Choosing The Route of Hysterectomy

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Here’s the RoshReview Question of the Week!

​​A 49-year-old P3003 woman presents to the clinic with a complaint of heavy menses for several years and asks for definitive management. She has a history of type 4 fibroids, all < 3 cm, and hypercholesterolemia. Her obstetrical history is significant for two vaginal deliveries and one cesarean section. On physical examination, her BMI is 31 kg/m2. Her uterus is anteverted, and the fundus reaches 3 fingerbreadths below the umbilicus. What surgical intervention would be most cost- and clinically effective for this patient?

Check if you got the right answer at the links above!

Reading: Committee Opinion 701 - Choosing the Route of Hysterectomy for Benign Disease 

Why do we do a hysterectomy?  

  • Hysts are one of the most common surgeries in the United States (per the CDC, over 600,000 are performed annually) 

  • Many of them are elective - ie. patients are choosing surgical option over medical for example  

What exactly are the ways to do a hyst anyway and why does route matter?

Note: We won’t go into exact techniques here since we are a podcast. However, some great resources include the Atlas of Pelvic Surgery online: http://www.atlasofpelvicsurgery.com/home.html

Also the textbook by Baggish and Karam: Atlas of Pelvic Anatomy and Gynecologic Surgery 

Vaginal hysterectomy 

  • First type of minimally invasive hysterectomy 

  • Advantages 

    • Preferred type of hysterectomy when possible due to no incisions on the abdomen and minimally invasive route 

    • High safety and low cost

      • Meta-analysis of seven trials report similar rates of visceral injury and long-term complication among vaginal and laparoscopic procedures 

    • Minimally invasive approach associated with faster recovery compared to laparotomy 

  • Disadvantages

    • Unfortunately, despite advantages, there are fewer vaginal hysts performed compared to others due to limited training, fewer numbers of hysts overall being performed and greater diversity of operative approaches 

    • Must remove cervix with this type of procedure - no option for supracervical hyst 

    • Small chance of converting to laparotomy 

Laparoscopic hysterectomy 

  • Usually performed with laparoscopic instruments via 3-4 small ports in the abdomen. Uterus can be morcellated and removed through a bag (morcellate in bag) or via the vagina 

  • Increasing in popularity 

  • Advantages 

    • Better visualization with minimally invasive surgery 

    • Can perform supracervical hyst if needed 

    • Can also perform last part vaginally for ease if needed 

    • May be easier in some obese patients 

  • Disadvantages 

    • Requires surgeon skilled in use of laparoscopy 

    • Certain patient populations with certain medical illnesses may not tolerate Trendelenburg position or pneumoperitoneum 

    • Possibility of conversion to laparotomy 

    • Slightly higher rate of vaginal cuff dehiscence compared to other routes of hyst (still low, like 0.64-1.1%) 

Robotic hysterectomy 

  • Very similar overall in terms of advantages and disadvantages to laparoscopic hysterectomy due requiring Trendelenburg and pneumoperitoneum, as well as minimally invasive course 

  • Advantages 

    • Superior visualization compared to traditional laparoscopy due to ability to move camera and 3D vision 

    • Mechanical improvement - wrists with robots 

    • Better stabilization of instruments 

    • Improved ergonomics for surgeons - you can sit down (as someone who has definitely passed out during a long case) 

    • Even more options for minimally invasive routes (ie. single port hyst) 

  • Disadvantages 

    • Additional surgical training 

    • Does not necessarily decrease time (in fact can increase cost and operating room times) 

      • Cost of instruments overall + cost of robot 

    • Lack of haptics (no tactile feedback) 

Abdominal hysterectomy  

  • Only non minimally-invasive technique 

  • Advantages

    • Visualization 

    • Ability to remove large masses and large uteruses 

    • Tactile feedback  

    • Lowest risk of vaginal cuff dehiscence compared to other methods 

    • Studies like the VALUE study and the eVALuate trial showed decreased rates of complications of abdominal hyst compared to laparoscopic hyst, but these studies are also old (1990s) 

  • Disadvantages 

    • Increased postoperative pain and length of stay (average LOS is 3 days after abdominal hyst) 

    • Increased risk of bleeding and infection 

    • Increased risk of VTE (also may be due to increased stasis) 

    • Increased risk of colonic stasis 

How do we pick the route of hysterectomy? 

