Complications of Laparoscopic Hysterectomy: Avoid the Risks

Results of more than 1500 laparoscopic hysterectomies have been reported since 1989. The complication rate is 10 to 11% in expert hands. However, a complication rate of 60% was reported in one community hospital series. The risks of laparoscopic hysterectomy are acceptable at 10% but not at 60%. Practitioners of laparoscopic assisted vaginal hysterectomy must review and understand the risks associated with the procedure in order to avoid them. This article addresses the complications of laparoscopic hysterectomy and gives techniques to avoid them.

hysterectomy (LAVH) to summarize the reports now available in the literature on compli- cations that have occurred with this procedure.In the first 67 LAVH procedures performed by Carter and Bailey [1], there were two instances of vaginal cuff cellulitis and one pulmonary infection requiting intra- venous antibiotics.There were also one Richter's her- nia, one lacerated inferior epigastric vessel, and two urinary tract infections in this series for a 10.5% com- plication rate.After introduction of the use of prophylactic antibiotics including cefotetan disodium and metronidazole hydrochloride, there have been no fur- ther cases of cuff cellulitis in the subsequent 200 pro- cedures.Pulmonary infections have been avoided by the use of postoperative incentive spirometry started immediately upon the patient's awakening.Richter's hernia is avoided by using the Carter-Thomason fas- cial closure device in a mass closure of all 10 mm and greater port sites [2].

Hill et al. [3] reported a 15.9% complication rate in the first 200 LAVH procedures.Anterior abdominal wall vessel injury occurred in 5 patients, bladder injury in 5, febrile illness in 13, secondary hemorrhage in 4, Rich er's hernia in 1, and temporary ureteral obstruction in 4. Five of the patients with febrile episodes actually had pelvic hematomas.One required general anesthesia to evacuate the hematoma.In the study of Padial et al. [4] of 75 patients undergoing LAVH, there was a 10.6% frequency of febrile mor- bidity with no organ injuries or wound infections with a mean hospital stay of 2.4 days.

In 839 LAVH procedures reviewed by Ou et al. [5], there were 8.8% minor complications and 2.7% major complications.The minor complications included uri- nary tract infections in 2%, fever in 1.2%, hematoma in 1.2%, hemorrhage in 1.1%, anemia in 1%, hema- turia in 0.6%, ileus in 0.5 , nausea in 0.4%, urine retention in 0.25%, abdominal pain in 0.25%, and arrhythmia, knee pain, tendonitis, and leg numbness in 0.1%.Major complications included 8 bladder injuries (1%), hemorrhage (0.9%), hernia (0.4%), trocar injury to epigastric vessels (0.35%), and pulmonary embolus 2 weeks postoperatively (0.1%).Liu and Reich [6] reported on the overall complica- tion rate in 518 total laparoscopic hysterectomies of 5.76% with 2.12% of patients having febrile morbid- ity, which included pneumonia, pelvic hematoma, dehydration, and transient febrile episodes.The only death associated with LAVH was reported in this series.The patient developed bilateral pneumonia with adult respiratory distress syndrome after her dis- charge from her initial operation.Boike et al. [7] reported two bowel obstructions in 82 LAVH proce- dures, both occurring as a result of bowel herniation into port sites of 10 mm and greater.Woodland  [8] reported on transection and ligation of the ureter with the linear stapling device.Kadar and Lemmerling [9] reported on ligation of the ureter with suture during the vaginal portion of the procedure. 10]pointed out that the complication rate with LAVH drops with the experience of the operators and that the rates can be comparable with vaginal hysterectomy even in a community hospital 11].Dicker et al. [12] demonstrated conclusively that complications of vaginal hysterectomy are far fewer than those for abdominal hysterectomy.Dicker et al.  [13] also demonstrated the trend toward abdominal hysterectomy in spite of the advantages of the vaginal approach.Nezhat et al. [14] and Carter et al. [15] clearly demonstrated that LAVH patients req ire fewer days of hospitalization, return to work much sooner, and require far less pain medicine than abdom- inal hysterectomy patients.Summit et al. 16] demonstrated that LAVH had no advantage over vaginal hysterectomy in patients in whom vaginal hysterectomy could be performed.By using gonadotropin releasing hormone (GnRH) ago- nist for 2 months before hysterectomy, Stovall et al. 17] were able to reduce uterine size by an average of 47%.Of patients given GnRH agonists, 80% had vagin l hysterectomies while 75% of patients who had not received GnRH agonists had abdominal hys- terectomies.Techniques such as those described by Groty [18] for extracting the large uterus were used extensively.Pelosi and Kadar 19] have demonstrated that even very large uteri (>500 g) can be safely removed vaginally by combining the laparoscopic approach with the principles described by Groty 18].

