ISTERECTOMIA MINIINVASIVA Massimo Luerti Dipartimento Materno Infantile Unità Operativa di Ostetricia e Ginecologia 1 A.O. della Provincia di Lodi Ospedale Maggiore di Lodi massimo.luerti@ao.lodi.it

ALTERNATIVE TECNICHE ATTUALI PER L’ISTERECTOMIA Isterectomia totale - laparotomica tradizionale - minilaparotomica - vaginale - laparoscopica Isterectomia subtotale - addominale

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

Mehra S Gynaecol Endosc 1999 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

Certified Vaginal Zealot “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 10.3 Vaginale 68 Addominale % Via 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 Infections 10.5% 13.0% 9.0% 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 9.7% (*) 10.9% 20.1% THL VH AH *-Chapron. 235 pz ,1999

Fistola vescicovaginale 1 (0.1) 1 (0.1) Danni intestinali 1 (0.1) 0 RUOLO DELLA CURVA DI APPRENDIMENTO NELLE COMPLICANZE DELL’ISTERECTOMIA LAPAROSCOPICA (A. Wattiez, 2002) 1989-1995 1996-1999 (n=695) (n=952) Trasfusioni 15 (2.2) 1 (0.1) Danni vescicali 11 (1.6) 6 (0.6) Danni ureterali 4 (0.6) 2 (0.2) Fistola vescicovaginale 1 (0.1) 1 (0.1) Danni intestinali 1 (0.1) 0 Reinterventi 9 (1.3) 3 (0.3) Ematoma parietale 10 5 Ematoma cupola vaginale 3 4 Iperpiressia 14 4 Infezione cupola vaginale 4 0 Infezione della parete 2 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

American College of Obstetricians and Gynecologists (ACOG), 1995 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 utero- sacrali 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

Type 0: Laparoscopic-directed preparation for vaginal hysterectomy 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 cardinal- uterosacral 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, radiofrequency- based 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

Suture (n 30) EBVS Statistical Significance (P) ELECTROSURGICAL BIPOLAR VESSEL SEALING IN VAGINAL HYSTERECTOMY .005 126.7 113.3 100 (25–600) 68.9 51.6 50.0 (20–200) Estimated blood loss (mL) .014 60.3 27.9 55.5 (37–160) 48.0 26.8 42.0 (22–93) Total procedure time* (min) .003 53.6 26.7 47 39.1 17.7 36 Procedure time (min) Statistical Significance (P) Suture (n 30) EBVS 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

+++ ++ + ++++ - no partially Yes Vcare Rumi Clermont Ferrand Hourcabie Tenuta del gas Maneggevolezza ++++ Facilità d’uso - Movimenti indipendenti Identificazione fornici Movimenti d’elevazione Movimenti laterali Movimenti anti- retroversione no partially Yes Poliuso Vcare Rumi Clermont Ferrand Hourcabie

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 “Cruciate Incision” 4-8 cm transverse skin incision 6-8 cm. vertical fascial incision

ISTERECTOMIA SUBTOTALE MINOR DURATA INTERVENTO ? MINORI COMPLICANZE e MIGLIOR RECUPERO POST-POSTOPERATORIO? RISCHIO DI CANCRO CERVICALE? MINOR INCIDENZA PROLASSI VAGINALI ? MINORI DANNI NEUROLOGICI A VESCICA, URETRA E PUNTO G? MIGLIORE ATTIVITA' SESSUALE ? ESITI NEGATIVI A DISTANZA?

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

Intercourse frequency worse outcome 42% (n = 10) 15% (n = 5) 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

Prospective study of 67 LSH Cervical stump biopsied at 12 and 6:00 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