What is a laparoscopic supracervical hysterectomy (LSH)?
The laparoscopic supracervical hysterectomy procedure was developed to provide a minimally invasive technique to the traditional abdominal hysterectomy. The LSH procedure requires a few small 1 centimeter incisions in the abdomen. The body of the uterus is removed, while the cervix is preserved. Also, the ovaries and the tubes can be preserved or removed, depending upon personal preference or ovarian disease. Usually, I recommend saving the ovaries if there is no history of ovarian disease (e.g. recurrent ovarian cysts or masses) and no family history of ovarian cancer.
What are the advantages of a laparoscopic supracervical hysterectomy (LSH) over an abdominal hysterectomy?
The advantages of a laparoscopic supracervical hysterectomy are:
- Smaller incisions (one centimeter in size) which allows for a quicker postoperative recovery with less postoperative pain.
- Shorter hospital stay (e.g. overnight stay) and patients go home the next day. The patient can return back to normal activities in usually 14-21 days.
- Preservation of the cervix (which does not disrupt the support of the pelvis tissue and the vaginal cavity). As a result, there is preservation of sexual function.
- Fewer surgical complications (e.g. less blood loss, decreased risk of infection, and decreased postoperative adhesion formation).
Surgical steps in the laparoscopic supracervical hysterectomy (LSH) procedure:
A laparoscopic supracervical hysterectomy is performed under general anesthesia. Three small one centimeter incisions are made in the abdomen (with one incision made inside the belly button and two additional one centimeter incisions are made in the left and right lower quadrants of the pelvis. For very large uteri, a 4th tiny incision is made in midline just above the mons pubis (pubic hair line) to provide better exposure. The pelvic cavity is then insufflated with carbon dioxide gas to create a larger surgical space to perform the surgery. A laparoscope (a small camera) is placed through the umbilicus to visualize the uterus, ovaries, and other pelvic organs.
This is an example of one of my laparoscopic supracervical hysterectomy cases in an 18 week sized fibroid uterus (in comparison to a normal sized uterus which is 6-8 weeks in size). This patient has severe menometrorrhagia (heavy bleeding during her menstrual period and in between her periods). This uterus is enlarged almost to the level of her umbilicus (belly button). This fibroid uterus is composed of multiple intramural, subserosal, and submucosal myomas.
A laparoscopic camera is placed through the umbilicus to visualize the fundus of uterus (the top of the uterus) and its multiple fibroids. For this 18 week sized uterus, you cannot see the entire uterus in a single view because of its large size.
This patient is 42 years old female who has failed conservative medical management to control for her heavy menstrual bleeding. Now, she desires a hysterectomy that allows her a quicker recovery with smaller incisions so that she can return back to her normal activities sooner. She desires preservation of both her ovaries and her cervix. The first step in the procedure is coagulation and cutting of the round ligaments using bipolar cutting forceps.
The next step in the procedure is coagulation and cutting of the utero-ovarian ligaments in order separate the ovaries from the uterus and save her ovaries.
The laparoscopic dissection continues until the uterine artery and vein are identified. The laparoscopic view provides superior visualization (in comparison to the abdominal approach) and thereby allows for less blood loss.
The uterine vessels are sealed and then the body of the uterus is amputated from the cervix, in order to preserve the cervix and the vaginal cavity.
The body of the uterus is completely separated from the cervix. The cervix is visualized along with plastic blue uterine manipulator in the cervical canal (which assists in the uterine mobilizations and visualization during the surgery). The uterus is then morcellated using a GYNECARE uterine morcellator. The morcellator grinds the large uterus into small sausage-like strips to allow the surgeon to remove a very large uterus through a small incision in the abdomen.
The final results show a morcellated uterus that is now composed of multiple thin strips of tissue.
What is the difference between a laparoscopic supracervical hysterectomy (LSH) and a total laparoscopic hysterectomy (TLH)?
| Laparoscopic Total Hysterectomy (TLH)
A total laparoscopic hysterectomy (TLH) removes both the uterus and the cervix. In comparison, a laparoscopic supracervical hysterectomy removes only the body of the uterus and leaves the cervix in place. This is a woman’s personal choice. One can either elect to leave the cervix or remove the cervix at the time of the hysterectomy.
The advantages of a LSH (in comparison to a TLH) are:
- Leaving the cervix intact maintains normal anatomical support of the pelvis. The ligaments (e.g. uterosacral ligaments) that support the cervix and the vagina are not disrupted. As a result, there is less chance of urinary incontinence and vaginal vault prolapse (the top of the vagina falling down).
- Leaving the cervix intact helps preserve sexual function. No incision is made into the vaginal canal so there is no disruption of the nerve and blood supply to the vaginal cavity. This allows one to return to normal intimacy sooner. However, more recent research shows that there is no difference in sexual function between a supracervical hysterectomy and a total hysterectomy.
- Leaving the cervix intact allows for a quicker postoperative recovery in comparison to the total laparoscopic hysterectomy (TLH). The operating room time is shorter and the time under general anesthesia is less because there is a little less cutting of tissue.
My opinion of the laparoscopic supracervical hysterectomy:
I am a big fan of the laparoscopic supracervical hysterectomy. The laparoscopic supracervical hysterectomy allows you to return to your normal activities sooner and also provides a higher degree patient satisfaction. But you must meet the proper indications for this procedure. The indications include: (a) Your physician has recommend a total abdominal hysterectomy and you are looking for a more minimally invasive option (b) Large fibroid uterus (c) Heavy menstrual cycles and failed medical management (e.g. failed birth control pills / progesterone) (d) Dysfunctional uterine bleeding (DUB) (e) Adenomyosis (f) Failed endometrial ablation (e.g. Novasure, Thermachoice, etc)
Limitations to the laparoscopic supracervical hysterectomy:
Although most hysterectomies can be performed laparoscopically, there are some limitations. For instance, if the size of the uterus is greater than 22 weeks in size, the fundus (the top) of the uterus reaches above the level of the umbilicus (belly button). When the laparoscopic camera is placed through the umbilicus to visualize the pelvis and the uterus, the visualization is poor and the laparoscopic access is challenging. As a result, it would significantly increase the risk of the surgical procedure. As a result,
I would recommend a total abdominal hysterectomy rather than a laparoscopic hysterectomy simply based on patient surgical safety.
What are the contraindications for a laparoscopic supracervical hysterectomy (LSH)?
The laparoscopic supracervical hysterectomy is not for everyone. The contraindications for a LSH include:
- History of abnormal pap smears (e.g. cervical dysplasia)
- History of chronic pelvic pain
- Dyspareunia (pain with intercourse), especially with deep penetration
- Pelvic organ prolapse (e.g. uterine prolapse or bladder prolapse)
- If one does not want to bleed anymore, then the cervix should be removed. With the cervix in place, there is a small chance of vaginal spotting each month.
f you meet any of the criteria above, I would strongly recommend removing the cervix along with the uterus (e.g. total laparoscopic hysterectomy (TLH) or LAVH.)