Surgical Techniques

The author has no financial relationships relevant to this article.

CASE: Inadvertent ureteral transection

A gynecologic surgeon operates via Pfannenstiel incision to remove a 12-cm complex left adnexal mass from a 36-year-old obese woman. When she discovers that the mass is densely adherent to the pelvic peritoneum, the surgeon incises the peritoneum lateral to the mass and opens the retroperitoneal space. However, the size and relative immobility of the mass, coupled with the low transverse incision, impair visualization of retroperitoneal structures.

The surgeon clamps and divides the ovarian vessels above the mass but, afterward, suspects that the ureter has been transected and that its ends are included within the clamps. She separates the ovarian vessels above the clamp and ligates them, at which time transection of the ureter is confirmed.

How should she proceed?

The ureter is intimately associated with the female internal genitalia in a way that challenges the gynecologic surgeon to avoid it. In a small percentage of cases involving surgical extirpation in a woman who has severe pelvic pathology, ureteral injury may be inevitable.

Several variables predispose a patient to ureteral injury, including limited exposure, as in the opening case. Others include distorted anatomy of the urinary tract relative to internal genitalia and operations that require extensive resection of pelvic tissues.

This article describes:

• prevention and intraoperative recognition of ureteral injury during gynecologic surgery
• management of intraoperatively recognized ureteral injury.

Maintain a high index of suspicion

The surgeon in the opening case has already taken the first and most important step in ensuring a good outcome: She suspected ureteral injury. In high-risk situations, intraoperative recognition of ureteral injury is more likely when the operative field is inspected thoroughly during and at the conclusion of the surgical procedure.

In a high-risk case, the combined use of intravenous indigo carmine, careful inspection of the operative field, cystoscopy, and ureteral dissection is recommended and should be routine.

Common sites of injury

During gynecologic surgery, the ureter is susceptible to injury along its entire course through the pelvis (see “The ureter takes a course fraught with hazard,”).

During adnexectomy, the gonadal vessels are generally ligated 2 to 3 cm above the adnexa. The ureter lies in close proximity to these vessels and may inadvertently be included in the ligation.

During hysterectomy, the ureter is susceptible to injury as it passes through the parametrium a short distance from the uterus and vaginal fornix.

Sutures placed in the posterior lateral cul de sac during prolapse surgery lie near the midpelvic ureter, and sutures placed during vaginal cuff closure, anterior colporrhaphy, and retropubic urethropexy are in close proximity to the trigonal portion of the ureter.

The ureter takes a course fraught with hazard

The ureter extends from the renal pelvis to the bladder, with a length that ranges from 25 to 30 cm, depending on the patient’s height. It crosses the pelvic brim near the bifurcation of the common iliac artery, where it becomes the “pelvic” ureter. The abdominal and pelvic portions of the ureter are approximately equal in length.

ILLUSTRATIONS BY ROB FLEWELL FOR OBG MANAGEMENT

The blood supply of the ureter derives from branches of the major arterial system of the lower abdomen and pelvis. These branches reach the medial aspect of the abdominal ureter and the lateral side of the pelvic ureter to form an anastomotic vascular network protected by an adventitial layer surrounding the ureter.

The ureter is attached to the posterior lateral pelvic peritoneum running dorsal to ovarian vessels. At the midpelvis, it separates from the peritoneum to pierce the base of the broad ligament underneath the uterine artery. At this point, the ureter is about 1.5 to 2 cm lateral to the uterus and curves medially and ventrally, tunneling through the cardinal and vesicovaginal ligaments to enter the bladder trigone.

Risky procedures

In gynecologic surgery, ureteral injury occurs most often during abdominal hysterectomy—probably because of how frequently this operation is performed and the range of pathology managed. The incidence of ureteral injury is much higher during abdominal hysterectomy than vaginal hysterectomy.^1-4

Laparoscopic hysterectomy also has been associated with a higher incidence of ureteral injury, especially in the early phase of training.^5,6 Possible explanations include:

• greater difficulty identifying the ureter
• a steeper learning curve
• more frequent use of energy to hemostatically divide pedicles, with the potential for thermal injury
• less traction–countertraction, resulting in dissection closer to the ureter
• management of complex pathology.

Although the overall incidence of ureteral injury during adnexectomy is low, it is probably much higher in women undergoing this procedure after a previous hysterectomy or in the presence of complex adnexal pathology.

When injury is likely

Compromised exposure, distorted anatomy, and certain procedures can heighten the risk of ureteral injury. Large tumors may limit the ability of the surgeon to visualize or palpate the ureter (FIGURE 1). Extensive adhesions may cause similar difficulties, and a small incision or obesity may hinder identification of pelvic sidewall structures.

A number of pathologic conditions can distort the anatomy of the ureter, especially as it relates to the female genital tract:

• Malignancies such as ovarian cancer often encroach on and occasionally encase the ureter
• Pelvic inflammatory disease, endometriosis, and a history of surgery or pelvic radiotherapy can retract and encase the ureter toward the gynecologic tract
• Some masses expand against the lower ureter, such as cervical or broad-ligament leiomyomata or placenta previa with accreta
• During vaginal hysterectomy for complete uterine prolapse, the ureters frequently extend beyond the introitus well within the operative field
• Congenital anomalies of the ureter or hydroureter can also cause distortion.

Even in the presence of relatively normal anatomy, certain procedures predispose the ureter to injury. For example, radical hysterectomy involves the almost complete separation of the pelvic ureter from the gynecologic tract and its surrounding soft tissue. When pelvic pathology is significant, the plane of dissection will always be near the ureter.

FIGURE 1 Access to the ureter is obstructed, putting it in jeopardy

Large tumors may limit the ability of the surgeon to visualize or palpate the ureter.

Prevention is the best strategy

At least 50% of ureteral injuries reported during gynecologic surgery have occurred in the absence of a recognizable risk factor.^2,7 Nevertheless, knowledge of anatomy and the ability to recognize situations in which there is an elevated risk for ureteral injury will best enable the surgeon to prevent such injury.

When a high-risk situation is encountered, critical preventive steps include:

• adequate exposure
• competent assistance
• exposure of the path of the ureter through the planned course of dissection. Dissecting the ureter beyond this area is usually unnecessary and may itself cause injury.

Skip preoperative IVP in most cases

The vast majority of women who undergo gynecologic surgery do not benefit from preoperative intravenous pyelography (IVP). This measure does not appear to reduce the likelihood of ureteral injury, even in the face of obvious gynecologic disease. However, preoperative identification of obvious ureteral involvement by the disease process is useful. In such cases, the plane of dissection will probably lie closer to the ureter. One of the goals of surgery will then be to clear the urinary tract from the affected area.

When there is a high index of suspicion of an abnormality such as obstruction, intrinsic ureteral endometriosis, or congenital anomaly, preoperative IVP is indicated.

A stent may be helpful in some cases

Ureteral stents are sometimes placed in order to aid in identification and dissection of the ureters during surgery. Some authors of reports on this topic, including Hoffman, believe that stents are useful in certain situations, such as excision of an ovarian remnant, radical vaginal hysterectomy, and when pelvic organs are encased by malignant ovarian tumors. However, stents do not clearly reduce the risk of injury and, in some cases, may increase the risk by providing a false sense of security and predisposing the ureter to adventitial injury during difficult dissection.

Anticipate the effects of disease

The surgeon must have a thorough knowledge of the gynecologic disease process as it relates to surgery involving the urinary tract. For example, an ovarian remnant will almost always be somewhat densely adherent to the pelvic ureter. When severe endometriosis involves the posterior leaf of the broad ligament, the ureter will often be fibrotically retracted toward the operative field.

Certain procedures have special challenges. During resection of adnexa, for example, it is important that the ureter be identified in the retroperitoneum before the ovarian vessels are ligated. During hysterectomy, soft tissues that contain the bladder and ureters should be mobilized caudally and laterally, respectively, creating a U-shaped region (“U” for urinary tract, FIGURE 2) to which the surgeon must limit dissection.

FIGURE 2 During hysterectomy, mobilize the bladder and ureter

Mobilize the soft tissues that contain the bladder and ureters caudally and laterally, respectively, creating a U-shaped region. During division of the paracervical tissues, the surgeon must remain within this region.

Intraoperative detection

Two main types of ureteral injury occur during gynecologic surgery: transection and destruction. The latter includes ligation, crushing, devascularization, and thermal injury.

Intraoperative detection of ureteral injury is more likely when the surgeon recognizes at the outset that the operation places the ureter at increased risk. When dissection has been difficult or complicated for any reason, be concerned about possible injury.

In general, ureteral injury is first recognized by careful inspection of the surgical field. Begin by instilling 5 ml of indigo carmine intravenously. Once the dye begins to appear in the Foley catheter, inspect the area of dissection under a small amount of irrigation fluid, looking for extravasation of dye that indicates partial or complete transection.

If no injury is identified, cystoscopy is the next step. I perform all major abdominal operations with the patient in the low lithotomy position, which provides easy access to the perineum. Cystoscopic identification of urine jetting from both ureteral orifices confirms patency. When only wisps of dye are observed, it is likely that the ureter in question has been partially occluded (e.g., by acute angulation). Failure of any urine to appear from one of the orifices highly suggests injury to that ureter.

During inspection of the operative field, attempt to pass a ureteral stent into the affected orifice. If the stent passes easily and dyed urine is seen to drip freely from it, look for possible angulation of the ureter. If you find none, remove the stent and inspect the orifice again for jetting urine.

If the ureteral stent will move only a few centimeters into the ureteral orifice, ligation (with or without transection) is likely. In this case, leave the stent in place. If the operative site is readily accessible, dissect the applicable area to identify the problem. Depending on the circumstances, you may wish to infuse dye through the stent to aid in operative identification or radiographic evaluation.

Intraoperative IVP may be useful, especially when cystoscopy is unavailable.

Fundamentals of repair

Repair of major injury to the pelvic ureter is generally best accomplished by ureteroneocystostomy or, in selected cases involving injury to the proximal pelvic ureter, by ureteroureterostomy.

When intraoperatively recognized injury to the pelvic ureter appears to be minor, it can be managed by placing a ureteral stent and a closed-suction pelvic drain. Also consider wrapping the injured area with vascularized tissue such as perivesical fat. Minor lacerations can be closed perpendicular to the axis of the ureter using interrupted 4-0 delayed absorbable suture.

Most injuries to the pelvic ureter are optimally managed by ureteroneocystostomy (FIGURE 3). When a significant portion of the pelvic ureter has been lost, ureteroneocystostomy usually requires a combination of:

• extensive mobilization of the bladder
• conservative mobilization of the ureter
• elongation of the bladder
• psoas hitch.

When necessary, mobilization of the kidney with suturing of the caudal perinephric fascia to the psoas muscle will bridge an additional 2- to 3-cm gap.

Major injury to the distal half of the pelvic ureter is repaired using straightforward ureteroneocystostomy.

When there is no significant pelvic disease and the distal ureter is healthy, injury to the proximal pelvic ureter during division of the ovarian vessels may be repaired via ureteroureterostomy. If the ureteral ends will be anastomosed on tension or there is any question about the integrity of the distal portion of the ureter, as when extensive distal ureterolysis has been necessary, consider ureteroneocystostomy.

FIGURE 3 When the distal ureter is injured

Most injuries to the pelvic ureter are managed optimally by ureteroneocystostomy.

Postoperative management

After repair of a ureteral injury, leave a closed-suction pelvic drain in place for 2 to 3 days so that any major urinary leak can be detected; it also enhances spontaneous closure and helps prevent potentially infected fluid from accumulating in the region of anastomosis.

The cystotomy performed during ureteroneocystostomy generally heals quickly with a low risk of complications.

Leave a large-bore (20 or 22 French) urethral Foley catheter in place for 2 weeks.

I recommend that a 6 French double-J ureteral stent be left in place for 6 weeks. Potential benefits of the stent include:

• prevention of stricture
• stabilization and immobilization of the ureter during healing
• reduced risk of extravasation of urine
• reduced risk of angulation of the ureter
• isolation of the repair from infection, retroperitoneal fibrosis, and cancer.

I perform IVP approximately 1 week after stent removal to ensure ureteral patency.

CASE RESOLVED

Exposure is improved by widening the incision and dividing the tendonous insertions of the rectus abdominus muscles. The surgeon then removes the mass, preserving the distal ureter, which is estimated to be 12 cm in length and to have intact adventitia.

The surgeon performs a double-spatulated end-to-end ureteroureterostomy over a 6 French double-J ureteral stent that has been passed proximally into the renal pelvis and distally into the bladder. The stent is removed 6 weeks postoperatively, and an IVP the following week demonstrates excellent patency.

The author has no financial relationships relevant to this article.

CASE: Inadvertent ureteral transection

A gynecologic surgeon operates via Pfannenstiel incision to remove a 12-cm complex left adnexal mass from a 36-year-old obese woman. When she discovers that the mass is densely adherent to the pelvic peritoneum, the surgeon incises the peritoneum lateral to the mass and opens the retroperitoneal space. However, the size and relative immobility of the mass, coupled with the low transverse incision, impair visualization of retroperitoneal structures.

The surgeon clamps and divides the ovarian vessels above the mass but, afterward, suspects that the ureter has been transected and that its ends are included within the clamps. She separates the ovarian vessels above the clamp and ligates them, at which time transection of the ureter is confirmed.

How should she proceed?

The ureter is intimately associated with the female internal genitalia in a way that challenges the gynecologic surgeon to avoid it. In a small percentage of cases involving surgical extirpation in a woman who has severe pelvic pathology, ureteral injury may be inevitable.

Several variables predispose a patient to ureteral injury, including limited exposure, as in the opening case. Others include distorted anatomy of the urinary tract relative to internal genitalia and operations that require extensive resection of pelvic tissues.

This article describes:

• prevention and intraoperative recognition of ureteral injury during gynecologic surgery
• management of intraoperatively recognized ureteral injury.

Maintain a high index of suspicion

The surgeon in the opening case has already taken the first and most important step in ensuring a good outcome: She suspected ureteral injury. In high-risk situations, intraoperative recognition of ureteral injury is more likely when the operative field is inspected thoroughly during and at the conclusion of the surgical procedure.

In a high-risk case, the combined use of intravenous indigo carmine, careful inspection of the operative field, cystoscopy, and ureteral dissection is recommended and should be routine.

Common sites of injury

During gynecologic surgery, the ureter is susceptible to injury along its entire course through the pelvis (see “The ureter takes a course fraught with hazard,”).

During adnexectomy, the gonadal vessels are generally ligated 2 to 3 cm above the adnexa. The ureter lies in close proximity to these vessels and may inadvertently be included in the ligation.

During hysterectomy, the ureter is susceptible to injury as it passes through the parametrium a short distance from the uterus and vaginal fornix.

Sutures placed in the posterior lateral cul de sac during prolapse surgery lie near the midpelvic ureter, and sutures placed during vaginal cuff closure, anterior colporrhaphy, and retropubic urethropexy are in close proximity to the trigonal portion of the ureter.

The ureter takes a course fraught with hazard

The ureter extends from the renal pelvis to the bladder, with a length that ranges from 25 to 30 cm, depending on the patient’s height. It crosses the pelvic brim near the bifurcation of the common iliac artery, where it becomes the “pelvic” ureter. The abdominal and pelvic portions of the ureter are approximately equal in length.

ILLUSTRATIONS BY ROB FLEWELL FOR OBG MANAGEMENT

The blood supply of the ureter derives from branches of the major arterial system of the lower abdomen and pelvis. These branches reach the medial aspect of the abdominal ureter and the lateral side of the pelvic ureter to form an anastomotic vascular network protected by an adventitial layer surrounding the ureter.

The ureter is attached to the posterior lateral pelvic peritoneum running dorsal to ovarian vessels. At the midpelvis, it separates from the peritoneum to pierce the base of the broad ligament underneath the uterine artery. At this point, the ureter is about 1.5 to 2 cm lateral to the uterus and curves medially and ventrally, tunneling through the cardinal and vesicovaginal ligaments to enter the bladder trigone.

Risky procedures

In gynecologic surgery, ureteral injury occurs most often during abdominal hysterectomy—probably because of how frequently this operation is performed and the range of pathology managed. The incidence of ureteral injury is much higher during abdominal hysterectomy than vaginal hysterectomy.^1-4

Laparoscopic hysterectomy also has been associated with a higher incidence of ureteral injury, especially in the early phase of training.^5,6 Possible explanations include:

• greater difficulty identifying the ureter
• a steeper learning curve
• more frequent use of energy to hemostatically divide pedicles, with the potential for thermal injury
• less traction–countertraction, resulting in dissection closer to the ureter
• management of complex pathology.

Although the overall incidence of ureteral injury during adnexectomy is low, it is probably much higher in women undergoing this procedure after a previous hysterectomy or in the presence of complex adnexal pathology.

When injury is likely

Compromised exposure, distorted anatomy, and certain procedures can heighten the risk of ureteral injury. Large tumors may limit the ability of the surgeon to visualize or palpate the ureter (FIGURE 1). Extensive adhesions may cause similar difficulties, and a small incision or obesity may hinder identification of pelvic sidewall structures.

A number of pathologic conditions can distort the anatomy of the ureter, especially as it relates to the female genital tract:

• Malignancies such as ovarian cancer often encroach on and occasionally encase the ureter
• Pelvic inflammatory disease, endometriosis, and a history of surgery or pelvic radiotherapy can retract and encase the ureter toward the gynecologic tract
• Some masses expand against the lower ureter, such as cervical or broad-ligament leiomyomata or placenta previa with accreta
• During vaginal hysterectomy for complete uterine prolapse, the ureters frequently extend beyond the introitus well within the operative field
• Congenital anomalies of the ureter or hydroureter can also cause distortion.

Even in the presence of relatively normal anatomy, certain procedures predispose the ureter to injury. For example, radical hysterectomy involves the almost complete separation of the pelvic ureter from the gynecologic tract and its surrounding soft tissue. When pelvic pathology is significant, the plane of dissection will always be near the ureter.

FIGURE 1 Access to the ureter is obstructed, putting it in jeopardy

Large tumors may limit the ability of the surgeon to visualize or palpate the ureter.

Prevention is the best strategy

At least 50% of ureteral injuries reported during gynecologic surgery have occurred in the absence of a recognizable risk factor.^2,7 Nevertheless, knowledge of anatomy and the ability to recognize situations in which there is an elevated risk for ureteral injury will best enable the surgeon to prevent such injury.

When a high-risk situation is encountered, critical preventive steps include:

• adequate exposure
• competent assistance
• exposure of the path of the ureter through the planned course of dissection. Dissecting the ureter beyond this area is usually unnecessary and may itself cause injury.

Skip preoperative IVP in most cases

The vast majority of women who undergo gynecologic surgery do not benefit from preoperative intravenous pyelography (IVP). This measure does not appear to reduce the likelihood of ureteral injury, even in the face of obvious gynecologic disease. However, preoperative identification of obvious ureteral involvement by the disease process is useful. In such cases, the plane of dissection will probably lie closer to the ureter. One of the goals of surgery will then be to clear the urinary tract from the affected area.

When there is a high index of suspicion of an abnormality such as obstruction, intrinsic ureteral endometriosis, or congenital anomaly, preoperative IVP is indicated.

A stent may be helpful in some cases

Ureteral stents are sometimes placed in order to aid in identification and dissection of the ureters during surgery. Some authors of reports on this topic, including Hoffman, believe that stents are useful in certain situations, such as excision of an ovarian remnant, radical vaginal hysterectomy, and when pelvic organs are encased by malignant ovarian tumors. However, stents do not clearly reduce the risk of injury and, in some cases, may increase the risk by providing a false sense of security and predisposing the ureter to adventitial injury during difficult dissection.

Anticipate the effects of disease

The surgeon must have a thorough knowledge of the gynecologic disease process as it relates to surgery involving the urinary tract. For example, an ovarian remnant will almost always be somewhat densely adherent to the pelvic ureter. When severe endometriosis involves the posterior leaf of the broad ligament, the ureter will often be fibrotically retracted toward the operative field.

Certain procedures have special challenges. During resection of adnexa, for example, it is important that the ureter be identified in the retroperitoneum before the ovarian vessels are ligated. During hysterectomy, soft tissues that contain the bladder and ureters should be mobilized caudally and laterally, respectively, creating a U-shaped region (“U” for urinary tract, FIGURE 2) to which the surgeon must limit dissection.

FIGURE 2 During hysterectomy, mobilize the bladder and ureter

Mobilize the soft tissues that contain the bladder and ureters caudally and laterally, respectively, creating a U-shaped region. During division of the paracervical tissues, the surgeon must remain within this region.

Intraoperative detection

Two main types of ureteral injury occur during gynecologic surgery: transection and destruction. The latter includes ligation, crushing, devascularization, and thermal injury.

Intraoperative detection of ureteral injury is more likely when the surgeon recognizes at the outset that the operation places the ureter at increased risk. When dissection has been difficult or complicated for any reason, be concerned about possible injury.

In general, ureteral injury is first recognized by careful inspection of the surgical field. Begin by instilling 5 ml of indigo carmine intravenously. Once the dye begins to appear in the Foley catheter, inspect the area of dissection under a small amount of irrigation fluid, looking for extravasation of dye that indicates partial or complete transection.

If no injury is identified, cystoscopy is the next step. I perform all major abdominal operations with the patient in the low lithotomy position, which provides easy access to the perineum. Cystoscopic identification of urine jetting from both ureteral orifices confirms patency. When only wisps of dye are observed, it is likely that the ureter in question has been partially occluded (e.g., by acute angulation). Failure of any urine to appear from one of the orifices highly suggests injury to that ureter.

During inspection of the operative field, attempt to pass a ureteral stent into the affected orifice. If the stent passes easily and dyed urine is seen to drip freely from it, look for possible angulation of the ureter. If you find none, remove the stent and inspect the orifice again for jetting urine.

If the ureteral stent will move only a few centimeters into the ureteral orifice, ligation (with or without transection) is likely. In this case, leave the stent in place. If the operative site is readily accessible, dissect the applicable area to identify the problem. Depending on the circumstances, you may wish to infuse dye through the stent to aid in operative identification or radiographic evaluation.

Intraoperative IVP may be useful, especially when cystoscopy is unavailable.

Fundamentals of repair

Repair of major injury to the pelvic ureter is generally best accomplished by ureteroneocystostomy or, in selected cases involving injury to the proximal pelvic ureter, by ureteroureterostomy.

When intraoperatively recognized injury to the pelvic ureter appears to be minor, it can be managed by placing a ureteral stent and a closed-suction pelvic drain. Also consider wrapping the injured area with vascularized tissue such as perivesical fat. Minor lacerations can be closed perpendicular to the axis of the ureter using interrupted 4-0 delayed absorbable suture.

Most injuries to the pelvic ureter are optimally managed by ureteroneocystostomy (FIGURE 3). When a significant portion of the pelvic ureter has been lost, ureteroneocystostomy usually requires a combination of:

• extensive mobilization of the bladder
• conservative mobilization of the ureter
• elongation of the bladder
• psoas hitch.

When necessary, mobilization of the kidney with suturing of the caudal perinephric fascia to the psoas muscle will bridge an additional 2- to 3-cm gap.

Major injury to the distal half of the pelvic ureter is repaired using straightforward ureteroneocystostomy.

When there is no significant pelvic disease and the distal ureter is healthy, injury to the proximal pelvic ureter during division of the ovarian vessels may be repaired via ureteroureterostomy. If the ureteral ends will be anastomosed on tension or there is any question about the integrity of the distal portion of the ureter, as when extensive distal ureterolysis has been necessary, consider ureteroneocystostomy.

FIGURE 3 When the distal ureter is injured

Most injuries to the pelvic ureter are managed optimally by ureteroneocystostomy.

Postoperative management

After repair of a ureteral injury, leave a closed-suction pelvic drain in place for 2 to 3 days so that any major urinary leak can be detected; it also enhances spontaneous closure and helps prevent potentially infected fluid from accumulating in the region of anastomosis.

The cystotomy performed during ureteroneocystostomy generally heals quickly with a low risk of complications.

Leave a large-bore (20 or 22 French) urethral Foley catheter in place for 2 weeks.

I recommend that a 6 French double-J ureteral stent be left in place for 6 weeks. Potential benefits of the stent include:

• prevention of stricture
• stabilization and immobilization of the ureter during healing
• reduced risk of extravasation of urine
• reduced risk of angulation of the ureter
• isolation of the repair from infection, retroperitoneal fibrosis, and cancer.

I perform IVP approximately 1 week after stent removal to ensure ureteral patency.

CASE RESOLVED

Exposure is improved by widening the incision and dividing the tendonous insertions of the rectus abdominus muscles. The surgeon then removes the mass, preserving the distal ureter, which is estimated to be 12 cm in length and to have intact adventitia.

The surgeon performs a double-spatulated end-to-end ureteroureterostomy over a 6 French double-J ureteral stent that has been passed proximally into the renal pelvis and distally into the bladder. The stent is removed 6 weeks postoperatively, and an IVP the following week demonstrates excellent patency.

The author has no financial relationships relevant to this article.

CASE: Inadvertent ureteral transection

A gynecologic surgeon operates via Pfannenstiel incision to remove a 12-cm complex left adnexal mass from a 36-year-old obese woman. When she discovers that the mass is densely adherent to the pelvic peritoneum, the surgeon incises the peritoneum lateral to the mass and opens the retroperitoneal space. However, the size and relative immobility of the mass, coupled with the low transverse incision, impair visualization of retroperitoneal structures.

The surgeon clamps and divides the ovarian vessels above the mass but, afterward, suspects that the ureter has been transected and that its ends are included within the clamps. She separates the ovarian vessels above the clamp and ligates them, at which time transection of the ureter is confirmed.

How should she proceed?

The ureter is intimately associated with the female internal genitalia in a way that challenges the gynecologic surgeon to avoid it. In a small percentage of cases involving surgical extirpation in a woman who has severe pelvic pathology, ureteral injury may be inevitable.

Several variables predispose a patient to ureteral injury, including limited exposure, as in the opening case. Others include distorted anatomy of the urinary tract relative to internal genitalia and operations that require extensive resection of pelvic tissues.

This article describes:

• prevention and intraoperative recognition of ureteral injury during gynecologic surgery
• management of intraoperatively recognized ureteral injury.

Maintain a high index of suspicion

The surgeon in the opening case has already taken the first and most important step in ensuring a good outcome: She suspected ureteral injury. In high-risk situations, intraoperative recognition of ureteral injury is more likely when the operative field is inspected thoroughly during and at the conclusion of the surgical procedure.

In a high-risk case, the combined use of intravenous indigo carmine, careful inspection of the operative field, cystoscopy, and ureteral dissection is recommended and should be routine.

Common sites of injury

During gynecologic surgery, the ureter is susceptible to injury along its entire course through the pelvis (see “The ureter takes a course fraught with hazard,”).

During adnexectomy, the gonadal vessels are generally ligated 2 to 3 cm above the adnexa. The ureter lies in close proximity to these vessels and may inadvertently be included in the ligation.

During hysterectomy, the ureter is susceptible to injury as it passes through the parametrium a short distance from the uterus and vaginal fornix.

Sutures placed in the posterior lateral cul de sac during prolapse surgery lie near the midpelvic ureter, and sutures placed during vaginal cuff closure, anterior colporrhaphy, and retropubic urethropexy are in close proximity to the trigonal portion of the ureter.

The ureter takes a course fraught with hazard

The ureter extends from the renal pelvis to the bladder, with a length that ranges from 25 to 30 cm, depending on the patient’s height. It crosses the pelvic brim near the bifurcation of the common iliac artery, where it becomes the “pelvic” ureter. The abdominal and pelvic portions of the ureter are approximately equal in length.

ILLUSTRATIONS BY ROB FLEWELL FOR OBG MANAGEMENT

The blood supply of the ureter derives from branches of the major arterial system of the lower abdomen and pelvis. These branches reach the medial aspect of the abdominal ureter and the lateral side of the pelvic ureter to form an anastomotic vascular network protected by an adventitial layer surrounding the ureter.

The ureter is attached to the posterior lateral pelvic peritoneum running dorsal to ovarian vessels. At the midpelvis, it separates from the peritoneum to pierce the base of the broad ligament underneath the uterine artery. At this point, the ureter is about 1.5 to 2 cm lateral to the uterus and curves medially and ventrally, tunneling through the cardinal and vesicovaginal ligaments to enter the bladder trigone.

Risky procedures

In gynecologic surgery, ureteral injury occurs most often during abdominal hysterectomy—probably because of how frequently this operation is performed and the range of pathology managed. The incidence of ureteral injury is much higher during abdominal hysterectomy than vaginal hysterectomy.^1-4

Laparoscopic hysterectomy also has been associated with a higher incidence of ureteral injury, especially in the early phase of training.^5,6 Possible explanations include:

• greater difficulty identifying the ureter
• a steeper learning curve
• more frequent use of energy to hemostatically divide pedicles, with the potential for thermal injury
• less traction–countertraction, resulting in dissection closer to the ureter
• management of complex pathology.

Although the overall incidence of ureteral injury during adnexectomy is low, it is probably much higher in women undergoing this procedure after a previous hysterectomy or in the presence of complex adnexal pathology.

When injury is likely

Compromised exposure, distorted anatomy, and certain procedures can heighten the risk of ureteral injury. Large tumors may limit the ability of the surgeon to visualize or palpate the ureter (FIGURE 1). Extensive adhesions may cause similar difficulties, and a small incision or obesity may hinder identification of pelvic sidewall structures.

