ORIGINAL ARTICLE

Outcome of Total Laparoscopic Hysterectomy

Samina Saleem Dojki and Alia Bano

ABSTRACT
Objective: To determine the surgical outcomes of total laparoscopic hysterectomy performed.
Study Design: Case series.
Place and Duration of Study: Obstetrics and Gynecologic Endoscopic Unit of Patel Hospital, Karachi, from February
2013 till February 2016.
Methodology: The study included all patients on whom total laparoscopic hysterectomy was performed during the study
period. Patients with malignancy were excluded from the study, except those with suspected stage 1 and 2 endometrial
carcinoma. The procedures were performed by two gynecologists keeping rest of the team constant, with similar technique.
The reviewed outcome measures were duration of surgery, and intraoperative and postoperative complications.
Results: Out of 209 patients, majority were multiparous with median age and weight of 45 (50-40) years and 69 (80-60)
Kgs, respectively. Previous history of abdominopelvic surgery was present in 33%. Heavy menstrual bleeding was the
leading indication. Median and interquartile value of operative time was 175 (225-120) minutes. Total rate of intraoperative
and postoperative complications was 12.9% and major complications were 3.8%. All postoperative complications were
minor. Of all, 3.3% of patients were converted to open surgery; there was no vascular injury or re-operation.
Conclusion: Total laparoscopic hysterectomy is safe, acceptable, and doable alternative to conventional standard
hysterectomy.

Key Words: Laparoscopy. Hysterectomy. Complications. Laparoscopic hysterectomy.

INTRODUCTION comparable to those of vaginal hysterectomy in terms of

Hysterectomy is one of the commonest surgical postoperative parameters and patient satisfaction.5 Time
procedures performed in gynecology worldwide.1 The taken for the procedure is more to begin with as it has its
common indications are fibroid uterus, endometrial learning curve but as one gains experience, its duration
pathology, endometriosis, and ovarian tumors. reduces markedly. The other approaches for hysterectomy
Laparoscopic method for gynecological indications has are open abdominal hysterectomy and vaginal hysterec-
gained popularity over the last 20 years, in terms of tomy. For years, vaginal hysterectomy is preferred over
safety as well as patient convenience. Gynecologic other routes, especially for uterovaginal prolapse. 6,7
endoscopy is no longer restricted to diagnostic or Literature is not available for TLH from Pakistan due to
simpler procedures. The approach is frequently being lack of training opportunities as well as acceptance of
used now for varied indications. Even acute pelvic change among gynecologists.8,9 This can be overcome
emergencies,2 are being performed by minimal access. by proving its advantages through local data.
After the first laparoscopic hysterectomy in 1989 by The aim of this study was to determine the surgical
Harvey Reich,3 there had been many advances in outcomes of total laparoscopic hysterectomy.
technique and instrumentation. These innovations and
gynecologists' persistence have led to rapid progress in METHODOLOGY
minimal invasive surgeries like robotics and natural
The records of all patients who underwent TLH during
orifice transluminal endoscopies. He et al., have shown
February 2013 to February 2016 were included in the
that these advances have resulted in better and
study. The data was reviewed and collected
comparable results for laparoscopic approach and
prospectively from patients’ files by the postgraduate
resulted in lesser intraoperative blood loss, shorter
trainees and entered on a predesigned proforma. The
hospital stay and quicker recovery.4
study proposal was submitted to Hospital Ethics
In experienced hands with well selected patient, the Committee and was granted exemption as patients'
results of total laparoscopic hysterectomy (TLH) are identity was not revealed. The surgery was performed by
one of the two authors with an additional diploma in
Department of Obstetrics and Gynecologic Endoscopic Unit, gynaecologic endoscopy. The study population included
Patel Hospital, Karachi.
patients of all ages, parity, and weight. The patients with
Correspondence: Dr. Samina Saleem Dojki, Department of benign disease, probable stage 1 and 2 endometrial
Obstetrics and Gynecology, Patel Hospital, Street 18, Block 4, malignancy as well as borderline ovarian malignancy
Gulshan-e-Iqbal, Karachi. were also included in the study. The demographics,
E-mail: [email protected] indications, duration of surgery, presence or absence of
Received: September 05, 2017; Accepted: March 20, 2018. previous abdominal/pelvic surgeries, intraoperative and

Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (6): 427-430 427
Samina Saleem Dojki and Alia Bano

postoperative outcomes, and duration of indwelling injury and one ureteric injury ended up in lapro-
catheter and hospital stay were reviewed. conversion and repair. Dense bowel adhesions were
The outcomes were categorised into major and minor observed in four cases after primary port entry and they
complications. Major complications were defined as were converted to laparotomy. There was one more
hemorrhage requiring transfusion, vascular injury, injury conversion due to failure of entry into the abdomen that
to the bowel, bladder or ureter, laproconversion or re- made it total 7 (3.3%) conversions.
operation and complete vault dehiscence. Minor Postoperative complications were observed in 15 (7.1%)
complications were defined as any infection or cases. All were minor including five port site infections;
temperature of more than 38º C on two occasions six
Table I: Baseline characteristics of patients and indications for surgery.
hours apart (excluding the first 24 hours after surgery),
port site infection (PSI), vault infection, and partial Median age of the patients 45 (50-40)

vaginal vault dehiscence. Blood loss was measured by

Parity distribution

the volume of blood contained in suction bottle before

Multiparous 133 (63.6%)
Grand multiparous 50 (23.9%)
irrigation is used or if irrigation was already used, the
Parity 1 14 (6.7%)
saline volume was deducted. Surgical duration was
Nulliparous 12 (5.75)
calculated in minutes from skin incision till skin closure.
Median (IQR) weight of uterus 140 (76)
The patients were followed up at two weeks and then at Previous abdomino pelvic surgery
six weeks. No 140 (67%)
Analysis was conducted with statistical package for Yes 69 (33%)
social science (SPSS) version 21. Shapiro-Wilk test was Previous LSCS
applied to check the normality of the data. Statistical No Previous LSCS 175 (83.7%)
analysis included simple descriptive analysis of the Previous 1 LSCS 19 (9.1%)
study variables in terms of median (IQR); whereas, Previous 2 LSCS 7 (3.3%)
frequencies and percentages of qualitative data were Previous 3 LSCS 7 (3.3%)
computed. Due care was taken to keep the patient Previous 4 LSCS 1 (0.5%)
confidentiality, and the identity was marked. Indication of surgery
Heavy menstrual bleeding 65 (31.1%)
RESULTS Fibroid 62 (29.7%)
Thickened endometrium 20 (9.6%)
During the study period, 209 patients underwent total Ovarian cyst 18 (8.6%)
laparoscopic hysterectomy. Patients' demographic and Post-menopausal bleeding 17 (8.1%)
clinical characteristics including age, parity, weight, Endometrial polyp 8 (3.8%)
previous abdominopelvic surgeries including Caesarean Endometriosis 4 (1.9%)
deliveries, uterine weight, and indications for the Pelvic inflammatory disease 4 (1.9%)
procedure are displayed in Table I. The median age and Fibroid + ovarian cyst 3 (1.4%)
weight of the women were 45 (50-40) years and 69 Cervical polyp 2 (1%)
(80-60) kgs, respectively. Majority, 133 (63.6%) of Carcinoma ovary 2 (1%)
patients were multiparous. Uterine volume ranged from Ca Endometrium 1 (0.5%)
normal to 18-week size. The largest uterus weighed 782 Chronic pelvic pain 1 (0.5%)
grams. Previous history of abdomino-pelvic surgery was Endometrial polyp 1 (0.5%)
present in 69 (33%), in which 32 (15.76%) had one or Dyspareunia 1 (0.5%)
more Caesarean sections and 27 (13%) had more than
one type of surgery. Heavy menstrual bleeding (HMB) Table II: Intraoperative and postoperative complications.
was the commonest indication, followed by uterine Per- and post-operative complications
fibroid uterus. No 180 (86.1%)
Yes 29 (13.9%)
Estimated blood loss, more than 100 ml, was found in 6
Per-operative complications
(2.9%), median and interquartile value of operative time
No complications 195 (93.3%)
was 175 (225-120) minutes, hours of postoperative Estimated blood loss >100 6 (2.9%)
indwelling catheterisation were 7 (8-5) hours and duration Conversion 6 (2.9%)
of postoperative hospital stay was 1 (2-1) day. Bowel injury 1 (0.5%)
The intra- and post-operative complications are detailed Conversion + bowl + bladder injury 10.5%)
in Table II. Total number of intra- and post-operative Post-op complications
complications was 29 (13.9%). Major complications No complication 193 (92.3%)
were observed in 8 (3.87%) patients. These major Fever 6 (2.9%)

complications included two sigmoidal tears and one Wound infection 5 (2.4%)

ureteric injury. Of the two sigmoid injuries, one was Partial vault dehiscence 2 (1%)

managed by laparoscopic suturing. The other sigmoid Vault infection 3 (1.4%)

