Total laparoscopic intrafascial hysterectomy
Authors: Lee P. I. 
Published: November 2003

Objectives

To evaluate the efficacy of a new technique, total laparoscopic intrafascial hysterectomy (TLIH) and investigate whether there are any advantages of TLIH over total laparoscopic hysterectomy (TLH) which included laparoscopically assisted vaginal hysterectomy (LAVH) and laparoscopic hysterectomy (LH).

Design

A retrospective chart review was conducted on all cases of TLIH (n = 112) and TLH (n = 72) performed between January 1 1995 and September 30 1995, and 86 cases of TLIH performed during the following 6 months from October 1 1995 to March 31 1996, at the Jeil Womens' Hospital, Seoul, Korea. All the procedures were performed utilizing electrocautery and/or suture ligature. The upper pedicles (round and infundibulo pelvic or utero‐ovarian ligaments) were treated in the usual manner, and the uterine artery was cut either at the level of the internal os of the cervix or immediately after its bifurcation from the hypogastric artery, depending upon the size of the uterus or pelvic side‐wall pathology such as severe endometriosis and chronic pelvic inflammatory disease. The cervix was circumcized intrafascially at the level of the internal os of the cervix, preserving the entire uterosacral and cardinal ligament complex and full length of the vagina. The vagina was closed either vertically or transversally and a modified McCall culdoplasty was also performed if necessary.

Results

There were no differences concerning patient characteristics and indications for surgery. Average uterine weight was slightly lower for the TLIH than the TLH patients (193.1 ± 96.2 vs. 237.4 ± 84.5 g). Among the TLIH patients there were 33 cases (29.46%) who had undergone previous surgery and 35 cases (31.25%) in whom moderate to severe concurrent pelvic endometriosis, was found during surgery besides the primary diagnosis, compared with 12 cases each (16.67%) in the TLH cases. Operation time was shorter with TLIH (117.6 ± 38.2 min) compared with TLH (134.9 ± 37.4 min). Less bleeding, less damage to the genitourinary tract and less granulation tissue formation occurred with TLIH compared with TLH. With respect to the TLIH cases, during the second review period there were more cases with previous surgery (39.53%) and with concurrent pelvic endometriosis (37.21%), the average uterine weight was greater (254.1 ± 82.5 g). However, the operation time was shorter in the second review period group compared with the first (109.2 ± 35.3 vs. 117.6 ± 38.2 min).

Conclusion

TLIH can be performed faster and more safely than TLH by an experienced surgeon. Fewer complications occurred with TLIH compared with TLH because surgery can be done more precisely under direct vision. TLIH has all the benefits of both laparoscopic total and subtotal hysterectomy with the advantage of lengthening of the vagina, fewer pelvic floor defects and fewer complications, such as damage to the urinary tract and granulation tissue formation on the vaginal cuff, and there is definitely no fear of cancer development on the cervical stump postoperatively. However, these issues warrant further long‐term follow‐up evaluation, with a randomized prospective study on a large scale.