A number of pathologic conditions can distort the anatomy of the ureter, especially as it relates to the female genital tract:

• Malignancies such as ovarian cancer often encroach on and occasionally encase the ureter
• Pelvic inflammatory disease, endometriosis, and a history of surgery or pelvic radiotherapy can retract and encase the ureter toward the gynecologic tract
• Some masses expand against the lower ureter, such as cervical or broad-ligament leiomyomata or placenta previa with accreta
• During vaginal hysterectomy for complete uterine prolapse, the ureters frequently extend beyond the introitus well within the operative field
• Congenital anomalies of the ureter or hydroureter can also cause distortion.

Even in the presence of relatively normal anatomy, certain procedures predispose the ureter to injury. For example, radical hysterectomy involves the almost complete separation of the pelvic ureter from the gynecologic tract and its surrounding soft tissue. When pelvic pathology is significant, the plane of dissection will always be near the ureter.

FIGURE 1 Access to the ureter is obstructed, putting it in jeopardy

Large tumors may limit the ability of the surgeon to visualize or palpate the ureter.

Prevention is the best strategy

At least 50% of ureteral injuries reported during gynecologic surgery have occurred in the absence of a recognizable risk factor.^2,7 Nevertheless, knowledge of anatomy and the ability to recognize situations in which there is an elevated risk for ureteral injury will best enable the surgeon to prevent such injury.

When a high-risk situation is encountered, critical preventive steps include:

• adequate exposure
• competent assistance
• exposure of the path of the ureter through the planned course of dissection. Dissecting the ureter beyond this area is usually unnecessary and may itself cause injury.

Skip preoperative IVP in most cases

The vast majority of women who undergo gynecologic surgery do not benefit from preoperative intravenous pyelography (IVP). This measure does not appear to reduce the likelihood of ureteral injury, even in the face of obvious gynecologic disease. However, preoperative identification of obvious ureteral involvement by the disease process is useful. In such cases, the plane of dissection will probably lie closer to the ureter. One of the goals of surgery will then be to clear the urinary tract from the affected area.

When there is a high index of suspicion of an abnormality such as obstruction, intrinsic ureteral endometriosis, or congenital anomaly, preoperative IVP is indicated.

A stent may be helpful in some cases

Ureteral stents are sometimes placed in order to aid in identification and dissection of the ureters during surgery. Some authors of reports on this topic, including Hoffman, believe that stents are useful in certain situations, such as excision of an ovarian remnant, radical vaginal hysterectomy, and when pelvic organs are encased by malignant ovarian tumors. However, stents do not clearly reduce the risk of injury and, in some cases, may increase the risk by providing a false sense of security and predisposing the ureter to adventitial injury during difficult dissection.

Anticipate the effects of disease

The surgeon must have a thorough knowledge of the gynecologic disease process as it relates to surgery involving the urinary tract. For example, an ovarian remnant will almost always be somewhat densely adherent to the pelvic ureter. When severe endometriosis involves the posterior leaf of the broad ligament, the ureter will often be fibrotically retracted toward the operative field.

Certain procedures have special challenges. During resection of adnexa, for example, it is important that the ureter be identified in the retroperitoneum before the ovarian vessels are ligated. During hysterectomy, soft tissues that contain the bladder and ureters should be mobilized caudally and laterally, respectively, creating a U-shaped region (“U” for urinary tract, FIGURE 2) to which the surgeon must limit dissection.

FIGURE 2 During hysterectomy, mobilize the bladder and ureter

Mobilize the soft tissues that contain the bladder and ureters caudally and laterally, respectively, creating a U-shaped region. During division of the paracervical tissues, the surgeon must remain within this region.

Intraoperative detection

Two main types of ureteral injury occur during gynecologic surgery: transection and destruction. The latter includes ligation, crushing, devascularization, and thermal injury.

Intraoperative detection of ureteral injury is more likely when the surgeon recognizes at the outset that the operation places the ureter at increased risk. When dissection has been difficult or complicated for any reason, be concerned about possible injury.

In general, ureteral injury is first recognized by careful inspection of the surgical field. Begin by instilling 5 ml of indigo carmine intravenously. Once the dye begins to appear in the Foley catheter, inspect the area of dissection under a small amount of irrigation fluid, looking for extravasation of dye that indicates partial or complete transection.

If no injury is identified, cystoscopy is the next step. I perform all major abdominal operations with the patient in the low lithotomy position, which provides easy access to the perineum. Cystoscopic identification of urine jetting from both ureteral orifices confirms patency. When only wisps of dye are observed, it is likely that the ureter in question has been partially occluded (e.g., by acute angulation). Failure of any urine to appear from one of the orifices highly suggests injury to that ureter.

During inspection of the operative field, attempt to pass a ureteral stent into the affected orifice. If the stent passes easily and dyed urine is seen to drip freely from it, look for possible angulation of the ureter. If you find none, remove the stent and inspect the orifice again for jetting urine.

If the ureteral stent will move only a few centimeters into the ureteral orifice, ligation (with or without transection) is likely. In this case, leave the stent in place. If the operative site is readily accessible, dissect the applicable area to identify the problem. Depending on the circumstances, you may wish to infuse dye through the stent to aid in operative identification or radiographic evaluation.

Intraoperative IVP may be useful, especially when cystoscopy is unavailable.

Fundamentals of repair

Repair of major injury to the pelvic ureter is generally best accomplished by ureteroneocystostomy or, in selected cases involving injury to the proximal pelvic ureter, by ureteroureterostomy.

When intraoperatively recognized injury to the pelvic ureter appears to be minor, it can be managed by placing a ureteral stent and a closed-suction pelvic drain. Also consider wrapping the injured area with vascularized tissue such as perivesical fat. Minor lacerations can be closed perpendicular to the axis of the ureter using interrupted 4-0 delayed absorbable suture.

Most injuries to the pelvic ureter are optimally managed by ureteroneocystostomy (FIGURE 3). When a significant portion of the pelvic ureter has been lost, ureteroneocystostomy usually requires a combination of:

• extensive mobilization of the bladder
• conservative mobilization of the ureter
• elongation of the bladder
• psoas hitch.

When necessary, mobilization of the kidney with suturing of the caudal perinephric fascia to the psoas muscle will bridge an additional 2- to 3-cm gap.

Major injury to the distal half of the pelvic ureter is repaired using straightforward ureteroneocystostomy.

When there is no significant pelvic disease and the distal ureter is healthy, injury to the proximal pelvic ureter during division of the ovarian vessels may be repaired via ureteroureterostomy. If the ureteral ends will be anastomosed on tension or there is any question about the integrity of the distal portion of the ureter, as when extensive distal ureterolysis has been necessary, consider ureteroneocystostomy.

FIGURE 3 When the distal ureter is injured

Most injuries to the pelvic ureter are managed optimally by ureteroneocystostomy.

Postoperative management

After repair of a ureteral injury, leave a closed-suction pelvic drain in place for 2 to 3 days so that any major urinary leak can be detected; it also enhances spontaneous closure and helps prevent potentially infected fluid from accumulating in the region of anastomosis.

The cystotomy performed during ureteroneocystostomy generally heals quickly with a low risk of complications.

Leave a large-bore (20 or 22 French) urethral Foley catheter in place for 2 weeks.

I recommend that a 6 French double-J ureteral stent be left in place for 6 weeks. Potential benefits of the stent include:

• prevention of stricture
• stabilization and immobilization of the ureter during healing
• reduced risk of extravasation of urine
• reduced risk of angulation of the ureter
• isolation of the repair from infection, retroperitoneal fibrosis, and cancer.

I perform IVP approximately 1 week after stent removal to ensure ureteral patency.

CASE RESOLVED

Exposure is improved by widening the incision and dividing the tendonous insertions of the rectus abdominus muscles. The surgeon then removes the mass, preserving the distal ureter, which is estimated to be 12 cm in length and to have intact adventitia.

The surgeon performs a double-spatulated end-to-end ureteroureterostomy over a 6 French double-J ureteral stent that has been passed proximally into the renal pelvis and distally into the bladder. The stent is removed 6 weeks postoperatively, and an IVP the following week demonstrates excellent patency.

Dr. Giesler reports that he serves on the speaker’s bureau for Ethicon Endo-Surgery. Dr. Vyas has no financial relationships relevant to this article.

CASE: Probable adhesions. Is laparoscopy practical?

A 54-year-old woman complains of perimenopausal bleeding that has not been controlled by hormone therapy, as well as increasing pelvic pain that has caused her to miss work. She wants you to perform hysterectomy to end these problems once and for all.

Aside from these complaints, her history is unremarkable except for a laparotomy at 13 years for a ruptured appendix. Her Pap smear, endometrial biopsy, and pelvic sonogram are negative.

Is she a candidate for laparoscopic hysterectomy?

A patient such as this one, who has a history of laparotomy, is likely to have extensive intra-abdominal adhesions. This pathology increases the risk of bowel injury during surgery—whether it is performed via laparotomy or laparoscopy.

The ability to simplify laparoscopic hysterectomy in a woman who has extensive adhesions requires an understanding of the ways in which adhesions form—in order to lyse them skillfully and avoid creating further adhesions. It also requires special techniques to enter the abdomen, identify the site of attachment, separate adhered structures, and conclude the hysterectomy. Attention to the type of energy that is used also is important.

In this article, we describe these techniques and considerations.

In Part 1 of this article, we discussed techniques that facilitate laparoscopic hysterectomy in a woman who has a large uterus.

Don’t overlook preoperative discussion, preparation

The patient needs to understand the risks and benefits of laparoscopic hysterectomy, particularly when extensive adhesions are likely, as well as the fact that it may be necessary to convert the procedure to laparotomy if the laparoscopic approach proves too difficult. She also needs to understand that conversion to laparotomy does not represent a failure of the procedure but an aim for greater safety.

Because bowel injury is a real risk when the patient has extensive adhesions, mechanical bowel preparation is important. Choose the regimen preferred by the colorectal surgeon likely to be consulted if intraoperative injury occurs.

The operating room (OR) and anesthesia staffs also need to be prepared, and the patient should be positioned for optimal access in the OR. These and other preoperative steps are described in Part 1 of this article and remain the same for the patient who has extensive intra-abdominal adhesions.

How adhesions form

When the peritoneum is injured, a fibrinous exudate develops, causing adjacent tissues to stick together. Normal peritoneum immediately initiates a process to break down this exudate, but traumatized peritoneum has limited ability to do so. As a result, a permanent adhesion can form in as few as 5 to 8 days.^1,2

Pelvic inflammatory disease and intraperitoneal blood associated with distant endometriosis implants are well known causes of abdominal adhesions; others are listed in the TABLE.

TABLE

7 causes of intra-abdominal adhesions

The challenge of safe entry

During laparotomy, adhesions can make it difficult to enter the abdomen. The same is true—but more so—for laparoscopic entry. The distortion caused by adhesions can lead to inadvertent injury to blood vessels, bowel, and bladder even in the best surgical hands. An attempt to lyse adhesions laparoscopically often prolongs the surgical procedure and increases the risk of visceral injury, bleeding, and fistula.¹

In more than 80% of patients experiencing injury during major abdominal surgery, the injury is associated with omental adhesions to the previous abdominal wall incision, and more than 50% have intestine included in the adhesion complex.¹

One study involving 918 patients who underwent laparoscopy found that 54.9% had umbilical adhesions of sufficient size to interfere with umbilical port placement.³ More important, 16% of this study group had only a single midline umbilical incision for laparoscopy before the adhesions were discovered.

The utility of Palmer’s point

Although multiple techniques have been described to minimize entry-related injury, no technique has completely eliminated the risk of inadvertent bowel or major large-vessel injury.³ In 1974, Palmer described an abdominal entry point for the Veress needle and small trocar for women who have a history of abdominal surgery.⁴ Many surgeons now consider “Palmer’s point,” in the left upper quadrant, as the safest peritoneal entry site.

Technique. After emptying the stomach of its contents using suction, insert the Veress needle into the peritoneal cavity at a point midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin (FIGURE). Advance it slowly until you hear three pops, signifying entry into the peritoneal cavity. Only minimal insertion is needed; insufflation pressure of less than 10 mm Hg indicates intraperitoneal placement of the needle tip.⁵

Once pneumoperitoneum pressure of 20 mm Hg is established, insert a 5-mm trocar perpendicular to the abdominal wall, 3 cm below the ribs, midway between the midclavicular line and the anterior axillary line.³ (There is a risk of colon injury at the splenic flexure if the entry point is further lateral.)

Inspect the abdominal cavity with the laparoscope from this access port to determine the best placement of remaining trocars under direct vision; lyse adhesions, if necessary, to perform the procedure.

FIGURE Enter the abdomen at Palmer’s point

This entry site (red dot) lies midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin. The other port sites (black dots) are described in Figure 2 in Part 1 of this article.

Success depends on careful lysis and minimal tissue injury

Adhesions in the abdomen may involve:

• omentum to peritoneum
• omentum to pelvic structures
• intestine to peritoneum
• intestine to pelvic structures.

Adhesions may be filmy and thin or dense and thick, avascular or vascular. They can be minimal, or a veritable curtain that prevents adequate visualization of the primary surgical site. When they are present, they must be managed successfully if the primary procedure is to be accomplished laparoscopically.

Successful management requires techniques to maximize adhesiolysis and minimize new adhesions or tissue injury:

• Use traction and countertraction to define the line of attachment; this is essential to separate two tissues bound by adhesions.
• Use atraumatic graspers to reduce the risk of tissue laceration.
• Avoid sharp dissection with scissors. Although this is the traditional method of lysis, it is often associated with bleeding that stains and obscures the line of dissection.
• Choose tools wisely. Electrosurgery and lasers use obliterative coagulation, working at temperatures of 150°C to 400°C to burn tissue. Blood and tissue are desiccated and oxidized, forming an eschar that covers and seals the bleeding area. Rebleeding during electrosurgery may occur when the instrument sticks to tissue and disrupts the eschar. In addition, monopolar instruments may cause undetected remote thermal injury, causing late complications.⁶ Both monopolar and bipolar techniques can also leave carbon particles during the oxidation process that become foci for future adhesions.⁷
• Consider ultrasonic energy. Unlike electrosurgery, ultrasonic energy is mechanical and works at much lower temperatures (50°C to 100°C), controlling bleeding by coaptive coagulation. The ultrasonic blade, vibrating at 55,500 Hz, disrupts and denatures protein to form a coagulum that seals small coapted vessels. When the effect is prolonged, secondary heat seals larger vessels. Ultrasonic energy involves minimal thermal spread, minimal carbon particle formation, and a cavitation effect similar to hydrodissection that helps expose the adhesive line. It creates minimal smoke, improving visibility. Because ultrasonic energy operates at a lower temperature, less char and necrotic tissue—important causes of adhesions—occur than with bipolar or monopolar electrical energy.⁷

Although different energy sources interact with human tissue using different mechanisms, clinical outcomes appear to be much the same and depend more on the skill of the individual surgeon than on the power source used. Data on this topic are limited.

Thawing the frozen pelvis

Many patients have adhesions that involve omentum or intestine that can be managed using simple laparoscopic techniques, but some have organs that are fixed in the pelvis by adhesions. In these cases, traction and countertraction techniques can be tedious and may cause inadvertent injury to critical structures or excessive bleeding that necessitates conversion to laparotomy.

A better way to approach the obliterated, or “frozen,” pelvis is to open the retroperitoneal space and identify critical structures:

• Enter the retroperitoneal space at the pelvic brim in an area free of adhesions. Identify the ureter and follow it to the bladder. This can be accomplished using hydrodissection techniques or cavitation techniques with ultrasonic energy.
• Skeletonize, coagulate, and cut the vessels once you reach the cardinal ligament and identify the ascending uterine blood supply.
• Dissect the structures of the obliterated cul de sac using standard techniques.
• Use sharp dissection for adhesiolysis. Laparoscopic blunt dissection of adhesions can lead to serosal tears and inadvertent enterotomy. Sharp dissection or mechanical energy devices are preferred to divide the tissue along the line of demarcation—but remember that monopolar and bipolar devices can cause remote thermal damage that goes undetected at the time of use.

When dissection becomes unproductive in one area, switch to another; dissection planes frequently open and demonstrate the relationships between pelvic structures and loops of bowel.⁸

Occasionally, the visceral peritoneum of the bowel is breached during adhesiolysis. If the mucosa and muscularis remain intact, denuded serosa need not be repaired. Surgical repair is necessary if mucosa is exposed, or perforation may occur.

Because most ObGyn residency programs offer limited training in management of bowel injuries, intraoperative consultation with a general surgeon may be indicated if more than a simple repair is required.⁸

CASE RESOLVED

You perform total laparoscopic hysterectomy and find multiple adhesions in the right lower quadrant, adjacent to the area of trocar insertion. Small intestine is adherent to the right lateral pelvic wall; sigmoid colon is adherent to the left pelvic wall; and the anterior fundus is adherent to the bladder peritoneal reflection, with the adhesions extending on either side to include the round ligaments.

You begin adhesiolysis in the right lower quadrant to optimize trocar movement. You transect the round ligaments in the mid-position, with dissection extended retroperitoneally on either side to the midline of the lower uterine segment; this opens access to the ascending branch of the uterine vessels. You dissect the intestine free of either pelvic sidewall along the line of demarcation.

Total blood loss is less than 25 mL. The patient is discharged 6 hours after surgery.

Dr. Giesler reports that he serves on the speaker’s bureau for Ethicon Endo-Surgery. Dr. Vyas has no financial relationships relevant to this article.

CASE: Probable adhesions. Is laparoscopy practical?

A 54-year-old woman complains of perimenopausal bleeding that has not been controlled by hormone therapy, as well as increasing pelvic pain that has caused her to miss work. She wants you to perform hysterectomy to end these problems once and for all.

Aside from these complaints, her history is unremarkable except for a laparotomy at 13 years for a ruptured appendix. Her Pap smear, endometrial biopsy, and pelvic sonogram are negative.

Is she a candidate for laparoscopic hysterectomy?

A patient such as this one, who has a history of laparotomy, is likely to have extensive intra-abdominal adhesions. This pathology increases the risk of bowel injury during surgery—whether it is performed via laparotomy or laparoscopy.

The ability to simplify laparoscopic hysterectomy in a woman who has extensive adhesions requires an understanding of the ways in which adhesions form—in order to lyse them skillfully and avoid creating further adhesions. It also requires special techniques to enter the abdomen, identify the site of attachment, separate adhered structures, and conclude the hysterectomy. Attention to the type of energy that is used also is important.

In this article, we describe these techniques and considerations.

In Part 1 of this article, we discussed techniques that facilitate laparoscopic hysterectomy in a woman who has a large uterus.

Don’t overlook preoperative discussion, preparation

The patient needs to understand the risks and benefits of laparoscopic hysterectomy, particularly when extensive adhesions are likely, as well as the fact that it may be necessary to convert the procedure to laparotomy if the laparoscopic approach proves too difficult. She also needs to understand that conversion to laparotomy does not represent a failure of the procedure but an aim for greater safety.

Because bowel injury is a real risk when the patient has extensive adhesions, mechanical bowel preparation is important. Choose the regimen preferred by the colorectal surgeon likely to be consulted if intraoperative injury occurs.

The operating room (OR) and anesthesia staffs also need to be prepared, and the patient should be positioned for optimal access in the OR. These and other preoperative steps are described in Part 1 of this article and remain the same for the patient who has extensive intra-abdominal adhesions.

How adhesions form

When the peritoneum is injured, a fibrinous exudate develops, causing adjacent tissues to stick together. Normal peritoneum immediately initiates a process to break down this exudate, but traumatized peritoneum has limited ability to do so. As a result, a permanent adhesion can form in as few as 5 to 8 days.^1,2

Pelvic inflammatory disease and intraperitoneal blood associated with distant endometriosis implants are well known causes of abdominal adhesions; others are listed in the TABLE.

TABLE

7 causes of intra-abdominal adhesions

The challenge of safe entry

During laparotomy, adhesions can make it difficult to enter the abdomen. The same is true—but more so—for laparoscopic entry. The distortion caused by adhesions can lead to inadvertent injury to blood vessels, bowel, and bladder even in the best surgical hands. An attempt to lyse adhesions laparoscopically often prolongs the surgical procedure and increases the risk of visceral injury, bleeding, and fistula.¹

In more than 80% of patients experiencing injury during major abdominal surgery, the injury is associated with omental adhesions to the previous abdominal wall incision, and more than 50% have intestine included in the adhesion complex.¹

One study involving 918 patients who underwent laparoscopy found that 54.9% had umbilical adhesions of sufficient size to interfere with umbilical port placement.³ More important, 16% of this study group had only a single midline umbilical incision for laparoscopy before the adhesions were discovered.

The utility of Palmer’s point

Although multiple techniques have been described to minimize entry-related injury, no technique has completely eliminated the risk of inadvertent bowel or major large-vessel injury.³ In 1974, Palmer described an abdominal entry point for the Veress needle and small trocar for women who have a history of abdominal surgery.⁴ Many surgeons now consider “Palmer’s point,” in the left upper quadrant, as the safest peritoneal entry site.

Technique. After emptying the stomach of its contents using suction, insert the Veress needle into the peritoneal cavity at a point midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin (FIGURE). Advance it slowly until you hear three pops, signifying entry into the peritoneal cavity. Only minimal insertion is needed; insufflation pressure of less than 10 mm Hg indicates intraperitoneal placement of the needle tip.⁵

Once pneumoperitoneum pressure of 20 mm Hg is established, insert a 5-mm trocar perpendicular to the abdominal wall, 3 cm below the ribs, midway between the midclavicular line and the anterior axillary line.³ (There is a risk of colon injury at the splenic flexure if the entry point is further lateral.)

Inspect the abdominal cavity with the laparoscope from this access port to determine the best placement of remaining trocars under direct vision; lyse adhesions, if necessary, to perform the procedure.

FIGURE Enter the abdomen at Palmer’s point

This entry site (red dot) lies midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin. The other port sites (black dots) are described in Figure 2 in Part 1 of this article.

Success depends on careful lysis and minimal tissue injury

Adhesions in the abdomen may involve:

• omentum to peritoneum
• omentum to pelvic structures
• intestine to peritoneum
• intestine to pelvic structures.

Adhesions may be filmy and thin or dense and thick, avascular or vascular. They can be minimal, or a veritable curtain that prevents adequate visualization of the primary surgical site. When they are present, they must be managed successfully if the primary procedure is to be accomplished laparoscopically.

Successful management requires techniques to maximize adhesiolysis and minimize new adhesions or tissue injury:

• Use traction and countertraction to define the line of attachment; this is essential to separate two tissues bound by adhesions.
• Use atraumatic graspers to reduce the risk of tissue laceration.
• Avoid sharp dissection with scissors. Although this is the traditional method of lysis, it is often associated with bleeding that stains and obscures the line of dissection.
• Choose tools wisely. Electrosurgery and lasers use obliterative coagulation, working at temperatures of 150°C to 400°C to burn tissue. Blood and tissue are desiccated and oxidized, forming an eschar that covers and seals the bleeding area. Rebleeding during electrosurgery may occur when the instrument sticks to tissue and disrupts the eschar. In addition, monopolar instruments may cause undetected remote thermal injury, causing late complications.⁶ Both monopolar and bipolar techniques can also leave carbon particles during the oxidation process that become foci for future adhesions.⁷
• Consider ultrasonic energy. Unlike electrosurgery, ultrasonic energy is mechanical and works at much lower temperatures (50°C to 100°C), controlling bleeding by coaptive coagulation. The ultrasonic blade, vibrating at 55,500 Hz, disrupts and denatures protein to form a coagulum that seals small coapted vessels. When the effect is prolonged, secondary heat seals larger vessels. Ultrasonic energy involves minimal thermal spread, minimal carbon particle formation, and a cavitation effect similar to hydrodissection that helps expose the adhesive line. It creates minimal smoke, improving visibility. Because ultrasonic energy operates at a lower temperature, less char and necrotic tissue—important causes of adhesions—occur than with bipolar or monopolar electrical energy.⁷

Although different energy sources interact with human tissue using different mechanisms, clinical outcomes appear to be much the same and depend more on the skill of the individual surgeon than on the power source used. Data on this topic are limited.

Thawing the frozen pelvis

Many patients have adhesions that involve omentum or intestine that can be managed using simple laparoscopic techniques, but some have organs that are fixed in the pelvis by adhesions. In these cases, traction and countertraction techniques can be tedious and may cause inadvertent injury to critical structures or excessive bleeding that necessitates conversion to laparotomy.

A better way to approach the obliterated, or “frozen,” pelvis is to open the retroperitoneal space and identify critical structures:

• Enter the retroperitoneal space at the pelvic brim in an area free of adhesions. Identify the ureter and follow it to the bladder. This can be accomplished using hydrodissection techniques or cavitation techniques with ultrasonic energy.
• Skeletonize, coagulate, and cut the vessels once you reach the cardinal ligament and identify the ascending uterine blood supply.
• Dissect the structures of the obliterated cul de sac using standard techniques.
• Use sharp dissection for adhesiolysis. Laparoscopic blunt dissection of adhesions can lead to serosal tears and inadvertent enterotomy. Sharp dissection or mechanical energy devices are preferred to divide the tissue along the line of demarcation—but remember that monopolar and bipolar devices can cause remote thermal damage that goes undetected at the time of use.

When dissection becomes unproductive in one area, switch to another; dissection planes frequently open and demonstrate the relationships between pelvic structures and loops of bowel.⁸

Occasionally, the visceral peritoneum of the bowel is breached during adhesiolysis. If the mucosa and muscularis remain intact, denuded serosa need not be repaired. Surgical repair is necessary if mucosa is exposed, or perforation may occur.

Because most ObGyn residency programs offer limited training in management of bowel injuries, intraoperative consultation with a general surgeon may be indicated if more than a simple repair is required.⁸

CASE RESOLVED

You perform total laparoscopic hysterectomy and find multiple adhesions in the right lower quadrant, adjacent to the area of trocar insertion. Small intestine is adherent to the right lateral pelvic wall; sigmoid colon is adherent to the left pelvic wall; and the anterior fundus is adherent to the bladder peritoneal reflection, with the adhesions extending on either side to include the round ligaments.

You begin adhesiolysis in the right lower quadrant to optimize trocar movement. You transect the round ligaments in the mid-position, with dissection extended retroperitoneally on either side to the midline of the lower uterine segment; this opens access to the ascending branch of the uterine vessels. You dissect the intestine free of either pelvic sidewall along the line of demarcation.

Total blood loss is less than 25 mL. The patient is discharged 6 hours after surgery.

Dr. Giesler reports that he serves on the speaker’s bureau for Ethicon Endo-Surgery. Dr. Vyas has no financial relationships relevant to this article.

CASE: Probable adhesions. Is laparoscopy practical?

A 54-year-old woman complains of perimenopausal bleeding that has not been controlled by hormone therapy, as well as increasing pelvic pain that has caused her to miss work. She wants you to perform hysterectomy to end these problems once and for all.

Aside from these complaints, her history is unremarkable except for a laparotomy at 13 years for a ruptured appendix. Her Pap smear, endometrial biopsy, and pelvic sonogram are negative.

Is she a candidate for laparoscopic hysterectomy?

A patient such as this one, who has a history of laparotomy, is likely to have extensive intra-abdominal adhesions. This pathology increases the risk of bowel injury during surgery—whether it is performed via laparotomy or laparoscopy.

The ability to simplify laparoscopic hysterectomy in a woman who has extensive adhesions requires an understanding of the ways in which adhesions form—in order to lyse them skillfully and avoid creating further adhesions. It also requires special techniques to enter the abdomen, identify the site of attachment, separate adhered structures, and conclude the hysterectomy. Attention to the type of energy that is used also is important.

In this article, we describe these techniques and considerations.

In Part 1 of this article, we discussed techniques that facilitate laparoscopic hysterectomy in a woman who has a large uterus.

Don’t overlook preoperative discussion, preparation

The patient needs to understand the risks and benefits of laparoscopic hysterectomy, particularly when extensive adhesions are likely, as well as the fact that it may be necessary to convert the procedure to laparotomy if the laparoscopic approach proves too difficult. She also needs to understand that conversion to laparotomy does not represent a failure of the procedure but an aim for greater safety.

Because bowel injury is a real risk when the patient has extensive adhesions, mechanical bowel preparation is important. Choose the regimen preferred by the colorectal surgeon likely to be consulted if intraoperative injury occurs.

The operating room (OR) and anesthesia staffs also need to be prepared, and the patient should be positioned for optimal access in the OR. These and other preoperative steps are described in Part 1 of this article and remain the same for the patient who has extensive intra-abdominal adhesions.

How adhesions form

When the peritoneum is injured, a fibrinous exudate develops, causing adjacent tissues to stick together. Normal peritoneum immediately initiates a process to break down this exudate, but traumatized peritoneum has limited ability to do so. As a result, a permanent adhesion can form in as few as 5 to 8 days.^1,2

Pelvic inflammatory disease and intraperitoneal blood associated with distant endometriosis implants are well known causes of abdominal adhesions; others are listed in the TABLE.

TABLE

7 causes of intra-abdominal adhesions

The challenge of safe entry

During laparotomy, adhesions can make it difficult to enter the abdomen. The same is true—but more so—for laparoscopic entry. The distortion caused by adhesions can lead to inadvertent injury to blood vessels, bowel, and bladder even in the best surgical hands. An attempt to lyse adhesions laparoscopically often prolongs the surgical procedure and increases the risk of visceral injury, bleeding, and fistula.¹

In more than 80% of patients experiencing injury during major abdominal surgery, the injury is associated with omental adhesions to the previous abdominal wall incision, and more than 50% have intestine included in the adhesion complex.¹

One study involving 918 patients who underwent laparoscopy found that 54.9% had umbilical adhesions of sufficient size to interfere with umbilical port placement.³ More important, 16% of this study group had only a single midline umbilical incision for laparoscopy before the adhesions were discovered.