Consideration of minimally invasive routes 

  • MIS should be considered whenever possible because of well-documented advantages over abdominal hysterectomy 

  • Vaginal hyst is preferred over other types due to cost, effectiveness, and overall outcomes 

  • Even if opportunistic salpingectomy is desired, these can be performed with vaginal hysterectomy 

Anatomy 

  • Size and shape of vagina and uterus + descent of uterus 

  • More difficult to perform a vaginal hysterectomy if there is no descent, if there is large uterus (bulky fibroids) and small introitus 

    • However, nulliparity is not a contraindication to vaginal hysterectomy 

    • Study showed that 92% of vaginal hysterectomies planned for women with no prior vaginal deliveries could be successfully completed 

  • Accessibility of the uterus also important - is there likely to be a lot of pelvic adhesive disease? (endometriosis) 

    • Large uterine size - morcellation has come under scrutiny previously 

    • However, still can morcellate in a bag 

    • Even if large, bulky uterus, can refer to skilled MIS surgeon

  • Need of concurrent procedures (ie. will the patient need their appendix removed as well?) 

  • Work up: 

    • Physical exam with evaluation of mobility of uterus on bimanual 

    • Evaluation for adnexal masses on bimanual 

    • Feel for fundal height 

    • Pelvic ultrasound may be helpful 

Surgeon comfort/preference 

  • Surgeon preference for other operative routes - no longer considered an appropriate reason to avoid vaginal approach 

  • Surgeon experience 

    • Average case volume

    • Available hospital technology, devices, and support 

Patient preference 

  • If patient desires supracervical hysterectomy, will need laparoscopic or abdominal approach 

  • However, no clinically significant difference in complication and uncertain benefit in terms of patient outcomes (ie. sexual function, urinary function, bowel function)

ACOG CO 701

Endometriosis Part II: Treatment

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How do we treat endometriosis? 

  • Approach 

    • Should be based on severity of symptoms and make sure that other causes of pelvic pain are excluded 

    • Usually, medications are tried first because of the risks, recovery, and costs of surgery

    • Discussion of desire for fertility in the future can also help guide your management 

    • Review with patients that this is a chronic disease - it is not curable, but can be treated. Also, discuss that the road through treatment can be long, and that one mode of therapy that is effective for some, may not be effective for others 

  • Medical 

    • NSAIDS 

      • Can be used to treat primary dysmenorrhea, and is first line for that 

      • However, no high-quality data reporting its efficacy in endometriosis; however it is low-cost and readily available; usually combined with combined hormonal therapy 

    • Estrogen-progestin contraceptives 

      • First line treatment for endometriosis because can be used long-term, well tolerated, and are relatively easy to use 

      • No formulation has demonstrated superiority

      • Both cyclic and continuous dose appear to be effective at reducing pain, but two systemic reviews reported that continuous COC regimens were more effective at reducing pain than cyclic (meaning you take the active pills in one pack → move on to the next pack, skip the placebos) 

      • This is because COCs suppress ovarian function while they are being taken and can reduce endometriosis disease activity and pain 

      • Obviously, there are risks and benefits of taking COCs, and there are many people that cannot take COCs because of the estrogen component (check out our past episode!)

