Hysterectomy is the gynecologic surgery most frequently performed worldwide. The abdominal approach (Total Abdominal Hysterectomy; TAH) was chosen predominantly in the past, while some gynecologists preferred Vaginal Hysterectomy (VH) in selected cases. Recently, an increasing number of minimally invasive approaches, such as laparoscopic and robotic hysterectomy, have been applied.

There are two major procedures in simple laparoscopic hysterectomy, namely Laparoscopically Assisted Vaginal Hysterectomy (LAVH) and Total Laparoscopic Hysterectomy (TLH) [1]. These procedures share relatively similar surgical processes, case indications, and possible complications. Therefore, many facilities perform either of these procedures according to their preferences, and most of the reports on the usefulness of minimally invasive hysterectomy have compared single procedures, either LAVH or TLH, with open surgery. Only recently have several reports been published in which LAVH and TLH have been compared directly [2].

For those facilities in which VH has been commonly performed and that have little experience with laparoscopy, LAVH is likely to be easier to introduce compared with TLH as minimally invasive surgery. In our facility, LAVH had also been performed routinely for benign lesions, such as uterine myoma and adenomyosis. However, with the growing prevalence of laparoscopic surgery and technical advancements among laparoscopic surgeons, an increasing number of facilities in Japan have begun to introduce TLH. Recently, we have been attempting to introduce TLH to substitute LAVH. To examine whether introduction of TLH in a facility in which LAVH has been predominantly performed has any specific risks, the first 23 cases were retrospectively compared with LAVH procedures performed in the past.

A total of 246 cases of LAVH performed in our facility from January 2007 to June 2013 were retrospectively compared with first 23 cases of TLH. All the cases in this period were included in this study. All the TLH was performed during recent two years. Mainly five surgeons who had well-trained for laparoscopy performed LAVH. Two surgeons who had experienced more than 50 LAVHs performed TLH for the first time in this period. The age of the patient, reproductive history, medical history, body weight, height, BMI, patient background, operative time, estimated blood loss during operation and duration of hospital stay were compared between the two groups. Calculation of blood loss was done by subtracting supplied saline from total aspirated fluid. Calculation of blood loss and operation time were routinely performed by the operative nurse and checked by the anesthesiologist. The study was approved by the ethical committee of our facility, and performed with an informed consent to the patients.

With both LAVH and TLH, first access was obtained by a closed procedure in the umbilicus. Each port location was shown in Figure 1. A 5-mm scope was used, and three other ports were usually used. In cases of LAVH, the ureter was first identified through the peritoneum. Then, the round ligament was electrocoagulated and dissected with an ultrasonic surgical apparatus (SonoSurg, Olympus, Tokyo, Japan). Subsequently, the proper ovarian ligament/fallopian tube or infundibulopelvic ligament was dissected, and the broad ligament was dissected. The bladder flap was detached from the uterine cervix. The remainder of the procedure, including dissection of the parametrium, uterine artery, and sacrouterine ligament and colpotomy, was performed via the vagina. After removal the uterus, the vaginal cuff was closed through the vagina. Then, peritoneal sutures were performed by laparoscopy. In TLH, the retroperitoneal space was developed to identify the ureter. Then, the uterine artery was isolated and ligated using #1.0 absorbable thread. The round ligament and the proper ovarian ligament/fallopian tube or infundibulopelvic ligament were sequentially isolated and electrocoagulated using a conventional bipolar device or a LigaSure (Covidien Japan, Tokyo, Japan). The bladder flap was formed, and the sacrouterine ligament was dissected. Then, the parametrial tissue was coagulated and dissected from the upper part to the level of the vagina using a harmonic scalpel (SonoSurg, Olympus, Tokyo, Japan) or a LigaSure. The line of colpotomy was determined using a vaginal pipe (Vagi-Pipe, Hakko Inc., Tokyo, Japan), and colpotomy was performed using a SonoSurg. The vaginal cuff was closed by laparoscopic continuous sutures, and the peritoneum was also closed under laparoscopy.

In statistical analyses, Mann-Whitney’s U test was used to compare the values in two groups, and Chi-square test was used to compare the ratio. P<0.05 was considered as significant.

