In 1989 Dr. Harry Reich performed the first laparoscopic hysterectomy using rather primitive instruments by today’s standards, and changed the gynecologic surgical landscape forever. Those of us who have performed laparoscopic hysterectomy during the 20-plus years since then have provided women with a faster recovery, less time in the hospital, and less pain than they would have experienced with a traditional abdominal approach.
The minimally invasive approach has become the mantra for most gynecologic procedures. Vaginal hysterectomy always has been considered its standard bearer, and as emphasized by the American College of Obstetricians and Gynecologists (ACOG) in its recent statement, it should remain the primary approach whenever it is feasible (Obstet. Gynecol. 2009;114:1156-8). In cases in which vaginal hysterectomy is not an option, however, laparoscopic hysterectomy is clearly the next-best technique.
In 2010, the AAGL published a position paper stating that most hysterectomies for benign disease should be performed either vaginally or laparoscopically, and that continued efforts should be taken to facilitate these approaches (J. Minimal. Invasive Gynecol. 2010 [doi: 10.1016/jmig.2010.10.001]). The recent consensus in the literature, moreover, has been that abdominal hysterectomy should be reserved for cases in which the patient cannot tolerate a laparoscopic approach. For example, a history of cardiopulmonary compromise or multiple gastrointestinal procedures may make a laparoscopic approach potentially too dangerous.
There have been some important refinements in laparoscopic hysterectomy over the past 20-plus years, including the ability to manage vascular pedicles with less thermal spread. This has decreased the potential for ureteral damage. Moreover, our ability to pinpoint the cervicovaginal margin, so as not to shorten the vagina, also has been an improvement. Overall, however, the technique has not changed significantly.
So what is new? The option in some hospitals of performing hysterectomies robotically is attracting surgeons who have not developed a skill set in traditional laparoscopy to perform the technique at bedside. This growing number of gynecologic surgeons is finding it easier and technically more enjoyable to use the da Vinci Surgical System.
Now, consequently, the focus of discussion and debate concerns the availability and cost of the robotic system, as well as the comparative complication rates and operating room times of robotic and traditional laparoscopic hysterectomy.
As gynecologic surgery faces this paradigm shift in the choice of surgical approaches, and as health care payment models continue to evolve, it is important to understand the value of each approach. One recent study found that robotic hysterectomies were associated with longer surgical times and cost an average of $2,600 more (J. Minim. Invasive Gynecol. 2010;17:730-8). Other studies have reported similar findings.
While some extra cost may be acceptable today, it will be less palatable if – or when – reimbursement models change and bundled payments become more common. Moreover, robotic technology is not universally available. Currently, the residents I teach do not have access to the da Vinci system. In the future, if access is available, their training in traditional laparoscopy will be valuable.
Thus, despite the increasing popularity of a robotic approach to hysterectomy, it is imperative that teaching the approach in laparoscopic hysterectomy not be pushed to the background.
While the learning curve of laparoscopic hysterectomy is not insignificant, it is more intimidating than it should be. Once the surgeon learns to suture laparoscopically, he or she has largely broken the barrier.
The Process and Technique
At the start of the procedure, before insufflation, I place a Rumi Uterine Manipulator and KOH colpotomizer (CooperSurgical, Trumbull, Conn.) to identify the anterior and posterior fornices in preparation for colpotomy. Other cupped manipulators such as the VCare uterine manipulator/elevator (CONMED EndoSurgery, Utica, N.Y.) and the McCarus-Volker system (LSI Solutions, Rochester, N.Y.) may be utilized, but I prefer the Rumi.
The application of the cup must be flush with the vaginal fornices, and the intrauterine stem must be the correct length to easily mobilize the uterus from side to side as well as anterior and posterior. If the manipulator is not used and placed properly, it will be more difficult to find the cervical cup when initiating the colpotomy and maintaining the pneumoperitoneum. Some surgeons suture the cup to the cervix to provide greater traction and easier retrieval of the specimen, but I don’t find this necessary.
I always employ a left upper quadrant approach for insufflation of the abdomen. I ask anesthesia to place an orogastric tube to empty the stomach of its contents and the air that has accumulated during intubation. The patient must not have had a prior splenectomy or surgery in the left upper quadrant.