.94)

0.03

3.63 (1.1311.70)

Referent
Referent
Referent

Referent
\0.0001

6.52 (2.3218.36)

0.34 (0.180.63)
Referent

Referent

No endometrial hyperplasia
Endometrial hyperplasia

0.001

Referent

No persistent cervical dysplasia

0.61 (0.221.68)
Referent

Referent
0.07

No uterine fibroids
Uterine fibroids

1.27 (0.712.27)

LAVH
Referent

0.34

Referent

No menometrorrhagia
Menometrorrhagia

0.77 (0.252.39)
Referent

No prior other pelvic surgery

Prior other pelvic surgery

P value

Referent
0.65

No prior hysteroscopy
Prior hysteroscopy

TLH

Referent

LSH laparoscopic supracervical hysterectomy, TLH total laparoscopic hysterectomy, LAVH laparoscopic-assisted vaginal hysterectomy

LAVH compared with LSH (OR 0.27; CI 0.150.47).

Although, such patients were 53% less likely to have TLH
as well, compared with LSH (OR 0.47; CI 0.211.06), this
difference was not significant. Women with uterine fibroids, compared with those with no fibroids were 74% less
likely to undergo LAVH compared with LSH (OR 0.26; CI
0.150.43). The diagnosis of uterine fibroid did not influence the choice between TLH and LSH. Patients with PCD
compared with women with no such history were

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significantly more likely to have TLH (OR 16.2; CI

6.3441.33) and LAVH (OR 8.88; CI 3.0425.94) compared to LSH. Lastly, patients with preoperative diagnosis
of endometrial hyperplasia, compared with those with no
such diagnosis, were significantly more likely to undergo
TLH compared with LSH (OR 6.52; CI 2.3218.36).
Similarly, such patients were significantly more likely to
undergo LAVH compared with LSH (OR 3.63; CI
1.1311.70).

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Intraoperative and immediate postoperative variables

were also compared between the three LH approaches
(Table 5). The duration of operation was significantly
shorter in patients who underwent LSH, compared with
those who underwent TLH or LAVH. There were no significant differences in the duration of operation when
LAVH was compared with TLH. The median (range) EBL
was significantly lower and LOS was significantly shorter
in patients who underwent LSH and TLH, compared with
those who underwent LAVH (Table 5). No statistically
significant difference was found when the EBL and LOS
were compared between those who underwent LSH and
TLH. The mean (SD) preoperative hemoglobin (g/dL) was
normal in all the three LH, and although no differences
were found regarding postoperative hemoglobin (excluding
patients who had blood transfusion), those who underwent
LAVH had a significantly higher drop in their hemoglobin
postoperatively compared with LSH and TLH (Table 5).
The drop in hemoglobin value was similar between LSH
and TLH. The proportion of patients who required blood
transfusion during and after their operative procedure was
similar among the three groups.
The trend in the proportion of fibroid uterus as an
indication for LH (Table 3) is mirrored by the distribution
of the weight of that organ encountered at operation
(Table 5). Patients with significantly larger uteri underwent
LSH, while those with the smallest uteri underwent LAVH
(Table 5). Although the weight of the uteri excised at TLH
was lighter than that removed at LSH, this difference was
not significant. In addition, the uterine weight was significantly heavier among those who underwent TLH

(P = 0.03) compared with those who underwent LAVH.

The uterine weight distribution was similar when the
uterine weight was converted to a dichotomous variable
(weight below and above the median uterine weight of 170
g), although the uterine weight among those who underwent TLH compared with those who underwent LAVH
was no longer significant (Table 5).
Lastly, we examined the major and minor perioperative
complications encountered during and after the operations
(Table 6). The rates of major perioperative complications,
including urological and bowel injuries, were not statistically significantly different among the three laparoscopic
hysterectomy approaches. There were too few vascular
injuries (2 cases; 1 each in the LSH and TLH group) to
allow meaningful statistical comparison. Also, there was
no difference in the rate of readmission to the hospital up to
6 months following their initial operation. Laparoscopicassisted vaginal hysterectomy was associated with more
postoperative respiratory infections (6.3% vs. 0.6%,
P \ 0.0001) and fever (10.4% vs. 4.4%, P = 0.02) than
LSH, but not TLH.

