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Laparoscopic hysterectomy techniques
Harry Reich MD and Professor Liselotte Mettler MD View the video:
Liselotte
Mettler, MD:
I’m Liselotte Mettler from Kiel, Germany. It is my pleasure to
interview my good friend Harry Reich on today’s topic, which was an issue:
what are the difficulties of hysterectomy? How do you deal with them
laparoscopically? Harry
Reich, MD: I’m
Harry Reich. I live and practice in Wilkes Barre, Pennsylvania
and I do many operations that would be considered very difficult by laparoscopy.
Most of the hysterectomies that I would do would have either very large
fibroids, or would have attendant endometriosis. In many of these cases I
believe the best way to work is to try to get to the retroperitoneal space as
soon as you can, identify your structures, enter into your uterine arteries
and/or ureter. Most of the time I hope to identify both, and then secure
haemostasis of the uterine vessels, very commonly before I do the upper
pedicles. Liselotte
Mettler, MD:
Where do you see it indicated what you call difficult compared to normal?
Do you do it in all normal cases? Harry
Reich, MD: There
are very few normal cases. But for me, in the last ten years I’ve had to do an
open operation for hysterectomy four times. One of them was a necrotic uterus,
where we had poor exposure because of the anaesthesiologist, who was really
upset by a Trendellenburg position, so we were operating on the patient
relatively flat, making everything difficult. The other case I had to open, which was about five years
ago, was almost a 3,000 gram uterus, which was just too big for me. I think
today we could probably handle it because of the technique that’s been
developed to get the uterine arteries early. And then we had a case in 1990; a women with endometrial
cancer and we started the case late. After four hours of careful dissection of
bowel adhesions, we finally reached the uterus. I looked at my team and they
were too tired to go on, it was midnight, so we did it open. Liselotte
Mettler, MD:
Today I saw in the uterus section, a few hysterectomies presented, which
in my opinion would not necessarily have had to be done laparoscopically. I’m
really questioning if people are not overdoing the approach and where is the
real indication for total laparoscopic assisted vaginal hysterectomy? Harry
Reich, MD: I
agree with what you’re saying. In fact, I learned at lot at this meeting
because I probably will start doing more vaginal hysterectomies, especially when
I look at these new devices to use bipolar to coagulate the uterine vessels from
the wall. I believe that the laparoscopic hysterectomy will be reserved for
those cases with very minimal vaginal access, or a frozen pelvis from extensive
endometriosis. Liselotte
Mettler, MD:
Then I think these are the really difficult cases that you are referring
to; endometriosis cases without uterine disease.
Once the people are performing, which can be done vaginally, it’s a big
question: do they need the laparoscopic side? And I think it’s nicer to agree
that we should go more to the vaginal surgery in these cases. Harry
Reich, MD: Exactly.
It’s almost like a rut. The way of thinking that, for me, most cases for years
I looked at to do laparoscopically. I believe that over this next year I am
going to try to do more and more of these, with some of these newer vaginal type
clamps. But on the other hand, I stress that even with the vag
approach, if there is prolapse, especially at the high McCall procedure, it is
much easier to be able to get a high McCall vaginal cup dispension using the
laparoscopic approach than the vaginal. In the laparoscopic approach the ureter
is out of harm’s way. With the vaginal approach, if you try to go too high,
there is certainly a very high chance that you can damage the ureter. Liselotte
Mettler, MD:
Some people are doing supracervical hysterectomy in what they call too
difficult a case for hysterectomy. Is that a real indication? Harry
Reich, MD: These
patients should be referred to surgeons who can do the whole operation. We saw
this when I was at Columbia, New York, many of the hysterectomies for
endometriosis were done by taking the top half of the uterus, in other words,
supracervical, and leaving all the disease behind on the rectum! Now part of my practice today is that I see those patients
and I have to try to take out the cervix. And if there’s endometriosis and
there’s no uterine fundus, what typically happens is the bowel grows over the
cervix, the bladder gets fused to the cervix, and those are some of my most
difficult operations. So please, if they have extensive endometriosis, don’t
do supracervical hysterectomy. You’re just going to hurt that patient’s life
further down the road. Liselotte
Mettler, MD:
That’s a really clear statement because supracervical hysterectomies
are indicated in other indications. Do you at all like supracervical
hysterectomies? Harry
Reich, MD: I
like it more and more today because if I have a big fibroid uterus and minimal
vaginal access, in the old days I would still have to morcellate for hours
trying to get it out vaginally. But now, if I use some of those better
morcellators out there I can do supracervical hysterectomy. It saves me probably
at least an hour of time doing supracervical, and I’ll use the morcellator to
morcellate the uterus. So, lots of ideas change over the years. Liselotte
Mettler, MD:
I think we are not too old yet to be flexible. I thank you for your
information. Harry Reich, MD: Thank you.
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