The 23 cases receiving TLH included 9 cases of uterine myoma, 1 case of adenomyosis, 2 cases of corpus cancer (stage 1A), 3 cases of atypical endometrial hyperplasia, 1 case of cervical cancer (stage 1A) and 7 cases of CIN. The LAVH cases consisted of 200 cases of uterine myoma and 46 cases of adenomyosis. The ages (mean ± S.D.) of the patients in each group were 49.8 ± 9.5 years old for TLH group and 45.0 ± 5.0 years old for LAVH group, and the LAVH group was significantly younger (p<0.01). Gravidity and parity for the TLH group were 1.5 ± 1.4 and 1.2 ± 1.1, respectively, and 2.3 ± 1.2 and 1.9 ± 0.8 for the LAVH group (p<0.01). Median age, gravidity and parity are not different between two groups (Table 1). There was no difference in Body Mass Index (BMI) between the TLH and LAVH groups (24.0 ± 5.1 and 22.8 ± 3.7, respectively).

Table 1: Patient Characteristics. Data is shown as Median, IQR (Interquartile
Range).

There were 55 and 5 cases with past surgical histories in LAVH and TLH group, respectively. Histories in LAVH consisted of 26 appendectomies, 22 caesarian sections, 8 salpingo-oophorectomies/ ovarian cystectomies, 3 laparoscopic myomectomies and other minor operations, and histories in TLH consisted of 2 caesarian sections, 3 salpingo-oophorectomies/ovarian cystectomies and one myomectomy (allowing overlap).

The operative time was significantly longer in the TLH group (196 ± 55 min. for the TLH group and 133 ± 41 min. for the LAVH group, p<0.01) (Table 2). The estimated blood loss during surgery was also significantly lower in the TLH group (102 ± 158 ml for the TLH group and 262 ± 304 ml for the LAVH group, p=0.0132). Four cases required blood transfusions in the LAVH group, while no cases needed blood transfusions in the TLH group. Complications related to surgery occurred in 12 cases in the LAVH group: 3 cases of peritonitis, 2 cases of vaginal cuff bleeding, 3 cases of vaginal cuff abscess, 1 case of pulmonary thrombosis, 1 case of vesico-vaginal fistula, 1 case of ureteral injury and 1 case of intestinal herniation at port site. There were no complications in the TLH group. The length of hospital stay was 3.8 ± 1.1 days for the TLH group and 4.0 ± 3.7 days for the LAVH group, with no significant difference.

Table 2: Operation Time and Bleeding are shown as mean ± S.D., median. TLH: Total Laparoscopic Hysterectomy; LAVH: Laparoscopically Assisted Vaginal; Hysterectomy; NS: Not Significant; (): number of cases.

Because gynecologists used to perform VH before introduction of laparoscopy, vaginal procedures for LAVH were familiar to gynecologists and it was easy to transfer from VH to LAVH. In contrast, TLH was significantly different from VH unless the surgeon could perform suturing as well as laparotomy. Therefore, many facilities, including ours, first introduced LAVH as minimally invasive surgery. In this regard, there have been many reports comparing the clinical outcomes and benefits between VH and LAVH. In 2001, Darai et al. compared VH and LAVH in enlarged uteri, and they showed that the LAVH group had more complications and longer operative times [3]. They concluded that LAVH had no advantages over VH, even in enlarged uteri. Similarly, Sesti et al. reported that surgical and immediate postoperative outcomes were significantly better in VH group than in LAVH group [4]. A meta-analysis by Guo et al, which included more than 300 cases of each procedure, showed no difference in complications, blood loss or hospital stay, but LAVH required a longer operative time, and the authors concluded that VH was the preferable procedure [5]. However, in 2009, Candiani et al. reported that laparoscopic hysterectomy resulted in less blood loss, less postoperative pain and a shorter hospital stay, suggesting an advantage of LAVH [6]. Drahonovsky et al. [2] and McCracken et al. [7] reported that VH resulted in more vault hematoma, compared with LAVH. Chang et al. reported that VH was superior for small-sized uteri, but LAVH was superior for enlarged uteri [8]. Chang et al. also reported that LAVH for large uterus could be conducted by various special strategies such as uterine artery preligation or transvaginal volume reduction [9].