    • Progestins 

      • If people can’t take estrogen, then they can use progestin only therapy 

      • Most commonly = norethindrone acetate 5 mg by mouth daily, but can be increased by 2.5 until l15 mg daily is the max

      • Depo Provera - 150 mg IM injection q12 weeks 

      • Progestins inhibit endometrial tissue growth. It also doesn’t carry the risk of VTE with COCs, and avoids risk of bone loss and menopausal symptoms associated with GnRH agonists

      • However, side effects include increased breakthrough bleeding, weight gain (Depo Provera), mood changes 

      • Alternatives: Etonogestrel implant - observational trial of 41 women showed it decreased intensity of endometriosis-related pain

      • LNG-IUD - limited evidence, but postop IUD can reduce recurrence of dysmenorrhea in women with surgically confirmed endo 

    • Gonadotropin-releasing hormone agonists 

      • I.e., leuprolide; others are things like buserelin, goserelin, etc 

      • Meta-analysis shows they are more effective than placebo, and just as effective as other medical therapies 

      • Common doses: Leuprolide 3.75 IM qmonth or 11.25 mg q3 month 

      • However, remember that it is a GnRH AGONIST 

        • Initially, can worsen symptoms for a little bit due to initial surge of LH and FSH before eventually suppressing the HPO axis (warn patients about 7-14 days of worsening symptoms) 

      • To counteract the hypoestrogenic effects (ie. menopausal symptoms, vasomotor symptoms), usually will do add-back therapy with 5 mg oral norethindrone 

    • GNRH Antagonist 

      • Also suppress HPO axis, but does so immediately, without initial LH and FSH surge like agonists 

      • Also induces a hypoestrogenic state and can cause vasomotor symptoms, as well as leads to decrease in bone density  

      • Easier to dose because they are oral rather than IM 

      • Ex: elagolix (Orilissa), dosed 150 daily up to 200 mg twice daily 

    • Danazol

      • Can be effective in reducing pain, but not common because it can cause androgenic side effects  

    • Aromatase inhibitors 

      • Usually reserved for severe, refractory endometriosis-related pain 

      • Often used in combination with progestins 

      • Off-label use of AI 

      • Limited data overall, but does seem to decrease pain compared to placebo 

      • Similarly, can cause hypoestrogenic side effects 

    • Neuropathic pain treatments 

      • Can be used if there is still pain from endometriosis (see other below)  

  • Other 

    • Often, long-lasting pain from endometriosis can become chronic pain 

    • See our chronic pain episode → basically can lead to a cycle of lowered threshold of stimulus to cause pain, central sensitization 

    • May also need other therapy such as pelvic floor PT

    • May need neuropathic pain treatments (ie. gabapentin) to decrease sensitization. Remember to remind your patients that gabapentin does not take pain away immediately, and needs to be used consistently for several weeks 

  • A note on opioids 

    • Patients with endometriosis and pelvic pain may receive opioids for pain relief when presenting for treatment urgently 

    • Opioids should be used sparingly or avoided for endometriosis and CPP because they only treat symptoms and do not address the issue 

    • Can lead to dependence and overuse 

  • Surgical 

    • There are many, many surgeries out there for endometriosis, from simple ablation, to adhesiolysis, to nerve transections, to hysterectomies. We will cover a few 

    • Surgery offers the benefit of definitive diagnosis, but risks include damage to organs (especially if there is heavy burden of endometriosis as well as adhesions) like bladder and bowel

    • Most people will achieve initially pain relief after surgery - women who underwent operative laparoscopy were 3x more likely to report improvement in pain at 12 months than controls who had diagnostic laparoscopy (one study showed 73 vs 21%) 

    • However, nearly 20% of patient will undergo repeat surgery within 2 years because of recurrent symptoms, and risk of symptom recurrence is as high as 40% at 10 year follow up 

    • Risk factors for persistent or recurrent pain: incomplete excision, ovarian cyst drainage instead of cyst excision, and ovarian conservation

    • Endometriosis tends to get better with Menopause, and so longer latency to menopause gives more time for symptoms to recur 

    • Postoperative medical therapy: ASRM advises posteropative medical suppressive therapy for most women treated surgically 

      •  6-24 months of suppression can reduce symptom recurrence and thus potentially avoid need for multiple surgeries 

      • Best evidence comes from 2 systemic reviews: one using LNG-IUD, and another for postoperative use of COCs for prevention of relapse 

  • Surgical techniques

    • Laparoscopy generally favored over laparotomy because less invasive and improves visualization, with better recovery and shorter hospital stay, elss pain 

    • Conservative 

      • Excision or ablation of endometriosis lesions with intent of preserving the uterus and as much ovarian tissue as possible 

      • First line option for most people who want surgery for endometriosis because it preserves fertility and hormone production

      • Remember: even in young patients who don’t want fertility, hormone production is necessary for bone and cardiac health!  