Galen et al. [20] have demonstrated that with proper patient preparation and selection the majority ofLAVHs can be performed in an outpatient setting.Lyons [21] demonstrated that the supracervical approach to the laparoscopic hysterectomy is even safer than the LAVH in his comparative study.Since Reich et al. [22] irst reported on the LAVH in 1989, safe introduction of the technique into the practice of skilled surgeons has been extensively reported [23][24][25][26][27][28][29][30].

However, Schwartz [31 pointed out that the com- plication rate can be unacceptably high (50%) when the procedure is performed by surgeons not suffi- ciently trained in these procedures.Shwadyer [32]  has demonstrated that there is a significant learning curve for the procedure, which results in a decreasing complication rate.Kadar  [33] developed an elegant and reproducible technique to avoid c

plications with the laparoscopic hysterectomy p
ocedure, which, however, requires a retroperitoneal approach to the hysterectomy.Smith et al. [34] in a landmark study reported a 60% complication rate in LAVH procedures at a community hospital.Excess blood loss occurred in 8 patients (mean 767 ml) and cysto- tomy in 1.

As the transfer of the technology associated with LAVH takes place from the very skilled laparo- scopists to the gynecologists who ar practicing laparoscopy as a part of their general practice, compli- cation rates appear to increase significantly.To elimi- nate certain complications (Richter's hernia) and to reduce significantly the likelihood of others (cuff infection, pulmonary infection, epigastric vessel lacer- ation, and ureter injury) certain principles for the performance of this procedure have been developed.


PERFORMANCE OF THE PROCEDURE Patient Selection

The key to a successful outcome for a laparoscopic hysterectomy is proper patient selection.Patients who cannot undergo appropriate anesthesia or who have a high risk for laparoscopic procedures should not be counseled to undergo these procedures.Topel's tech- nique of gasless LAVH under epidural anesthesia [30] allows for the extension of this procedure to those who cannot tolerate general anesthesia.

Patients should be counseled for the possibility of open exploratory surgery.Although in certain hands, a large uterus can be safely removed [19], certainly the initial procedures of laparoscopists should not involve uteri 500 g.

LAVH should be avoided in patients with exten- sive adhesions of the bowel, and general surgica

con- sultation shoul
be obtained if these are found unexpectedly and require dissection.Extensive stage IV endometriosis that involves either the ureters or the bowel or that is extensive enough to form an oblit- erated cul-de-sac, requires great care in dissection and may in fact obligate the surgeon to abandon the laparoscopic approach and perform an open proce- dure (31 ).

The golden rule of laparoscopic surgery is, "Know thy limits."What is appropriate and appears easy for the highly skilled laparoscopist may in fact lead to dis- aster for a person of average skill More than any other form of surgery, laparoscopic surgery depends on cer- tain inherent qualities of eye-hand coordination and the ability to operate in a closed environment using two-dimensional images.Inherent talents may vary considerably from one surgeon to another [31].


Patient Preparation

Patients in whom any bowel adhesions or bowel dis- ease is suspected sho

d be given mechanica
osmotic preparation solutions for bowel cleansing preoperatively.In addition, preoperative antibiotics with a reg- imen such as 1 g of cefotetan disodium and 500 mg of metronidazole hydrochloride is appropriate.With this combination of antibiotics, if the bowel is entered it can be safely repaired by primary closure performed laparoscopically.Also, pneumatic compression stock- ings should be used to reduce the risk of venous thrombosis and pulmonary embolus.

The anesthetist should empty the stomach with an orogastric or nasogastric tube and should avoid the use of nitrous oxide.This will reduce the risk of Verres needle or trocar injury to the transverse colon.A Foley catheter should be placed to ensure that the bladder has been completely emptied to avoid trauma to the bladder during placement of the secondary trocars.


