ISTERECTOMIA
MINIINVASIVA
Massimo Luerti
Dipartimento Materno Infantile
Unità Operativa di Ostetricia e Ginecologia 1
A.O. della Provincia di Lodi
Ospedale Maggiore di Lodi
[email protected]
ALTERNATIVE TECNICHE
ATTUALI PER L’ISTERECTOMIA
•Isterectomia totale
- laparotomica tradizionale
- minilaparotomica
- vaginale
- laparoscopica
•Isterectomia subtotale
- addominale
- minilaparotomica
- laparoscopica
- vaginale
Perioperative Pain Management
“The era of managed care and shorter hospital stays
has focused physicians and, in particular,
surgeons on elements of patient care that can be
addressed and improved. Reducing or
eliminating postoperative pain without excessive
sedation promotes rapid mobilization and return
to self-care”.
Levy BS, Carpenter R, J Am Assoc Gynecol Laparosc. 1995 Aug;2(4):381-7
“Minimizing tissue trauma
is the key to good
(and rapid ) recovery”
- every professor of surgery I’ve ever had
•VH has the lowest complication rate and the quickest
recovery
•Total AH has the highest patient morbidity and longest
convalescence.
Mehra S Gynaecol Endosc 1999
The post-operative rates of morbidity and complications
are lower with the vaginal approach than with any other
methods
Rates of complications associated with hysterectomy range
from
• 24 percent for the vaginal approach to
• 43 percent for an abdominal approach
CLINICAL PRACTICE GUIDELINES FOR HYSTERECTOMY
Committee of the Society of Obstetricians and Gynaecologists of Canada, 1995
“The only controindication for a vaginal
hysterectomy is if a vaginal hysterectomy has been
perfomed….”
Steven Cruikshank, MD
Certified Vaginal Zealot
LIMITI DELLA VH
• Sindrome dolorosa pelvica che richiede esplorazione pelvica o
specifici trattamenti
• Sospetta o accertata endometriosi
• Pregressa chirurgia pelvica-addominale ad alto rischio di
aderenze
• Utero largo e grosso:esperienza per la riduzione
• Insufficiente approccio vaginale
• Presenza di patologia annessiale non sospetta
TUTTI I LIMITI DELLA VH, TRANNE L’UTERO LARGO E
GROSSO POSSONO CONSIDERARSI INDICAZIONI PER
LA ISTERECTOMIA LAPAROSCOPICA
LA LAPAROSCOPIA DEVE QUINDI
AFFIANCARSI ALLA VIA VAGINALE E
NON SOSTITUIRLA
Dipendentemente dalle indicazioni, dal training del
chirurgo e dall’ esperienza, la laparoscopia puo’ essere
utilizzata per assistere una isterectomia che puo’
concludersi per via vaginale (LAVH) o per una
isterectomia totale o sopracervicale
HYSTERECTOMY %
via VAGINAL ROUTE
Brown DA & Frazer MI/
Australia medicare 79/19
Summit RI /USA 77/25
Kovac SR/USA 89/25
Querleu D 77
Sheth SS 82
Sweden 11
In most countries the percentage of uteri
removed abdominally is above 50%
Finnish national survey (1998) 93%
United Kingdom (1998) 74%
Dutch Hospitals (1998) 54%
ANNESSIECTOMIA IN CORSO DI
ISTERECTOMIA VAGINALE
USA: 1.700.000 isterectomie 1988-1990
Via
Addominale
Vaginale
%
68
10.3
Wilcox LS Obstet Gynecol 1994
ANNESSIECTOMIA IN CORSO DI
ISTERECTOMIA VAGINALE
Una inchiesta tra gli iscritti alla British Society of
Gynacological Endoscopy evidenzia che, su un
totale di 147 risposte (46% del campione), il 57%
sceglieva solo una isterectomia per via addominale
se aveva in programma anche una annessiectomia,
e solo il 7% effettuava direttamente una
isterectomia vaginale.