Discussion
Hysterectomy remains the mainstay of gynecologic surgery
for menorrhagia and uterine leiomyoma despite the advent
of uterine conservation and minimally invasive treatment
options for these conditions [10]. When VH (the surgical
procedure of choice) is not feasible, the open approach to
hysterectomy is now being increasingly replaced by the

Table 5 Operative and postoperative variables during different laparoscopic hysterectomy procedures
Variables

LSH

Op time (min)

799

141 60

EBL (mL)

797

100 (104,100)*

LOS (days)
Preop Hb (g/dL)

798
738

2 (011)*
12.2 1.6

TLH

62

181 67*

LAVH

P value

96

189 68*

96

200 (502,300)

\0.0001
\0.0001
\0.001

62

137.5 (25675)*

62
58

2 (15)*
12.4 1.7

96
89

3 (140)
13.2 1.7

\0.0001

Postop Hb (g/dL)

613

10.5 1.5

55

10.6 1.7

78

10.7 2.0

0.47

Blood transfusion

799

47 (5.9%)

62

4 (6.5%)

96

3 (7.3%)

0.85

Change in Hb (g/dL)

600

1.7 (-26)*

Uterine wt (g)

776

189.5 (53,200)*

Uterine wt C170 g

766

417 (53.7%)*

55

1.70 (05)*

60

155.0 (251,600)*

60

27 (45.0%)*

\0.0001

78

2.35 (06)

88

121.5 (19700)

88

26 (29.5%)*

\0.0001
\0.0001

Data are in mean standard deviation and median (range)

N number of patients, LSH laparoscopic supracervical hysterectomy, TLH total laparoscopic hysterectomy, LAVH laparoscopic-assisted vaginal
hysterectomy, EBL estimated blood loss, LOS length of stay, op operative, Hb hemoglobin, Wt weight
P [ 0.05 not significant
* Not significant

0.03

0.007

\0.0001

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Table 6 Major and minor perioperative complications during laparoscopic hysterectomy procedures
Complications

LSH (%)
(n = 799)

TLH (%)
(n = 62)

LAVH (%)
(n = 96)

P value

Major
DVT/PE
Urological injury

1 (0.1)
11 (1.4)

0 (0)

0 (0)

0.91

1 (1.6)

1 (1.0)

0.95
0.45

Bowel injury

8 (1.0)

0 (0)

0 (0)

Vascular injury

1 (0.1)

1 (1.6)

0 (0)

0.04

31 (3.9)

5 (8.1)

3 (3.1)

0.25

1 (1.1)

0.61

Readmissions
Minor
Vaginal cuff infection
Fever

0 (0)
35 (4.4)*

4 (6.5)

10 (10.4)*

0.04

UTI

5 (0.6)

1 (1.6)

1 (1.0)

0.63

Ileus

3 (0.4)

1 (1.6)

2 (2.1)

Respiratory infection

5 (0.6)

0 (0)

6 (6.3)

0.08

\0.0001

Numbers in n (percentage)
LSH laparoscopic supracervical hysterectomy, TLH total laparoscopic hysterectomy, LAVH laparoscopic-assisted vaginal hysterectomy, DVT
deep venous thrombosis, PE pulmonary embolism, UTI urinary tract infection
P [ 0.05 not significant
* 0.02

\0.0001

laparoscopic approach. The proportion of the different

types of hysterectomies performed in our institution (71,
21, and 8% for TAH, LH, and VH, respectively) was not
consistent with the trend seen nationally in the USA, in
figures published in 2009 in which 64, 14, and 22% were
TAH, LH, and VH, respectively [3]. At the present time,
the use of laparoscopy for minimally invasive hysterectomy has increased in scope and in some studies has proven
to be safer and associated with several advantages as
compared to the open abdominal hysterectomy [5].
In this cohort study, we identified several antecedent
gynecological conditions associated with, and indications
for, the three LH approaches. Although older age has been
consistently reported as associated with decreased odds of
LH [3], we found no significant age difference in relation
to the different LH approaches. Similarly, BMI did not
influence the choice of LH approach in our patient population, in which the majority of patients were obese. In
addition, we found no significant difference in parity
between the three groups. The reason for this may be due to
a type II error or to the fact that a large proportion of
patients with high parity simply underwent VH (a preferred
option), which was not analyzed as part of this study.
History of postmenopausal bleeding (PMB) was not
associated with the choice between the different laparoscopic approaches. This would suggest that having excluded intrauterine pathology (with endometrial biopsy or
with hysteroscopy and curettage), patients and their physicians are comfortable with any of the different laparoscopic approaches when hysterectomy becomes necessary.