The utility of Palmer’s point

Although multiple techniques have been described to minimize entry-related injury, no technique has completely eliminated the risk of inadvertent bowel or major large-vessel injury.³ In 1974, Palmer described an abdominal entry point for the Veress needle and small trocar for women who have a history of abdominal surgery.⁴ Many surgeons now consider “Palmer’s point,” in the left upper quadrant, as the safest peritoneal entry site.

Technique. After emptying the stomach of its contents using suction, insert the Veress needle into the peritoneal cavity at a point midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin (FIGURE). Advance it slowly until you hear three pops, signifying entry into the peritoneal cavity. Only minimal insertion is needed; insufflation pressure of less than 10 mm Hg indicates intraperitoneal placement of the needle tip.⁵

Once pneumoperitoneum pressure of 20 mm Hg is established, insert a 5-mm trocar perpendicular to the abdominal wall, 3 cm below the ribs, midway between the midclavicular line and the anterior axillary line.³ (There is a risk of colon injury at the splenic flexure if the entry point is further lateral.)

Inspect the abdominal cavity with the laparoscope from this access port to determine the best placement of remaining trocars under direct vision; lyse adhesions, if necessary, to perform the procedure.

FIGURE Enter the abdomen at Palmer’s point

This entry site (red dot) lies midway between the midclavicular line and the anterior axillary line, 3 cm below the costal margin. The other port sites (black dots) are described in Figure 2 in Part 1 of this article.

Success depends on careful lysis and minimal tissue injury

Adhesions in the abdomen may involve:

• omentum to peritoneum
• omentum to pelvic structures
• intestine to peritoneum
• intestine to pelvic structures.

Adhesions may be filmy and thin or dense and thick, avascular or vascular. They can be minimal, or a veritable curtain that prevents adequate visualization of the primary surgical site. When they are present, they must be managed successfully if the primary procedure is to be accomplished laparoscopically.

Successful management requires techniques to maximize adhesiolysis and minimize new adhesions or tissue injury:

• Use traction and countertraction to define the line of attachment; this is essential to separate two tissues bound by adhesions.
• Use atraumatic graspers to reduce the risk of tissue laceration.
• Avoid sharp dissection with scissors. Although this is the traditional method of lysis, it is often associated with bleeding that stains and obscures the line of dissection.
• Choose tools wisely. Electrosurgery and lasers use obliterative coagulation, working at temperatures of 150°C to 400°C to burn tissue. Blood and tissue are desiccated and oxidized, forming an eschar that covers and seals the bleeding area. Rebleeding during electrosurgery may occur when the instrument sticks to tissue and disrupts the eschar. In addition, monopolar instruments may cause undetected remote thermal injury, causing late complications.⁶ Both monopolar and bipolar techniques can also leave carbon particles during the oxidation process that become foci for future adhesions.⁷
• Consider ultrasonic energy. Unlike electrosurgery, ultrasonic energy is mechanical and works at much lower temperatures (50°C to 100°C), controlling bleeding by coaptive coagulation. The ultrasonic blade, vibrating at 55,500 Hz, disrupts and denatures protein to form a coagulum that seals small coapted vessels. When the effect is prolonged, secondary heat seals larger vessels. Ultrasonic energy involves minimal thermal spread, minimal carbon particle formation, and a cavitation effect similar to hydrodissection that helps expose the adhesive line. It creates minimal smoke, improving visibility. Because ultrasonic energy operates at a lower temperature, less char and necrotic tissue—important causes of adhesions—occur than with bipolar or monopolar electrical energy.⁷

Although different energy sources interact with human tissue using different mechanisms, clinical outcomes appear to be much the same and depend more on the skill of the individual surgeon than on the power source used. Data on this topic are limited.

Thawing the frozen pelvis

Many patients have adhesions that involve omentum or intestine that can be managed using simple laparoscopic techniques, but some have organs that are fixed in the pelvis by adhesions. In these cases, traction and countertraction techniques can be tedious and may cause inadvertent injury to critical structures or excessive bleeding that necessitates conversion to laparotomy.

A better way to approach the obliterated, or “frozen,” pelvis is to open the retroperitoneal space and identify critical structures:

• Enter the retroperitoneal space at the pelvic brim in an area free of adhesions. Identify the ureter and follow it to the bladder. This can be accomplished using hydrodissection techniques or cavitation techniques with ultrasonic energy.
• Skeletonize, coagulate, and cut the vessels once you reach the cardinal ligament and identify the ascending uterine blood supply.
• Dissect the structures of the obliterated cul de sac using standard techniques.
• Use sharp dissection for adhesiolysis. Laparoscopic blunt dissection of adhesions can lead to serosal tears and inadvertent enterotomy. Sharp dissection or mechanical energy devices are preferred to divide the tissue along the line of demarcation—but remember that monopolar and bipolar devices can cause remote thermal damage that goes undetected at the time of use.

When dissection becomes unproductive in one area, switch to another; dissection planes frequently open and demonstrate the relationships between pelvic structures and loops of bowel.⁸

Occasionally, the visceral peritoneum of the bowel is breached during adhesiolysis. If the mucosa and muscularis remain intact, denuded serosa need not be repaired. Surgical repair is necessary if mucosa is exposed, or perforation may occur.

Because most ObGyn residency programs offer limited training in management of bowel injuries, intraoperative consultation with a general surgeon may be indicated if more than a simple repair is required.⁸

CASE RESOLVED

You perform total laparoscopic hysterectomy and find multiple adhesions in the right lower quadrant, adjacent to the area of trocar insertion. Small intestine is adherent to the right lateral pelvic wall; sigmoid colon is adherent to the left pelvic wall; and the anterior fundus is adherent to the bladder peritoneal reflection, with the adhesions extending on either side to include the round ligaments.

You begin adhesiolysis in the right lower quadrant to optimize trocar movement. You transect the round ligaments in the mid-position, with dissection extended retroperitoneally on either side to the midline of the lower uterine segment; this opens access to the ascending branch of the uterine vessels. You dissect the intestine free of either pelvic sidewall along the line of demarcation.

Total blood loss is less than 25 mL. The patient is discharged 6 hours after surgery.

The authors report no financial relationships relevant to this article.

CASE: Large fibroid uterus. Is laparoscopy feasible?

A 41-year-old woman known to have uterine fibroids consults you after two other gynecologists have recommended abdominal hysterectomy. She weighs 320 lb, stands 5 ft 2 in, and is nulliparous and sexually inactive. Pelvic ultrasonography reveals multiple fibroids approximating 18 weeks’ gestational size. Although she has hypertension and reactive airway disease, these conditions are well controlled by medication. Her Pap smear and endometrial biopsy are negative.

Because her professional commitments limit her time for recovery, she hopes to bypass abdominal hysterectomy in favor of the laparoscopic approach.

Is this desire realistic?

Twenty years have passed since Reich performed the first total laparoscopic hysterectomy,¹ but only a small percentage of hysterectomies performed in the United States utilize that approach. In 2003, 12% of 602,457 hysterectomies were done laparoscopically; the rest were performed using the abdominal or vaginal approach (66% and 22%, respectively).²

Yet laparoscopic hysterectomy has much to recommend it. Compared with abdominal hysterectomy, it involves a shorter hospital stay, less blood loss, a speedier return to normal activities, and fewer wound infections.³ Unlike vaginal hysterectomy, it also facilitates intra-abdominal inspection.

Although the opening case represents potentially difficult surgery because of the size of the uterus, the laparoscopic approach is feasible. When the uterus weighs more than 450 g, contains fibroids larger than 6 cm, or exceeds 12 to 14 cm in size,^4-7 there is an increased risk of visceral injury, bleeding necessitating transfusion, prolonged operative time, and conversion to laparotomy. This article describes techniques that simplify laparoscopic management when the uterus exceeds 14 weeks’ size. By incorporating these techniques, we have performed laparoscopic hysterectomy in uteri as large as 22 to 24 weeks’ size without increased complications.

In Part 2 of this article, we address techniques that simplify laparoscopy when extensive intra-abdominal adhesions are present.

Why do some surgeons avoid laparoscopy?

Major complications occur in approximately 5% to 6% of women who undergo total laparoscopic hysterectomy.^8,9 That is one of the reasons many surgeons who perform laparoscopic procedures revert to the more traditional vaginal or abdominal approach when faced with a potentially difficult hysterectomy. These surgeons cite uteri larger than 14 weeks’ size, extensive intra-abdominal adhesions, and morbid obesity as common indications for a more conservative approach. Others cite the limitations of working with inexperienced surgeons or residents, inadequate laparoscopic instruments, and distorted pelvic anatomy. Still others avoid laparoscopy when the patient has medical problems that preclude use of pneumoperitoneum or a steep Trendelenburg position.

In some cases, laparoscopic hysterectomy is simply not practical. In others, however, such as the presence of a large uterus, it can be achieved with attention to detail, a few key techniques, and proper counseling of the patient.

Success begins preop

All surgical decisions begin with the patient. A comprehensive preoperative discussion of pertinent management options allows both patient and surgeon to proceed with confidence. Easing the patient’s preoperative anxiety is important. It can be achieved by explaining what to expect—not only the normal recovery for laparoscopic hysterectomy, but also the expected recovery if it becomes necessary to convert to laparotomy. If the patient has clear expectations, unexpected outcomes such as conversion are better tolerated. When it comes down to a choice between the surgeon’s ego or patient safety, the patient always wins. Conversion is not failure.

Another important topic to discuss with the patient is the risk of bowel injury. Mechanical bowel preparation is not essential for every patient who undergoes laparoscopic hysterectomy, but the risk of injury to the bowel necessitating colorectal surgical assistance may be heightened in women who have a large uterus or extensive intra-abdominal adhesions. Because of this risk, mechanical bowel preparation with oral polyethylene glycol solution or sodium phosphate should be considered. Most patients prefer the latter.¹⁰

What data show about bowel preps

The literature provides conflicting messages about the effectiveness of mechanical bowel preparation in averting additional complications when bowel injury occurs. Nichols and colleagues surveyed 808 active board-certified colorectal surgeons in the United States and Canada in 1995.¹¹ All of the 471 (58%) surgeons who responded reported using some form of mechanical bowel preparation for their elective and emergency colorectal procedures.

Zmora and associates described the difficulty of designing a multicenter study to evaluate the role of mechanical bowel preparation in patient outcome.¹⁰ Of the many variables that warrant consideration, surgical technique was the single most important factor influencing surgical outcome.

In a review of evidence supporting the need for prophylactic mechanical bowel preparation prior to elective colorectal surgery, Guenaga and colleagues concluded that this practice is unsupported by the data.¹²

Bottom line. Given these data, the gynecologist wanting to practice evidence-based medicine should base his or her recommendations about bowel preparation on the preferences of the general or colorectal surgeon who will be called if a bowel injury occurs.

Don’t forget the team

After preparing the patient, prepare your support team—the operating room (OR) and anesthesia staffs. The OR staff should ensure that extra sutures, instruments, and retractors are unopened, in the room, and available in case conversion is necessary. Inform the anesthesia staff of your anticipated surgical time and potential pitfalls. Let them know you will need maximum Trendelenburg position for pelvic exposure, but remain flexible if the patient has trouble with oxygenation and ventilation. Making your anesthesiologist aware of your willingness to work together will benefit both you and your patient immensely.

Preparation continues in the OR

Appropriate patient positioning is key to successful completion of difficult laparoscopic cases. Position the patient’s buttocks several inches beyond the table break to facilitate maximal uterine manipulation, which may be needed for completion of the colpotomy.

Place the patient in the dorsal lithotomy position using Allen stirrups, with the knees flexed at a 90° angle. Keep the knees level with the hips and the hips extended neutrally.

Arm position is important to maximize room for the surgeon alongside the OR table. Space is limited when the patient’s arms are positioned on arm boards. Tucking the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, improves the surgical field and secures the patient to the OR table (FIGURE 1). Protect the elbows and hands with cushions.

Place sequential compression devices (on the calf or foot) for the duration of the procedure to minimize the risk of blood stasis and clots that sometimes develop in the legs with prolonged surgical times. Many complex laparoscopic cases last longer than 2 hours.

FIGURE 1 Positioning the patient

Tuck the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, to improve the surgical field.

Maximum Trendelenburg position is a must

This positioning is essential for successful anatomic exposure in complex laparoscopic surgical cases. If the patient is positioned securely, maximum Trendelenburg position does not increase the risk of the patient sliding off the OR table, nor does it affect oxygenation in most morbidly obese patients. Rather, it allows the intestines to drop out of the pelvis into the upper abdomen, facilitating visualization and decreasing the risk of bowel injury.

Anesthesia staffers often limit the degree of Trendelenburg position unless the surgeon insists otherwise. Alternating patient position between maximum Trendelenburg for optimal surgical exposure and a less steep angle when patient oxygenation requires it allows the gynecologic surgeon and anesthesiologist to work together in the patient’s best interest.

Video monitor placement is key

It helps determine how efficiently you operate. Use of a single central monitor requires both the surgeon and assistant to turn their heads acutely during prolonged procedures, accelerating their fatigue and potentially increasing the risk of injury. Using two monitors—each placed to allow the surgeon and assistant to maintain neutral head position—minimizes fatigue and its attendant risks.

Entering the abdomen

Abdominal entry poses theoretical obstacles when the patient has a large uterus, but all types of entry remain safe as long as laparoscopic surgical principles are followed scrupulously. We have successfully used traditional Veress needle entry, open laparoscopic entry, and left upper quadrant entry.

Is entry above the umbilicus helpful?

Anecdotal reports suggest a midline port above the umbilicus when the uterus extends above the umbilicus, but we do not alter standard port placement in these cases. By tenting the abdominal wall at the umbilicus, we create adequate distance to achieve pneumoperitoneum and space for directed trocar entry to avoid injury to the uterus. The conventional umbilical primary port allows use of standard-length instruments. The cephalad uterine blood supply (infundibulopelvic ligament vessels or utero-ovarian ligament vessels) remains at or below the level of the umbilicus in almost all of these patients.

Placement of ports

Port placement in the patient who has a large uterus is the same as it is for other laparoscopic hysterectomies in our practice. We use an 11-mm trocar at the umbilicus for a 10-mm endoscope. We use the 10-mm endoscope because the light it provides to the surgical field is superior to that of a 5-mm endoscope, and the 10-mm scope is more durable.

We place a 5-mm trocar just above the anterior iliac crest on each side, lateral to the ascending inferior epigastric vessels (FIGURE 2). We place an 11-mm trocar 10 cm medial and cephalad to the lower iliac crest port on the side of the primary surgeon. This trocar serves a dual purpose: It is the primary port for the surgeon, and removal of the trocar sleeve later in the procedure allows for easy insertion of the morcellator.

Some patients will require a fifth port on the side opposite the primary surgeon to allow better access to the uterine blood supply or to facilitate uterine manipulation.

FIGURE 2 Port placement when the uterus is large

A midline umbilical port (A) is possible even when the uterus is large. Other ports include a 5-mm trocar just above the anterior iliac crest on each side (B), and an 11-mm trocar 10 cm medial and cephalad to the lower iliac crest port nearest the primary surgeon (C).

Why an angled scope is superior

Many gynecologists fear laparoscopic surgery in patients who have a large uterus. The reason? Poor visualization of the surgical field. However, the type of endoscope that is used has a bearing on visualization.

Most gynecologists are trained to use a 0° endoscope for laparoscopic surgery. However, when the uterus is large, the 0° scope yields an inadequate field of view, whether the endoscope is placed at the umbilicus or through a lateral port. Critical structures like the vascular bundles, ureters, and even the bladder may be inadequately visualized using the 0° endoscope (FIGURE 3).

Gynecologists routinely use angled scopes in hysteroscopy and cystoscopy, but tend to avoid them in laparoscopy because of difficulty orienting the surgical field. As gynecologists, we readily accept that use of an angled scope in hysteroscopy and cystoscopy requires rotation of the scope while the camera maintains its horizontal position. The same concept applies to laparoscopy.

Use of the angled scope in the abdomen is a two-step process. First, it must be rotated to achieve the desired field of view. Then, as the endoscope is held firmly to maintain this view, the camera head must be rotated on the scope to return the field to a horizontal position.

Many surgeons find this action difficult because they or the assistant are holding the camera in one hand and an instrument in the other. We solve this problem by using a mechanical scope holder to secure the camera and endoscope in the position we desire.

In some cases, the camera head does not attach securely to the eyepiece, and the scope rotates on the camera as soon as it is released. This difficulty arises when the eyepiece of the endoscope is slightly smaller than the camera attachment. The problem is easily solved by placing a small piece of surgical skin closure tape on one edge of the eyepiece, slightly increasing its diameter. The camera attachment then holds the scope securely.

Human scope holders may tire during long cases, causing field drift at critical moments. In contrast, a mechanical scope holder is easily and intermittently adjusted for field of view, producing a steady field of view and minimizing the impact of manual manipulation of the scope on surgical outcome. It also allows the surgeon and first assistant to use two hands while operating.

The 45° scope is best

General surgeons and urologists often use 30° endoscopes. Gynecologists working in the pelvis see better using a 45° scope (FIGURE 3). Most ORs offer a 30° endoscope but do not always have a 45° endoscope available in the instrument room. This is regrettable. Compared with the 30° scope, the 45° instrument provides better visual access to the low lateral uterine blood supply and bladder flap, particularly when the patient has a globular uterus or large, low anterior fibroid. We include both 5-mm and 10-mm 45° endoscopes in our laparoscopic tool chest, and believe they are essential options.

FIGURE 3 The 45° laparoscope provides better visual access

(A) 0° scope, uterus midline: Right broad ligament view obstructed. (B) 0° scope, uterus to left: Right broad ligament view still obstructed. (C) 45° scope, uterus midline: Right broad ligament view improved. (D) 45° scope, uterus to left: Right broad ligament view optimal.

Control the blood supply

Our laparoscopic approach is very similar to our technique for abdominal hysterectomy, beginning with the blood supply. The main blood supply to the uterus enters at only four points. If this blood supply is adequately controlled, morcellation of the large uterus can proceed without excessive blood loss.

Visualization of the blood supply is normally restricted because of tense, taut round ligaments that limit mobility of the large uterus. A simple step to improve mobility is to transect each round ligament in its middle position before addressing the uterine blood supply.

If the ovaries are being conserved, transect the utero-ovarian ligament and tube as close to the ovary as possible with your instrument and technique of choice (electrical or mechanical energy, etc); they all work. Stay close to the ovary to avert bleeding that might otherwise occur when the ascending uterine vascular coils are cut tangentially.

If the ovaries are being removed, transect the infundibulopelvic ligament close to the ovary, being careful not to include ovarian tissue in the pedicle. Use your method of choice, but relieve tension on the pedicle as it is being transected to minimize the risk of pedicle bleeding.

Now, 20% to 40% of the uterine blood supply is controlled, with minimal blood loss.

The key to controlling the remaining blood supply is transecting the ascending vascular bundle as low as possible on either side. The 45° endoscope provides optimal visualization for this part of the procedure. Many times the field of view attained using the 45° endoscope is all that is necessary to facilitate occlusion and transection of these vessels at the level of the internal cervical os.

We commonly use ultrasonic energy to coagulate and cut the ascending vascular bundle. Ultrasonic energy provides excellent hemostasis for this part of the procedure. Again, use the technique of your choice.

Use a laparoscopic “leash”

At times, large broad-ligament fibroids obscure the field of view and access to the ascending vascular bundle. Standard laparoscopic graspers cannot maintain a firm hold on the tissue to improve visibility or access. The solution? A laparoscopic “leash,” first described in 1999 by Tsin and colleagues.¹³

Giesler extended that concept with a “puppet string” variation to maximize exposure in difficult cases. To apply the “puppet string” technique, using No. 1 Prolene suture, place a large figure-of-eight suture through the tissue to be retracted (FIGURE 4). Bring the suture out of the abdomen adjacent to the trocar sleeve in a location that provides optimal traction. (First, bring the suture through the trocar sleeve. Then remove the trocar sleeve and reinsert it adjacent to the retraction suture.) This secure attachment allows better visualization and greater access to the blood supply at a lower level. It also is possible to manipulate this suture inside the abdomen using traditional graspers to provide reliable repositioning of the uterus. This degree of tissue control improves field of vision and allows the procedure to advance smoothly.

FIGURE 4 A “puppet string” improves access

This secure attachment allows better visualization and greater access to the blood supply at a lower level. Manipulation of this suture inside the abdomen using traditional graspers also helps reposition the uterus.

Morcellation techniques

Once the ascending blood supply has been managed on both sides, morcellation can be performed with minimal blood loss using one of two techniques:

• Amputate the body of the uterus above the level where the blood supply has been interrupted
• Morcellate the uterine body to a point just above the level where the blood supply has been interrupted.

Use basic principles, regardless of the technique chosen

• Hold the morcellator in one hand and a toothed grasper in the other hand to pull tissue into the morcellator. Do not push the morcellator into tissue or you may injure nonvisualized structures on the other side.
• Morcellate tissue in half-moon portions, skimming along the top of the fundus, instead of coring the uterus like an apple; it creates longer strips of tissue and is faster. This technique also allows continuous observation of the active blade, which helps avoid inadvertent injury to tissues behind the blade.
• Attempt morcellation in the anterior abdominal space to avoid injury to blood vessels, ureters, and bowel in the posterior abdominal space. The assistant feeds uterine tissue to the surgeon in the anterior space.

It is essential to control the blood supply to the tissue to be morcellated before morcellation to avoid massive hemorrhage.

Amputating the upper uterine body

Amputation of the large body of the uterus from the lower uterine segment assures complete control of the blood supply and avoids further blood loss during morcellation, but it also poses difficulties. The free uterine mass is held in position by the assistant using only one grasper. If this grasper slips, the mass can be inadvertently released while the morcellator blade is active. If the assistant is also holding the camera, there are no options for stabilizing the free uterine mass. If a mechanical scope holder or second assistant is available to hold the camera, a second trocar port can be placed on the side of the assistant to provide access for a second grasper to stabilize the uterine body during morcellation. The need for a stable uterine mass is important to minimize the risk of injury.

Once the upper body of the uterus has been removed by morcellation, the lower uterine segment and cervix must be removed—using your procedure of choice—to finish the hysterectomy.

Morcellating the upper uterine body

If the uterus remains attached to the cervix, it already has one fixed point of stability. During morcellation, the assistant has one hand available to direct the camera. Blood loss during morcellation of the uterus while it is still attached to the cervix is minimal because the ascending vascular bundles on either side have been interrupted under direct vision.

For greater control of the large uterus, a second port can be placed on the assistant’s side for a second grasper, as described above. Most of the large uterus that is still connected to the cervix can be morcellated in the anterior abdominal space in horizontal fashion, as for the free uterine mass just described.

Uterine manipulation by the assistant keeps the uterus away from critical structures as it is reduced to 8 to 10 weeks’ size. Once this size is attained, resume normal technique for total laparoscopic hysterectomy to separate the remaining tissue from the vagina.

2 types of morcellators in use today

One has a disposable 15-mm blade that attaches to a drive unit adjacent to the OR table (Gynecare-Ethicon Women’s Health and Urology). The other has a sterile, reusable drive unit with a disposable blade (Storz). Both work well on large uteri.

The reusable drive unit has more power to morcellate calcified fibroids and offers a choice between 12-mm, 15-mm, and 20-mm disposable blades for faster morcellation.

Concluding the procedure

Chips of fibroid and uterine tissue created during morcellation often remain in the pelvis after the uterus has been removed. Place them in a 10-cm specimen-collection bag and extract it through the vagina after removal of the residual uterus and cervix. This is faster and easier than recovering them one at a time with the gall bladder stone scoop through a trocar port. The value of the OR time saved with use of the specimen-collection bag is significantly greater than that of the disposable collection device.

CASE RESOLVED

You perform total laparoscopic hysterectomy and find 6-cm fibroids in both broad ligament areas and over the cervical–vaginal junction on the left. You use a “puppet string” to apply directed traction to the fibroids to simplify their extraction. The 45° endoscope allows clear visualization of the ascending vascular bundle on both sides, and the mechanical scope holder allows a fixed field of view for the meticulous dissection required to remove the broad-ligament fibroids.

You morcellate the entire 663-g uterus and remove it in pieces through the abdominal wall. The extensive morcellation required, coupled with technical issues related to the patient’s morbid obesity, prolong the procedure to more than 4 hours.

Postoperatively, the patient voids without a catheter, walks around the nursing unit, and eats half a sandwich within 4 hours. She is discharged home in less than 24 hours and is able to drive 4 days after her surgery.

The authors report no financial relationships relevant to this article.

CASE: Large fibroid uterus. Is laparoscopy feasible?

A 41-year-old woman known to have uterine fibroids consults you after two other gynecologists have recommended abdominal hysterectomy. She weighs 320 lb, stands 5 ft 2 in, and is nulliparous and sexually inactive. Pelvic ultrasonography reveals multiple fibroids approximating 18 weeks’ gestational size. Although she has hypertension and reactive airway disease, these conditions are well controlled by medication. Her Pap smear and endometrial biopsy are negative.

Because her professional commitments limit her time for recovery, she hopes to bypass abdominal hysterectomy in favor of the laparoscopic approach.

Is this desire realistic?

Twenty years have passed since Reich performed the first total laparoscopic hysterectomy,¹ but only a small percentage of hysterectomies performed in the United States utilize that approach. In 2003, 12% of 602,457 hysterectomies were done laparoscopically; the rest were performed using the abdominal or vaginal approach (66% and 22%, respectively).²

Yet laparoscopic hysterectomy has much to recommend it. Compared with abdominal hysterectomy, it involves a shorter hospital stay, less blood loss, a speedier return to normal activities, and fewer wound infections.³ Unlike vaginal hysterectomy, it also facilitates intra-abdominal inspection.

Although the opening case represents potentially difficult surgery because of the size of the uterus, the laparoscopic approach is feasible. When the uterus weighs more than 450 g, contains fibroids larger than 6 cm, or exceeds 12 to 14 cm in size,^4-7 there is an increased risk of visceral injury, bleeding necessitating transfusion, prolonged operative time, and conversion to laparotomy. This article describes techniques that simplify laparoscopic management when the uterus exceeds 14 weeks’ size. By incorporating these techniques, we have performed laparoscopic hysterectomy in uteri as large as 22 to 24 weeks’ size without increased complications.

In Part 2 of this article, we address techniques that simplify laparoscopy when extensive intra-abdominal adhesions are present.

Why do some surgeons avoid laparoscopy?

Major complications occur in approximately 5% to 6% of women who undergo total laparoscopic hysterectomy.^8,9 That is one of the reasons many surgeons who perform laparoscopic procedures revert to the more traditional vaginal or abdominal approach when faced with a potentially difficult hysterectomy. These surgeons cite uteri larger than 14 weeks’ size, extensive intra-abdominal adhesions, and morbid obesity as common indications for a more conservative approach. Others cite the limitations of working with inexperienced surgeons or residents, inadequate laparoscopic instruments, and distorted pelvic anatomy. Still others avoid laparoscopy when the patient has medical problems that preclude use of pneumoperitoneum or a steep Trendelenburg position.

In some cases, laparoscopic hysterectomy is simply not practical. In others, however, such as the presence of a large uterus, it can be achieved with attention to detail, a few key techniques, and proper counseling of the patient.

Success begins preop

All surgical decisions begin with the patient. A comprehensive preoperative discussion of pertinent management options allows both patient and surgeon to proceed with confidence. Easing the patient’s preoperative anxiety is important. It can be achieved by explaining what to expect—not only the normal recovery for laparoscopic hysterectomy, but also the expected recovery if it becomes necessary to convert to laparotomy. If the patient has clear expectations, unexpected outcomes such as conversion are better tolerated. When it comes down to a choice between the surgeon’s ego or patient safety, the patient always wins. Conversion is not failure.

Another important topic to discuss with the patient is the risk of bowel injury. Mechanical bowel preparation is not essential for every patient who undergoes laparoscopic hysterectomy, but the risk of injury to the bowel necessitating colorectal surgical assistance may be heightened in women who have a large uterus or extensive intra-abdominal adhesions. Because of this risk, mechanical bowel preparation with oral polyethylene glycol solution or sodium phosphate should be considered. Most patients prefer the latter.¹⁰

What data show about bowel preps

The literature provides conflicting messages about the effectiveness of mechanical bowel preparation in averting additional complications when bowel injury occurs. Nichols and colleagues surveyed 808 active board-certified colorectal surgeons in the United States and Canada in 1995.¹¹ All of the 471 (58%) surgeons who responded reported using some form of mechanical bowel preparation for their elective and emergency colorectal procedures.

Zmora and associates described the difficulty of designing a multicenter study to evaluate the role of mechanical bowel preparation in patient outcome.¹⁰ Of the many variables that warrant consideration, surgical technique was the single most important factor influencing surgical outcome.

In a review of evidence supporting the need for prophylactic mechanical bowel preparation prior to elective colorectal surgery, Guenaga and colleagues concluded that this practice is unsupported by the data.¹²

Bottom line. Given these data, the gynecologist wanting to practice evidence-based medicine should base his or her recommendations about bowel preparation on the preferences of the general or colorectal surgeon who will be called if a bowel injury occurs.

Don’t forget the team

After preparing the patient, prepare your support team—the operating room (OR) and anesthesia staffs. The OR staff should ensure that extra sutures, instruments, and retractors are unopened, in the room, and available in case conversion is necessary. Inform the anesthesia staff of your anticipated surgical time and potential pitfalls. Let them know you will need maximum Trendelenburg position for pelvic exposure, but remain flexible if the patient has trouble with oxygenation and ventilation. Making your anesthesiologist aware of your willingness to work together will benefit both you and your patient immensely.