(Clark TJ 2001)
ISTERECTOMIA VAGINALE
Revisione critica di una casistica di 500 isterectomie
consecutive (68.4% AH, 19.2% VH), da parte degli stessi
operatori (A. Magos e coll.):

353 (70,6%) proponibili per una isterectomia vaginale, ma solo 1/3 ha
evitato la laparotomia

la via vaginale è proposta in modo variabile dagli operatori (da 9.9 a
100%)

le variabili principali all’indicazione sono:
 dimensioni dell’utero
 abilità del chirurgo
VANTAGGI DELL’ISTERECTOMIA
LAPAROSCOPICA RISPETTO
ALL’ISTERECTOMIA ADDOMINALE
•Perdita ematica minore
•Minore dolore postoperatorio
•Minore durata della degenza
•Più precoce recupero postoperatorio
•Maggiore facilità di annessiectomia
•Possibilità di adesiolisi
•Migliore emostasi della trancia vaginale e toilette
•Minore quantità di tessuto necrotico
J.H. Olsson et al. BMJ,1995;103:345-350
R.I. Summit et al. Obst & Gyn,1998;92:321-326
FIHYST 1996
AH
VH
LH
cases
5875
1801
2434
OVERALL COMPLICATIONS
17.2%
23.3%
19.0%
Infections
10.5%
13.0%
9.0%
Hemorrhagic events
2.1%
3.1%
2.7%
Bowel injuries
0.2%
0.5%
0.4%
Ureter injuries
0.2%
0
1.1%
Bladder injuries
0.5%
0.2%
1.2%
Makinen, 2001
COMPLICANZE PER TIPO DI ISTERECTOMIA
AH
VH
THL
20.1%
10.9%
9.7% (*)
*-Chapron. 235 pz ,1999
RUOLO DELLA CURVA DI APPRENDIMENTO
NELLE COMPLICANZE DELL’ISTERECTOMIA
LAPAROSCOPICA (A. Wattiez, 2002)
Trasfusioni
Danni vescicali
Danni ureterali
Fistola vescicovaginale
Danni intestinali
Reinterventi
Ematoma parietale
Ematoma cupola vaginale
Iperpiressia
Infezione cupola vaginale
Infezione della parete
1989-1995
(n=695)
1996-1999
(n=952)
15 (2.2)
11 (1.6)
4 (0.6)
1 (0.1)
1 (0.1)
9 (1.3)
10
3
14
4
2
1 (0.1)
6 (0.6)
2 (0.2)
1 (0.1)
0
3 (0.3)
5
4
4
0
0
VH is superior in terms of operative time and
immediate inflammatory response when compared
with TAH and LH, and therefore it should be the
first option for hysterectomy.
LH should be the preferred option when the
vaginal approach is unfeasible, showing clear
advantages over TAH.
A randomized study of total abdominal, vaginal and laparoscopic hysterectomy
S.C. Ribeiro, International Journal of Gynecology and Obstetrics 83 (2003) 37–43
•Any patient requiring a hysterectomy should
be offered the vaginal approach as the
morbidity and post-operative complications
are less.
•Laparoscopic assisted vaginal hysterectomy
may be used instead of an abdominal
hysterectomy, but is of no advantage where a
vaginal hysterectomy can be performed.
CLINICAL PRACTICE GUIDELINES FOR HYSTERECTOMY
Clinical Practice Guidelines – Gynaecology,Committee of the Society of Obstetricians and
Gynaecologists of Canada, December, 1995.
