Special Focus on Subtotal Laparoscopic Hysterectomy

Special Article: Hysterectomy

Austin J Surg. 2023; 10(1): 1298.

Special Focus on Subtotal Laparoscopic Hysterectomy

Liselotte Mettler*; Alkatout Ibrahim

Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Germany

*Corresponding author: Liselotte Mettler Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3/24, 24105 Kiel/ Germany. Email: profmettler@gmx.de

Received: March 30, 2023 Accepted: April 18, 2023 Published: April 25, 2023

Abstract

Today 80 percent of hysterectomies in patients with benigne and malignant disease are done by endoscopic procedures. Clear indications for Laparoscopic Subtotal Hysterectomy include a cervix free of any disturbances, a multifibroid uterus and the wish of the patient to reserve the normal function of her pelvic organs. Laparoscopically this procedure can be easily performed without any side effects. Recently in China Li, Zi-Jun et al. [25] 2020 described a new technique called Anterograde Vaginal Subtotal Hysterectomy (AVSH) which appears to be much more complicated than our Kiel based LSH initiated by Kurt Semm in 1991 [13]. It is the aim of this chapter to line out the easiness and beauty of Laparoscopic Subtotal Hysterectomy (LSH). This is not intended to be a research paper but a historical development presentation for LSH.

Keywords: Laparoscopic Subtotal Hysterectomy (LSH) or Laparoscopic supracervical hysterectomy; Anterograde Vaginal Subtotal Hysterectomy (AVSH)

Introduction

Subtotal hysterectomy, first performed by Freund [1] was the leading technique of hysterectomy for over 80 years until Tervilä [2] described the danger of cervical cancer as 0.3 to 1.9% following supracervical hysterectomy. From 1950 onward, hysterectomy was performed almost exclusively as total hysterectomy until Semm [3] revived interest in supracervical hysterectomy in the 1990s by introducing the Classic Intrafascial Supracervical Hysterectomy (CISH technique) to be performed by laparoscopy and laparotomy [3-10] with coring of the inner cervix. Other major contributions to this technique soon followed [11,12].

Materials and Methods

Classic Intrafascial Supracervical Hysterectomy (CISH)

The CISH technique, as one method of supracervical or subtotal hysterectomy, was performed in Kiel from 1989 until 2005 and was then replaced by the Laparoscopic Subtotal Hysterectomy (LSH) technique.

In the years 1988 -1989, when there was still a lot of opposition from traditional gynecological surgeons against the Minimal Invasive Surgery (MIS). For Hysterectom CISH was developed to exclude the possible development of a cervical stump malignancy in the cervical functional tissue. The transformation zone was resected by transvaginal cylindrical coring of the cervical tissue using a 15, 20, or 24mm Calibrated Uterine Resection Tool (CURT). This coring involved transvaginal excision of the functional cervical tissue from the muscular and connective tissue components of the uterine cervix. To ensure the safety of this excision without endangering ureters or the uterine artery, it was necessary to manipulate the uterus which normally lies in ante- or retroflected position into a straight position. This was done by introducing a 5 mm perforation rod into the external cervical os and pushing it through the internal os into the cavity and finally perforating the uterus in the middle of the fundus. Even in cases of large uterine fibroids, it was possible to find the uterine cavity. The device for coring out of a tissue cylinder is demonstrated in Figure 1. Once a straight line has been established between the cervical canal and the uterine fundus, a preselected CURT was applied over the perforation rod to cut out the appropriate cylinder leaving the cervical outer shell intact. Four steps characterize the technique, two from the vaginal side and two transabdominally. We describe these steps as a historical development only but proceed with the LASH technique which is internationally called LSH (laparoscopic subtotal hysterectomy) today.