Preparation continues in the OR

Appropriate patient positioning is key to successful completion of difficult laparoscopic cases. Position the patient’s buttocks several inches beyond the table break to facilitate maximal uterine manipulation, which may be needed for completion of the colpotomy.

Place the patient in the dorsal lithotomy position using Allen stirrups, with the knees flexed at a 90° angle. Keep the knees level with the hips and the hips extended neutrally.

Arm position is important to maximize room for the surgeon alongside the OR table. Space is limited when the patient’s arms are positioned on arm boards. Tucking the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, improves the surgical field and secures the patient to the OR table (FIGURE 1). Protect the elbows and hands with cushions.

Place sequential compression devices (on the calf or foot) for the duration of the procedure to minimize the risk of blood stasis and clots that sometimes develop in the legs with prolonged surgical times. Many complex laparoscopic cases last longer than 2 hours.

FIGURE 1 Positioning the patient

Tuck the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, to improve the surgical field.

Maximum Trendelenburg position is a must

This positioning is essential for successful anatomic exposure in complex laparoscopic surgical cases. If the patient is positioned securely, maximum Trendelenburg position does not increase the risk of the patient sliding off the OR table, nor does it affect oxygenation in most morbidly obese patients. Rather, it allows the intestines to drop out of the pelvis into the upper abdomen, facilitating visualization and decreasing the risk of bowel injury.

Anesthesia staffers often limit the degree of Trendelenburg position unless the surgeon insists otherwise. Alternating patient position between maximum Trendelenburg for optimal surgical exposure and a less steep angle when patient oxygenation requires it allows the gynecologic surgeon and anesthesiologist to work together in the patient’s best interest.

Video monitor placement is key

It helps determine how efficiently you operate. Use of a single central monitor requires both the surgeon and assistant to turn their heads acutely during prolonged procedures, accelerating their fatigue and potentially increasing the risk of injury. Using two monitors—each placed to allow the surgeon and assistant to maintain neutral head position—minimizes fatigue and its attendant risks.

Entering the abdomen

Abdominal entry poses theoretical obstacles when the patient has a large uterus, but all types of entry remain safe as long as laparoscopic surgical principles are followed scrupulously. We have successfully used traditional Veress needle entry, open laparoscopic entry, and left upper quadrant entry.

Is entry above the umbilicus helpful?

Anecdotal reports suggest a midline port above the umbilicus when the uterus extends above the umbilicus, but we do not alter standard port placement in these cases. By tenting the abdominal wall at the umbilicus, we create adequate distance to achieve pneumoperitoneum and space for directed trocar entry to avoid injury to the uterus. The conventional umbilical primary port allows use of standard-length instruments. The cephalad uterine blood supply (infundibulopelvic ligament vessels or utero-ovarian ligament vessels) remains at or below the level of the umbilicus in almost all of these patients.

Placement of ports

Port placement in the patient who has a large uterus is the same as it is for other laparoscopic hysterectomies in our practice. We use an 11-mm trocar at the umbilicus for a 10-mm endoscope. We use the 10-mm endoscope because the light it provides to the surgical field is superior to that of a 5-mm endoscope, and the 10-mm scope is more durable.

We place a 5-mm trocar just above the anterior iliac crest on each side, lateral to the ascending inferior epigastric vessels (FIGURE 2). We place an 11-mm trocar 10 cm medial and cephalad to the lower iliac crest port on the side of the primary surgeon. This trocar serves a dual purpose: It is the primary port for the surgeon, and removal of the trocar sleeve later in the procedure allows for easy insertion of the morcellator.

Some patients will require a fifth port on the side opposite the primary surgeon to allow better access to the uterine blood supply or to facilitate uterine manipulation.

FIGURE 2 Port placement when the uterus is large

A midline umbilical port (A) is possible even when the uterus is large. Other ports include a 5-mm trocar just above the anterior iliac crest on each side (B), and an 11-mm trocar 10 cm medial and cephalad to the lower iliac crest port nearest the primary surgeon (C).

Why an angled scope is superior

Many gynecologists fear laparoscopic surgery in patients who have a large uterus. The reason? Poor visualization of the surgical field. However, the type of endoscope that is used has a bearing on visualization.

Most gynecologists are trained to use a 0° endoscope for laparoscopic surgery. However, when the uterus is large, the 0° scope yields an inadequate field of view, whether the endoscope is placed at the umbilicus or through a lateral port. Critical structures like the vascular bundles, ureters, and even the bladder may be inadequately visualized using the 0° endoscope (FIGURE 3).

Gynecologists routinely use angled scopes in hysteroscopy and cystoscopy, but tend to avoid them in laparoscopy because of difficulty orienting the surgical field. As gynecologists, we readily accept that use of an angled scope in hysteroscopy and cystoscopy requires rotation of the scope while the camera maintains its horizontal position. The same concept applies to laparoscopy.

Use of the angled scope in the abdomen is a two-step process. First, it must be rotated to achieve the desired field of view. Then, as the endoscope is held firmly to maintain this view, the camera head must be rotated on the scope to return the field to a horizontal position.

Many surgeons find this action difficult because they or the assistant are holding the camera in one hand and an instrument in the other. We solve this problem by using a mechanical scope holder to secure the camera and endoscope in the position we desire.

In some cases, the camera head does not attach securely to the eyepiece, and the scope rotates on the camera as soon as it is released. This difficulty arises when the eyepiece of the endoscope is slightly smaller than the camera attachment. The problem is easily solved by placing a small piece of surgical skin closure tape on one edge of the eyepiece, slightly increasing its diameter. The camera attachment then holds the scope securely.

Human scope holders may tire during long cases, causing field drift at critical moments. In contrast, a mechanical scope holder is easily and intermittently adjusted for field of view, producing a steady field of view and minimizing the impact of manual manipulation of the scope on surgical outcome. It also allows the surgeon and first assistant to use two hands while operating.

The 45° scope is best

General surgeons and urologists often use 30° endoscopes. Gynecologists working in the pelvis see better using a 45° scope (FIGURE 3). Most ORs offer a 30° endoscope but do not always have a 45° endoscope available in the instrument room. This is regrettable. Compared with the 30° scope, the 45° instrument provides better visual access to the low lateral uterine blood supply and bladder flap, particularly when the patient has a globular uterus or large, low anterior fibroid. We include both 5-mm and 10-mm 45° endoscopes in our laparoscopic tool chest, and believe they are essential options.

FIGURE 3 The 45° laparoscope provides better visual access

(A) 0° scope, uterus midline: Right broad ligament view obstructed. (B) 0° scope, uterus to left: Right broad ligament view still obstructed. (C) 45° scope, uterus midline: Right broad ligament view improved. (D) 45° scope, uterus to left: Right broad ligament view optimal.

Control the blood supply

Our laparoscopic approach is very similar to our technique for abdominal hysterectomy, beginning with the blood supply. The main blood supply to the uterus enters at only four points. If this blood supply is adequately controlled, morcellation of the large uterus can proceed without excessive blood loss.

Visualization of the blood supply is normally restricted because of tense, taut round ligaments that limit mobility of the large uterus. A simple step to improve mobility is to transect each round ligament in its middle position before addressing the uterine blood supply.

If the ovaries are being conserved, transect the utero-ovarian ligament and tube as close to the ovary as possible with your instrument and technique of choice (electrical or mechanical energy, etc); they all work. Stay close to the ovary to avert bleeding that might otherwise occur when the ascending uterine vascular coils are cut tangentially.

If the ovaries are being removed, transect the infundibulopelvic ligament close to the ovary, being careful not to include ovarian tissue in the pedicle. Use your method of choice, but relieve tension on the pedicle as it is being transected to minimize the risk of pedicle bleeding.

Now, 20% to 40% of the uterine blood supply is controlled, with minimal blood loss.

The key to controlling the remaining blood supply is transecting the ascending vascular bundle as low as possible on either side. The 45° endoscope provides optimal visualization for this part of the procedure. Many times the field of view attained using the 45° endoscope is all that is necessary to facilitate occlusion and transection of these vessels at the level of the internal cervical os.

We commonly use ultrasonic energy to coagulate and cut the ascending vascular bundle. Ultrasonic energy provides excellent hemostasis for this part of the procedure. Again, use the technique of your choice.

Use a laparoscopic “leash”

At times, large broad-ligament fibroids obscure the field of view and access to the ascending vascular bundle. Standard laparoscopic graspers cannot maintain a firm hold on the tissue to improve visibility or access. The solution? A laparoscopic “leash,” first described in 1999 by Tsin and colleagues.¹³

Giesler extended that concept with a “puppet string” variation to maximize exposure in difficult cases. To apply the “puppet string” technique, using No. 1 Prolene suture, place a large figure-of-eight suture through the tissue to be retracted (FIGURE 4). Bring the suture out of the abdomen adjacent to the trocar sleeve in a location that provides optimal traction. (First, bring the suture through the trocar sleeve. Then remove the trocar sleeve and reinsert it adjacent to the retraction suture.) This secure attachment allows better visualization and greater access to the blood supply at a lower level. It also is possible to manipulate this suture inside the abdomen using traditional graspers to provide reliable repositioning of the uterus. This degree of tissue control improves field of vision and allows the procedure to advance smoothly.

FIGURE 4 A “puppet string” improves access

This secure attachment allows better visualization and greater access to the blood supply at a lower level. Manipulation of this suture inside the abdomen using traditional graspers also helps reposition the uterus.

Morcellation techniques

Once the ascending blood supply has been managed on both sides, morcellation can be performed with minimal blood loss using one of two techniques:

• Amputate the body of the uterus above the level where the blood supply has been interrupted
• Morcellate the uterine body to a point just above the level where the blood supply has been interrupted.

Use basic principles, regardless of the technique chosen

• Hold the morcellator in one hand and a toothed grasper in the other hand to pull tissue into the morcellator. Do not push the morcellator into tissue or you may injure nonvisualized structures on the other side.
• Morcellate tissue in half-moon portions, skimming along the top of the fundus, instead of coring the uterus like an apple; it creates longer strips of tissue and is faster. This technique also allows continuous observation of the active blade, which helps avoid inadvertent injury to tissues behind the blade.
• Attempt morcellation in the anterior abdominal space to avoid injury to blood vessels, ureters, and bowel in the posterior abdominal space. The assistant feeds uterine tissue to the surgeon in the anterior space.

It is essential to control the blood supply to the tissue to be morcellated before morcellation to avoid massive hemorrhage.

Amputating the upper uterine body

Amputation of the large body of the uterus from the lower uterine segment assures complete control of the blood supply and avoids further blood loss during morcellation, but it also poses difficulties. The free uterine mass is held in position by the assistant using only one grasper. If this grasper slips, the mass can be inadvertently released while the morcellator blade is active. If the assistant is also holding the camera, there are no options for stabilizing the free uterine mass. If a mechanical scope holder or second assistant is available to hold the camera, a second trocar port can be placed on the side of the assistant to provide access for a second grasper to stabilize the uterine body during morcellation. The need for a stable uterine mass is important to minimize the risk of injury.

Once the upper body of the uterus has been removed by morcellation, the lower uterine segment and cervix must be removed—using your procedure of choice—to finish the hysterectomy.

Morcellating the upper uterine body

If the uterus remains attached to the cervix, it already has one fixed point of stability. During morcellation, the assistant has one hand available to direct the camera. Blood loss during morcellation of the uterus while it is still attached to the cervix is minimal because the ascending vascular bundles on either side have been interrupted under direct vision.

For greater control of the large uterus, a second port can be placed on the assistant’s side for a second grasper, as described above. Most of the large uterus that is still connected to the cervix can be morcellated in the anterior abdominal space in horizontal fashion, as for the free uterine mass just described.

Uterine manipulation by the assistant keeps the uterus away from critical structures as it is reduced to 8 to 10 weeks’ size. Once this size is attained, resume normal technique for total laparoscopic hysterectomy to separate the remaining tissue from the vagina.

2 types of morcellators in use today

One has a disposable 15-mm blade that attaches to a drive unit adjacent to the OR table (Gynecare-Ethicon Women’s Health and Urology). The other has a sterile, reusable drive unit with a disposable blade (Storz). Both work well on large uteri.

The reusable drive unit has more power to morcellate calcified fibroids and offers a choice between 12-mm, 15-mm, and 20-mm disposable blades for faster morcellation.

Concluding the procedure

Chips of fibroid and uterine tissue created during morcellation often remain in the pelvis after the uterus has been removed. Place them in a 10-cm specimen-collection bag and extract it through the vagina after removal of the residual uterus and cervix. This is faster and easier than recovering them one at a time with the gall bladder stone scoop through a trocar port. The value of the OR time saved with use of the specimen-collection bag is significantly greater than that of the disposable collection device.

CASE RESOLVED

You perform total laparoscopic hysterectomy and find 6-cm fibroids in both broad ligament areas and over the cervical–vaginal junction on the left. You use a “puppet string” to apply directed traction to the fibroids to simplify their extraction. The 45° endoscope allows clear visualization of the ascending vascular bundle on both sides, and the mechanical scope holder allows a fixed field of view for the meticulous dissection required to remove the broad-ligament fibroids.

You morcellate the entire 663-g uterus and remove it in pieces through the abdominal wall. The extensive morcellation required, coupled with technical issues related to the patient’s morbid obesity, prolong the procedure to more than 4 hours.

Postoperatively, the patient voids without a catheter, walks around the nursing unit, and eats half a sandwich within 4 hours. She is discharged home in less than 24 hours and is able to drive 4 days after her surgery.

The authors report no financial relationships relevant to this article.

CASE: Large fibroid uterus. Is laparoscopy feasible?

A 41-year-old woman known to have uterine fibroids consults you after two other gynecologists have recommended abdominal hysterectomy. She weighs 320 lb, stands 5 ft 2 in, and is nulliparous and sexually inactive. Pelvic ultrasonography reveals multiple fibroids approximating 18 weeks’ gestational size. Although she has hypertension and reactive airway disease, these conditions are well controlled by medication. Her Pap smear and endometrial biopsy are negative.

Because her professional commitments limit her time for recovery, she hopes to bypass abdominal hysterectomy in favor of the laparoscopic approach.

Is this desire realistic?

Twenty years have passed since Reich performed the first total laparoscopic hysterectomy,¹ but only a small percentage of hysterectomies performed in the United States utilize that approach. In 2003, 12% of 602,457 hysterectomies were done laparoscopically; the rest were performed using the abdominal or vaginal approach (66% and 22%, respectively).²

Yet laparoscopic hysterectomy has much to recommend it. Compared with abdominal hysterectomy, it involves a shorter hospital stay, less blood loss, a speedier return to normal activities, and fewer wound infections.³ Unlike vaginal hysterectomy, it also facilitates intra-abdominal inspection.

Although the opening case represents potentially difficult surgery because of the size of the uterus, the laparoscopic approach is feasible. When the uterus weighs more than 450 g, contains fibroids larger than 6 cm, or exceeds 12 to 14 cm in size,^4-7 there is an increased risk of visceral injury, bleeding necessitating transfusion, prolonged operative time, and conversion to laparotomy. This article describes techniques that simplify laparoscopic management when the uterus exceeds 14 weeks’ size. By incorporating these techniques, we have performed laparoscopic hysterectomy in uteri as large as 22 to 24 weeks’ size without increased complications.

In Part 2 of this article, we address techniques that simplify laparoscopy when extensive intra-abdominal adhesions are present.

Why do some surgeons avoid laparoscopy?

Major complications occur in approximately 5% to 6% of women who undergo total laparoscopic hysterectomy.^8,9 That is one of the reasons many surgeons who perform laparoscopic procedures revert to the more traditional vaginal or abdominal approach when faced with a potentially difficult hysterectomy. These surgeons cite uteri larger than 14 weeks’ size, extensive intra-abdominal adhesions, and morbid obesity as common indications for a more conservative approach. Others cite the limitations of working with inexperienced surgeons or residents, inadequate laparoscopic instruments, and distorted pelvic anatomy. Still others avoid laparoscopy when the patient has medical problems that preclude use of pneumoperitoneum or a steep Trendelenburg position.

In some cases, laparoscopic hysterectomy is simply not practical. In others, however, such as the presence of a large uterus, it can be achieved with attention to detail, a few key techniques, and proper counseling of the patient.

Success begins preop

All surgical decisions begin with the patient. A comprehensive preoperative discussion of pertinent management options allows both patient and surgeon to proceed with confidence. Easing the patient’s preoperative anxiety is important. It can be achieved by explaining what to expect—not only the normal recovery for laparoscopic hysterectomy, but also the expected recovery if it becomes necessary to convert to laparotomy. If the patient has clear expectations, unexpected outcomes such as conversion are better tolerated. When it comes down to a choice between the surgeon’s ego or patient safety, the patient always wins. Conversion is not failure.

Another important topic to discuss with the patient is the risk of bowel injury. Mechanical bowel preparation is not essential for every patient who undergoes laparoscopic hysterectomy, but the risk of injury to the bowel necessitating colorectal surgical assistance may be heightened in women who have a large uterus or extensive intra-abdominal adhesions. Because of this risk, mechanical bowel preparation with oral polyethylene glycol solution or sodium phosphate should be considered. Most patients prefer the latter.¹⁰

What data show about bowel preps

The literature provides conflicting messages about the effectiveness of mechanical bowel preparation in averting additional complications when bowel injury occurs. Nichols and colleagues surveyed 808 active board-certified colorectal surgeons in the United States and Canada in 1995.¹¹ All of the 471 (58%) surgeons who responded reported using some form of mechanical bowel preparation for their elective and emergency colorectal procedures.

Zmora and associates described the difficulty of designing a multicenter study to evaluate the role of mechanical bowel preparation in patient outcome.¹⁰ Of the many variables that warrant consideration, surgical technique was the single most important factor influencing surgical outcome.

In a review of evidence supporting the need for prophylactic mechanical bowel preparation prior to elective colorectal surgery, Guenaga and colleagues concluded that this practice is unsupported by the data.¹²

Bottom line. Given these data, the gynecologist wanting to practice evidence-based medicine should base his or her recommendations about bowel preparation on the preferences of the general or colorectal surgeon who will be called if a bowel injury occurs.

Don’t forget the team

After preparing the patient, prepare your support team—the operating room (OR) and anesthesia staffs. The OR staff should ensure that extra sutures, instruments, and retractors are unopened, in the room, and available in case conversion is necessary. Inform the anesthesia staff of your anticipated surgical time and potential pitfalls. Let them know you will need maximum Trendelenburg position for pelvic exposure, but remain flexible if the patient has trouble with oxygenation and ventilation. Making your anesthesiologist aware of your willingness to work together will benefit both you and your patient immensely.

Preparation continues in the OR

Appropriate patient positioning is key to successful completion of difficult laparoscopic cases. Position the patient’s buttocks several inches beyond the table break to facilitate maximal uterine manipulation, which may be needed for completion of the colpotomy.

Place the patient in the dorsal lithotomy position using Allen stirrups, with the knees flexed at a 90° angle. Keep the knees level with the hips and the hips extended neutrally.

Arm position is important to maximize room for the surgeon alongside the OR table. Space is limited when the patient’s arms are positioned on arm boards. Tucking the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, improves the surgical field and secures the patient to the OR table (FIGURE 1). Protect the elbows and hands with cushions.

Place sequential compression devices (on the calf or foot) for the duration of the procedure to minimize the risk of blood stasis and clots that sometimes develop in the legs with prolonged surgical times. Many complex laparoscopic cases last longer than 2 hours.

FIGURE 1 Positioning the patient

Tuck the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, to improve the surgical field.

Maximum Trendelenburg position is a must

This positioning is essential for successful anatomic exposure in complex laparoscopic surgical cases. If the patient is positioned securely, maximum Trendelenburg position does not increase the risk of the patient sliding off the OR table, nor does it affect oxygenation in most morbidly obese patients. Rather, it allows the intestines to drop out of the pelvis into the upper abdomen, facilitating visualization and decreasing the risk of bowel injury.

Anesthesia staffers often limit the degree of Trendelenburg position unless the surgeon insists otherwise. Alternating patient position between maximum Trendelenburg for optimal surgical exposure and a less steep angle when patient oxygenation requires it allows the gynecologic surgeon and anesthesiologist to work together in the patient’s best interest.

Video monitor placement is key

It helps determine how efficiently you operate. Use of a single central monitor requires both the surgeon and assistant to turn their heads acutely during prolonged procedures, accelerating their fatigue and potentially increasing the risk of injury. Using two monitors—each placed to allow the surgeon and assistant to maintain neutral head position—minimizes fatigue and its attendant risks.

Entering the abdomen

Abdominal entry poses theoretical obstacles when the patient has a large uterus, but all types of entry remain safe as long as laparoscopic surgical principles are followed scrupulously. We have successfully used traditional Veress needle entry, open laparoscopic entry, and left upper quadrant entry.

Is entry above the umbilicus helpful?

Anecdotal reports suggest a midline port above the umbilicus when the uterus extends above the umbilicus, but we do not alter standard port placement in these cases. By tenting the abdominal wall at the umbilicus, we create adequate distance to achieve pneumoperitoneum and space for directed trocar entry to avoid injury to the uterus. The conventional umbilical primary port allows use of standard-length instruments. The cephalad uterine blood supply (infundibulopelvic ligament vessels or utero-ovarian ligament vessels) remains at or below the level of the umbilicus in almost all of these patients.

Placement of ports

Port placement in the patient who has a large uterus is the same as it is for other laparoscopic hysterectomies in our practice. We use an 11-mm trocar at the umbilicus for a 10-mm endoscope. We use the 10-mm endoscope because the light it provides to the surgical field is superior to that of a 5-mm endoscope, and the 10-mm scope is more durable.

We place a 5-mm trocar just above the anterior iliac crest on each side, lateral to the ascending inferior epigastric vessels (FIGURE 2). We place an 11-mm trocar 10 cm medial and cephalad to the lower iliac crest port on the side of the primary surgeon. This trocar serves a dual purpose: It is the primary port for the surgeon, and removal of the trocar sleeve later in the procedure allows for easy insertion of the morcellator.

Some patients will require a fifth port on the side opposite the primary surgeon to allow better access to the uterine blood supply or to facilitate uterine manipulation.

FIGURE 2 Port placement when the uterus is large

A midline umbilical port (A) is possible even when the uterus is large. Other ports include a 5-mm trocar just above the anterior iliac crest on each side (B), and an 11-mm trocar 10 cm medial and cephalad to the lower iliac crest port nearest the primary surgeon (C).

Why an angled scope is superior

Many gynecologists fear laparoscopic surgery in patients who have a large uterus. The reason? Poor visualization of the surgical field. However, the type of endoscope that is used has a bearing on visualization.

Most gynecologists are trained to use a 0° endoscope for laparoscopic surgery. However, when the uterus is large, the 0° scope yields an inadequate field of view, whether the endoscope is placed at the umbilicus or through a lateral port. Critical structures like the vascular bundles, ureters, and even the bladder may be inadequately visualized using the 0° endoscope (FIGURE 3).

Gynecologists routinely use angled scopes in hysteroscopy and cystoscopy, but tend to avoid them in laparoscopy because of difficulty orienting the surgical field. As gynecologists, we readily accept that use of an angled scope in hysteroscopy and cystoscopy requires rotation of the scope while the camera maintains its horizontal position. The same concept applies to laparoscopy.

Use of the angled scope in the abdomen is a two-step process. First, it must be rotated to achieve the desired field of view. Then, as the endoscope is held firmly to maintain this view, the camera head must be rotated on the scope to return the field to a horizontal position.

Many surgeons find this action difficult because they or the assistant are holding the camera in one hand and an instrument in the other. We solve this problem by using a mechanical scope holder to secure the camera and endoscope in the position we desire.

In some cases, the camera head does not attach securely to the eyepiece, and the scope rotates on the camera as soon as it is released. This difficulty arises when the eyepiece of the endoscope is slightly smaller than the camera attachment. The problem is easily solved by placing a small piece of surgical skin closure tape on one edge of the eyepiece, slightly increasing its diameter. The camera attachment then holds the scope securely.

Human scope holders may tire during long cases, causing field drift at critical moments. In contrast, a mechanical scope holder is easily and intermittently adjusted for field of view, producing a steady field of view and minimizing the impact of manual manipulation of the scope on surgical outcome. It also allows the surgeon and first assistant to use two hands while operating.

The 45° scope is best

General surgeons and urologists often use 30° endoscopes. Gynecologists working in the pelvis see better using a 45° scope (FIGURE 3). Most ORs offer a 30° endoscope but do not always have a 45° endoscope available in the instrument room. This is regrettable. Compared with the 30° scope, the 45° instrument provides better visual access to the low lateral uterine blood supply and bladder flap, particularly when the patient has a globular uterus or large, low anterior fibroid. We include both 5-mm and 10-mm 45° endoscopes in our laparoscopic tool chest, and believe they are essential options.

FIGURE 3 The 45° laparoscope provides better visual access

(A) 0° scope, uterus midline: Right broad ligament view obstructed. (B) 0° scope, uterus to left: Right broad ligament view still obstructed. (C) 45° scope, uterus midline: Right broad ligament view improved. (D) 45° scope, uterus to left: Right broad ligament view optimal.

Control the blood supply

Our laparoscopic approach is very similar to our technique for abdominal hysterectomy, beginning with the blood supply. The main blood supply to the uterus enters at only four points. If this blood supply is adequately controlled, morcellation of the large uterus can proceed without excessive blood loss.

Visualization of the blood supply is normally restricted because of tense, taut round ligaments that limit mobility of the large uterus. A simple step to improve mobility is to transect each round ligament in its middle position before addressing the uterine blood supply.

If the ovaries are being conserved, transect the utero-ovarian ligament and tube as close to the ovary as possible with your instrument and technique of choice (electrical or mechanical energy, etc); they all work. Stay close to the ovary to avert bleeding that might otherwise occur when the ascending uterine vascular coils are cut tangentially.

If the ovaries are being removed, transect the infundibulopelvic ligament close to the ovary, being careful not to include ovarian tissue in the pedicle. Use your method of choice, but relieve tension on the pedicle as it is being transected to minimize the risk of pedicle bleeding.

Now, 20% to 40% of the uterine blood supply is controlled, with minimal blood loss.

The key to controlling the remaining blood supply is transecting the ascending vascular bundle as low as possible on either side. The 45° endoscope provides optimal visualization for this part of the procedure. Many times the field of view attained using the 45° endoscope is all that is necessary to facilitate occlusion and transection of these vessels at the level of the internal cervical os.

We commonly use ultrasonic energy to coagulate and cut the ascending vascular bundle. Ultrasonic energy provides excellent hemostasis for this part of the procedure. Again, use the technique of your choice.

Use a laparoscopic “leash”

At times, large broad-ligament fibroids obscure the field of view and access to the ascending vascular bundle. Standard laparoscopic graspers cannot maintain a firm hold on the tissue to improve visibility or access. The solution? A laparoscopic “leash,” first described in 1999 by Tsin and colleagues.¹³

Giesler extended that concept with a “puppet string” variation to maximize exposure in difficult cases. To apply the “puppet string” technique, using No. 1 Prolene suture, place a large figure-of-eight suture through the tissue to be retracted (FIGURE 4). Bring the suture out of the abdomen adjacent to the trocar sleeve in a location that provides optimal traction. (First, bring the suture through the trocar sleeve. Then remove the trocar sleeve and reinsert it adjacent to the retraction suture.) This secure attachment allows better visualization and greater access to the blood supply at a lower level. It also is possible to manipulate this suture inside the abdomen using traditional graspers to provide reliable repositioning of the uterus. This degree of tissue control improves field of vision and allows the procedure to advance smoothly.

FIGURE 4 A “puppet string” improves access

This secure attachment allows better visualization and greater access to the blood supply at a lower level. Manipulation of this suture inside the abdomen using traditional graspers also helps reposition the uterus.

Morcellation techniques

Once the ascending blood supply has been managed on both sides, morcellation can be performed with minimal blood loss using one of two techniques:

• Amputate the body of the uterus above the level where the blood supply has been interrupted
• Morcellate the uterine body to a point just above the level where the blood supply has been interrupted.

Use basic principles, regardless of the technique chosen

• Hold the morcellator in one hand and a toothed grasper in the other hand to pull tissue into the morcellator. Do not push the morcellator into tissue or you may injure nonvisualized structures on the other side.
• Morcellate tissue in half-moon portions, skimming along the top of the fundus, instead of coring the uterus like an apple; it creates longer strips of tissue and is faster. This technique also allows continuous observation of the active blade, which helps avoid inadvertent injury to tissues behind the blade.
• Attempt morcellation in the anterior abdominal space to avoid injury to blood vessels, ureters, and bowel in the posterior abdominal space. The assistant feeds uterine tissue to the surgeon in the anterior space.

It is essential to control the blood supply to the tissue to be morcellated before morcellation to avoid massive hemorrhage.

Amputating the upper uterine body

Amputation of the large body of the uterus from the lower uterine segment assures complete control of the blood supply and avoids further blood loss during morcellation, but it also poses difficulties. The free uterine mass is held in position by the assistant using only one grasper. If this grasper slips, the mass can be inadvertently released while the morcellator blade is active. If the assistant is also holding the camera, there are no options for stabilizing the free uterine mass. If a mechanical scope holder or second assistant is available to hold the camera, a second trocar port can be placed on the side of the assistant to provide access for a second grasper to stabilize the uterine body during morcellation. The need for a stable uterine mass is important to minimize the risk of injury.

Once the upper body of the uterus has been removed by morcellation, the lower uterine segment and cervix must be removed—using your procedure of choice—to finish the hysterectomy.

Morcellating the upper uterine body

If the uterus remains attached to the cervix, it already has one fixed point of stability. During morcellation, the assistant has one hand available to direct the camera. Blood loss during morcellation of the uterus while it is still attached to the cervix is minimal because the ascending vascular bundles on either side have been interrupted under direct vision.