LAVH is “to assist in the performance of a
vaginal hysterectomy in situations in which an
abdominal approach might otherwise be
indicated”
American College of Obstetricians and Gynecologists (ACOG), 1995
CLASSIFICAZIONE DELLE ISTERECTOMIE CON
TEMPO LAPAROSCOPICO
•LAVH (Laparoscopic Assisted Vaginal Hysterectomy)
con tempo laparoscopico che arriva fino ai vasi uterini esclusi
•LH
(Laparoscopic Hysterectomy)
con vasi uterini affrontati per via laparoscopica mentre i legamenti uterosacrali e cardinali e la parete vaginale possono essere affrontati come si vuole:
sutura vaginale dal basso
•TLH (Total Laparoscopic Hysterectomy)
con totale dissezione del pezzo operatorio e la sutura della parete vaginale
per via laparoscopica
AAGL ABBREVIATED CLASSIFICATION SYSTEM FOR
LAPAROSCOPIC HYSTERECTOMY
J Am Assoc Gynecol Laparosc 7(1):9-15,2000
Type 0: Laparoscopic-directed preparation for vaginal
hysterectomy
Type I: Occlusion and division of at least one ovarian
pedicle, but not including uterine artery(es)
Type II: Type I plus occlusion and division of the uterine
artery, unilateral or bilateral
Type III: Type II plus a portion of the cardinaluterosacral ligament complex, unilateral or bilateral
Type IV: Complete detachment of cardinal-uterosacral
ligament complex, unilateral or bilateral, with or without
entry into the vagina
BIPOLAR VESSEL SEALING
• Conventional bipolar electrosurgery
• Ultrasonic and laser-based systems
• Pulsed plasma kinetic electrosurgical
• Feedback-controlled, radiofrequencybased bipolar devices
ELECTROSURGICAL BIPOLAR VESSEL SEALER
•Can effectively seal vessels and vascular bundles up to 7mm
in diameter.
•Application of mechanical energy or pressure in conjunction
with the delivery of electrical energy
•Electrosurgical generator measures both voltage and current
to monitor tissue response: as tissue impedance changes
because of resistive heating, voltage and current will vary
accordingly.
•When tissue response indicates a successful seal, a cool
cycle is entered, during which time the device position is
maintained and no power is delivered. After the cooling
period, the generator emits an audible tone to indicate cycle
completion. On average, the entire sealing and cooling cycle
takes approximately 5 seconds.
Randomized Trial of Suture Versus ElectrosurgicalBipolar Vessel Sealing in Vaginal Hysterectomy
Barbara Levy, MD, and Laura Emery
VOL. 102, NO. 1, JULY 2003
OBSTETRICS & GYNECOLOGY
ELECTROSURGICAL BIPOLAR VESSEL SEALING IN VAGINAL HYSTERECTOMY
EBVS
(n 30)
Suture
(n 30)
Statistical
Significance (P)
39.1 17.7
36
(22–93)
53.6 26.7
47
(37–160)
.003
Total procedure
time* (min)
48.0 26.8
42.0
(22–93)
60.3 27.9
55.5
(37–160)
.014
Estimated blood
loss (mL)
68.9 51.6
50.0
(20–200)
126.7 113.3
100
(25–600)
.005
Procedure
time (min)
Randomized Trial of Suture Versus Electrosurgical Bipolar Vessel Sealing in Vaginal Hysterectomy
Barbara Levy, MD, and Laura Emery, VOL. 102, NO. 1, JULY 2003, OBSTETRICS & GYNECOLOGY
TECNICA
ISTERECTOMIA
LAPAROSCOPICA
OPERAZIONI PRELIMINARI
•Posizionamento della paziente
•Posizionamento dei trocars
•Posizionamento del mobilizzatore uterino
Hourcabie Clermont Ferrand
Rumi
Vcare
Poliuso
Yes
Yes
partially
no
Movimenti antiretroversione
++
++++
++++
++
Movimenti laterali
++
++++
++
++
++++
++
+
++
++
+++
Movimenti
indipendenti
++++
++++
-
+++
Facilità d’uso
++++
+
+
++++
+++
++
++
+++
+
+++