      • Less invasive and morbid than definitive surgery, and there is documented short term efficacy 

      • 2014 systematic review: decreased pain and increased live birth rate after conservative surgery 

      1. Disadvantages: 

        1. Rate of recurrent symptoms is higher compared to definitive surgery 

        2. Rate of reoperation increases with time, whereas it is relatively stable with definitive surgery 

    1. Hysterectomy without oophorectomy 

      1. For patients who have debilitating symptoms and whom have completed childbearing 

      2. Failed both medical therapy and at least one conservative treatment procedure 

      3. Also reasonable if other indications for a hyst (ie symptomatic fibroids, prolapse, etc) 

      4. Effective treatment for pain symptoms from endometriosis, with reoperative rates that are relatively low (19% in one study, compared to 58% in people undergoing conservative therapy) 

      5. Disadvantages 

        1. Longer, more morbid surgery with higher rates of complication 

    2. Hysterectomy with oophorectomy

      1. Those who would benefit are those with extensive adnexal disease and those for whom the risks of reoperation outweigh the risks of premature menopause 

      2. Likely increases the efficacy of definitive surgery but is accompanied by quality of life issues and potential adverse outcomes due to early menopause 

      3. Reason to do it: endometriosis is an estrogen-dependent disease, and tends to get better with menopause 

      4. Early menopause (<44 years) is associated with increase risks of overall mortality, cardiovascular disease, neurologic disease, osteoporosis 

Laparoscopy IV: Pneumoperitoneum

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We’re back today with Dr. Ruhotina and the next piece in our laparoscopy series. Today we’re talking all about gas and pneumoperitoneum. As before, Dr. Ruhotina made some awesome notes — take a look below!

Pneumoperitoneum Physiology 

-        Laparoscopic surgery involves insufflation of a gas (usually carbon dioxide) into the peritoneal cavity producing a pneumoperitoneum

-        Causes an increase in intra-abdominal pressure (IAP)

-        Insufflated at a rate of 4-6 L/Min to a pressure of 10-20mmHg

-        The pressure is maintained by a constant gas flow of 200-400 ml/min

Cardiovascular effects

-        Increased IAP affects venous return, systemic vascular resistance and myocardial function 

-        Increases in IAP result in compression of the vena cava decrease venous return decrease cardiac output 

-        Systemic vascular resistance is increase because of direct effects of IAP (+ increased circulating catecholamines)

o   The SVR change is usually greater than the reduction in cardiac output results in maintaining or even increasing systemic blood pressure

-        Increase SVR, systolic and diastolic pressures and tachycardia increased myocardial work load 

-        If IAP increases further decrease cardiac output further  decrease blood pressure 

Respiratory 

-        Supine position and general anesthesia decrease functional residual capacity 

-        Pneumoperitoneum + Trendelenburg cephalad shift of diaphragm further decrease FRC 

o   Can lead to atelectasis, ventilation-perfusion mismatch, potential hypoxemia, and hypercarbia 

Renal  Increased IAP increased renal vascular resistance and reduction in GFR decreased function and urine output 

 

GI Increased IAP can potential lead to regurgitation of gastric content with increased risk of pulmonary aspiration 

 

Neurological Rise in IAP increased intracranial pressure may result in decreased cerebral perfusion pressure 

 

Effects of gas absorption

-        CO2 most frequently used gas for insufflation colourless, nontoxic, nonflammable and has the greatest margin of safety in the event of a venous embolus since it is rapidly absorbed from the peritoneal cavity, additionally the  metabolic end products easily exhaled through the pulmonary alveoli. 