For greater control of the large uterus, a second port can be placed on the assistant’s side for a second grasper, as described above. Most of the large uterus that is still connected to the cervix can be morcellated in the anterior abdominal space in horizontal fashion, as for the free uterine mass just described.

Uterine manipulation by the assistant keeps the uterus away from critical structures as it is reduced to 8 to 10 weeks’ size. Once this size is attained, resume normal technique for total laparoscopic hysterectomy to separate the remaining tissue from the vagina.

2 types of morcellators in use today

One has a disposable 15-mm blade that attaches to a drive unit adjacent to the OR table (Gynecare-Ethicon Women’s Health and Urology). The other has a sterile, reusable drive unit with a disposable blade (Storz). Both work well on large uteri.

The reusable drive unit has more power to morcellate calcified fibroids and offers a choice between 12-mm, 15-mm, and 20-mm disposable blades for faster morcellation.

Concluding the procedure

Chips of fibroid and uterine tissue created during morcellation often remain in the pelvis after the uterus has been removed. Place them in a 10-cm specimen-collection bag and extract it through the vagina after removal of the residual uterus and cervix. This is faster and easier than recovering them one at a time with the gall bladder stone scoop through a trocar port. The value of the OR time saved with use of the specimen-collection bag is significantly greater than that of the disposable collection device.

CASE RESOLVED

You perform total laparoscopic hysterectomy and find 6-cm fibroids in both broad ligament areas and over the cervical–vaginal junction on the left. You use a “puppet string” to apply directed traction to the fibroids to simplify their extraction. The 45° endoscope allows clear visualization of the ascending vascular bundle on both sides, and the mechanical scope holder allows a fixed field of view for the meticulous dissection required to remove the broad-ligament fibroids.

You morcellate the entire 663-g uterus and remove it in pieces through the abdominal wall. The extensive morcellation required, coupled with technical issues related to the patient’s morbid obesity, prolong the procedure to more than 4 hours.

Postoperatively, the patient voids without a catheter, walks around the nursing unit, and eats half a sandwich within 4 hours. She is discharged home in less than 24 hours and is able to drive 4 days after her surgery.

The author reports no financial relationships relevant to this article.

CASE Postoperative abdominal pain. Is it gastroenteritis?

R.B., 35 years old, undergoes laparoscopic adhesiolysis for abdominal pain. Previously, she underwent exploratory laparotomy for a ruptured tubal pregnancy and, in separate operations, right oophorectomy via laparotomy for a ruptured corpus luteum cyst and diagnostic laparoscopy.

During the current surgery, extensive adhesions are observed, including interloop intestinal adhesions. The adhesions are lysed using monopolar scissors and a needle electrode, and R.B. is discharged home the same day.

Later that day and the next day, R.B. complains of abdominal pain that does not respond to prescribed analgesics, as well as nausea and vomiting. A nurse practitioner takes her call and prescribes a stronger analgesic, an antiemetic, and an antibiotic.

The following day, the patient’s husband telephones the treating gynecologist to report that his wife is still experiencing severe pain and nausea. He is told to bring her to the office, where she is described as having mild lower abdominal tenderness and mild rebound. An abdominal radiograph shows air-fluid levels and distended bowel. The gynecologist determines that the patient is experiencing gastroenteritis.

On postop day 3, R.B. continues to suffer from severe abdominal pain, nausea, and vomiting, and is unable to get out of bed. Her husband takes her to the emergency room at another hospital, where she is found to have diffuse peritonitis, absent bowel sounds, and:

• temperature, 101.8°F
• heart rate, 130/min
• respiratory rate, 24/min
• blood pressure, 90/60 mm Hg
• white blood cell (WBC) count, 21.5 × 10³/μL
• x-ray showing free air.

A general surgeon performs an exploratory laparotomy and finds foul-smelling abdominal fluid, 200 to 300 mL of pus, and a 1-cm perforation of the sigmoid colon. He performs sigmoid colon resection and a left-colon colostomy. A second laparotomy is necessary to drain a subphrenic abscess.

Four months later, the colostomy is taken down and bowel continuity is established.

Subsequently, the patient experiences episodes of gaseous and fecal incontinence, which are thought to be secondary to nerve damage. A ventral hernia is also diagnosed.

Could this outcome have been avoided?

No physician would wish a major complication of surgery upon any patient. Yet, sometimes, preventive efforts fall short of the goal or the physician is slow to suspect injury when the patient experiences postoperative abdominal pain and other symptoms. Intestinal injury may not be common during laparoscopy, but it is certainly not rare. And the longer diagnosis is delayed, the greater the risk of sepsis, even death.

Recognizing the limitations of laparoscopic surgery is a first step toward reducing the complication rate.^1,2 The ability to determine when laparotomy would better serve the patient’s interests is also critical, and prompt diagnosis and repair of any complication that does occur will ensure and speed the patient’s recovery.

The most serious complications associated with diagnostic and operative laparoscopy are major vessel and intestinal injuries. Both types of injury significantly raise the risk of mortality, which ranges from 2% to 23%.^3,4 The overall risk of injury to the gastrointestinal tract averages 1.6 to 2.0 for every 1,000 cases. The risk of major vessel injury averages 0.5 for every 1,000 cases.^5-9

In an earlier article for OBG Management, I reviewed vascular injury during laparoscopy.¹⁰ In Part 1 of this article, I focus on ways to avoid intestinal injury.In Part 2 , I outline strategies to identify it in a timely manner when it does occur.

Familiarity with intestinal and pelvic anatomy can prevent surgical injury

A thorough familiarity with pelvic anatomy is important to avoid injury at trocar entry, but it is even more critical in regard to operative injury. The small intestine spreads diffusely throughout the abdomen beneath the anterior abdominal wall. It lies beneath the umbilicus and anterior midline, whereas the large bowel is located at the periphery. The sigmoid colon swings left to right before joining the rectum anterior to the presacral space. The sigmoid junction with the descending colon lies well to the left of the midline, and the cecum lies at the pelvic brim to the right of midline.

In some women, the intestines droop into the pelvis and cover the adnexa, making adhesions between these structures highly likely following dissection in the vicinity of the tubes and ovaries.

Depending on the degree of redundancy of the mesentery of the cecum or sigmoid colon, these structures may droop into the pelvis and cover the adnexa. Therefore, adhesions are likely to develop between the large or small intestine, or both, and the adnexa following dissection in the vicinity of or immediately over the tubes and ovaries. Knowing the normal anatomic relationships is vital for restorative surgery.

When severe adhesions involve the large intestine, it is critical to know the anatomy of the retroperitoneum and be skilled enough to gain safe entry and to dissect that space to safely separate the adnexa when they are densely adhered to the pelvic sidewall in the area of the obturator fossa.

As laparoscopy evolves, the injury rate rises

Over the past 40 years, laparoscopy has evolved from an uncommonly utilized diagnostic tool to a minimally invasive alternative to laparotomy for even the most difficult and complex operations, reaching a high point with robotic laparoscopy. As this technology has developed, serious complications—to some degree, unique to laparoscopy—have increased. In the future, as less skilled surgeons perform a greater percentage of laparoscopic surgeries, a still greater number of complications will arise.

The frequency of intestinal perforation is not great relative to the total number of laparoscopic procedures performed. The TABLE lists several series totaling more than 380,000 laparoscopic operations. The risk of reported bowel perforation ranged from 0.6 to 6 for every 1,000 procedures, with a mean risk of 2.4 for every 1,000. However, these data are inconclusive because the total number of laparoscopic operations performed in the United States is not accurately known. Nor is the precise number of complications associated with these procedures known—specifically, the number of intestinal perforations—as no law requires them to be reported.

Research surveys are unreliable in many cases. In addition, the relative expertise of the surgeon is impossible to quantify. For example, although a surgeon may have many years of operative experience, it is unclear whether this always translates into skill or comfort with laparoscopic procedures. And, when a resident scrubs in with a faculty surgeon, any data collected fail to reflect which part of the surgery was performed by the resident and which by the fully trained gynecologist.

These unknown variables are important in terms of risk, surgical complications, and outcomes. Surgical skill is the greatest unknown factor in any outcome study of any surgical procedure.

TABLE

Studies of complications reveal: Gastrointestinal injury is no rare event during laparoscopic surgery

Classifying intestinal injuries

As in the case of major vessel injury, intestinal injury sustained during laparoscopy can be classified as either:

• Injury secondary to the approach. This category refers to entry complications associated with creation of the pneumoperitoneum and insertion of primary and secondary trocars.
• Injury secondary to the procedure or operation. This type of injury occurs as a result of manipulation with various devices during laparoscopy. The devices may include probes, forceps, scissors, or energy devices such as laser, electrosurgical, and ultrasonic instruments.

How trocar injury happens

Several studies have demonstrated that abdominal adhesions place any patient into a high-risk category for trocar injury to the intestines. Patients who have undergone multiple laparotomies, like the patient in the case that opened this article, are more likely to have severe adhesions and fall into the highest risk category for bowel perforation.¹¹ It is impossible to predict with any degree of accuracy whether the intestine is adherent to the entry site.

Pneumoperitoneum can be protective

Creation of a pneumoperitoneum creates a cushion of gas between the intestines and the anterior abdominal wall (provided the intestines are not adherent to the abdominal wall). Manufacturers of disposable trocars with a retractable shield recommend creating an adequate pneumoperitoneum so that the “safety shield” deploys quickly and properly, unlike direct insertion, in which no gas is infused and space is insufficient for complete shield activation.

Open laparoscopy techniques, which allow the surgeon to enter the peritoneal cavity by direct vision without a sharp trocar, may diminish but not eliminate the risk of bowel injury.

What the data show

Of the 130 intestinal injuries recently reported by Baggish, 62 of 81 (77%) small bowel injuries were related to trocar insertion, as were 20 of 49 (41%) large intestinal injuries.¹² In other words, 82 of 130 intestinal injuries (63%) were the direct result of trocar entry.

Bhoyrul and associates reported 629 trocar injuries, of which 182 were visceral.¹³ Of the 32 deaths, six were secondary to unrecognized bowel injury. Of 176 nonfatal visceral injuries, 128 (73%) involved the intestines, and 22 were unrecognized.

Optical-access and open laparoscopic systems were designed to prevent such injuries. Sharp and colleagues reported 24 intestinal injuries out of a total of 79 complications (30%) associated with optical-access trocars after reviewing data obtained from the Medical Device Reports (MDR) and Maude databases maintained by the Food and Drug Administration.¹⁴ In the Baggish series, 4.6% of injuries were associated with open laparoscopy.¹²

Champault and colleagues reviewed complications in a survey of 103,852 operations.¹⁵ Although they recommended use of open laparoscopy as opposed to blind insertion, they presented no data on the safety of open techniques.

How intraoperative injury happens

Operative injury of the large or small bowel often occurs during sharp or blunt dissection, performed during laparoscopy using accessory mechanical or energy devices. The latter type of device is utilized increasingly because laparoscopic knot tying and suturing are rather awkward and slow, and laparoscopic suturing to control bleeding is difficult. The size of the needle required for laparoscopic suture placement must be small enough to navigate a trocar sleeve.

Avoid blunt dissection when adhesions are present

The separation of dense adhesions between the intestines and neighboring bowel, other viscera, or abdominal wall is risky when blunt dissection is used. The tensile strength of the fibrotic connective tissue may well exceed that of the thin intestinal wall. Tearing the adhesion free may bring with it a portion of the bowel wall. Such injuries are frequently missed or described as serosal injuries and left unexplored and unrepaired.

Hydrodissection is a safer alternative. It involves the infiltration of sterile water or saline under low pressure between the parietal peritoneum and underlying retroperitoneal structures, providing a safe and natural plane for dissection. In addition, when the CO₂ laser is used, the liquid acts as a heat sink to absorb any penetrating laser energy.

Energy devices create thermal effects

Energy devices used to cut tissue during operative laparoscopy coagulate blood vessels in a variety of ways, but the common pathway is thermal. Many hypotheses have evolved to explain how vessels are sealed, but none has demonstrated nonthermal activity except for cryocoagulation.

The devices most commonly used for cutting and hemostasis at laparoscopy are:

• electrosurgical (both monopolar and bipolar). Bipolar electrosurgical devices have advantages over monopolar devices when it comes to high-frequency leaks, direct coupling, and capacitive coupling.
• laser (CO₂, holmium:YAG, Nd:YAG, KTP-532, argon). As I mentioned, CO₂ laser devices are effectively backstopped by water, especially in strategic areas such as over and around intestines, major vessels, and the ureters.
• ultrasonic (Harmonic Scalpel, ultrasonic aspirator [CUSA]).

Laser and ultrasonic devices do not require a flow of electrons to create coagulation, but do produce heat that will spread peripherally by thermal conduction from the zone of impact (target).

The extent of energy-inflicted injury cannot be predicted

Inadvertent injury with energy devices can occur directly through contact with the bowel, indirectly by heat conduction through tissue, through capacitive coupling (monopolar electrical only), and by forward scatter (laser only).

Upon direct contact with the intestine, energy devices cut into the tissue in a manner similar to mechanical scissors or a knife but produce a larger wound. The reason? The transfer of heat to areas adjacent to the primary wound produces additional necrosis. Heat conduction, capacitive coupling, high-frequency leaks, and front scatter coagulate the intestinal wall with subsequent tissue devitalization and necrosis, the extent of which depends on the power density at contact and the duration of energy applied.

It is impossible to predict the depth or area of devitalization in energy-inflicted injury by visualization of the event.

In the Baggish review of 130 intestinal injuries, the number of injuries sustained during the operative procedure was 19 involving the small intestine and 29 involving the large bowel.¹² Of this subset, 44% (21 cases) were secondary to the use of energy devices, with monopolar electrosurgical instruments alone accounting for 9 (43%) of the injuries.

Even best-laid plans can go awry

Despite our best intentions and precautions, accidents do sometimes happen, and bowel injury is no exception.In Part 2 of this article, I detail steps you can take to detect injuries in as timely a manner as possible.

The author reports no financial relationships relevant to this article.

CASE Postoperative abdominal pain. Is it gastroenteritis?

R.B., 35 years old, undergoes laparoscopic adhesiolysis for abdominal pain. Previously, she underwent exploratory laparotomy for a ruptured tubal pregnancy and, in separate operations, right oophorectomy via laparotomy for a ruptured corpus luteum cyst and diagnostic laparoscopy.

During the current surgery, extensive adhesions are observed, including interloop intestinal adhesions. The adhesions are lysed using monopolar scissors and a needle electrode, and R.B. is discharged home the same day.

Later that day and the next day, R.B. complains of abdominal pain that does not respond to prescribed analgesics, as well as nausea and vomiting. A nurse practitioner takes her call and prescribes a stronger analgesic, an antiemetic, and an antibiotic.

The following day, the patient’s husband telephones the treating gynecologist to report that his wife is still experiencing severe pain and nausea. He is told to bring her to the office, where she is described as having mild lower abdominal tenderness and mild rebound. An abdominal radiograph shows air-fluid levels and distended bowel. The gynecologist determines that the patient is experiencing gastroenteritis.

On postop day 3, R.B. continues to suffer from severe abdominal pain, nausea, and vomiting, and is unable to get out of bed. Her husband takes her to the emergency room at another hospital, where she is found to have diffuse peritonitis, absent bowel sounds, and:

• temperature, 101.8°F
• heart rate, 130/min
• respiratory rate, 24/min
• blood pressure, 90/60 mm Hg
• white blood cell (WBC) count, 21.5 × 10³/μL
• x-ray showing free air.

A general surgeon performs an exploratory laparotomy and finds foul-smelling abdominal fluid, 200 to 300 mL of pus, and a 1-cm perforation of the sigmoid colon. He performs sigmoid colon resection and a left-colon colostomy. A second laparotomy is necessary to drain a subphrenic abscess.

Four months later, the colostomy is taken down and bowel continuity is established.

Subsequently, the patient experiences episodes of gaseous and fecal incontinence, which are thought to be secondary to nerve damage. A ventral hernia is also diagnosed.

Could this outcome have been avoided?

No physician would wish a major complication of surgery upon any patient. Yet, sometimes, preventive efforts fall short of the goal or the physician is slow to suspect injury when the patient experiences postoperative abdominal pain and other symptoms. Intestinal injury may not be common during laparoscopy, but it is certainly not rare. And the longer diagnosis is delayed, the greater the risk of sepsis, even death.

Recognizing the limitations of laparoscopic surgery is a first step toward reducing the complication rate.^1,2 The ability to determine when laparotomy would better serve the patient’s interests is also critical, and prompt diagnosis and repair of any complication that does occur will ensure and speed the patient’s recovery.

The most serious complications associated with diagnostic and operative laparoscopy are major vessel and intestinal injuries. Both types of injury significantly raise the risk of mortality, which ranges from 2% to 23%.^3,4 The overall risk of injury to the gastrointestinal tract averages 1.6 to 2.0 for every 1,000 cases. The risk of major vessel injury averages 0.5 for every 1,000 cases.^5-9

In an earlier article for OBG Management, I reviewed vascular injury during laparoscopy.¹⁰ In Part 1 of this article, I focus on ways to avoid intestinal injury.In Part 2 , I outline strategies to identify it in a timely manner when it does occur.

Familiarity with intestinal and pelvic anatomy can prevent surgical injury

A thorough familiarity with pelvic anatomy is important to avoid injury at trocar entry, but it is even more critical in regard to operative injury. The small intestine spreads diffusely throughout the abdomen beneath the anterior abdominal wall. It lies beneath the umbilicus and anterior midline, whereas the large bowel is located at the periphery. The sigmoid colon swings left to right before joining the rectum anterior to the presacral space. The sigmoid junction with the descending colon lies well to the left of the midline, and the cecum lies at the pelvic brim to the right of midline.

In some women, the intestines droop into the pelvis and cover the adnexa, making adhesions between these structures highly likely following dissection in the vicinity of the tubes and ovaries.

Depending on the degree of redundancy of the mesentery of the cecum or sigmoid colon, these structures may droop into the pelvis and cover the adnexa. Therefore, adhesions are likely to develop between the large or small intestine, or both, and the adnexa following dissection in the vicinity of or immediately over the tubes and ovaries. Knowing the normal anatomic relationships is vital for restorative surgery.

When severe adhesions involve the large intestine, it is critical to know the anatomy of the retroperitoneum and be skilled enough to gain safe entry and to dissect that space to safely separate the adnexa when they are densely adhered to the pelvic sidewall in the area of the obturator fossa.

As laparoscopy evolves, the injury rate rises

Over the past 40 years, laparoscopy has evolved from an uncommonly utilized diagnostic tool to a minimally invasive alternative to laparotomy for even the most difficult and complex operations, reaching a high point with robotic laparoscopy. As this technology has developed, serious complications—to some degree, unique to laparoscopy—have increased. In the future, as less skilled surgeons perform a greater percentage of laparoscopic surgeries, a still greater number of complications will arise.

The frequency of intestinal perforation is not great relative to the total number of laparoscopic procedures performed. The TABLE lists several series totaling more than 380,000 laparoscopic operations. The risk of reported bowel perforation ranged from 0.6 to 6 for every 1,000 procedures, with a mean risk of 2.4 for every 1,000. However, these data are inconclusive because the total number of laparoscopic operations performed in the United States is not accurately known. Nor is the precise number of complications associated with these procedures known—specifically, the number of intestinal perforations—as no law requires them to be reported.

Research surveys are unreliable in many cases. In addition, the relative expertise of the surgeon is impossible to quantify. For example, although a surgeon may have many years of operative experience, it is unclear whether this always translates into skill or comfort with laparoscopic procedures. And, when a resident scrubs in with a faculty surgeon, any data collected fail to reflect which part of the surgery was performed by the resident and which by the fully trained gynecologist.

These unknown variables are important in terms of risk, surgical complications, and outcomes. Surgical skill is the greatest unknown factor in any outcome study of any surgical procedure.

TABLE

Studies of complications reveal: Gastrointestinal injury is no rare event during laparoscopic surgery

Classifying intestinal injuries

As in the case of major vessel injury, intestinal injury sustained during laparoscopy can be classified as either:

• Injury secondary to the approach. This category refers to entry complications associated with creation of the pneumoperitoneum and insertion of primary and secondary trocars.
• Injury secondary to the procedure or operation. This type of injury occurs as a result of manipulation with various devices during laparoscopy. The devices may include probes, forceps, scissors, or energy devices such as laser, electrosurgical, and ultrasonic instruments.

How trocar injury happens

Several studies have demonstrated that abdominal adhesions place any patient into a high-risk category for trocar injury to the intestines. Patients who have undergone multiple laparotomies, like the patient in the case that opened this article, are more likely to have severe adhesions and fall into the highest risk category for bowel perforation.¹¹ It is impossible to predict with any degree of accuracy whether the intestine is adherent to the entry site.

Pneumoperitoneum can be protective

Creation of a pneumoperitoneum creates a cushion of gas between the intestines and the anterior abdominal wall (provided the intestines are not adherent to the abdominal wall). Manufacturers of disposable trocars with a retractable shield recommend creating an adequate pneumoperitoneum so that the “safety shield” deploys quickly and properly, unlike direct insertion, in which no gas is infused and space is insufficient for complete shield activation.

Open laparoscopy techniques, which allow the surgeon to enter the peritoneal cavity by direct vision without a sharp trocar, may diminish but not eliminate the risk of bowel injury.

What the data show

Of the 130 intestinal injuries recently reported by Baggish, 62 of 81 (77%) small bowel injuries were related to trocar insertion, as were 20 of 49 (41%) large intestinal injuries.¹² In other words, 82 of 130 intestinal injuries (63%) were the direct result of trocar entry.

Bhoyrul and associates reported 629 trocar injuries, of which 182 were visceral.¹³ Of the 32 deaths, six were secondary to unrecognized bowel injury. Of 176 nonfatal visceral injuries, 128 (73%) involved the intestines, and 22 were unrecognized.

Optical-access and open laparoscopic systems were designed to prevent such injuries. Sharp and colleagues reported 24 intestinal injuries out of a total of 79 complications (30%) associated with optical-access trocars after reviewing data obtained from the Medical Device Reports (MDR) and Maude databases maintained by the Food and Drug Administration.¹⁴ In the Baggish series, 4.6% of injuries were associated with open laparoscopy.¹²

Champault and colleagues reviewed complications in a survey of 103,852 operations.¹⁵ Although they recommended use of open laparoscopy as opposed to blind insertion, they presented no data on the safety of open techniques.

How intraoperative injury happens

Operative injury of the large or small bowel often occurs during sharp or blunt dissection, performed during laparoscopy using accessory mechanical or energy devices. The latter type of device is utilized increasingly because laparoscopic knot tying and suturing are rather awkward and slow, and laparoscopic suturing to control bleeding is difficult. The size of the needle required for laparoscopic suture placement must be small enough to navigate a trocar sleeve.

Avoid blunt dissection when adhesions are present

The separation of dense adhesions between the intestines and neighboring bowel, other viscera, or abdominal wall is risky when blunt dissection is used. The tensile strength of the fibrotic connective tissue may well exceed that of the thin intestinal wall. Tearing the adhesion free may bring with it a portion of the bowel wall. Such injuries are frequently missed or described as serosal injuries and left unexplored and unrepaired.

Hydrodissection is a safer alternative. It involves the infiltration of sterile water or saline under low pressure between the parietal peritoneum and underlying retroperitoneal structures, providing a safe and natural plane for dissection. In addition, when the CO₂ laser is used, the liquid acts as a heat sink to absorb any penetrating laser energy.

Energy devices create thermal effects

Energy devices used to cut tissue during operative laparoscopy coagulate blood vessels in a variety of ways, but the common pathway is thermal. Many hypotheses have evolved to explain how vessels are sealed, but none has demonstrated nonthermal activity except for cryocoagulation.

The devices most commonly used for cutting and hemostasis at laparoscopy are:

• electrosurgical (both monopolar and bipolar). Bipolar electrosurgical devices have advantages over monopolar devices when it comes to high-frequency leaks, direct coupling, and capacitive coupling.
• laser (CO₂, holmium:YAG, Nd:YAG, KTP-532, argon). As I mentioned, CO₂ laser devices are effectively backstopped by water, especially in strategic areas such as over and around intestines, major vessels, and the ureters.
• ultrasonic (Harmonic Scalpel, ultrasonic aspirator [CUSA]).

Laser and ultrasonic devices do not require a flow of electrons to create coagulation, but do produce heat that will spread peripherally by thermal conduction from the zone of impact (target).

The extent of energy-inflicted injury cannot be predicted

Inadvertent injury with energy devices can occur directly through contact with the bowel, indirectly by heat conduction through tissue, through capacitive coupling (monopolar electrical only), and by forward scatter (laser only).

Upon direct contact with the intestine, energy devices cut into the tissue in a manner similar to mechanical scissors or a knife but produce a larger wound. The reason? The transfer of heat to areas adjacent to the primary wound produces additional necrosis. Heat conduction, capacitive coupling, high-frequency leaks, and front scatter coagulate the intestinal wall with subsequent tissue devitalization and necrosis, the extent of which depends on the power density at contact and the duration of energy applied.

It is impossible to predict the depth or area of devitalization in energy-inflicted injury by visualization of the event.

In the Baggish review of 130 intestinal injuries, the number of injuries sustained during the operative procedure was 19 involving the small intestine and 29 involving the large bowel.¹² Of this subset, 44% (21 cases) were secondary to the use of energy devices, with monopolar electrosurgical instruments alone accounting for 9 (43%) of the injuries.

Even best-laid plans can go awry

Despite our best intentions and precautions, accidents do sometimes happen, and bowel injury is no exception.In Part 2 of this article, I detail steps you can take to detect injuries in as timely a manner as possible.

The author reports no financial relationships relevant to this article.

CASE Postoperative abdominal pain. Is it gastroenteritis?

R.B., 35 years old, undergoes laparoscopic adhesiolysis for abdominal pain. Previously, she underwent exploratory laparotomy for a ruptured tubal pregnancy and, in separate operations, right oophorectomy via laparotomy for a ruptured corpus luteum cyst and diagnostic laparoscopy.

During the current surgery, extensive adhesions are observed, including interloop intestinal adhesions. The adhesions are lysed using monopolar scissors and a needle electrode, and R.B. is discharged home the same day.

Later that day and the next day, R.B. complains of abdominal pain that does not respond to prescribed analgesics, as well as nausea and vomiting. A nurse practitioner takes her call and prescribes a stronger analgesic, an antiemetic, and an antibiotic.

The following day, the patient’s husband telephones the treating gynecologist to report that his wife is still experiencing severe pain and nausea. He is told to bring her to the office, where she is described as having mild lower abdominal tenderness and mild rebound. An abdominal radiograph shows air-fluid levels and distended bowel. The gynecologist determines that the patient is experiencing gastroenteritis.

On postop day 3, R.B. continues to suffer from severe abdominal pain, nausea, and vomiting, and is unable to get out of bed. Her husband takes her to the emergency room at another hospital, where she is found to have diffuse peritonitis, absent bowel sounds, and:

• temperature, 101.8°F
• heart rate, 130/min
• respiratory rate, 24/min
• blood pressure, 90/60 mm Hg
• white blood cell (WBC) count, 21.5 × 10³/μL
• x-ray showing free air.

A general surgeon performs an exploratory laparotomy and finds foul-smelling abdominal fluid, 200 to 300 mL of pus, and a 1-cm perforation of the sigmoid colon. He performs sigmoid colon resection and a left-colon colostomy. A second laparotomy is necessary to drain a subphrenic abscess.

Four months later, the colostomy is taken down and bowel continuity is established.

Subsequently, the patient experiences episodes of gaseous and fecal incontinence, which are thought to be secondary to nerve damage. A ventral hernia is also diagnosed.

Could this outcome have been avoided?

No physician would wish a major complication of surgery upon any patient. Yet, sometimes, preventive efforts fall short of the goal or the physician is slow to suspect injury when the patient experiences postoperative abdominal pain and other symptoms. Intestinal injury may not be common during laparoscopy, but it is certainly not rare. And the longer diagnosis is delayed, the greater the risk of sepsis, even death.

Recognizing the limitations of laparoscopic surgery is a first step toward reducing the complication rate.^1,2 The ability to determine when laparotomy would better serve the patient’s interests is also critical, and prompt diagnosis and repair of any complication that does occur will ensure and speed the patient’s recovery.

The most serious complications associated with diagnostic and operative laparoscopy are major vessel and intestinal injuries. Both types of injury significantly raise the risk of mortality, which ranges from 2% to 23%.^3,4 The overall risk of injury to the gastrointestinal tract averages 1.6 to 2.0 for every 1,000 cases. The risk of major vessel injury averages 0.5 for every 1,000 cases.^5-9

In an earlier article for OBG Management, I reviewed vascular injury during laparoscopy.¹⁰ In Part 1 of this article, I focus on ways to avoid intestinal injury.In Part 2 , I outline strategies to identify it in a timely manner when it does occur.

Familiarity with intestinal and pelvic anatomy can prevent surgical injury

A thorough familiarity with pelvic anatomy is important to avoid injury at trocar entry, but it is even more critical in regard to operative injury. The small intestine spreads diffusely throughout the abdomen beneath the anterior abdominal wall. It lies beneath the umbilicus and anterior midline, whereas the large bowel is located at the periphery. The sigmoid colon swings left to right before joining the rectum anterior to the presacral space. The sigmoid junction with the descending colon lies well to the left of the midline, and the cecum lies at the pelvic brim to the right of midline.

In some women, the intestines droop into the pelvis and cover the adnexa, making adhesions between these structures highly likely following dissection in the vicinity of the tubes and ovaries.