++
+++
Movimenti
d’elevazione
Identificazione
fornici
Maneggevolezza
Tenuta del gas
++++ ++++
PRECAUZIONI PER EVITARE DANNI
ELETTRICI ALL’URETERE

buona preparazione e scheletrizzazione del fascio
vascolare

scelta del punto di coagulazione, sulla branca
ascendente dell’arteria uterina

tempo di coagulazione, più breve possibile: coagulazioni
brevi e ripetute sono preferibili ad una coagulazione
prolungata

applicazione perpendicolare al fascio vascolare della
pinza bipolare, introdotta dal trocar omolaterale

forte laterodeviazione controlaterale dell’utero
CAUSE DI DIFFICOLTA’
• The presence of large uterus over 300
grams (or 12 weeks) with or without a
poor vaginal access
• The presence of adhesions due to
previous caesarean sections or
previous pelvic surgeries
(myomectomies)
• The presence of pelvic varicosities
• The presence of other pathologies like
endometriosis
MEZZI PER SUPERARE LE DIFFICOLTA’
• Preoperative treatment with GnRH
analogs
• Trocar placement and ergonomics
• 30° laparoscope
• Securing uterine vessels and
decreasing the risk of hemorrhage
• Changing strategies
• Morcellation
VARIANTE TECNICA
La chiusura dell’arteria uterina
può essere effettuata come primo
tempo operatorio, aprendo il
legamento largo e andando a
coagulare l’arteria alla sua
emergenza dall’arteria
ipogastrica
MINILAPAROTOMIA:
Un'alternativa miniinvasiva e meno dolorosa
per la chirurgia ginecologica maggiore
MINILAP PRINCIPLES
• Smaller incisions are less traumatic
–
–
–
–
•
•
•
•
•
•
•
Decreased post-op pain
Shorter hospital stay
Early ambulation
Earlier return to normal activities
Vessels at same level regardless of uterine size
You only need to see what you’re cutting
Movement of uterus under incision allows access
Movement of incision to vascular pedicles
Minimal packing and bowel handling avoids ileus
Like doing a vaginal hysterectomy through the abdomen
Faster, easier to learn/teach, less costly than laparoscopy
Effects of presurgical local infiltration of bupivicaine in the
surgical field on postsurgical wound pain in laparoscopic
gynecologic examinations: a possible preemptive analgesic
effect
Kato J, Ogawa S, et al. Clin J Pain. 2000 Mar;16(1):12-17
• Incidence of wound pain significantly lower at 10 hrs. post op in
treated vs control (p<.05)
• Mean visual analog pain intensity less in treated (p<.05)
• Patients requesting analgesics and who complained of sleep
disturbance higher in control group (p<.05)
• Mean cumulative dose of diclofenac at 24 hrs signifcantly lower in
treated vs controls (p<.05)
“Cruciate Incision”
4-8 cm transverse skin
incision
6-8 cm. vertical fascial
incision
ISTERECTOMIA SUBTOTALE
The operation time and the
blood loss were significantly
less in the subtotal abdominal
hysterectomy group compared
with total abdominal
hysterectomy
Helga Gimbel. BJOG.December 2003, Vol. 110, pp. 1088–1098
Laparoscopic supracervical
hysterectomy has shorter
operating times, shorter length of
stays, and less morbidity than
laparoscopically assisted vaginal
hysterectomy
A Comparison of Laparoscopic Supracervical Hysterectomy
Versus Laparoscopically AssistedVaginal Hysterectomy
Andrew Sokol, MD
Obstetrics & Gynecology, VOL. 95, NO. 4 (SUPPLEMENT), APRIL 2000
TAH
SCH
Intercourse frequency, orgasm frequency, and overall sexual
satisfaction were all significantly related to type of procedure (P
= 0.01, 0.03, and 0.03, respectively).