Patient Positioning

The patient should be positioned on a mechanical table which allows sufficient tilt for a steep Trendelenberg position and should have the legs appropriately placed to allow the performance of the vaginal part of the pro- cedure.Great care must be taken to avoid pressure on the peroneal nerve as well as excess traction on the femoral or sciatic nerve to ensure that no nerve palsies result.The arms should be placed at the sides

avoid excess traction in the
rea of the brachial plexus, and the surgeon should be provided with adequate space by having the anesthetist posistion the anesthesia equipment well up at the head of the table with no excess equipment in the surgeon's way.The surgeon may prefer to begin with the patient in a modified lithotomy position with the thighs nearly horizontal and the knees flexed (Fig. 1) and then elevate the knees and feet to provide room to complete the vaginal portion of the procedure.The author has found it pos- sible to place the legs in a position 60 from horizontal and 30 from vertical, which allows the author to perform the abdominal portion of the procedure without interferance from the extremities and then procede to the vaginal portion of the procedure without the need for a change in the positions of the stirrups (Fig. 2).


Trocar Placement and Position

Introduction of the trocar can be performed either in a closed or an open procedure and can be preceded or not preceded by insufflation through a Verres' needle [35].The most important principle to follow for the introduction of the trocars is to avoid areas where adhesions are likely.Many surgeons will simply use the umbilical incision point regardless of whether pre- vious surgery has taken place.However, studies indi- cate that as many as 35% of patients with previous vertical incisions and 25% with Pfannenstiel's inci- sions will have adhesions extensive enough near the umbilicus that these create dangers for the individual patient [36].In these patients, the use of the Palmer [37] point (Figs. 3 and 4) (midclavicular line, left upper quadrant) is more appropriate for the placement of the initial trocar.The author uses the Palmer point in all cases where adhesions are suspected because of previous surgery.For placement of the initial trocar at Palmer's point, the author prefers to use a 5-mm trocar with direct puncture while elevating the abdominal wall just below the point of entry.The trocar is inserted in a near vertical plane o iented only a few degrees toward the caudad direction.If the Verres' needle is used, its position should be verified with the drop test or injection of 20 ml of normal saline and withdrawal on the syringe.At withdrawal on the syringe there should be an aspiration feeling of a vac- uum as the properly placed needle will be inside the peritoneal cavity, which has a negative pressure.After the position check, the CO2 insufflator can be attached and the insufflation initiated at low rates (1 liter/min) and the initial pressure of insufflation carefully checked.This should be less than 6 mm Hg 15].

After insufflation to 15 mm Hg pressure, the initial trocar placement can be performed.Perhaps the safest way to approach this is to place a small 5 mm trocar at the umbilicus, check the position with a 5-mm laparoscope, and then dilate the trocar site with an appropri- ate dilating system to allow for placement of the diagnostic 10-mm scope.A second approach is to sim- ply place the 10-mm trocar to allow for the insertion of diagnostic 10-mm scope.

Trocar placement is an operator preference, but if 12-mm trocars are used for a linear stapling device, the entry point should be chosen well lateral to the inferior epigastric vessels on either side and lateral as well to the rectus sheath.Care must be taken to identify the position of the superficial circumflex artery and vein.All these vessels should be avoided, and yet at times, bleeding will still occur whether with a 5or a 12-mm puncture.When this occurs, the bleeding can be stopped by placement of sutures appropriately intro- duced by one of the available emergency needles or suture passers currently present in mos

operating rooms [2].Trocar p
acement should be adjusted for the body habitus of the patient and the size of the uterus, as well as the presence or absence of other diseases such as ovarian cysts, adhesions, or endometriosis.