Depending on the degree of redundancy of the mesentery of the cecum or sigmoid colon, these structures may droop into the pelvis and cover the adnexa. Therefore, adhesions are likely to develop between the large or small intestine, or both, and the adnexa following dissection in the vicinity of or immediately over the tubes and ovaries. Knowing the normal anatomic relationships is vital for restorative surgery.

When severe adhesions involve the large intestine, it is critical to know the anatomy of the retroperitoneum and be skilled enough to gain safe entry and to dissect that space to safely separate the adnexa when they are densely adhered to the pelvic sidewall in the area of the obturator fossa.

As laparoscopy evolves, the injury rate rises

Over the past 40 years, laparoscopy has evolved from an uncommonly utilized diagnostic tool to a minimally invasive alternative to laparotomy for even the most difficult and complex operations, reaching a high point with robotic laparoscopy. As this technology has developed, serious complications—to some degree, unique to laparoscopy—have increased. In the future, as less skilled surgeons perform a greater percentage of laparoscopic surgeries, a still greater number of complications will arise.

The frequency of intestinal perforation is not great relative to the total number of laparoscopic procedures performed. The TABLE lists several series totaling more than 380,000 laparoscopic operations. The risk of reported bowel perforation ranged from 0.6 to 6 for every 1,000 procedures, with a mean risk of 2.4 for every 1,000. However, these data are inconclusive because the total number of laparoscopic operations performed in the United States is not accurately known. Nor is the precise number of complications associated with these procedures known—specifically, the number of intestinal perforations—as no law requires them to be reported.

Research surveys are unreliable in many cases. In addition, the relative expertise of the surgeon is impossible to quantify. For example, although a surgeon may have many years of operative experience, it is unclear whether this always translates into skill or comfort with laparoscopic procedures. And, when a resident scrubs in with a faculty surgeon, any data collected fail to reflect which part of the surgery was performed by the resident and which by the fully trained gynecologist.

These unknown variables are important in terms of risk, surgical complications, and outcomes. Surgical skill is the greatest unknown factor in any outcome study of any surgical procedure.

TABLE

Studies of complications reveal: Gastrointestinal injury is no rare event during laparoscopic surgery

Classifying intestinal injuries

As in the case of major vessel injury, intestinal injury sustained during laparoscopy can be classified as either:

• Injury secondary to the approach. This category refers to entry complications associated with creation of the pneumoperitoneum and insertion of primary and secondary trocars.
• Injury secondary to the procedure or operation. This type of injury occurs as a result of manipulation with various devices during laparoscopy. The devices may include probes, forceps, scissors, or energy devices such as laser, electrosurgical, and ultrasonic instruments.

How trocar injury happens

Several studies have demonstrated that abdominal adhesions place any patient into a high-risk category for trocar injury to the intestines. Patients who have undergone multiple laparotomies, like the patient in the case that opened this article, are more likely to have severe adhesions and fall into the highest risk category for bowel perforation.¹¹ It is impossible to predict with any degree of accuracy whether the intestine is adherent to the entry site.

Pneumoperitoneum can be protective

Creation of a pneumoperitoneum creates a cushion of gas between the intestines and the anterior abdominal wall (provided the intestines are not adherent to the abdominal wall). Manufacturers of disposable trocars with a retractable shield recommend creating an adequate pneumoperitoneum so that the “safety shield” deploys quickly and properly, unlike direct insertion, in which no gas is infused and space is insufficient for complete shield activation.

Open laparoscopy techniques, which allow the surgeon to enter the peritoneal cavity by direct vision without a sharp trocar, may diminish but not eliminate the risk of bowel injury.

What the data show

Of the 130 intestinal injuries recently reported by Baggish, 62 of 81 (77%) small bowel injuries were related to trocar insertion, as were 20 of 49 (41%) large intestinal injuries.¹² In other words, 82 of 130 intestinal injuries (63%) were the direct result of trocar entry.

Bhoyrul and associates reported 629 trocar injuries, of which 182 were visceral.¹³ Of the 32 deaths, six were secondary to unrecognized bowel injury. Of 176 nonfatal visceral injuries, 128 (73%) involved the intestines, and 22 were unrecognized.

Optical-access and open laparoscopic systems were designed to prevent such injuries. Sharp and colleagues reported 24 intestinal injuries out of a total of 79 complications (30%) associated with optical-access trocars after reviewing data obtained from the Medical Device Reports (MDR) and Maude databases maintained by the Food and Drug Administration.¹⁴ In the Baggish series, 4.6% of injuries were associated with open laparoscopy.¹²

Champault and colleagues reviewed complications in a survey of 103,852 operations.¹⁵ Although they recommended use of open laparoscopy as opposed to blind insertion, they presented no data on the safety of open techniques.

How intraoperative injury happens

Operative injury of the large or small bowel often occurs during sharp or blunt dissection, performed during laparoscopy using accessory mechanical or energy devices. The latter type of device is utilized increasingly because laparoscopic knot tying and suturing are rather awkward and slow, and laparoscopic suturing to control bleeding is difficult. The size of the needle required for laparoscopic suture placement must be small enough to navigate a trocar sleeve.

Avoid blunt dissection when adhesions are present

The separation of dense adhesions between the intestines and neighboring bowel, other viscera, or abdominal wall is risky when blunt dissection is used. The tensile strength of the fibrotic connective tissue may well exceed that of the thin intestinal wall. Tearing the adhesion free may bring with it a portion of the bowel wall. Such injuries are frequently missed or described as serosal injuries and left unexplored and unrepaired.

Hydrodissection is a safer alternative. It involves the infiltration of sterile water or saline under low pressure between the parietal peritoneum and underlying retroperitoneal structures, providing a safe and natural plane for dissection. In addition, when the CO₂ laser is used, the liquid acts as a heat sink to absorb any penetrating laser energy.

Energy devices create thermal effects

Energy devices used to cut tissue during operative laparoscopy coagulate blood vessels in a variety of ways, but the common pathway is thermal. Many hypotheses have evolved to explain how vessels are sealed, but none has demonstrated nonthermal activity except for cryocoagulation.

The devices most commonly used for cutting and hemostasis at laparoscopy are:

• electrosurgical (both monopolar and bipolar). Bipolar electrosurgical devices have advantages over monopolar devices when it comes to high-frequency leaks, direct coupling, and capacitive coupling.
• laser (CO₂, holmium:YAG, Nd:YAG, KTP-532, argon). As I mentioned, CO₂ laser devices are effectively backstopped by water, especially in strategic areas such as over and around intestines, major vessels, and the ureters.
• ultrasonic (Harmonic Scalpel, ultrasonic aspirator [CUSA]).

Laser and ultrasonic devices do not require a flow of electrons to create coagulation, but do produce heat that will spread peripherally by thermal conduction from the zone of impact (target).

The extent of energy-inflicted injury cannot be predicted

Inadvertent injury with energy devices can occur directly through contact with the bowel, indirectly by heat conduction through tissue, through capacitive coupling (monopolar electrical only), and by forward scatter (laser only).

Upon direct contact with the intestine, energy devices cut into the tissue in a manner similar to mechanical scissors or a knife but produce a larger wound. The reason? The transfer of heat to areas adjacent to the primary wound produces additional necrosis. Heat conduction, capacitive coupling, high-frequency leaks, and front scatter coagulate the intestinal wall with subsequent tissue devitalization and necrosis, the extent of which depends on the power density at contact and the duration of energy applied.

It is impossible to predict the depth or area of devitalization in energy-inflicted injury by visualization of the event.

In the Baggish review of 130 intestinal injuries, the number of injuries sustained during the operative procedure was 19 involving the small intestine and 29 involving the large bowel.¹² Of this subset, 44% (21 cases) were secondary to the use of energy devices, with monopolar electrosurgical instruments alone accounting for 9 (43%) of the injuries.

Even best-laid plans can go awry

Despite our best intentions and precautions, accidents do sometimes happen, and bowel injury is no exception.In Part 2 of this article, I detail steps you can take to detect injuries in as timely a manner as possible.

In Part 1 of this article, I outlined circumstances in which abdominal adhesions should be anticipated and described strategies to prevent intestinal injury during operative procedures. Here, I describe ways to identify intestinal injury as soon as possible after it occurs, which is vital to prevent serious sequelae such as sepsis and even death.

During operative laparoscopy, a quick search for injury through the laparoscope cannot assure any surgeon that the intestinal wall has not been seriously denuded. A damaged muscularis—even if it is not recognized as transmural injury—may subsequently rupture if it is not appropriately repaired intraoperatively.

Following dissection of adhesions, irrigate the neighboring intestine with sterile saline, and perform a detailed inspection of the intestine to ascertain integrity of the bowel wall. The color of the intestine is important, as it can indicate whether the abundant vascular supply has been compromised. Include a detailed description of the intestines in the operative note.

Avoid stapling or vascular clips when repairing any wound; careful suturing is preferred.

Why early diagnosis is critical

The most favorable time to diagnose an iatrogenic intestinal perforation is within the intraoperative period. Prompt recognition and repair of bowel perforation offers several advantages:

• A second or third operation is less likely (
• The risk of abdominal sepsis is decreased.
  
• The volume of peripheral injury to the intestine is reduced.
  
• The patient can be followed for subsequent complications more precisely, permitting earlier diagnosis, more timely and effective treatment, and lower morbidity.
  

The 130 intestinal injuries reported by Baggish reflect the clinical significance of timely diagnosis.¹ Seventy percent of small bowel and 51% of large bowel perforations were correctly diagnosed more than 48 hours postoperatively. Sepsis was present in a majority of these cases at the time of diagnosis.

Reasons for diagnostic delay

• The gynecologic surgeon fails to place intestinal injury at the top of the differential diagnosis.
  
• A surgical consultant is delayed in making a correct diagnosis. Surgeons have less experience with perforation than do gynecologists, and invariably consider the postoperative abdominal problem to be ileus or intestinal obstruction. The presence of postoperative pneumoperitoneum is incorrectly thought to be lingering CO₂ gas from the initial laparoscopy rather than air from a perforated viscus.
  
• Ancillary diagnosis confuses the primary physician. Pleural effusion, chest pain, and tachypnea are usually thought to indicate pulmonary embolism; as a result, the gynecologist and consulting pulmonologist focus on pulmonary embolus and deep-vein thrombosis. Only a spiral computed tomography (CT) scan, a ventilation perfusion (VQ) scan, or arteriogram quickly rules pulmonary embolus in or out. Peritonitis associated with ileus or third-space fluid leakage resulting in diaphragmatic elevation also creates pleural effusion, tachypnea, and dyspnea.
  

Presumptive diagnosis is critical

Definitive diagnosis of intestinal perforation happens at the operating table under direct vision and is corroborated by the pathology laboratory if bowel resection is performed. However, presumptive diagnosis helps overcome inertia and gets the patient to the operating room sooner.

The process by which the presumptive diagnosis is made is the most important issue in this article. The shorter the process, the lower the patient’s morbidity, and vice versa.

Look for steady improvement. Worry when it is absent

After any laparoscopic operation, the postoperative course should be one of steady clinical improvement. When a patient deviates from this model, the foremost presumptive diagnosis should be laparoscopy-associated injury, and the intestine should top the list of organs that may be injured. Other diagnoses should be subordinate to the principal presumptive diagnosis; these include ileus, bowel obstruction, pulmonary embolus, gastroenteritis, and hematoma, to name a few.

I do not mean to imply that a potentially life-threatening complication such as pulmonary embolus should not be ruled in or out, but that the necessary imaging should be performed in a timely fashion. The abdominal-pelvic CT scan will offer clues to the presence of free air, free fluid, air-fluid levels, and foreign bodies. It also is useful in detecting intra-abdominal—specifically, subphrenic—abscess. If necessary, a VQ scan or spiral CT scan can then be performed without delaying the diagnosis of the primary intra-abdominal catastrophe responsible for the pulmonary symptoms.

In the opening case, before making an improbable presumptive diagnosis, the surgeon should have questioned why an otherwise healthy woman would coincidentally develop gastroenteritis after laparoscopic surgery. The same can be said for diagnoses of intestinal obstruction or vascular thrombosis involving the intestinal blood supply.

Typical presentation of the injured patient

An injured patient does not experience daily improvement and a return to normal activity. Instead, the postoperative period is marked by persistent and worsening pain, often compounded by nausea or vomiting, or both. The patient may complain of fever, chills, weakness, or simply not feeling normal. Breathing may be labored. As time elapses, the symptoms become worse.

Reports of more than one visit to an emergency care facility are not uncommon. When examined, the patient exhibits direct or rebound tenderness, or both. The abdomen may or may not be distended, but usually is increased in girth. Bowel sounds are diminished or absent.

Vital signs initially reveal normal, low-grade, or subnormal temperature, and tachycardia, tachypnea, and normal blood pressure are typical. As time and sepsis progress, however, fever and hypotension develop. Most other symptoms and signs become progressively more abnormal in direct proportion to the length of time the diagnosis is delayed.

Seminal laboratory values for sepsis include a lower than normal white blood cell (WBC) count, elevated immature white-cell elements (e.g., “bandemia”), elevated liver chemistries, and an elevated serum creatinine level.

Mortality is most often the result of overwhelming and prolonged sepsis, leading to multiorgan failure, bleeding diathesis, and adult respiratory distress syndrome.

Among 130 laparoscopic surgical cases complicated by bowel injury and reported by Baggish, sepsis was diagnosed in 100% of colonic perforations and 50% of small-bowel perforations when the diagnosis was delayed more than 48 hours after surgery.¹

TABLE 1 lists the signs and frequency of sepsis in these 100 cases, and TABLE 2 collates the signs and symptoms that were observed. Peritoneal cultures obtained at the time of exploratory laparotomy revealed multiple organisms (polymicrobial) in 60% of cases.

TABLE 1

Frequency of signs of sepsis among 130 patients with colon or small-bowel injury

Watch for signs and symptoms of intestinal injury

Concurrent injuries to neighboring structures

A number of collateral injuries may occur in conjunction with intestinal perforation, depending on the location of the trauma. The most dangerous combination includes indirect laceration of one of the major retroperitoneal vessels. A through-and-through perforation of the cecum can also involve one or more of the right iliac vessels. A trocar perforation of the ileum may continue directly into the presacral space or pass above it and penetrate the left common iliac vein or aorta. Similarly, perforation of the sigmoid colon may penetrate the left iliac vessels.

Careful inspection of the posterior peritoneum for tears and evidence of retroperitoneal hematoma is required to avoid missing a serious collateral injury. More likely, however, is a penetrating injury to the small bowel presenting with collateral mesenteric damage and compromise of the blood supply of an entire segment of bowel. The ureter and bladder may also be injured when dissection along the pelvic sidewall, or a trocar thrust, deviates to the right or left of midline. In thin patients, the stomach may be perforated as well as the small intestine or transverse colon.

In one memorable case, a primary trocar penetrated the omentum, injuring several underlying structures. In its transit, the trocar passed through both the anterior and posterior walls of the duodenum and finally entered the superior mesenteric artery. The gynecologic surgeon performing the laparoscopic tubal ligation failed to recognize any of these injuries. The patient went into shock in the recovery room and was returned to the operating room. Fortunately, a transplant surgeon from a neighboring theater was immediately available to consult and repair the damage.

Another danger: intestinal ischemic necrosis

Abnormalities in splanchnic blood flow are sometimes caused by elevations in intra-abdominal pressure. Caldwell and Ricotta inflated the abdomens of nine dogs and reported a significant reduction of blood flow to omentum, stomach, duodenum, jejunum, ileum, colon, pancreas, liver, and spleen, but not to the adrenal glands.² The splanchnic flow reductions essentially shunted blood away from abdominal viscera with auto-transfusion to the heart, lungs, and systemic circulation.

Eleftheriadis and colleagues studied 16 women randomized to laparoscopic versus open cholecystectomy.³ Significant depression of the hepatic microcirculation during the period of CO₂ gas insufflation was noted in the laparoscopy cohort but not in the control group. Gastric mucosal ischemia also was observed in the laparoscopy group.

Several case reports of catastrophic intestinal ischemia have appeared in the literature (1994–1995).^4-7 These articles have mainly involved laparoscopic upper abdominal operations in elderly people.

Recently, however, Hasson and colleagues reported a case of possible ischemic necrosis of the small intestine following laparoscopic adhesiolysis and bipolar myolysis.⁸ The authors emphasized that CO₂ pneumoperitoneum reduces splanchnic blood flow, predisposing the patient to ischemia, but that ischemia with infarction requires an underlying vasculopathy or inciting factors such as traction on a short mesentery, atherosclerosis, or thrombosis.

A high index of suspicion for bowel ischemia following laparoscopic surgery should occur when, postoperatively, a patient experiences inordinately severe abdominal pain associated with tachypnea, tachycardia, and alterations in the WBC count. A paucity of physical abdominal signs in the early phases of this disorder should alert the clinician to the possibility of bowel ischemia.

Diagnosing and treating ischemia

A CT scan with contrast can suggest ischemia, but angiography is usually required for definitive diagnosis.

Treatment begins with infusion of papaverine into the intestinal vasculature via angiography cannula. In some cases, anticoagulation may be indicated. Surgery by laparotomy is clearly indicated for patients who fail to respond to vasodilatation measures.

This condition can be ameliorated by intermittent intraoperative decompression of the abdomen. Avoiding prolonged CO₂ pneumoperitoneum and a lengthy laparoscopic operation also may diminish the risk of intestinal ischemia.

In Part 1 of this article, I outlined circumstances in which abdominal adhesions should be anticipated and described strategies to prevent intestinal injury during operative procedures. Here, I describe ways to identify intestinal injury as soon as possible after it occurs, which is vital to prevent serious sequelae such as sepsis and even death.

During operative laparoscopy, a quick search for injury through the laparoscope cannot assure any surgeon that the intestinal wall has not been seriously denuded. A damaged muscularis—even if it is not recognized as transmural injury—may subsequently rupture if it is not appropriately repaired intraoperatively.

Following dissection of adhesions, irrigate the neighboring intestine with sterile saline, and perform a detailed inspection of the intestine to ascertain integrity of the bowel wall. The color of the intestine is important, as it can indicate whether the abundant vascular supply has been compromised. Include a detailed description of the intestines in the operative note.

Avoid stapling or vascular clips when repairing any wound; careful suturing is preferred.

Why early diagnosis is critical

The most favorable time to diagnose an iatrogenic intestinal perforation is within the intraoperative period. Prompt recognition and repair of bowel perforation offers several advantages:

• A second or third operation is less likely (
• The risk of abdominal sepsis is decreased.
  
• The volume of peripheral injury to the intestine is reduced.
  
• The patient can be followed for subsequent complications more precisely, permitting earlier diagnosis, more timely and effective treatment, and lower morbidity.
  

The 130 intestinal injuries reported by Baggish reflect the clinical significance of timely diagnosis.¹ Seventy percent of small bowel and 51% of large bowel perforations were correctly diagnosed more than 48 hours postoperatively. Sepsis was present in a majority of these cases at the time of diagnosis.

Reasons for diagnostic delay

• The gynecologic surgeon fails to place intestinal injury at the top of the differential diagnosis.
  
• A surgical consultant is delayed in making a correct diagnosis. Surgeons have less experience with perforation than do gynecologists, and invariably consider the postoperative abdominal problem to be ileus or intestinal obstruction. The presence of postoperative pneumoperitoneum is incorrectly thought to be lingering CO₂ gas from the initial laparoscopy rather than air from a perforated viscus.
  
• Ancillary diagnosis confuses the primary physician. Pleural effusion, chest pain, and tachypnea are usually thought to indicate pulmonary embolism; as a result, the gynecologist and consulting pulmonologist focus on pulmonary embolus and deep-vein thrombosis. Only a spiral computed tomography (CT) scan, a ventilation perfusion (VQ) scan, or arteriogram quickly rules pulmonary embolus in or out. Peritonitis associated with ileus or third-space fluid leakage resulting in diaphragmatic elevation also creates pleural effusion, tachypnea, and dyspnea.
  

Presumptive diagnosis is critical

Definitive diagnosis of intestinal perforation happens at the operating table under direct vision and is corroborated by the pathology laboratory if bowel resection is performed. However, presumptive diagnosis helps overcome inertia and gets the patient to the operating room sooner.

The process by which the presumptive diagnosis is made is the most important issue in this article. The shorter the process, the lower the patient’s morbidity, and vice versa.

Look for steady improvement. Worry when it is absent

After any laparoscopic operation, the postoperative course should be one of steady clinical improvement. When a patient deviates from this model, the foremost presumptive diagnosis should be laparoscopy-associated injury, and the intestine should top the list of organs that may be injured. Other diagnoses should be subordinate to the principal presumptive diagnosis; these include ileus, bowel obstruction, pulmonary embolus, gastroenteritis, and hematoma, to name a few.

I do not mean to imply that a potentially life-threatening complication such as pulmonary embolus should not be ruled in or out, but that the necessary imaging should be performed in a timely fashion. The abdominal-pelvic CT scan will offer clues to the presence of free air, free fluid, air-fluid levels, and foreign bodies. It also is useful in detecting intra-abdominal—specifically, subphrenic—abscess. If necessary, a VQ scan or spiral CT scan can then be performed without delaying the diagnosis of the primary intra-abdominal catastrophe responsible for the pulmonary symptoms.

In the opening case, before making an improbable presumptive diagnosis, the surgeon should have questioned why an otherwise healthy woman would coincidentally develop gastroenteritis after laparoscopic surgery. The same can be said for diagnoses of intestinal obstruction or vascular thrombosis involving the intestinal blood supply.

Typical presentation of the injured patient

An injured patient does not experience daily improvement and a return to normal activity. Instead, the postoperative period is marked by persistent and worsening pain, often compounded by nausea or vomiting, or both. The patient may complain of fever, chills, weakness, or simply not feeling normal. Breathing may be labored. As time elapses, the symptoms become worse.

Reports of more than one visit to an emergency care facility are not uncommon. When examined, the patient exhibits direct or rebound tenderness, or both. The abdomen may or may not be distended, but usually is increased in girth. Bowel sounds are diminished or absent.

Vital signs initially reveal normal, low-grade, or subnormal temperature, and tachycardia, tachypnea, and normal blood pressure are typical. As time and sepsis progress, however, fever and hypotension develop. Most other symptoms and signs become progressively more abnormal in direct proportion to the length of time the diagnosis is delayed.

Seminal laboratory values for sepsis include a lower than normal white blood cell (WBC) count, elevated immature white-cell elements (e.g., “bandemia”), elevated liver chemistries, and an elevated serum creatinine level.

Mortality is most often the result of overwhelming and prolonged sepsis, leading to multiorgan failure, bleeding diathesis, and adult respiratory distress syndrome.

Among 130 laparoscopic surgical cases complicated by bowel injury and reported by Baggish, sepsis was diagnosed in 100% of colonic perforations and 50% of small-bowel perforations when the diagnosis was delayed more than 48 hours after surgery.¹

TABLE 1 lists the signs and frequency of sepsis in these 100 cases, and TABLE 2 collates the signs and symptoms that were observed. Peritoneal cultures obtained at the time of exploratory laparotomy revealed multiple organisms (polymicrobial) in 60% of cases.

TABLE 1

Frequency of signs of sepsis among 130 patients with colon or small-bowel injury

Watch for signs and symptoms of intestinal injury

Concurrent injuries to neighboring structures

A number of collateral injuries may occur in conjunction with intestinal perforation, depending on the location of the trauma. The most dangerous combination includes indirect laceration of one of the major retroperitoneal vessels. A through-and-through perforation of the cecum can also involve one or more of the right iliac vessels. A trocar perforation of the ileum may continue directly into the presacral space or pass above it and penetrate the left common iliac vein or aorta. Similarly, perforation of the sigmoid colon may penetrate the left iliac vessels.

Careful inspection of the posterior peritoneum for tears and evidence of retroperitoneal hematoma is required to avoid missing a serious collateral injury. More likely, however, is a penetrating injury to the small bowel presenting with collateral mesenteric damage and compromise of the blood supply of an entire segment of bowel. The ureter and bladder may also be injured when dissection along the pelvic sidewall, or a trocar thrust, deviates to the right or left of midline. In thin patients, the stomach may be perforated as well as the small intestine or transverse colon.

In one memorable case, a primary trocar penetrated the omentum, injuring several underlying structures. In its transit, the trocar passed through both the anterior and posterior walls of the duodenum and finally entered the superior mesenteric artery. The gynecologic surgeon performing the laparoscopic tubal ligation failed to recognize any of these injuries. The patient went into shock in the recovery room and was returned to the operating room. Fortunately, a transplant surgeon from a neighboring theater was immediately available to consult and repair the damage.

Another danger: intestinal ischemic necrosis

Abnormalities in splanchnic blood flow are sometimes caused by elevations in intra-abdominal pressure. Caldwell and Ricotta inflated the abdomens of nine dogs and reported a significant reduction of blood flow to omentum, stomach, duodenum, jejunum, ileum, colon, pancreas, liver, and spleen, but not to the adrenal glands.² The splanchnic flow reductions essentially shunted blood away from abdominal viscera with auto-transfusion to the heart, lungs, and systemic circulation.

Eleftheriadis and colleagues studied 16 women randomized to laparoscopic versus open cholecystectomy.³ Significant depression of the hepatic microcirculation during the period of CO₂ gas insufflation was noted in the laparoscopy cohort but not in the control group. Gastric mucosal ischemia also was observed in the laparoscopy group.

Several case reports of catastrophic intestinal ischemia have appeared in the literature (1994–1995).^4-7 These articles have mainly involved laparoscopic upper abdominal operations in elderly people.

Recently, however, Hasson and colleagues reported a case of possible ischemic necrosis of the small intestine following laparoscopic adhesiolysis and bipolar myolysis.⁸ The authors emphasized that CO₂ pneumoperitoneum reduces splanchnic blood flow, predisposing the patient to ischemia, but that ischemia with infarction requires an underlying vasculopathy or inciting factors such as traction on a short mesentery, atherosclerosis, or thrombosis.

A high index of suspicion for bowel ischemia following laparoscopic surgery should occur when, postoperatively, a patient experiences inordinately severe abdominal pain associated with tachypnea, tachycardia, and alterations in the WBC count. A paucity of physical abdominal signs in the early phases of this disorder should alert the clinician to the possibility of bowel ischemia.

Diagnosing and treating ischemia

A CT scan with contrast can suggest ischemia, but angiography is usually required for definitive diagnosis.

Treatment begins with infusion of papaverine into the intestinal vasculature via angiography cannula. In some cases, anticoagulation may be indicated. Surgery by laparotomy is clearly indicated for patients who fail to respond to vasodilatation measures.

This condition can be ameliorated by intermittent intraoperative decompression of the abdomen. Avoiding prolonged CO₂ pneumoperitoneum and a lengthy laparoscopic operation also may diminish the risk of intestinal ischemia.

In Part 1 of this article, I outlined circumstances in which abdominal adhesions should be anticipated and described strategies to prevent intestinal injury during operative procedures. Here, I describe ways to identify intestinal injury as soon as possible after it occurs, which is vital to prevent serious sequelae such as sepsis and even death.

During operative laparoscopy, a quick search for injury through the laparoscope cannot assure any surgeon that the intestinal wall has not been seriously denuded. A damaged muscularis—even if it is not recognized as transmural injury—may subsequently rupture if it is not appropriately repaired intraoperatively.

Following dissection of adhesions, irrigate the neighboring intestine with sterile saline, and perform a detailed inspection of the intestine to ascertain integrity of the bowel wall. The color of the intestine is important, as it can indicate whether the abundant vascular supply has been compromised. Include a detailed description of the intestines in the operative note.

Avoid stapling or vascular clips when repairing any wound; careful suturing is preferred.

Why early diagnosis is critical

The most favorable time to diagnose an iatrogenic intestinal perforation is within the intraoperative period. Prompt recognition and repair of bowel perforation offers several advantages:

• A second or third operation is less likely (
• The risk of abdominal sepsis is decreased.
  
• The volume of peripheral injury to the intestine is reduced.
  
• The patient can be followed for subsequent complications more precisely, permitting earlier diagnosis, more timely and effective treatment, and lower morbidity.
  

The 130 intestinal injuries reported by Baggish reflect the clinical significance of timely diagnosis.¹ Seventy percent of small bowel and 51% of large bowel perforations were correctly diagnosed more than 48 hours postoperatively. Sepsis was present in a majority of these cases at the time of diagnosis.

Reasons for diagnostic delay

• The gynecologic surgeon fails to place intestinal injury at the top of the differential diagnosis.
  
• A surgical consultant is delayed in making a correct diagnosis. Surgeons have less experience with perforation than do gynecologists, and invariably consider the postoperative abdominal problem to be ileus or intestinal obstruction. The presence of postoperative pneumoperitoneum is incorrectly thought to be lingering CO₂ gas from the initial laparoscopy rather than air from a perforated viscus.
  
• Ancillary diagnosis confuses the primary physician. Pleural effusion, chest pain, and tachypnea are usually thought to indicate pulmonary embolism; as a result, the gynecologist and consulting pulmonologist focus on pulmonary embolus and deep-vein thrombosis. Only a spiral computed tomography (CT) scan, a ventilation perfusion (VQ) scan, or arteriogram quickly rules pulmonary embolus in or out. Peritonitis associated with ileus or third-space fluid leakage resulting in diaphragmatic elevation also creates pleural effusion, tachypnea, and dyspnea.
  

Presumptive diagnosis is critical

Definitive diagnosis of intestinal perforation happens at the operating table under direct vision and is corroborated by the pathology laboratory if bowel resection is performed. However, presumptive diagnosis helps overcome inertia and gets the patient to the operating room sooner.

The process by which the presumptive diagnosis is made is the most important issue in this article. The shorter the process, the lower the patient’s morbidity, and vice versa.