Comparisons of VH and TLH have also been performed in several reports. In the report by Drahonovsky et al. [2], VH had a shorter operative time and less severe complications, but more febrile events, compared with TLH. Ghezzi et al. evaluated postoperative pain after these procedures and concluded that TLH was superior in terms of requirements for rescue analgesia and length of hospital stay, with similar perioperative outcomes [10]. Similarly, in a metaanalysis comparing VH and TLH, TLH was associated with reduced postoperative pain scores and shorter hospital stays, with no differences in complications, blood loss or urinary tract injury [11]. These authors also concluded that TLH might be superior to VH.

LAVH and TLH are relatively similar in their surgical processes as laparoscopic procedures. Therefore, many facilities perform either of them, irrespective of the case conditions. There have not been many reports comparing LAVH and TLH in a single facility. In a comparative study between LAVH and TLH, Roy et al. suggested that TLH required a significantly longer operative time, whereas it resulted in less blood loss [1]. There were no significant differences in postoperative outcomes. Long et al. compared 60 cases of LAVH and 41 cases of TLH and found that TLH required a longer operative time but resulted in relatively less blood loss [12]. Shin et al. compared 72 LAVH cases and 96 TLH cases and concluded that, although both procedures were safe and feasible, LAVH was superior for relatively large uteri [13]. In our study, TLH required a longer operative time but resulted in less blood loss. This finding cannot simply be ascribed to the difference in the procedures; we spent a longer time with TLH because of our lack of experience with this technique. Actually in case of TLH, which is recently introduced, the operation time tends to decrease overtime, namely, learning curve. Because introduction of TLH was done by two experienced laparoscopist, improvement of the surgical skill might have been faster. Also we tended to avoid TLH in patients with large uteri. Therefore, there was significant bias in the case selection. However, these tendencies shown from our experience were generally consistent with the reports mentioned above, and they might have been the case even in the introductory phase of a new operative procedure.

Collectively, there have been no definite conclusions regarding superiority among VH, LAVH and TLH. VH tends to be associated with a shorter operative time. TLH has shown less blood loss, compared with VH and LAVH. LAVH might offer advantages in cases with large uteri. However, these tendencies have not necessarily been shown in all of the reports, but they have differed from report to report, suggesting that the advantages may differ according to the facility and the individual case. These procedures require specific techniques compared with abdominal hysterectomy, and the results can depend on the experience of the surgeon.

There are several variations among TLH procedures; in particular, the treatment of the ureter and uterine artery varies according to the surgeon. Sinha et al. randomly compared procedures in which the uterine artery was ligated at the beginning of the surgery with those in which the uterine artery was secured later as in conventional open procedures, and they indicated that the former approach resulted in less blood loss [14]. In contrast, Pan et al. compared TLH versus coagulation of uterine arteries at their origin plus TLH for the management of myoma and adenomyosis, and they found that the procedures were comparable in terms of blood loss [15]. Recently, vessel sealing devices have been increasingly used to secure the uterine artery. Gol et al. reported on the usefulness of retroperitoneal uterine artery sealing using a LigaSure [16]. Demirturk et al. reported that vessel sealing system is superior to harmonic scalpel in this procedure [17]. Aytan et al. compared three vessel sealers, Liga Sure, HALO PKS Cutting Forceps and Enseal Tissue Sealer, and found no difference [18]. Generally, early detection of the ureter and ligation of the uterine artery by exploring the retroperitoneal space are believed to reduce accidental ureter injury and blood loss only when they are performed safely by an experienced laparoscopic surgeon. Therefore, such techniques should be used only in certain cases. In our facility, we usually isolate and ligate the uterine artery by absorbable thread in the early part of the operation in TLH, which could have contributed to less blood loss in the TLH group. To minimize thermal damage to the ureter as much as possible, we are so far using simple ligation. However, this procedure may be safely performed by vessel sealing using such as LigaSure [17,18].

We here reported our experience with the introduction of TLH in a facility in which LAVH used to be performed. TLH was safely introduced to experienced laparoscopic surgeons, and it tended to result in reduced blood loss. Although there are, so far, no conclusive advantages of TLH over LAVH, with increasing experience with laparoscopy and decreased experience with the vaginal approaches, such as VH, among younger doctors, an increasing number of hysterectomies are going to be performed with TLH procedures, at least in Japan. Therefore, it is necessary to safely introduce TLH to doctors who have used LAVH or open surgery.