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Similarly, women with history of previous hysteroscopy,

compared with those with no such history, were 66% less
likely to undergo LAVH compared with LSH. History of
previous hysteroscopy was not associated with the choice
between TLH and LSH. Therefore, it would seem that
patients and their physicians are more comfortable with
LSH once malignancy has been excluded by hysteroscopy.
We found no significant differences in the other antecedent
gynecology characteristics, such as Depot-Lupron use (as a
preoperative adjunct for uterine fibroids), prior endometrial
ablation, laparoscopy, and laparotomy.
Although patients with a history of other prior pelvic
surgeries were more likely to undergo TLH and LAVH
compared with LSH, these differences were not significant.
This would suggest that knowledge of previous pelvicrelated operation might not sway the patient and surgeon
toward any particular approach when LH is performed in
our institution.
Multinomial logistic regression [9] confirmed that those
with a history of CD were less likely than those with no
such history to undergo LAVH, compared with LSH but
not TLH. This is understandable given that patients with a
history of prior CD(s) are more likely to have adhesions in
the lower pole of the uterus and cervix, making the performance of TLH or LAVH relatively more complicated
compared to LSH. There are few absolute contraindications
for VH such as severe endometriosis, uterine size greater
than 1618 weeks, and advanced pelvic malignancy [11].
However, many clinicians believe that women with prior
pelvic surgery and previous CDs are not candidates for VH

Arch Gynecol Obstet (2012) 285:13531361

due to it being more technically challenging. All other

patients are excellent candidates for LSH, the majority of
whom underwent the procedure because of menometrorrhagia, uterine fibroids, and chronic pelvic pain.
A recent nationwide cross-sectional study found that a
diagnosis of uterine fibroids was associated with nearly
30% lower odds of LH as compared to TAH, although the
type of LH approach was not analyzed in that study [3].
Similar to other studies [6, 12], we identified that LSH was
associated with a shorter operating time and lower blood
loss, and that the uterine size should not be a deterrent to
the use of this approach compared with other laparoscopic
approaches. Thus, the common indications for LH are
similar to the most common surgical indications for TAH,
which include abnormal uterine bleeding, uterine leiomyomas, adenomyosis, and chronic pelvic pain [3, 13, 14].
Similar to our study, many of the indications were not
mutually exclusive.
In a cohort study, Milad et al. [7] analyzed 132 patients
(27 of whom underwent LSH and 105 underwent LAVH)
and found that while none of the patients submitted to LSH
experienced morbidity, 13% of those who underwent
LAVH did (bladder injury, n = 3; blood loss [1,000 ml,
n = 7; vaginal cuff hematoma, n = 4). These authors
concluded that the practice of routine cervicectomy at
laparoscopic hysterectomy should be reconsidered. This is
in agreement with the findings in our study that patients
who underwent LAVH had a longer operation, lost more
blood, had more postoperative infectious morbidity, and
stayed in the hospital the longest. In contrast, however,
other parameters such as the number of patients transfused,
those with other pelvic organ damage, and the proportion
of patients who were readmitted due to events related to
their surgery were similar in all the groups. Given that the
overall morbidity was low and minor, we are of the opinion
that the cervix can be removed with the uterus if technically feasible, especially by TLH. We concur that difficult
dissections at the infundibulopelvic, uterosacral, and cardinal ligaments or pelvic sidewall [8] can predispose to
injury to the ureter, bladder, and bowel. However, laparoscopic skill and laparoscopic equipments have improved
since these last two studies were published in 1993 [7] and
2001 [8], respectively. Similar to previous studies [7, 15],
we found that patients, who underwent LAVH, although
they had significantly higher preoperative hemoglobin,
were more likely to lose more blood with associated significant drop (excluding those who received blood transfusion) in their postoperative hemoglobin compared with
those who underwent LSH and TLH. Similarly, the average
duration of the surgery, though no different in those who
underwent LAVH and TLH, was significantly longer when
compared with those who underwent LSH. Although not
significant, those who underwent LAVH in our study

1359

stayed a day longer than those who underwent LSH or

TLH.
It has been theorized that LSH maintains the integrity of
the pelvic floor as the uterosacral and cardinal ligaments
are not interrupted; however, pelvic organ prolapse has
been observed in women post-hysterectomy regardless of
the surgical approach [16]. Indeed, Altman et al. [17], in a
large population-based cohort study that spanned 30 years
up to 2003 from Sweden, recorded a doubling in pelvic
organ prolapse rate in women who underwent subtotal
hysterectomy (SH), which almost quadrupled among
women with a previous vaginal hysterectomy. However,
these authors were unable to calculate a valid risk analysis
for LAVH or LH because of insufficient numbers of subsequent prolapse surgeries for these groups [17]. As for
other complications associated with vaginal prolapse, a
study by Thakar et al. [18] and a recent metaanalysis by
Robert et al. [19] found no statistical evidence of a different risk of urinary incontinence after SH and TAH.
It has also been suggested that concerns about impairment of sexual function [20, 21] may account for the rise in
the number of SH performed in recent years [22]. This
trend seems to continue with the laparoscopic approach to
hysterectomy as depicted by our data. Although concerns
about operative morbidity may have swayed surgeons
toward LSH, the findings from this study do not support
this assertion. If the cervix is left in situ, it is imperative
that the patient be adequately counseled about the possibility of subsequent problems such as pain, discharge,
bleeding, cervical dysplasia, and invasive cervical cancer.
Such patients need routine Papanicolaou smear and/or
human papilloma virus (HPV) testing, and in the event of
an abnormal test result, closer scrutiny such as colposcopic
examination with or without biopsy and an excision procedure may be warranted. However, if a woman has not
had an abnormal cervical cytology or more importantly a
current positive HPV DNA test, an LSH is a reasonable
surgical approach. Of note, ten of our patients with cervical
dysplasia underwent LSH. An evaluation of their records
failed to ascertain the reason(s) why these patients underwent LSH. Given that our follow-up was limited to
6 months postoperatively, the results of future cervical
examinations are uncertain.
We did not analyze sexual function after hysterectomy
in this study; however, a previous randomized controlled
study refuted the claim that removing the cervix impaired
sexual function [18]. In addition, a recent systematic
review from Canada concluded that hysterectomy was
usually associated with improved quality of life, including
improved sexual function, whether or not the cervix was
removed [23]. Nevertheless, patients with significant cervical disease should undergo treatment that incorporates
excision of the cervix (TLH or LAVH) as there is an