Look for steady improvement. Worry when it is absent

After any laparoscopic operation, the postoperative course should be one of steady clinical improvement. When a patient deviates from this model, the foremost presumptive diagnosis should be laparoscopy-associated injury, and the intestine should top the list of organs that may be injured. Other diagnoses should be subordinate to the principal presumptive diagnosis; these include ileus, bowel obstruction, pulmonary embolus, gastroenteritis, and hematoma, to name a few.

I do not mean to imply that a potentially life-threatening complication such as pulmonary embolus should not be ruled in or out, but that the necessary imaging should be performed in a timely fashion. The abdominal-pelvic CT scan will offer clues to the presence of free air, free fluid, air-fluid levels, and foreign bodies. It also is useful in detecting intra-abdominal—specifically, subphrenic—abscess. If necessary, a VQ scan or spiral CT scan can then be performed without delaying the diagnosis of the primary intra-abdominal catastrophe responsible for the pulmonary symptoms.

In the opening case, before making an improbable presumptive diagnosis, the surgeon should have questioned why an otherwise healthy woman would coincidentally develop gastroenteritis after laparoscopic surgery. The same can be said for diagnoses of intestinal obstruction or vascular thrombosis involving the intestinal blood supply.

Typical presentation of the injured patient

An injured patient does not experience daily improvement and a return to normal activity. Instead, the postoperative period is marked by persistent and worsening pain, often compounded by nausea or vomiting, or both. The patient may complain of fever, chills, weakness, or simply not feeling normal. Breathing may be labored. As time elapses, the symptoms become worse.

Reports of more than one visit to an emergency care facility are not uncommon. When examined, the patient exhibits direct or rebound tenderness, or both. The abdomen may or may not be distended, but usually is increased in girth. Bowel sounds are diminished or absent.

Vital signs initially reveal normal, low-grade, or subnormal temperature, and tachycardia, tachypnea, and normal blood pressure are typical. As time and sepsis progress, however, fever and hypotension develop. Most other symptoms and signs become progressively more abnormal in direct proportion to the length of time the diagnosis is delayed.

Seminal laboratory values for sepsis include a lower than normal white blood cell (WBC) count, elevated immature white-cell elements (e.g., “bandemia”), elevated liver chemistries, and an elevated serum creatinine level.

Mortality is most often the result of overwhelming and prolonged sepsis, leading to multiorgan failure, bleeding diathesis, and adult respiratory distress syndrome.

Among 130 laparoscopic surgical cases complicated by bowel injury and reported by Baggish, sepsis was diagnosed in 100% of colonic perforations and 50% of small-bowel perforations when the diagnosis was delayed more than 48 hours after surgery.¹

TABLE 1 lists the signs and frequency of sepsis in these 100 cases, and TABLE 2 collates the signs and symptoms that were observed. Peritoneal cultures obtained at the time of exploratory laparotomy revealed multiple organisms (polymicrobial) in 60% of cases.

TABLE 1

Frequency of signs of sepsis among 130 patients with colon or small-bowel injury

Watch for signs and symptoms of intestinal injury

Concurrent injuries to neighboring structures

A number of collateral injuries may occur in conjunction with intestinal perforation, depending on the location of the trauma. The most dangerous combination includes indirect laceration of one of the major retroperitoneal vessels. A through-and-through perforation of the cecum can also involve one or more of the right iliac vessels. A trocar perforation of the ileum may continue directly into the presacral space or pass above it and penetrate the left common iliac vein or aorta. Similarly, perforation of the sigmoid colon may penetrate the left iliac vessels.

Careful inspection of the posterior peritoneum for tears and evidence of retroperitoneal hematoma is required to avoid missing a serious collateral injury. More likely, however, is a penetrating injury to the small bowel presenting with collateral mesenteric damage and compromise of the blood supply of an entire segment of bowel. The ureter and bladder may also be injured when dissection along the pelvic sidewall, or a trocar thrust, deviates to the right or left of midline. In thin patients, the stomach may be perforated as well as the small intestine or transverse colon.

In one memorable case, a primary trocar penetrated the omentum, injuring several underlying structures. In its transit, the trocar passed through both the anterior and posterior walls of the duodenum and finally entered the superior mesenteric artery. The gynecologic surgeon performing the laparoscopic tubal ligation failed to recognize any of these injuries. The patient went into shock in the recovery room and was returned to the operating room. Fortunately, a transplant surgeon from a neighboring theater was immediately available to consult and repair the damage.

Another danger: intestinal ischemic necrosis

Abnormalities in splanchnic blood flow are sometimes caused by elevations in intra-abdominal pressure. Caldwell and Ricotta inflated the abdomens of nine dogs and reported a significant reduction of blood flow to omentum, stomach, duodenum, jejunum, ileum, colon, pancreas, liver, and spleen, but not to the adrenal glands.² The splanchnic flow reductions essentially shunted blood away from abdominal viscera with auto-transfusion to the heart, lungs, and systemic circulation.

Eleftheriadis and colleagues studied 16 women randomized to laparoscopic versus open cholecystectomy.³ Significant depression of the hepatic microcirculation during the period of CO₂ gas insufflation was noted in the laparoscopy cohort but not in the control group. Gastric mucosal ischemia also was observed in the laparoscopy group.

Several case reports of catastrophic intestinal ischemia have appeared in the literature (1994–1995).^4-7 These articles have mainly involved laparoscopic upper abdominal operations in elderly people.

Recently, however, Hasson and colleagues reported a case of possible ischemic necrosis of the small intestine following laparoscopic adhesiolysis and bipolar myolysis.⁸ The authors emphasized that CO₂ pneumoperitoneum reduces splanchnic blood flow, predisposing the patient to ischemia, but that ischemia with infarction requires an underlying vasculopathy or inciting factors such as traction on a short mesentery, atherosclerosis, or thrombosis.

A high index of suspicion for bowel ischemia following laparoscopic surgery should occur when, postoperatively, a patient experiences inordinately severe abdominal pain associated with tachypnea, tachycardia, and alterations in the WBC count. A paucity of physical abdominal signs in the early phases of this disorder should alert the clinician to the possibility of bowel ischemia.

Diagnosing and treating ischemia

A CT scan with contrast can suggest ischemia, but angiography is usually required for definitive diagnosis.

Treatment begins with infusion of papaverine into the intestinal vasculature via angiography cannula. In some cases, anticoagulation may be indicated. Surgery by laparotomy is clearly indicated for patients who fail to respond to vasodilatation measures.

This condition can be ameliorated by intermittent intraoperative decompression of the abdomen. Avoiding prolonged CO₂ pneumoperitoneum and a lengthy laparoscopic operation also may diminish the risk of intestinal ischemia.

The author reports no financial relationships relevant to this article.

Part 1 of this article, in the May 2008 issue, discusses how to counsel patients who are found to have a uterine fibroid.

CASE 1 Menorrhagia with anemia

G.L. is a 44-year-old G2P2 who comes to the office for a second opinion on treatment for menorrhagia and a 10-weeks–size fibroid uterus. She reports that her periods last 8 days, and that for 3 of those days she changes a pad once an hour. Her most recent hemoglobin level was 10.2 g/dL. Her regular gynecologist has recommended abdominal hysterectomy. She would like to avoid major surgery and asks about alternatives. What therapies do you tell her are appropriate?

Most women who have uterine fibroids are asymptomatic or mildly symptomatic; they do not require treatment. In one study, 77% of women choosing observation for their fibroids had no significant changes in bleeding, pain, bothersome symptoms, mental health, general health, or activity after 1 year.¹ After menopause, fibroids shrink, and the rate of surgery decreases greatly.² For women such as these, “watchful waiting” may allow them to avoid treatment indefinitely.

For such women as G.L., however, who develop severe anemia from fibroid-related menorrhagia, treatment is necessary. It also is indicated in the rare case of hydro-nephrosis due to obstruction of the ureter(s) by fibroids, or when menorrhagia, pelvic pain or pressure, or urinary frequency or incontinence compromises quality of life.

The distress experienced by women with symptoms such as these can be severe. In one study, women who chose hysterectomy for fibroid-related symptoms assessed their quality of life as worse than that of women who suffered hypertension, heart disease, chronic lung disease, or arthritis.³

Nevertheless, when symptomatic women were offered hysterectomy as a first and sometimes sole treatment, some chose to adapt to symptoms and stop seeking treatment. In fact, hysterectomy is not the only option. A number of alternatives are available, including:

• medical therapy
• the progesterone-releasing IUD
• endometrial ablation
• hysteroscopic, laparoscopic, and abdominal myomectomy
• uterine artery embolization (UAE).⁴

With the exception of medical therapy, all of these modalities are described here.

Progesterone-releasing intrauterine system

In a woman who has fibroids no larger than 12-weeks size and a normal uterine cavity, the levonorgestrel-releasing intrauterine system (IUS) (brand name, Mirena) has been shown to substantially reduce menstrual bleeding.⁵ Within 3 months, 22 of 26 (85%) women with documented menorrhagia treated in this way had normal bleeding and, by 12 months, 40% of all 76 women studied were amenorrheic.

CASE 1 CONTINUED

You perform an office hysteroscopy on G.L., which reveals a 3-cm, type 1 submucosal fibroid, suggesting, by its size, that the levonorgestrel-releasing IUS is unlikely to relieve her bleeding. What other treatments might be appropriate?

Hysteroscopic myomectomy

Studies show a reduction in bleeding following hysteroscopic resection of submucous fibroids. One hundred ninety-six consecutive women who had menorrhagia and one or more submucous myomas were followed for an average of 73 months after hysteroscopic myomectomy.⁶ Sixty-eight percent reported “satisfaction and ability to lead a normal life,” and 32% considered results unsatisfactory.

In a report of 285 consecutive women treated with hysteroscopic myomectomy for menorrhagia or metrorrhagia, additional surgery was necessary for 9.5% by 2 years, 10.8% by 5 years, and 26.7% by 8 years.⁷

Endometrial ablation

In women who do not desire future childbearing, endometrial ablation with or without hysteroscopic myomectomy may be an option. One study that used pad counts as an objective measure found that abnormal bleeding resolved in 48 of 51 women (94%) following endometrial ablation, after an average follow-up of 2 years.⁸

A study of 33 women who had uterine myomas and total uterine volume smaller than 16-weeks size, and who were followed for a mean of 8 months after Nd:YAG laser ablation of the endometrium, reported amenorrhea in 16 women (49%) and eumenorrhea or hypomenorrhea in the other 17.⁹

Hydrothermal ablation was used to treat 22 women who had submucous myomas as large as 4 cm in diameter, with 91% reporting amenorrhea, hypomenorrhea, or eumenorrhea after a minimum of 12 months of follow-up.¹⁰

Sixty-five women who suffered from menometrorrhagia with hysteroscopically confirmed type I or type II submucous myomas as large as 3 cm had endometrial ablation with the NovaSure System.¹¹ After 1 year, 95% had a reduction in bleeding to a normal degree; 69% had amenorrhea. No intraoperative or postoperative complications occurred.

Uterine artery embolization

UAE appears to be an effective treatment for some women who have fibroids. At the moment, the effect of UAE on premature ovarian failure, fertility, and pregnancy is not clear; most interventional radiologists advise against the procedure for women who want to become pregnant. Although very rare, complications of UAE may necessitate lifesaving hysterectomy, and women who would not accept hysterectomy even under these circumstances should not undergo UAE.

Contraindications to UAE include active genitourinary infection, genital tract malignancy, reduced immune status, severe vascular disease, allergy to intravenous (IV) contrast, or impaired renal function. Relative contraindications include large submucous myomas, pedunculated myomas, recent gonadotropin-releasing hormone (GnRH) agonist treatment, previous iliac or uterine artery occlusion, and postmenopausal status.¹²

How UAE works

In UAE, a trained interventional radiologist performs percutaneous cannulation of the femoral artery. Embolization of the uterine artery and its branches (FIGURE 1) is accomplished with gelatin sponges, polyvinyl alcohol particles (PVA), or tris-acryl gelatin microspheres under fluoroscopic guidance. Total radiation exposure is equivalent to one to two computed tomography (CT) scans.

Postprocedural pain usually requires pain management in the hospital overnight, but most women are discharged the next day on a nonsteroidal anti-inflammatory drug (NSAID). Most women can return to normal activity in 1 to 3 weeks, although about 5% to 10% of women experience a longer bout of pain.

Postembolization syndrome requires admission for treatment with IV fluids, an NSAID, and pain management. It usually resolves in 48 to 72 hours. Persistent fever should be managed with antibiotics, but a failure to respond to antibiotics may indicate sepsis, indicating the need for aggressive management with hysterectomy. ACOG recommends that women considering UAE have a thorough evaluation with a gynecologist to help facilitate collaboration with the interventional radiologist, and that protocols be in place to establish the responsibility of caring for the patient at all times.¹³

FIGURE 1 Target: blood supply

Arteriogram showing blood supply to fibroid to be targeted during uterine artery embolization.

What the data show

The largest prospective study of UAE included 555 women, 18 to 59 years old, 40% of whom had required time off from work for fibroid-related symptoms. Three months after UAE, the largest myomas were reduced by a mean of 33%. Menorrhagia had improved in 83%; dysmenorrhea, in 77%; and urinary frequency, in 86%.¹⁴ Interestingly, improvement in menorrhagia was not related to pre-UAE uterine volume or the volume reduction attained.

Hysterectomy was performed for complications in 1.5% of women: two for infection, four for persistent postembolization pain, one for prolapsed myoma, and one for continued vaginal bleeding. Of 400 women followed for a mean of 16.7 months, 74% were considered a clinical success.¹⁵

More than 50,000 UAE procedures have been performed worldwide. Five deaths have been reported: two from septic shock, one from a pulmonary embolus, and two from uncertain causes. This compares favorably with the mortality of 3 for every 10,000 hysterectomies in a similar group of women, which was reported in the national inpatient sample of the Healthcare Cost and Utilization Project (HCUP) database of the Agency for HealthCare Research and Quality, available at http://hcup.ahrq.gov/HCUPnet.asp.

Effects on fertility

Following UAE, amenorrhea has been reported in 3% of women under 40 but in 41% of women over 50.¹⁶ Although normal follicle-stimulating hormone (FSH), estradiol, ovarian volume, and antral follicle counts have been found in most women shortly after UAE, such testing is unable to predict the onset of menopause.

Loss of follicles as a result of misembolization to the ovarian vessels and decreased ovarian perfusion might cause ovarian failure at an earlier age than expected (Robert Vogetzang, MD, personal communication, 2007). Long-term follow-up of women who have had UAE will be necessary to answer this important question.

CASE 1 RESOLVED

G.L. chose hysteroscopic myomectomy and endometrial ablation for her menorrhagia. Twelve months later, she remains amenorrheic.

CASE 2 Large fibroids; options other than hysterectomy?

A.M., a 39-year-old G2P2, complains of pelvic pressure and urinary frequency. On examination, you find a 14-weeks–size fibroid uterus. She has not given up hope for giving birth to one more child, and wants to avoid hysterectomy. Ultrasonography shows two fundal fibroids, both about 7 cm in diameter. A.M. asks what treatment options are available for her. What can you offer this patient?

Abdominal myomectomy

Myomectomy is used less often than hysterectomy. In 1999, when one third of the 598,000 hysterectomies performed annually were performed for fibroids, only 30,000 myomectomies were performed.¹⁷

As long ago as 1931, Victor Bonney advocated abdominal myomectomy because he believed that the procedure best served what should be the “ultimate goal of surgical treatment, the restoration and maintenance of physiologic function.” Yet women are still being told that hysterectomy is safer, associated with less blood loss—or that myomectomy is inappropriate because sarcoma may be present. Recent reports do not support these concerns.

Myomectomy vs hysterectomy

A review of 197 women who underwent myomectomy and 197 women who underwent hysterectomy with similar uterine size (14.4 vs 15.6 weeks) found the risks of hemorrhage, fever, unintended surgical procedures, life-threatening events, and rehospitalization equivalent between the two procedures.¹⁸ Women in the hysterectomy group had more surgical blood loss (484 mL vs 227 mL) and suffered more complications (13%), including one cystotomy, one ureteral injury, three bowel injuries, eight cases of ileus, and six cases of pelvic abscess.¹⁹

In contrast, only 5% of the myomectomy patients had a complication, which included one cystotomy, two reoperations for small bowel obstruction, and six cases of ileus. The authors concluded that myomectomy is a safe alternative to hysterectomy.

Myomectomy may be feasible even with large fibroids

Abdominal myomectomy may be considered even for women who have large uterine fibroids (FIGURE 2) and who wish to retain their uterus. A study of 91 women who had uterine size larger than 16 weeks (range, 16 to 36 weeks) and underwent abdominal myomectomy reported no instance of conversion to hysterectomy. Complications included one bowel injury, one bladder injury, and one reoperation for bowel obstruction.²⁰

In the past, enlarging fibroids have been deemed an indication that hysterectomy should be performed because leiomyosarcoma may be present. This concern is unfounded. A study of 371 women with a “rapidly growing uterus” found leiomyosarcoma in only one.²¹

FIGURE 2 Abdominal myomectomy

Myomectomy may be appropriate even for women who have large fibroids who wish to retain their uterus.

Removing large fibroids safely

Surgical techniques available for myomectomy allow safe removal of even large fibroids. Tourniquets and vasoconstrictive substances (vasopressin [off-label use]) may be used to limit blood loss. Continuing the uterine incisions through the myometrium and entire pseudocapsule until the fibroid is clearly seen exposes a less vascular surgical plane, which is deeper than commonly appreciated. Vascular corrosion casting shows that fibroids are totally surrounded by a dense vascular layer and that no distinct “vascular pedicle” exists at the base of the myoma.²²

Fibroids that are near dominant fibroids can be removed through the same uterine incision, but avoid tunneling through the myometrium to remove distant fibroids; many myometrial tunnels are hard to close and can continue to bleed. Promptly closing each incision allows immediate hemostasis and, although multiple uterine incisions may be needed, adhesion barriers may help limit formation of adhesions.²³

Avoiding heterologous transfusion

Cell-saver technology has been used extensively in orthopedic, cardiac, and neurologic surgery; consider it during myomectomy (or hysterectomy).

The cell saver suctions blood from the operative field and mixes it with heparinized saline. If blood reinfusion is necessary, the blood is washed with saline, filtered, centrifuged to a hematocrit of approximately 50%, and given back to the patient via an IV line. The need for preoperative autologous blood donation or heterologous blood transfusion can therefore often be avoided, eliminating the risk of infection and transfusion reaction.²⁴

Seventy of 91 women who underwent myomectomy for uterine size of 16 to 36 weeks had cell-saver blood reinfused (mean volume, 355 mL); only seven women required heterologous transfusion.²⁰

Laparoscopic myomectomy

Instrumentation makes laparoscopic myomectomy feasible, although the application of this approach is limited by the size and number of fibroids that can be reasonably removed and by the difficulty of laparoscopic suturing. However, a study of 131 women randomized to abdominal and laparoscopic myomectomy for nonpedunculated large myomas (mean diameter, 7 cm) found a higher postoperative hemoglobin level, lower incidence of postoperative fever, and shorter hospital stays with laparoscopic myomectomy.²⁵

A case series of 144 women (largest fibroid, 18 cm [mean, 7.8 cm]) reported that only two (1.4%) women required conversion to laparotomy.²⁶

Myomas do not recur

Once individual myomas are removed, they do not recur, although new myomas may appear. Most women require no additional treatment. If the first myomectomy is performed for one fibroid, 11% of women require subsequent surgery (mean follow-up, 7.6 years). If multiple fibroids are removed initially, 26% require subsequent surgery.²⁷

The appearance of a new myoma may reflect the persistence of fibroids not removed initially—as ultrasonography has demonstrated in 29% of women after myomectomy.²⁸

CASE 2 RESOLVED

A.M. underwent pelvic magnetic resonance imaging, which revealed two 7-cm intramural fibroids and four other intramural fibroids between 2 cm and 4 cm in size. She chose abdominal myomectomy and is now attempting pregnancy.

CASE 3 Patient asks for hysterectomy

S.L. is a 44-year-old G2P2 who complains of missing a few days of work every month because of heavy menstrual bleeding and fatigue. Her hemoglobin level is now 8.2 g/dL. She underwent myomectomy about 10 years ago, successfully followed by two pregnancies, but her uterus is now about 12-weeks size. She is not interested in getting pregnant again and wants to be able to work without bleeding through her clothes. She has explored other options, but has decided to have a hysterectomy. She asks whether laparoscopic supracervical hysterectomy is appropriate for her situation. What do you advise?

Treating preoperative anemia

The first step for this patient is to treat her anemia.

Erythropoietin alfa and epoetin have been shown to increase preoperative hemoglobin concentrations in cardiac, orthopedic, and neurologic surgery. They should be considered more often, when appropriate, before gynecologic surgery.²⁹ A randomized study showed that approximately 15,000 U of epoetin a week for 3 weeks before surgery raised the hemoglobin concentration by 1.6 g/dL and significantly reduced the transfusion rate when compared with controls.³⁰ No side effects were reported.

GnRH agonists have been shown to reduce uterine volume, fibroid volume, and bleeding; these benefits may be limited, however, by side effects and risks. Reduction in uterine size occurs mostly within the first 3 months of treatment; after 6 months, fibroid volume is reduced by 30% and total uterine volume by 35%.^31,32 Heavy bleeding responds well to GnRH agonists; in one study, 37 of 38 women had resolution by 6 months.

Side effects generally do not deter treatment

Side effects are common with GnRH agonists: 78% experience hot flushes; 32%, vaginal dryness; and 55%, transient headache. Arthralgia, myalgia, insomnia, emotional lability, and decreased libido are reported less often. However, only 8% of women terminate treatment because of side effects.³³

Bone loss is significant after 6 months of a GnRH agonist.³⁴

A Cochrane review found that women who have myomas and who were treated preoperatively with 3 to 4 months of a GnRH agonist had significantly reduced uterine volume and uterine size; an improved preoperative hemoglobin level; and reduced operating times and hospital stay.³⁵ Although operative blood loss was less for both abdominal hysterectomy and abdominal myomectomy patients, there was no significant difference in the transfusion rate.

Hysterectomy

Fibroids were the indication for hysterectomy in 40% of abdominal, 17% of vaginal, and 29% of laparoscopic hysterectomies, according to a review in the United States.¹⁷ Women with intractable symptoms who have not been helped by other therapies may benefit from hysterectomy. The Maine Women’s Health Study found that, following hysterectomy (35% of which were performed for myomas) for moderate or severe symptoms, 72% of women felt “much better,” 16% felt a “little better,” and 3% felt worse than they did before surgery.¹

Laparoscopic hysterectomy

Either total or supracervical laparoscopic hysterectomy is feasible. Benefits include less postoperative pain, short hospital stay, and quick recovery. However, if a vaginal hysterectomy is feasible, there is no benefit to laparoscopic hysterectomy.³⁶

What the data show

A prospective, randomized, multicenter study concluded that laparoscopic-assisted hysterectomy offered the benefits of less invasive surgery without increased risk.³⁷ Eighty women whose uterus was between 280 g and 700 g were randomized to laparoscopic-assisted vaginal and abdominal hysterectomy. Estimated blood loss, postoperative day 1 hemoglobin level, pain, and hospital stay were all significantly better for the laparoscopic-assisted group. Complications in the abdominal hysterectomy group included one woman who had a cuff hematoma and who required transfusion; one who had bleeding requiring reoperation and transfusion; and five who had fever. The only complication in the laparoscopic group was postoperative fever in two women.

Even large fibroids may benefit from laparoscopy

In experienced hands, the benefits of laparoscopic hysterectomy may extend to women who have large fibroids. A retrospective cohort study compared laparoscopic hysterectomy in 34 women who had a uterine weight greater than 500 g (range, 500 to 1,230 g) with 68 women whose uterus weighed less than 300 g.³⁸ Operating time was significantly shorter in women with smaller uteri, but no difference was observed in complications, blood loss, hospital stay, or recovery, and no patient required conversion to laparotomy.

CASE 3 RESOLVED

S.L. underwent laparoscopic supracervical hysterectomy, which involved a 1-night hospital stay, and returned to work in 2 weeks. She is happy to be free of monthly bleeding and believes she made the right treatment decision.

The author reports no financial relationships relevant to this article.

Part 1 of this article, in the May 2008 issue, discusses how to counsel patients who are found to have a uterine fibroid.

CASE 1 Menorrhagia with anemia

G.L. is a 44-year-old G2P2 who comes to the office for a second opinion on treatment for menorrhagia and a 10-weeks–size fibroid uterus. She reports that her periods last 8 days, and that for 3 of those days she changes a pad once an hour. Her most recent hemoglobin level was 10.2 g/dL. Her regular gynecologist has recommended abdominal hysterectomy. She would like to avoid major surgery and asks about alternatives. What therapies do you tell her are appropriate?

Most women who have uterine fibroids are asymptomatic or mildly symptomatic; they do not require treatment. In one study, 77% of women choosing observation for their fibroids had no significant changes in bleeding, pain, bothersome symptoms, mental health, general health, or activity after 1 year.¹ After menopause, fibroids shrink, and the rate of surgery decreases greatly.² For women such as these, “watchful waiting” may allow them to avoid treatment indefinitely.

For such women as G.L., however, who develop severe anemia from fibroid-related menorrhagia, treatment is necessary. It also is indicated in the rare case of hydro-nephrosis due to obstruction of the ureter(s) by fibroids, or when menorrhagia, pelvic pain or pressure, or urinary frequency or incontinence compromises quality of life.

The distress experienced by women with symptoms such as these can be severe. In one study, women who chose hysterectomy for fibroid-related symptoms assessed their quality of life as worse than that of women who suffered hypertension, heart disease, chronic lung disease, or arthritis.³

Nevertheless, when symptomatic women were offered hysterectomy as a first and sometimes sole treatment, some chose to adapt to symptoms and stop seeking treatment. In fact, hysterectomy is not the only option. A number of alternatives are available, including:

• medical therapy
• the progesterone-releasing IUD
• endometrial ablation
• hysteroscopic, laparoscopic, and abdominal myomectomy
• uterine artery embolization (UAE).⁴

With the exception of medical therapy, all of these modalities are described here.

Progesterone-releasing intrauterine system

In a woman who has fibroids no larger than 12-weeks size and a normal uterine cavity, the levonorgestrel-releasing intrauterine system (IUS) (brand name, Mirena) has been shown to substantially reduce menstrual bleeding.⁵ Within 3 months, 22 of 26 (85%) women with documented menorrhagia treated in this way had normal bleeding and, by 12 months, 40% of all 76 women studied were amenorrheic.

CASE 1 CONTINUED

You perform an office hysteroscopy on G.L., which reveals a 3-cm, type 1 submucosal fibroid, suggesting, by its size, that the levonorgestrel-releasing IUS is unlikely to relieve her bleeding. What other treatments might be appropriate?

Hysteroscopic myomectomy

Studies show a reduction in bleeding following hysteroscopic resection of submucous fibroids. One hundred ninety-six consecutive women who had menorrhagia and one or more submucous myomas were followed for an average of 73 months after hysteroscopic myomectomy.⁶ Sixty-eight percent reported “satisfaction and ability to lead a normal life,” and 32% considered results unsatisfactory.

In a report of 285 consecutive women treated with hysteroscopic myomectomy for menorrhagia or metrorrhagia, additional surgery was necessary for 9.5% by 2 years, 10.8% by 5 years, and 26.7% by 8 years.⁷

Endometrial ablation

In women who do not desire future childbearing, endometrial ablation with or without hysteroscopic myomectomy may be an option. One study that used pad counts as an objective measure found that abnormal bleeding resolved in 48 of 51 women (94%) following endometrial ablation, after an average follow-up of 2 years.⁸

A study of 33 women who had uterine myomas and total uterine volume smaller than 16-weeks size, and who were followed for a mean of 8 months after Nd:YAG laser ablation of the endometrium, reported amenorrhea in 16 women (49%) and eumenorrhea or hypomenorrhea in the other 17.⁹

Hydrothermal ablation was used to treat 22 women who had submucous myomas as large as 4 cm in diameter, with 91% reporting amenorrhea, hypomenorrhea, or eumenorrhea after a minimum of 12 months of follow-up.¹⁰

Sixty-five women who suffered from menometrorrhagia with hysteroscopically confirmed type I or type II submucous myomas as large as 3 cm had endometrial ablation with the NovaSure System.¹¹ After 1 year, 95% had a reduction in bleeding to a normal degree; 69% had amenorrhea. No intraoperative or postoperative complications occurred.

Uterine artery embolization

UAE appears to be an effective treatment for some women who have fibroids. At the moment, the effect of UAE on premature ovarian failure, fertility, and pregnancy is not clear; most interventional radiologists advise against the procedure for women who want to become pregnant. Although very rare, complications of UAE may necessitate lifesaving hysterectomy, and women who would not accept hysterectomy even under these circumstances should not undergo UAE.

Contraindications to UAE include active genitourinary infection, genital tract malignancy, reduced immune status, severe vascular disease, allergy to intravenous (IV) contrast, or impaired renal function. Relative contraindications include large submucous myomas, pedunculated myomas, recent gonadotropin-releasing hormone (GnRH) agonist treatment, previous iliac or uterine artery occlusion, and postmenopausal status.¹²

How UAE works

In UAE, a trained interventional radiologist performs percutaneous cannulation of the femoral artery. Embolization of the uterine artery and its branches (FIGURE 1) is accomplished with gelatin sponges, polyvinyl alcohol particles (PVA), or tris-acryl gelatin microspheres under fluoroscopic guidance. Total radiation exposure is equivalent to one to two computed tomography (CT) scans.

Postprocedural pain usually requires pain management in the hospital overnight, but most women are discharged the next day on a nonsteroidal anti-inflammatory drug (NSAID). Most women can return to normal activity in 1 to 3 weeks, although about 5% to 10% of women experience a longer bout of pain.