-        Alternatives to CO2: NO, Air, Helium, Argon

o   NO: Benefits: less acid-base disturbance, may be better for severe cardiopul disease, less post op pain, Risks: supports combustion, not flammable itself only when combustible gas present hydrogen or methane seen with bowel perforation

o   Argon/Helium(inert gases): avoids complications of hypercarbia or acidosis, although decreased solubility in blood therefore increased risk of extraperitoneal gas extravasation such as gas embolus, more expensive 

-        CO2 gas can be administered cold or heated, with or without humidification.

o   Compared with cold gas, heated gas led to only a minimal, clinically insignificant rise in core body temperature of 0.31° Celsius (95% CI 0.09-0.53), without any meaningful improvement in patient outcomes or ease of surgery extra cost of heating and/or humidifying gas used in laparoscopy cannot be justified, according to a Cochrane review of 22 randomized trials

-        Absorbed readily from peritoneum causing increase in PaCO2  increasing cardiac contractility and reduction in diastolic filling which can result in decreased myocardial oxygen supply to demand ratio and greater risk of myocardial ischemia 

-        Arrythmias  nodal rhythm, sinus bradycardia and asystole attributed to vagal stimulation that can be initiated by stretching the peritoneum 

o   Can see this effect more pronounced at the beginning of insufflation 

-        Subcutaneous emphysema, pneumomediastinum and pneumothorax

o   May occur because of incorrect positioning of the gas insufflation needle or trocars or by gas dissecting across weak tissue planes attributed to increased abdominal pressure

-        Venous gas embolism

o   Rare but fatal complication

o   May occur if carbon dioxide is insufflated directly into a blood vessel or by gas being drawn into an open vessel 

o   The physiological effect caused by CO2 are less than that with air because of its greater solubility 

o   However you can see hypotension, desaturation, and mill wheel murmur 

o   Treatment rapid deflation of the abdomen and resuscitation, place in left lateral position and the air aspirated from the central line 

 

Indicators on insufflator machines: 

Important readings of insufflator.

  • Preset Insufflation pressure,

  • Actual Pressure

  • Gas flow rate and

  • Volume of gas consumed

 

Preset Pressure

-        Pressure adjusted by surgeon before starting insufflation

-        The preset pressure ideally should be 12 mmhg- 15mmhg

-        Fifteen mmHg is used as the standard insufflation pressure. 

o   multiple reasons for the use of a 15 mmHg threshold most importantly it is a function of basic cardiovascular physiology

o   Elevated IAP exerts its effects primarily on the cardiovascular system and secondarily on the pulmonary and renal systems. It is well known that the cardiopulmonary, renal and abdominal affects are minimal and still reversible at an insufflation pressure of less then or equal to 15mmHg

o   Animal studies have shown that an intra-abdominal pressures of 20 mmHg has the following effects:

§  markedly impairs renal function, reducing GFR and RBF to 21% and 23% of their baseline values

§  Adverse cardiac and pulmonary effects for prolonged intra-abdominal pressures of 20mmHg lasting over three hours

§  Brief increases to a pressure of 20mm are tolerable

-        Whenever intra abdominal pressure decreases due to leak of gas outside, insufflator eject some gas inside to maintain the pressure equal to preset pressure and if intra-abdominal pressure increases due to external pressure, insufflator sucks some gas from abdominal cavity to again maintain the pressure to preset pressure.

 

Actual Pressure

-        Actual intra-abdominal pressure sensed by insufflator

-        With veress needle is attached there is some error in actual pressure reading because of resistance of flow of gas through small caliber of veress needle. Many microprocessor controlled good quality insufflator deliver pulsatile flow of gas when veress needle is connected, in which the low reading of actual pressure measures the true intra-abdominal pressure.

-        If there is any major gas leak actual pressure will be less and insufflator will try to maintain the pressure by ejecting gas through its full capacity.

