Laparoscopic Hysterectomy

C. Y. Liu, M. D., F. A. C. O. G.

"But Doctor," asked Linda, "you mean that I can go home the next morning after my hysterectomy, and be back to work in about 10 days?"

"That's right Linda."

"But one of my friends had a hysterectomy, and she had to stay in the hospital for almost a week. And it was about two months after that before she could go back to work."

Linda Johnston, an attractive, intelligent 38-year-old Executive Secretary, and her husband Phil, were in my office for a pre-surgical consultation. She had been a patient of mine for many years. In fact, I had delivered all three of their children. For some time, she had been having female problems - pelvic pain, heavy menstrual bleeding and cramping, painful sexual intercourse, leg pain, and low backache. "I find myself getting irritable and not feeling well much of the time." She added.

Her enlarged uterus and the other symptoms indicated uterine fibroids (non-malignant tumors) and possible adenomyosis (a condition in which the lining of the uterine cavity grows into the muscle layer of the uterus, causing pelvic pain and heavy menstrual bleeding and cramping). Since she had already had a D&C (surgical scraping of the uterine lining) but to no avail, a hysterectomy was new indicated. She had heard about the laparoscopic hysterectomy and was now inquiring about it. As with all my pre-surgery consultations, I began to explain to Linda and Phil about the surgery.

First of all, a laparoscope is a tiny, less than half-inch diameter, telescope that allows the surgeon to look into the abdomen and perform a variety of surgical procedures without making a large incision. We can cut, suture, coagulate, cauterize, repair and remove organs -- all through the laparoscope. Some of the procedures done laparoscopically include removal of the uterus, ovaries, ovarian cysts, ectopic pregnancies, extensive endometriosis, and scar tissue in the abdomen or pelvis. We can also perform some very sophisticated fertility promoting surgeries such as opening up obstructed fallopian tubes.

"You mean you can do all that through a half-inch laparoscope?" asked Phil incredulously.

"That's right. In fact, within the past couple of years, because of improved video equipment, we don't even look through the laparoscope; instead we do surgery by looking at the greatly magnified pictures on the TV screen. We first make a tiny incision less than an inch long in the patient's navel, through which we insert the laparoscope. With a very bright light source going through the laparoscope and with a sophisticated video camera, the internal organs are greatly magnified on to the television monitor."

We then proceed to identify and separate the organs surrounding the uterus, tubes, and ovaries. After identifying both ureters (the draining tubes connecting the kidneys to the bladder) and the uterine blood vessels, and under the direct visualization of the ureters, we then seal and cut the uterine blood vessels by electrosurgical equipment. As you know, Linda, the uterus and vagina are connected. Just as a baby emerges from the uterus and is delivered through the vagina, so once the uterus is freed from the surrounding tissue, the vagina opens up. We can then just remove the uterus through the vagina and close the tip of the vagina with a few dissolvable stitches."

"How long will the surgery take?" asked Linda.

"About an hour and a half, on the average; but, of course, it depends on the extent of pathology that we find at the time of surgery." "Of course," I added teasingly, "since you will be asleep, it'll seem like only a minute to you. Afterwards you will be able to be up and about, and then out of the hospital by the next morning. Oh yes, and you'll be able to eat regular foods too."

"Sounds good. But," asked Linda, "what about pain after surgery. Will I have much of it?"

"Less than you're having right now. You see, postoperative pain is caused by tissue damage, inflammation, swelling, and scar tissue formation With the use of laser and electrosurgical equipment, there is less tissue damage. Also by cauterizing blood vessels instead of using sutures, which is a foreign body, there is almost no bleeding, and much less inflammatory reaction and tissue swelling."

"What about gas pains? I've heard they're awful."

"You'll have very little or no gas pains, because the abdomen is distended by carbon dioxide and the pelvic organs are clearly seen on the TV screen, so we no longer have to push and pack the bowels around in order to see the pelvic organs. "Furthermore, the complication rate is much lower than that of the traditional abdominal hysterectomy. In my own series of more than 650 patients, my complication rate was 5.7%, which is much less compared to a nationwide complication rate of 42% for the traditional abdominal hysterectomy. Thirty-two percent of these complications were due to postoperative fever."

"A major reason for such a low complication rate for laparoscopic hysterectomy is that with the magnification, there is little chance of injury to the neighboring organs such as the bladder, ureters, and intestines. Other frequent complications are internal bleeding and infection. With the traditional hysterectomy, after closing the abdomen or the vaginal cuff, the surgeon has no way of knowing whether there is bleeding inside. With laparoscopic hysterectomy, after the uterus is removed, we routinely fill the pelvis with physiologic solution; and putting the camera underwater, we examine the entire surgical area. Even microscopic oozing of blood can be detected this way. The irrigation of physiologic fluid washes out debris, blood, and bacteria that might he left behind and thereby reduces the chance of infection and scar tissue formation. Blood clot and pulmonary complications are also reduced because the patient is able to be up and around so soon after surgery."

"Well, Dr. Liu, this is all quite impressive." Phil interjected. "How long has this surgery been around?"

"Laparoscopic surgeries are not new. Back in the 60's laparoscopic surgery was initially used for tubal ligations and diagnosis of causes of infertility and pelvic pain. By the late 70's we began using it for treatment of diseases, and in the early 80's we began to laparoscopically remove organs such as ovaries, tubes, and extensive endometriosis. While laparoscopic hysterectomies were performed in France and Germany during the last decade, it wasn't until 1988 that the first one was done in this country. I have been performing them since May, 1990. With continued advances in surgical equipment, sophisticated procedures can now be done effectively and safely."