Postembolization syndrome requires admission for treatment with IV fluids, an NSAID, and pain management. It usually resolves in 48 to 72 hours. Persistent fever should be managed with antibiotics, but a failure to respond to antibiotics may indicate sepsis, indicating the need for aggressive management with hysterectomy. ACOG recommends that women considering UAE have a thorough evaluation with a gynecologist to help facilitate collaboration with the interventional radiologist, and that protocols be in place to establish the responsibility of caring for the patient at all times.¹³

FIGURE 1 Target: blood supply

Arteriogram showing blood supply to fibroid to be targeted during uterine artery embolization.

What the data show

The largest prospective study of UAE included 555 women, 18 to 59 years old, 40% of whom had required time off from work for fibroid-related symptoms. Three months after UAE, the largest myomas were reduced by a mean of 33%. Menorrhagia had improved in 83%; dysmenorrhea, in 77%; and urinary frequency, in 86%.¹⁴ Interestingly, improvement in menorrhagia was not related to pre-UAE uterine volume or the volume reduction attained.

Hysterectomy was performed for complications in 1.5% of women: two for infection, four for persistent postembolization pain, one for prolapsed myoma, and one for continued vaginal bleeding. Of 400 women followed for a mean of 16.7 months, 74% were considered a clinical success.¹⁵

More than 50,000 UAE procedures have been performed worldwide. Five deaths have been reported: two from septic shock, one from a pulmonary embolus, and two from uncertain causes. This compares favorably with the mortality of 3 for every 10,000 hysterectomies in a similar group of women, which was reported in the national inpatient sample of the Healthcare Cost and Utilization Project (HCUP) database of the Agency for HealthCare Research and Quality, available at http://hcup.ahrq.gov/HCUPnet.asp.

Effects on fertility

Following UAE, amenorrhea has been reported in 3% of women under 40 but in 41% of women over 50.¹⁶ Although normal follicle-stimulating hormone (FSH), estradiol, ovarian volume, and antral follicle counts have been found in most women shortly after UAE, such testing is unable to predict the onset of menopause.

Loss of follicles as a result of misembolization to the ovarian vessels and decreased ovarian perfusion might cause ovarian failure at an earlier age than expected (Robert Vogetzang, MD, personal communication, 2007). Long-term follow-up of women who have had UAE will be necessary to answer this important question.

CASE 1 RESOLVED

G.L. chose hysteroscopic myomectomy and endometrial ablation for her menorrhagia. Twelve months later, she remains amenorrheic.

CASE 2 Large fibroids; options other than hysterectomy?

A.M., a 39-year-old G2P2, complains of pelvic pressure and urinary frequency. On examination, you find a 14-weeks–size fibroid uterus. She has not given up hope for giving birth to one more child, and wants to avoid hysterectomy. Ultrasonography shows two fundal fibroids, both about 7 cm in diameter. A.M. asks what treatment options are available for her. What can you offer this patient?

Abdominal myomectomy

Myomectomy is used less often than hysterectomy. In 1999, when one third of the 598,000 hysterectomies performed annually were performed for fibroids, only 30,000 myomectomies were performed.¹⁷

As long ago as 1931, Victor Bonney advocated abdominal myomectomy because he believed that the procedure best served what should be the “ultimate goal of surgical treatment, the restoration and maintenance of physiologic function.” Yet women are still being told that hysterectomy is safer, associated with less blood loss—or that myomectomy is inappropriate because sarcoma may be present. Recent reports do not support these concerns.

Myomectomy vs hysterectomy

A review of 197 women who underwent myomectomy and 197 women who underwent hysterectomy with similar uterine size (14.4 vs 15.6 weeks) found the risks of hemorrhage, fever, unintended surgical procedures, life-threatening events, and rehospitalization equivalent between the two procedures.¹⁸ Women in the hysterectomy group had more surgical blood loss (484 mL vs 227 mL) and suffered more complications (13%), including one cystotomy, one ureteral injury, three bowel injuries, eight cases of ileus, and six cases of pelvic abscess.¹⁹

In contrast, only 5% of the myomectomy patients had a complication, which included one cystotomy, two reoperations for small bowel obstruction, and six cases of ileus. The authors concluded that myomectomy is a safe alternative to hysterectomy.

Myomectomy may be feasible even with large fibroids

Abdominal myomectomy may be considered even for women who have large uterine fibroids (FIGURE 2) and who wish to retain their uterus. A study of 91 women who had uterine size larger than 16 weeks (range, 16 to 36 weeks) and underwent abdominal myomectomy reported no instance of conversion to hysterectomy. Complications included one bowel injury, one bladder injury, and one reoperation for bowel obstruction.²⁰

In the past, enlarging fibroids have been deemed an indication that hysterectomy should be performed because leiomyosarcoma may be present. This concern is unfounded. A study of 371 women with a “rapidly growing uterus” found leiomyosarcoma in only one.²¹

FIGURE 2 Abdominal myomectomy

Myomectomy may be appropriate even for women who have large fibroids who wish to retain their uterus.

Removing large fibroids safely

Surgical techniques available for myomectomy allow safe removal of even large fibroids. Tourniquets and vasoconstrictive substances (vasopressin [off-label use]) may be used to limit blood loss. Continuing the uterine incisions through the myometrium and entire pseudocapsule until the fibroid is clearly seen exposes a less vascular surgical plane, which is deeper than commonly appreciated. Vascular corrosion casting shows that fibroids are totally surrounded by a dense vascular layer and that no distinct “vascular pedicle” exists at the base of the myoma.²²

Fibroids that are near dominant fibroids can be removed through the same uterine incision, but avoid tunneling through the myometrium to remove distant fibroids; many myometrial tunnels are hard to close and can continue to bleed. Promptly closing each incision allows immediate hemostasis and, although multiple uterine incisions may be needed, adhesion barriers may help limit formation of adhesions.²³

Avoiding heterologous transfusion

Cell-saver technology has been used extensively in orthopedic, cardiac, and neurologic surgery; consider it during myomectomy (or hysterectomy).

The cell saver suctions blood from the operative field and mixes it with heparinized saline. If blood reinfusion is necessary, the blood is washed with saline, filtered, centrifuged to a hematocrit of approximately 50%, and given back to the patient via an IV line. The need for preoperative autologous blood donation or heterologous blood transfusion can therefore often be avoided, eliminating the risk of infection and transfusion reaction.²⁴

Seventy of 91 women who underwent myomectomy for uterine size of 16 to 36 weeks had cell-saver blood reinfused (mean volume, 355 mL); only seven women required heterologous transfusion.²⁰

Laparoscopic myomectomy

Instrumentation makes laparoscopic myomectomy feasible, although the application of this approach is limited by the size and number of fibroids that can be reasonably removed and by the difficulty of laparoscopic suturing. However, a study of 131 women randomized to abdominal and laparoscopic myomectomy for nonpedunculated large myomas (mean diameter, 7 cm) found a higher postoperative hemoglobin level, lower incidence of postoperative fever, and shorter hospital stays with laparoscopic myomectomy.²⁵

A case series of 144 women (largest fibroid, 18 cm [mean, 7.8 cm]) reported that only two (1.4%) women required conversion to laparotomy.²⁶

Myomas do not recur

Once individual myomas are removed, they do not recur, although new myomas may appear. Most women require no additional treatment. If the first myomectomy is performed for one fibroid, 11% of women require subsequent surgery (mean follow-up, 7.6 years). If multiple fibroids are removed initially, 26% require subsequent surgery.²⁷

The appearance of a new myoma may reflect the persistence of fibroids not removed initially—as ultrasonography has demonstrated in 29% of women after myomectomy.²⁸

CASE 2 RESOLVED

A.M. underwent pelvic magnetic resonance imaging, which revealed two 7-cm intramural fibroids and four other intramural fibroids between 2 cm and 4 cm in size. She chose abdominal myomectomy and is now attempting pregnancy.

CASE 3 Patient asks for hysterectomy

S.L. is a 44-year-old G2P2 who complains of missing a few days of work every month because of heavy menstrual bleeding and fatigue. Her hemoglobin level is now 8.2 g/dL. She underwent myomectomy about 10 years ago, successfully followed by two pregnancies, but her uterus is now about 12-weeks size. She is not interested in getting pregnant again and wants to be able to work without bleeding through her clothes. She has explored other options, but has decided to have a hysterectomy. She asks whether laparoscopic supracervical hysterectomy is appropriate for her situation. What do you advise?

Treating preoperative anemia

The first step for this patient is to treat her anemia.

Erythropoietin alfa and epoetin have been shown to increase preoperative hemoglobin concentrations in cardiac, orthopedic, and neurologic surgery. They should be considered more often, when appropriate, before gynecologic surgery.²⁹ A randomized study showed that approximately 15,000 U of epoetin a week for 3 weeks before surgery raised the hemoglobin concentration by 1.6 g/dL and significantly reduced the transfusion rate when compared with controls.³⁰ No side effects were reported.

GnRH agonists have been shown to reduce uterine volume, fibroid volume, and bleeding; these benefits may be limited, however, by side effects and risks. Reduction in uterine size occurs mostly within the first 3 months of treatment; after 6 months, fibroid volume is reduced by 30% and total uterine volume by 35%.^31,32 Heavy bleeding responds well to GnRH agonists; in one study, 37 of 38 women had resolution by 6 months.

Side effects generally do not deter treatment

Side effects are common with GnRH agonists: 78% experience hot flushes; 32%, vaginal dryness; and 55%, transient headache. Arthralgia, myalgia, insomnia, emotional lability, and decreased libido are reported less often. However, only 8% of women terminate treatment because of side effects.³³

Bone loss is significant after 6 months of a GnRH agonist.³⁴

A Cochrane review found that women who have myomas and who were treated preoperatively with 3 to 4 months of a GnRH agonist had significantly reduced uterine volume and uterine size; an improved preoperative hemoglobin level; and reduced operating times and hospital stay.³⁵ Although operative blood loss was less for both abdominal hysterectomy and abdominal myomectomy patients, there was no significant difference in the transfusion rate.

Hysterectomy

Fibroids were the indication for hysterectomy in 40% of abdominal, 17% of vaginal, and 29% of laparoscopic hysterectomies, according to a review in the United States.¹⁷ Women with intractable symptoms who have not been helped by other therapies may benefit from hysterectomy. The Maine Women’s Health Study found that, following hysterectomy (35% of which were performed for myomas) for moderate or severe symptoms, 72% of women felt “much better,” 16% felt a “little better,” and 3% felt worse than they did before surgery.¹

Laparoscopic hysterectomy

Either total or supracervical laparoscopic hysterectomy is feasible. Benefits include less postoperative pain, short hospital stay, and quick recovery. However, if a vaginal hysterectomy is feasible, there is no benefit to laparoscopic hysterectomy.³⁶

What the data show

A prospective, randomized, multicenter study concluded that laparoscopic-assisted hysterectomy offered the benefits of less invasive surgery without increased risk.³⁷ Eighty women whose uterus was between 280 g and 700 g were randomized to laparoscopic-assisted vaginal and abdominal hysterectomy. Estimated blood loss, postoperative day 1 hemoglobin level, pain, and hospital stay were all significantly better for the laparoscopic-assisted group. Complications in the abdominal hysterectomy group included one woman who had a cuff hematoma and who required transfusion; one who had bleeding requiring reoperation and transfusion; and five who had fever. The only complication in the laparoscopic group was postoperative fever in two women.

Even large fibroids may benefit from laparoscopy

In experienced hands, the benefits of laparoscopic hysterectomy may extend to women who have large fibroids. A retrospective cohort study compared laparoscopic hysterectomy in 34 women who had a uterine weight greater than 500 g (range, 500 to 1,230 g) with 68 women whose uterus weighed less than 300 g.³⁸ Operating time was significantly shorter in women with smaller uteri, but no difference was observed in complications, blood loss, hospital stay, or recovery, and no patient required conversion to laparotomy.

CASE 3 RESOLVED

S.L. underwent laparoscopic supracervical hysterectomy, which involved a 1-night hospital stay, and returned to work in 2 weeks. She is happy to be free of monthly bleeding and believes she made the right treatment decision.

The author reports no financial relationships relevant to this article.

Part 1 of this article, in the May 2008 issue, discusses how to counsel patients who are found to have a uterine fibroid.

CASE 1 Menorrhagia with anemia

G.L. is a 44-year-old G2P2 who comes to the office for a second opinion on treatment for menorrhagia and a 10-weeks–size fibroid uterus. She reports that her periods last 8 days, and that for 3 of those days she changes a pad once an hour. Her most recent hemoglobin level was 10.2 g/dL. Her regular gynecologist has recommended abdominal hysterectomy. She would like to avoid major surgery and asks about alternatives. What therapies do you tell her are appropriate?

Most women who have uterine fibroids are asymptomatic or mildly symptomatic; they do not require treatment. In one study, 77% of women choosing observation for their fibroids had no significant changes in bleeding, pain, bothersome symptoms, mental health, general health, or activity after 1 year.¹ After menopause, fibroids shrink, and the rate of surgery decreases greatly.² For women such as these, “watchful waiting” may allow them to avoid treatment indefinitely.

For such women as G.L., however, who develop severe anemia from fibroid-related menorrhagia, treatment is necessary. It also is indicated in the rare case of hydro-nephrosis due to obstruction of the ureter(s) by fibroids, or when menorrhagia, pelvic pain or pressure, or urinary frequency or incontinence compromises quality of life.

The distress experienced by women with symptoms such as these can be severe. In one study, women who chose hysterectomy for fibroid-related symptoms assessed their quality of life as worse than that of women who suffered hypertension, heart disease, chronic lung disease, or arthritis.³

Nevertheless, when symptomatic women were offered hysterectomy as a first and sometimes sole treatment, some chose to adapt to symptoms and stop seeking treatment. In fact, hysterectomy is not the only option. A number of alternatives are available, including:

• medical therapy
• the progesterone-releasing IUD
• endometrial ablation
• hysteroscopic, laparoscopic, and abdominal myomectomy
• uterine artery embolization (UAE).⁴

With the exception of medical therapy, all of these modalities are described here.

Progesterone-releasing intrauterine system

In a woman who has fibroids no larger than 12-weeks size and a normal uterine cavity, the levonorgestrel-releasing intrauterine system (IUS) (brand name, Mirena) has been shown to substantially reduce menstrual bleeding.⁵ Within 3 months, 22 of 26 (85%) women with documented menorrhagia treated in this way had normal bleeding and, by 12 months, 40% of all 76 women studied were amenorrheic.

CASE 1 CONTINUED

You perform an office hysteroscopy on G.L., which reveals a 3-cm, type 1 submucosal fibroid, suggesting, by its size, that the levonorgestrel-releasing IUS is unlikely to relieve her bleeding. What other treatments might be appropriate?

Hysteroscopic myomectomy

Studies show a reduction in bleeding following hysteroscopic resection of submucous fibroids. One hundred ninety-six consecutive women who had menorrhagia and one or more submucous myomas were followed for an average of 73 months after hysteroscopic myomectomy.⁶ Sixty-eight percent reported “satisfaction and ability to lead a normal life,” and 32% considered results unsatisfactory.

In a report of 285 consecutive women treated with hysteroscopic myomectomy for menorrhagia or metrorrhagia, additional surgery was necessary for 9.5% by 2 years, 10.8% by 5 years, and 26.7% by 8 years.⁷

Endometrial ablation

In women who do not desire future childbearing, endometrial ablation with or without hysteroscopic myomectomy may be an option. One study that used pad counts as an objective measure found that abnormal bleeding resolved in 48 of 51 women (94%) following endometrial ablation, after an average follow-up of 2 years.⁸

A study of 33 women who had uterine myomas and total uterine volume smaller than 16-weeks size, and who were followed for a mean of 8 months after Nd:YAG laser ablation of the endometrium, reported amenorrhea in 16 women (49%) and eumenorrhea or hypomenorrhea in the other 17.⁹

Hydrothermal ablation was used to treat 22 women who had submucous myomas as large as 4 cm in diameter, with 91% reporting amenorrhea, hypomenorrhea, or eumenorrhea after a minimum of 12 months of follow-up.¹⁰

Sixty-five women who suffered from menometrorrhagia with hysteroscopically confirmed type I or type II submucous myomas as large as 3 cm had endometrial ablation with the NovaSure System.¹¹ After 1 year, 95% had a reduction in bleeding to a normal degree; 69% had amenorrhea. No intraoperative or postoperative complications occurred.

Uterine artery embolization

UAE appears to be an effective treatment for some women who have fibroids. At the moment, the effect of UAE on premature ovarian failure, fertility, and pregnancy is not clear; most interventional radiologists advise against the procedure for women who want to become pregnant. Although very rare, complications of UAE may necessitate lifesaving hysterectomy, and women who would not accept hysterectomy even under these circumstances should not undergo UAE.

Contraindications to UAE include active genitourinary infection, genital tract malignancy, reduced immune status, severe vascular disease, allergy to intravenous (IV) contrast, or impaired renal function. Relative contraindications include large submucous myomas, pedunculated myomas, recent gonadotropin-releasing hormone (GnRH) agonist treatment, previous iliac or uterine artery occlusion, and postmenopausal status.¹²

How UAE works

In UAE, a trained interventional radiologist performs percutaneous cannulation of the femoral artery. Embolization of the uterine artery and its branches (FIGURE 1) is accomplished with gelatin sponges, polyvinyl alcohol particles (PVA), or tris-acryl gelatin microspheres under fluoroscopic guidance. Total radiation exposure is equivalent to one to two computed tomography (CT) scans.

Postprocedural pain usually requires pain management in the hospital overnight, but most women are discharged the next day on a nonsteroidal anti-inflammatory drug (NSAID). Most women can return to normal activity in 1 to 3 weeks, although about 5% to 10% of women experience a longer bout of pain.

Postembolization syndrome requires admission for treatment with IV fluids, an NSAID, and pain management. It usually resolves in 48 to 72 hours. Persistent fever should be managed with antibiotics, but a failure to respond to antibiotics may indicate sepsis, indicating the need for aggressive management with hysterectomy. ACOG recommends that women considering UAE have a thorough evaluation with a gynecologist to help facilitate collaboration with the interventional radiologist, and that protocols be in place to establish the responsibility of caring for the patient at all times.¹³

FIGURE 1 Target: blood supply

Arteriogram showing blood supply to fibroid to be targeted during uterine artery embolization.

What the data show

The largest prospective study of UAE included 555 women, 18 to 59 years old, 40% of whom had required time off from work for fibroid-related symptoms. Three months after UAE, the largest myomas were reduced by a mean of 33%. Menorrhagia had improved in 83%; dysmenorrhea, in 77%; and urinary frequency, in 86%.¹⁴ Interestingly, improvement in menorrhagia was not related to pre-UAE uterine volume or the volume reduction attained.

Hysterectomy was performed for complications in 1.5% of women: two for infection, four for persistent postembolization pain, one for prolapsed myoma, and one for continued vaginal bleeding. Of 400 women followed for a mean of 16.7 months, 74% were considered a clinical success.¹⁵

More than 50,000 UAE procedures have been performed worldwide. Five deaths have been reported: two from septic shock, one from a pulmonary embolus, and two from uncertain causes. This compares favorably with the mortality of 3 for every 10,000 hysterectomies in a similar group of women, which was reported in the national inpatient sample of the Healthcare Cost and Utilization Project (HCUP) database of the Agency for HealthCare Research and Quality, available at http://hcup.ahrq.gov/HCUPnet.asp.

Effects on fertility

Following UAE, amenorrhea has been reported in 3% of women under 40 but in 41% of women over 50.¹⁶ Although normal follicle-stimulating hormone (FSH), estradiol, ovarian volume, and antral follicle counts have been found in most women shortly after UAE, such testing is unable to predict the onset of menopause.

Loss of follicles as a result of misembolization to the ovarian vessels and decreased ovarian perfusion might cause ovarian failure at an earlier age than expected (Robert Vogetzang, MD, personal communication, 2007). Long-term follow-up of women who have had UAE will be necessary to answer this important question.

CASE 1 RESOLVED

G.L. chose hysteroscopic myomectomy and endometrial ablation for her menorrhagia. Twelve months later, she remains amenorrheic.

CASE 2 Large fibroids; options other than hysterectomy?

A.M., a 39-year-old G2P2, complains of pelvic pressure and urinary frequency. On examination, you find a 14-weeks–size fibroid uterus. She has not given up hope for giving birth to one more child, and wants to avoid hysterectomy. Ultrasonography shows two fundal fibroids, both about 7 cm in diameter. A.M. asks what treatment options are available for her. What can you offer this patient?

Abdominal myomectomy

Myomectomy is used less often than hysterectomy. In 1999, when one third of the 598,000 hysterectomies performed annually were performed for fibroids, only 30,000 myomectomies were performed.¹⁷

As long ago as 1931, Victor Bonney advocated abdominal myomectomy because he believed that the procedure best served what should be the “ultimate goal of surgical treatment, the restoration and maintenance of physiologic function.” Yet women are still being told that hysterectomy is safer, associated with less blood loss—or that myomectomy is inappropriate because sarcoma may be present. Recent reports do not support these concerns.

Myomectomy vs hysterectomy

A review of 197 women who underwent myomectomy and 197 women who underwent hysterectomy with similar uterine size (14.4 vs 15.6 weeks) found the risks of hemorrhage, fever, unintended surgical procedures, life-threatening events, and rehospitalization equivalent between the two procedures.¹⁸ Women in the hysterectomy group had more surgical blood loss (484 mL vs 227 mL) and suffered more complications (13%), including one cystotomy, one ureteral injury, three bowel injuries, eight cases of ileus, and six cases of pelvic abscess.¹⁹

In contrast, only 5% of the myomectomy patients had a complication, which included one cystotomy, two reoperations for small bowel obstruction, and six cases of ileus. The authors concluded that myomectomy is a safe alternative to hysterectomy.

Myomectomy may be feasible even with large fibroids

Abdominal myomectomy may be considered even for women who have large uterine fibroids (FIGURE 2) and who wish to retain their uterus. A study of 91 women who had uterine size larger than 16 weeks (range, 16 to 36 weeks) and underwent abdominal myomectomy reported no instance of conversion to hysterectomy. Complications included one bowel injury, one bladder injury, and one reoperation for bowel obstruction.²⁰

In the past, enlarging fibroids have been deemed an indication that hysterectomy should be performed because leiomyosarcoma may be present. This concern is unfounded. A study of 371 women with a “rapidly growing uterus” found leiomyosarcoma in only one.²¹

FIGURE 2 Abdominal myomectomy

Myomectomy may be appropriate even for women who have large fibroids who wish to retain their uterus.

Removing large fibroids safely

Surgical techniques available for myomectomy allow safe removal of even large fibroids. Tourniquets and vasoconstrictive substances (vasopressin [off-label use]) may be used to limit blood loss. Continuing the uterine incisions through the myometrium and entire pseudocapsule until the fibroid is clearly seen exposes a less vascular surgical plane, which is deeper than commonly appreciated. Vascular corrosion casting shows that fibroids are totally surrounded by a dense vascular layer and that no distinct “vascular pedicle” exists at the base of the myoma.²²

Fibroids that are near dominant fibroids can be removed through the same uterine incision, but avoid tunneling through the myometrium to remove distant fibroids; many myometrial tunnels are hard to close and can continue to bleed. Promptly closing each incision allows immediate hemostasis and, although multiple uterine incisions may be needed, adhesion barriers may help limit formation of adhesions.²³

Avoiding heterologous transfusion

Cell-saver technology has been used extensively in orthopedic, cardiac, and neurologic surgery; consider it during myomectomy (or hysterectomy).

The cell saver suctions blood from the operative field and mixes it with heparinized saline. If blood reinfusion is necessary, the blood is washed with saline, filtered, centrifuged to a hematocrit of approximately 50%, and given back to the patient via an IV line. The need for preoperative autologous blood donation or heterologous blood transfusion can therefore often be avoided, eliminating the risk of infection and transfusion reaction.²⁴

Seventy of 91 women who underwent myomectomy for uterine size of 16 to 36 weeks had cell-saver blood reinfused (mean volume, 355 mL); only seven women required heterologous transfusion.²⁰

Laparoscopic myomectomy

Instrumentation makes laparoscopic myomectomy feasible, although the application of this approach is limited by the size and number of fibroids that can be reasonably removed and by the difficulty of laparoscopic suturing. However, a study of 131 women randomized to abdominal and laparoscopic myomectomy for nonpedunculated large myomas (mean diameter, 7 cm) found a higher postoperative hemoglobin level, lower incidence of postoperative fever, and shorter hospital stays with laparoscopic myomectomy.²⁵

A case series of 144 women (largest fibroid, 18 cm [mean, 7.8 cm]) reported that only two (1.4%) women required conversion to laparotomy.²⁶

Myomas do not recur

Once individual myomas are removed, they do not recur, although new myomas may appear. Most women require no additional treatment. If the first myomectomy is performed for one fibroid, 11% of women require subsequent surgery (mean follow-up, 7.6 years). If multiple fibroids are removed initially, 26% require subsequent surgery.²⁷

The appearance of a new myoma may reflect the persistence of fibroids not removed initially—as ultrasonography has demonstrated in 29% of women after myomectomy.²⁸

CASE 2 RESOLVED

A.M. underwent pelvic magnetic resonance imaging, which revealed two 7-cm intramural fibroids and four other intramural fibroids between 2 cm and 4 cm in size. She chose abdominal myomectomy and is now attempting pregnancy.

CASE 3 Patient asks for hysterectomy

S.L. is a 44-year-old G2P2 who complains of missing a few days of work every month because of heavy menstrual bleeding and fatigue. Her hemoglobin level is now 8.2 g/dL. She underwent myomectomy about 10 years ago, successfully followed by two pregnancies, but her uterus is now about 12-weeks size. She is not interested in getting pregnant again and wants to be able to work without bleeding through her clothes. She has explored other options, but has decided to have a hysterectomy. She asks whether laparoscopic supracervical hysterectomy is appropriate for her situation. What do you advise?

Treating preoperative anemia

The first step for this patient is to treat her anemia.

Erythropoietin alfa and epoetin have been shown to increase preoperative hemoglobin concentrations in cardiac, orthopedic, and neurologic surgery. They should be considered more often, when appropriate, before gynecologic surgery.²⁹ A randomized study showed that approximately 15,000 U of epoetin a week for 3 weeks before surgery raised the hemoglobin concentration by 1.6 g/dL and significantly reduced the transfusion rate when compared with controls.³⁰ No side effects were reported.

GnRH agonists have been shown to reduce uterine volume, fibroid volume, and bleeding; these benefits may be limited, however, by side effects and risks. Reduction in uterine size occurs mostly within the first 3 months of treatment; after 6 months, fibroid volume is reduced by 30% and total uterine volume by 35%.^31,32 Heavy bleeding responds well to GnRH agonists; in one study, 37 of 38 women had resolution by 6 months.

Side effects generally do not deter treatment

Side effects are common with GnRH agonists: 78% experience hot flushes; 32%, vaginal dryness; and 55%, transient headache. Arthralgia, myalgia, insomnia, emotional lability, and decreased libido are reported less often. However, only 8% of women terminate treatment because of side effects.³³

Bone loss is significant after 6 months of a GnRH agonist.³⁴

A Cochrane review found that women who have myomas and who were treated preoperatively with 3 to 4 months of a GnRH agonist had significantly reduced uterine volume and uterine size; an improved preoperative hemoglobin level; and reduced operating times and hospital stay.³⁵ Although operative blood loss was less for both abdominal hysterectomy and abdominal myomectomy patients, there was no significant difference in the transfusion rate.

Hysterectomy

Fibroids were the indication for hysterectomy in 40% of abdominal, 17% of vaginal, and 29% of laparoscopic hysterectomies, according to a review in the United States.¹⁷ Women with intractable symptoms who have not been helped by other therapies may benefit from hysterectomy. The Maine Women’s Health Study found that, following hysterectomy (35% of which were performed for myomas) for moderate or severe symptoms, 72% of women felt “much better,” 16% felt a “little better,” and 3% felt worse than they did before surgery.¹

Laparoscopic hysterectomy

Either total or supracervical laparoscopic hysterectomy is feasible. Benefits include less postoperative pain, short hospital stay, and quick recovery. However, if a vaginal hysterectomy is feasible, there is no benefit to laparoscopic hysterectomy.³⁶

What the data show

A prospective, randomized, multicenter study concluded that laparoscopic-assisted hysterectomy offered the benefits of less invasive surgery without increased risk.³⁷ Eighty women whose uterus was between 280 g and 700 g were randomized to laparoscopic-assisted vaginal and abdominal hysterectomy. Estimated blood loss, postoperative day 1 hemoglobin level, pain, and hospital stay were all significantly better for the laparoscopic-assisted group. Complications in the abdominal hysterectomy group included one woman who had a cuff hematoma and who required transfusion; one who had bleeding requiring reoperation and transfusion; and five who had fever. The only complication in the laparoscopic group was postoperative fever in two women.

Even large fibroids may benefit from laparoscopy

In experienced hands, the benefits of laparoscopic hysterectomy may extend to women who have large fibroids. A retrospective cohort study compared laparoscopic hysterectomy in 34 women who had a uterine weight greater than 500 g (range, 500 to 1,230 g) with 68 women whose uterus weighed less than 300 g.³⁸ Operating time was significantly shorter in women with smaller uteri, but no difference was observed in complications, blood loss, hospital stay, or recovery, and no patient required conversion to laparotomy.

CASE 3 RESOLVED

S.L. underwent laparoscopic supracervical hysterectomy, which involved a 1-night hospital stay, and returned to work in 2 weeks. She is happy to be free of monthly bleeding and believes she made the right treatment decision.