 

Flow rate

-        Rate of flow of CO2 though the tubing of insufflator

-        Some information suggests that when you attach the veress needle the flow rate should be adjusted for 1 liter per minute. 

o   Experiment were performed on animals where direct I.V. CO2 were administered and it was found that risk of air embolism is less if rate is within 1 liter/minute.

o   At the time of access using veress needle technique sometime veress needle may be inadvertently enter inside a vessel but if the flow rate is 1 liter/minute there is less chance of serious complication

-        When initial pneumoperitoneum is achieved and canulla is inside abdominal cavity the insufflators flow rate may be set at maximum

 

Total Gas used

-        Fourth indicator of insufflator

-        Normal size human abdominal cavity need 1.5 liter CO2 to achieve intra-abdominal actual pressure of 12 mm Hg. In some big size abdominal cavity and in multipara patients sometime we need 3 liter of CO2 (rarely 5 to 6 liters) to get desired pressure of 12mm Hg. Whenever there is less or more amount of gas is used to inflate a normal abdominal cavity, surgeon should suspect some error in pneumoperitoneum technique. These errors may be leak or may be pre-peritoneal space creation or extravasations of gas.

 

Prior to starting your case: 

-        Turn the insufflator on and check the carbon dioxide (CO2) cylinder to make sure it contains sufficient gas to complete the procedure

o   Have extra CO2 container in room if needed

-        Check the insufflator to assure it is functioning properly

o   After  connecting sterile insufflation tubing  Turn the insufflator to high flow the actual pressure indicator should register 0 

o   Kink the tubing to shut off the flow of gas The pressure indicator should rapidly rise to 30mmHg and flow indicator should go to zero (Fig. 2.2). The pressure/flow shutoff mechanism is essential to the performance of safe laparoscopy. These simple checks verify that it is operating properly. 

 

Closed entry abdominal technique opening abdominal pressure

-        several prospective studies have demonstrated that the initial intra- abdominal pressure (IAP) 8 mmHg provides a reliable confirmation of appropriate Veress needle tip placement through the umbilicus or Palmer’s point [48–50]. 

o   In obese women IAP may be higher than in non-obese women, and can be up to 10 mmHg when the Veress needle is correctly inserted. 

 

TROUBLESHOOTING 

  • Loss of working space → ACTUAL PRESSURE HIGHER THAN SET PRESSURE, FLOW RATE = 0

    • Check actual and set pressure of pneumoperitoneum

    • Check status of relaxation of the patient (look for intraabdominal muscle contractions or firmness of abdomen, this is different than anesthesia checking neuromuscular twitch as diaphragm relaxation is different than intraabdominal)

    • Check valve on for connection insufflator tubing

    • Check insufflator tubing along the entire path, make sure it is not kinked

    • Mechanical obstruction- kinking of tubing, someone standing on tubing, closed valve 

  • Loss of working space→ ACTUAL PRESSURE LOWER THAN SET PRESSURE, FLOW RATE= HIGH indicates a leak 

    • Check insufflator tubing to make sure tubing is connected to insufflator and port

    • Check all ports and make sure the valves are closed

    • Check all ports for leaking co2 

    • Check for distention of bowel and bladder catheter as CO2 can escape into hollow organ (bladder or bowel)

  • Loss of working space→ ACTUAL PRESSURE IS LOWER THAN SET PRESSURE, FLOW RATE=0 (no flow)

    • Ensure power is on 

    • Check tank gas level

  • If screen blank

    • Most likely = disconnected power cords, disconnected cables, blown light source, disconnected light cable 

Fundamentals of Laparoscopy: Part III

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Today we’re joined again by Dr. Merima Ruhotina, a minimally-invasive gynecologic surgery fellow at Yale New Haven Hospital in Connecticut. Meri has prepared for us a big series on laparoscopy in gynecology covering many of the fundamentals, particularly to help with the aptly named “Fundamentals of Laparoscopic Surgery” exam that ABOG began to require in 2020.

Here are her notes for Part III!

Fundamentals of Laparoscopy: Part II

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Today we’re joined again by Dr. Merima Ruhotina, a minimally-invasive gynecologic surgery fellow at Yale New Haven Hospital in Connecticut. Meri has prepared for us a big series on laparoscopy in gynecology covering many of the fundamentals, particularly to help with the aptly named “Fundamentals of Laparoscopic Surgery” exam that ABOG began to require in 2020.

Here are her notes for Part II!