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increased risk of cervical cancer in such a cohort, and

cervical excision will reduce the risk of neoplasia in the
future [24]. However, the incidence of cervical stump
carcinoma following SH varies from 0.1 to 1.9% [2527],
rates that are similar to the rate of vaginal cancer after TAH
[28, 29], although this assertion for vault cancer has been
refuted by others [30]. Nevertheless, stage-by-stage cancer
of the cervical stump has been shown to be associated with
the same 5-year survival rate as cervical cancer when the
uterus is removed by radical surgery [31].
LAVH was associated with more postoperative respiratory infections and postoperative fevers than LSH, but
not TLH in our study. It is tempting to attribute these
increases to vaginal contamination; however, both TLH
and LAVH are predisposed to vaginal contamination,
although LAVH is associated with more vaginal manipulation and dissection compared with TLH. Therefore, the
reason(s) why LAVH was associated with more postoperative respiratory infections in our patients remain unknown
and appear to be a random coincidence. In contrast to our
study, Drahonovsky et al. [32] concluded that TLH was
associated with significantly more febrile episodes or
unspecified infections compared to LAVH. In concurrence
with other studies [13, 33, 34], the rate of urological injury,
bowel injury, thromboembolism, and vaginal cuff infection
were not statistically different among the three LH
approaches. A recent Italian randomized study comparing
LSH with TLH reported that patients assigned to LSH
tended to have more hospital readmissions during a followup of 2 years when they weighed more than 100 kg [35]. It
is of note that most of the patients in our study were obese
and we did not find any difference in the rates of
re-admissions in the three groups after 6 months of follow-up.
Although our study benefits from the inclusion of all the
different hysterectomy approaches performed by operative
laparoscopy, several limitations must be acknowledged.
First, this was a retrospective cohort study and although we
attempted to account for known patient characteristics that
might have been associated with the choice of surgical
approach, it was not possible to determine all individual
patient and physician preferences that were associated with
treatment planning. Given that a large majority of our
patients underwent LSH, a preference for the performance
of LSH exists at our institution, which may introduce bias
in the comparison of outcomes with different types of LH.
Similarly, we have not addressed the individual surgeons
experience (such as training, surgical volume, or practice
setting) as well as surgical approach preference, all of
which could bias the results of our study. The study is from
one major academic institution, which may not reflect
hysterectomy practices in other institutions or regions. In
addition, the follow-up in our series was limited to
6 months; therefore, there is the possibility that some of

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Arch Gynecol Obstet (2012) 285:13531361

those who underwent LSH could have subsequent problems with the cervix. Because our institution is a referral
center, and the study population was from multiple providers, our information regarding complications of the
procedures was limited to inpatient records. Therefore,
some of the differences between groups could be secondary
to patients following up at their primary gynecologist
offices rather than at our institution.
To date, there is no accepted view on the most appropriate surgical approach for LH. We found that a history of
prior hysteroscopy and CD was associated with the type of
laparoscopic hysterectomy performed in our institution.
LSH was the most common approach, especially in patients
with menorrhagia and large uterine fibroids, and was
associated with significantly less peri- and postoperative
morbidity than LAVH. The results of our study also suggest that when a decision has been reached to not perform a
VH and to remove the uterus and cervix, TLH may be
associated with less perioperative morbidity than LAVH. It
is hoped that knowledge of the intraoperative complications and the risk conferred by the different laparoscopic
approaches may be helpful to both patients and the treating
physicians in making informed decisions about optimal
surgical approach in a given situation.
Conflict of interest

None.

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