428 Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (6): 427-430
Outcome of total laparoscopic hysterectomy

fever was reported in six. One patient had partial vault one was a tear during adhesinolysis due to endometriosis;
dehiscence, while three cases of vault infections were and both were recognised and repaired intraoperatively.
observed. All responded to conservative management. The conversion rate of 3.3% is much less than that quoted
There was no vascular injury and no patient received by a French study, which reported 7% conversions in a
intraoperative or postoperative blood transfusion and group of 416 patients.21
ICU transfer. None case required re-operation.
The minor complications, though in a bigger number
Postoperatively, all patients were mobilised 4-6 hours than major ones, all were managed conservatively; none
after surgery and Foley's catheter was removed at the required surgical intervention. The most troublesome of
same time. Most of the patients were discharged within these partial vault dehiscence was only 1 (0.47%). This
24 hours after surgery. is comparable to 0.39% reported by Hur et al. in his
recent study in 2011,21 and much less than his earlier
DISCUSSION reported incidence of 4.9% in 2007.22 In his study,
The study documents a series of 209 consecutive total majority experienced complete vault dehiscence and
laparoscopic hysterectomies. The demographics of this needed surgical repair, while our patient was managed
study are similar to the study done by Vincent with conservatively. The rest of the minor complications were
respect to age (mean 45 years vs. 47 years) and weight low grade fever for one or two days, vaginal discharge
(mean 69 Kgs vs. 67 Kgs).10 History of one or more due to vault infection. Both of these responded well to
C sections was more 32% in this series vs. 12.6%.10 antibiotics. Port site infection after all sorts of
Both studies included wide range of age and parity. laparoscopic surgeries is rare but can be so much
Similarly, weight was not the exclusion criteria and the bothersome that it might undermine the benefits of this
study encompassed the weight from lean to morbidly minimal invasive approach. The overall incidence of
obese. This helps in drawing results from wide variety of umbilical PSI has been reported as 8% with maximum
sample. Literature also supports that neither age, weight being after laparoscopic cholecystectomy.23
nor parity or previous abdominal surgeries is a The debate about the route of this commonly needed
limitation.10-12 Conventionally, history of previous procedure is, for years now, relates to the surgical time
abdominopelvic surgery has been considered as a risk and the rate of complications. Now, as more and more
factor for complications and a factor of prolonged the procedures are being performed and more advanced
surgical time. This study did not exclude this factor; Cem techniques and instruments are being innovated, the
Celik and Remzi Abal have already reported equivalent results are comparable on both aspects. The better
results for patients with or without such history.13 results regarding early recovery and better cosmetic
Median and interquartile value of operative time was 175 value are already known.
(225-120) minutes, which is comparable to those studies The strength of this study was similar technique of all
done in initial years by Nezhat et al., which was 160 cases done by only two surgeons. Also the sample size
minutes;14 while it is little more when compared to 111.5 is good, considering the first study from a country. This
minutes in his more recent study.15 This depicts the effect is the first ever study on laparoscopic hysterectomy from
of learning curve when surgeons show consistency. our country, so the results cannot be compared with
local literature. The limitation in the study was that the
The major complication rate reported in literature by
general surgeons and urologists in our institute perform
Hoffman et al. and Heinberg et al. range from 5.6% and
open surgeries only which led to option of laparoscopic
14.4%, respectively,16,17 while Chaperon reported
conversion in visceral injuries.
complications in 10% cases in his study.18 The major
complications rate in our study was 3.87%. The lesser
CONCLUSION
number of complications in this study is encouraging.19
This may also imply the need of a larger number of The demographics, varied indications, previous history
surgeries and then comparing with bigger local and of surgeries, and the outcomes show that a wide range
international studies. of patients can be provided with the emerging facility of
laparoscopic hysterectomy. The current study outcome
There was one ureteric injury (0.478%) in a patient with measures correlate well with recent international
endometriosis, which was recognised and repaired by literature. Laparoscopic hysterectomy is safe and a
the urologist at the same time. The reported incidence of doable method. Appropriate training in minimal invasive
ureteric injuries in literature is 0.2% to 2%,19 and surgery and skills are fundamental. This recommendation
corresponds well to that in the current study. needs vigour by more local data; a dire need of time.
In 2012, Jensen et al. reported access-related bowel
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