Although laparoscopic hysterectomy offers a minimally invasive alternative to laparotomy when vaginal hysterectomy is contraindicated, it has its drawbacks. Among them: the cost of expensive equipment, the long learning curve, and prolonged operating time.
We describe another alternative to open surgery that is comparable to laparoscopic hysterectomy in postoperative pain, cosmetic results, and time to return to normal activities. Our procedure—a redesigned minilaparotomy hysterectomy—relies on traditional open techniques and inexpensive novel instrumentation, making it significantly faster than laparoscopy and easy to perform and teach.
For patients who cannot undergo vaginal hysterectomy, this new modality offers an expeditious, minimal-access option. Gynecologists reluctant to relinquish the routine use of standard laparotomy may find this approach an appealing, less-invasive alternative.
Position, incision, and retraction are crucial to success
Our minilaparotomy hysterectomy is a systemized approach with elements derived from both open and laparoscopic surgery. Three preparatory components are involved:
- position
- incision
- retraction
All are critical to a successful hysterectomy, ensuring that the procedure never becomes a haphazard struggle through an improvised, scaled-down, conventional Pfannenstiel or vertical incision. Our approach also avoids cumbersome traditional laparotomy exposure maneuvers and positioning.
Position: Modified lithotomy. After regional or general anesthesia is given, position the patient in a modified lithotomy with both arms tucked as for laparoscopic surgery. Place the legs in boot-type stirrups, with no hip flexion and sufficient thigh abduction to expose the vagina.
Next, perform a thorough pelvic examination and place an indwelling, transurethral catheter. A sturdy, hinged uterine manipulator is of paramount importance for the hysterectomy, as it facilitates exposure of the adnexa as well as elevation/rotation of the uterus and the uterine attachments. We recommend the Pelosi Uterine Manipulator (Apple Medical Corporation, Marlboro, Mass) or its equivalent (FIGURE 1).
Development of the Pelosi minilaparotomy hysterectomy technique
Standard minilaparotomy
The use of standard minilaparotomy—which is nothing more than a conventional laparotomy of limited length (3 cm to 6 cm), performed either transversely or vertically—has been confined to the surgical treatment of benign pelvic pathology of limited extent.
To generate sufficient exposure to work effectively, surgeons using the standard minilaparotomy have relied on the length of the abdominal incision and, secondarily, bowel packing and metal handheld or self-retaining fixed retraction systems. When exposure is difficult to achieve or maintain, however, routine surgical maneuvers become frustrating and time-consuming—unless the clinician uses extensive traction force, extends the incision length, or performs muscle-splitting. These alternatives often result in an uncomfortable, slow recovery typical of most laparotomies, thereby negating the primary goal of minimally invasive surgery.
Use of traditional minilaparotomy for hysterectomy has been reported only rarely. Hoffman et al1 found the procedure safe and effective in nonobese women in whom a vaginal approach was precluded. Benedetti Panicci et al2,3 also have used minilaparotomy successfully in benign gynecologic disease and hysterectomy.
The Kustner incision
Originally reported in 1896,4 this incision is avoided by most surgeons in favor of complete transverse or complete vertical incisions—largely due to difficulties with exposure, troublesome seroma formation, and wound complications secondary to increased fluid accumulation in the large dead space that results from wide dissection of the subcutaneous flap.
In the early 1990s, we realized the potential benefits of a scaled-down Kustner’s incision (2 cm to 5 cm) when assistance was needed via minilaparotomy during such laparoscopic-assisted procedures as uterine morcellation, tubal reanastomosis, and extensive uterine suture and reconstruction following complex laparoscopic myomectomy.5 As a substitute for laparoscopy and laparotomy, we then tried a minilaparotomy Kustner’s incision (3 cm to 5 cm) as the sole means of surgical access, assessment, and treatment for benign pelvic conditions.
Benefits of this incision. When a sturdy uterine manipulator was used to facilitate exposure of the adnexa and uterine elevation/rotation, we found this technique more effective than similar procedures using a scaled-down Pfannenstiel or Maylard incision. In addition, because the incision was small and the extent of subcutaneous dissection required to expose the rectus fascia in a vertical fashion was limited, there was no need for incision drainage. Nor was the procedure associated with seroma formation, as the full-sized Kustner’s incision had been.3 However, the minilaparotomy Kustner’s incision still suffered from limited surgical exposure.
Adding the retractor
It became clear that a soft, self-retaining abdominal retractor that is capable of creating a rapid, effective, nontraumatic, and predictable circular area of abdominal retraction would be helpful, particularly one that could be placed through the minilaparotomy Kustner’s incision.6 Once this retractor system was developed, using technology borrowed from hand-assisted laparoscopy,7-10 the minilaparotomy hysterectomy became a much simpler, more useful surgical option.
REFERENCES
1. Hoffman MS, Lynch CM. Minilaparotomy hysterectomy. Am J Obstet Gynecol. 1998;179:316-320.
2. Benedetti Panicci P, Maneschi F, Cutillo G, et al. Surgery by minilaparotomy in benign gynecologic disease. Obstet Gynecol. 1996;87:456-459.
3. Benedetti Panicci P, Zullo MA, Casalino B, et al. Subcutaneous drainage versus no drainage after minilaparotomy in gynecologic benign conditions. Am J Obstet Gynecol. 2003;188:71-75.
4. Kustner O. Der suprasymphysare kruzschnitt, eine methode der coeliotomie bei wening umfanglichen affektionen der weiblichen beckenorgane. Monatsschr Geburtshilfe Gynakol. 1896;4:197-206.
5. Pelosi MA, II, Pelosi MA, III. The suprapubic cruciate incision for laparoscopic assisted microceliotomy. J Soc Laparoendosc Surg. 1997;1:269-272.
6. Pelosi MA, II, Pelosi MA, III. Self-retaining abdominal retractor for minilaparotomy. Obstet Gynecol. 2000;96:775-778.
7. Pelosi MA, II, Pelosi MA, III. Hand-assisted laparoscopy for complex hysterectomy. J Am Assoc Gynecol Laparosc. 1999;6:183-188.
8. Pelosi MA, II, Pelosi MA, III. Hand-assisted laparoscopic cholecystectomy at cesarean section. J Am Assoc Gynecol Laparosc. 1999;6:491-495.
9. Pelosi MA, II, Pelosi MA, III. Hand-assisted laparoscopy (handoscopy) for megamyomectomy: A case study. J Reprod Med. 2000;45:519-525.
10. Pelosi MA, II, Pelosi MA, III, Eim J. Hand-assisted laparoscopy for pelvic malignancy. J Laparoendosc Adv Surg Tech. 2000;10:143-150.