Performance of the procedure can be accomplished with stapling devices, sutures, or cautery.All have certain inherent risks and advantages and disadvan- tages.Perhaps the most important concern with the use of the stapler is to ensure that the course of the ureter is well-demarcated and to ensure that no bleed- ing occurs from the ligated stapled pedicl s.If bleed- ing is noted, this should be treated with the careful application of bipolar cautery in the area behind the staple line.If bipolar cautery is used, again the sur- FIGURE 2 Leg position in stirrups so that no change in position is required to change from laparosc

ic to vaginal position.

geon must be aware of th
possibility of thermal trans- fer of energy, because an application of 8 sec of bipo- lar energy in the area of the uterine artery can lead to a increase in temperature 1 cm away from the point of application that is approximately 100C and exceeds the temperature at which tissue can remain viable [38].Care must be taken to apply the bipolar coagulation instrument only to the point when boiling ceases and avoid the point of carbonization so that a well-sealed vessel is obtained.Suture techniques are certainly appropriate and relatively straightforward for the sur- geon.With the development of new suture devices, the possibility exists that suturing will become simple enough for the average gynecologic laparoscopist.At the present time and with current instrumentation, suturing is time-consuming and can lead to significant frust ation for the laparoscopist.However, suturing skills should be mastered so that appropriate suturing procedures can be performed, such as simple repair of small lacerations of the bladder.


Completion of the Procedure

The laparoscopic hysterectomy can be completed either laparoscopically or vaginally, and either a supracervi- cal or total hysterectomy can be performed.The sur- geon must remember that if the procedure is completed vagi

lly, care m
st be taken to keep all clamps very near the cervix and uterus to ens re that the ureter is not injured on this portion of the surgery.Especially at the point of taking the angle sutures for cuff closure, the surgeon must avoid too deep a placement in lateral position because of the course of the ureter at this point.

For large uteri, morcellation and bivalving tech- niques should be studied and utilized [18].It helps to pretreat the large uterus with GnRH agonist to reduce its size so that it is more easily and readily removed at the point where the vaginal approach is undertaken [17].

Final Look and Exiting from the Abdominal Cavity After complete closure, irrigation is used to carefully evaluate all pedicles and potential areas of bleeding.In addition, the bowel is carefully inspected for injury.Before instruments are removed, 20 ml of 0.25% bupi- vacaine can be injected int the pelvic cavity to help provide for pain relief.The instruments and trocars are removed one by one, and as each trocar is removed, the incision site for that trocar is closed using through and through mass closure techniques to ensure that muscle, fascia, and peritoneum are incorporated into the closure.Techniques for doing this have been described and instruments are available to ensure that this closure is complete to avoid problems with inci- sional hernias [2].Instruments are removed under direct vision, including the final removal of the umbil- ical trocar and the laparoscope.

All incision sites are injected with 0.25% bupiva- caine.The anesthetist should keep the patient at normal temperature with the use of heating aids and by ensuring that appropriately warm solutions are used during the surgery.The patient should be evaluated postoperatively with a hemoglobin check to ensure that no postoperative bleeding is occurring.Patients can be discharged home once they are ambulatory and have active bowel sounds.

J.E. CARTER DISCUSSION With all of these precautions, complications still can and do occur.

First, there can be complications associated with dis- section of both small bowel and large bowel.These are the most dangerous of all the complications because damage is frequently unrecognized; the patient's pre- sentation postoperatively may simply be increasing pain and laboratory studies may not indicate the extent of the damage [39].To avoid this, adhesiolysis should only be undertaken if absolutely necessary for pain relie and visualization, and the adhesiolysis should be performed by an expert laparoscopic surgeon to ensure minimal likelihood of damage.

Bowel can also be injured by direct trocar insertion and by Verres' needle insertion.Avoid the umbilical site for entry in patients with previous vertical or Pfannenstiel's incisions, as well as in those who have had previous umbilical surgery [36,40].

Recognize that thermal injury to the bowel could occur, especially in areas where the bowel underlies the secondary trocar sites and is not visualized while surgery is being performed.This is especially true if a monopolar insulated electrosurgical i

trument is placed within
a conducting sheath, which is inside of an insulating threaded anchoring device.Remember that a white blanched appearance occurring in the area of the bowel indicates deep thermal damage, and a black charred area indicates more superficial dam- age.Bowel can also be injured in the process of resecting endometriosis, and if any possibility of damage exists, examination by insertion of a r

id sigmoidos
ope and insufflation of the bowel under water can be performed [39].Bowel can also be injured at the end of the procedure by leaving a peri-