Intercourse frequency
worse outcome
42% (n = 10)
15% (n = 5)
Decrease in the ability
to achieve orgasm
43% (n = 9)
6% (n = 2)
Worsening of overall
sexual satisfaction
33% (n = 8)
6% (n = 2)
Supracervical hysterectomy versus total abdominal hysterectomy:
perceived effects on sexual function
Jyot Saini
BMC Women's Health 2002, 2:1
doi:10.1186/1472-6874-2-1
CLINICAL PRACTICE GUIDELINES FOR HYSTERECTOMY
Committee of the Society of Obstetricians and Gynaecologists of Canada, 1995.
When a hysterectomy is performed
for benign disease, subtotal surgery
may be preferable to a patient who
has always had normal cytological
findings and who believes sexual
relations may be affected by removal
of the cervix
MINILAP SUPRACERVICAL HYSTERECTOMY
• Should only be considered when conservative
therapy fails
• Is NOT a substitute for vaginal hysterectomy
• Retention of the cervix is not an indication
– No scientific evidence that cervical retention prevents
prolapse
– No convincing scientific evidence that cervix enhances
sexuality
• Supracervical hysterectomy should be done since it
is technically easier and there are fewer
complications than total hysterectomy
Incidence of Cyclic Bleeding After Laparoscopic
Supracervical Hysterectomy
•
•
•
•
•
Prospective study of 67 LSH
Cervical stump biopsied at 12 and 6:00
All patients contacted 3-15 mos post- op
Overall bleeding incidence 19%
In group where biopsy showed endocervical
tissue, 17% experienced cyclic bleeding
• Continuous variables (eg endometriosis,
adenomyosis, BMI, uterine wt) not significant
Ghomi A, Hantes J, Lotze EC. JMIG 2005 May/June; 12(3):201-205
MINILAP SUPRACERVICAL HYSTERECTOMY:
TECHNIQUE
• Insert uterine manipulator
• Suprapubic transverse skin incision - 4 - 8 cm.
– Inject local prior to making incision
• 6 - 8 cm vertical facial incision (cruciate)
• Insert Mobius retractor and elevate uterus to ant abdominal wall
• Start at adnexae and work downward (like LAVH)
– Twist and deviate uterus with manipulator
– Use sutures, Hemalock clips, PK seal, Ligasure or PK short cutting forceps for
control of pedicles
– Dissect bladder flap downward
– Clamp, cut and tie (clip or coagulate) uterine vessels
• Elevate lower segment and amputate at int. os
– Red Robinson catheter or penrose drain
• “Reverse Cone” endocervix
• Suture cervical stump
Minilap Supracervical Hysterectomy: Technique (cont)
• Morcellate fundus using #10 scalpel - Doyen “ ladder
technique”
• Irrigate pelvis and incision with saline
• Close subcutaneous “dead space” with sutures to avoid seroma
• Subcuticular closure after injecting fascia and skin with local
• Decadron 6-8 mg, Toradol 60 mg intraoperative
• D/C Foley in OR – Void or Cath. Q 6-8 h.
• Band-Aid and steristrips to incision, vertical pressure dressing
until discharge
•1 per 1000 women develops carcinoma in
cervical stump.
•Twenty-five
percent
of
the
patients
continued to menstruate
•10% had symptoms of discharge.
•symptoms related to the cervical stump in
24% of patients, all requiring further
operations
•Adhesions, especially between the bowel and
the cervical stump, endometriotic lesions,
cervical pathologies (chronic cervicitis, SIL,
mucocoeles), myomas and prolapse have
been reported at long-term follow-ups
Myoma arising in a Cervical Stump. A. Rossetti, 2003
FATTORI CONDIZIONANTI LA SCELTA DEL
TIPO DI ISTERECTOMIA
• Il chirurgo
– Esperienza e predisposizione
• L’indicazione all’intervento
– Patologia annessiale
– Peso e disposizione volumetrica dell’utero
– Sospetta endometriosi
– Dolore pelvico cronico
– Flogosi acuta o cronica in atto
– Necessità di appendicectomia o annessiectomia
• Caratteristiche della paziente
– BMI
– Mobilità dell’utero
– Accesso vaginale
– Pregressa chirurgia pelvica