ADVANCING YOUR PRACTICE

Weigh the pros and cons of LASH
By Susan M. Goldberg, RN, CNOR, BS

Removing the uterus to excise disease or alleviate patients' symptoms isn't a new procedure. This approach to treating female reproductive disorders has been documented since the first successful vaginal hysterectomy was performed in 1813.¹ Currently, hysterectomies are one of the most frequently performed operations in the United States.²

The most common reason to perform a hysterectomy is dysfunctional uterine bleeding (DUB) that doesn't respond to other treatments.³ Other indications include chronic pelvic pain, bleeding that can't be controlled by any other therapeutic measure, an intra-uterine myoma (a fibroid tumor) that causes pain or begins to enlarge, or a malignancy.⁴

Advancing technology
During the early 1900s, surgery to remove the uterus usually left the cervix intact.¹ As surgical techniques improved, a procedure to remove the entire uterus with the cervix was developed and adopted by the majority of gynecologists. In the 1950s, most surgeons continued to remove the cervix with the uterus to prevent the future development of cervical cancer.⁴ Preservation of the cervix was rare.¹ Surgeons also wished to avoid any problems associated with a retained cervix, such as infection or vaginal bleeding that might lead to additional surgery in the future.²

Advances in laparoscopic surgery began to change the way gynecologic symptoms were addressed. Improvements in instrumentation, technique, and fiber optic lighting led to the ability to treat common problems with minimally invasive procedures. For example, a benign uterine polyp that causes heavy bleeding can now be diagnosed and removed via hysteroscopy. Instead of removing the entire uterus, the endometrial lining can be ablated to stop DUB.

Multiple benefits
The advantages of laparoscopic surgery versus an open abdominal procedure are well-known. Laparoscopic surgery is less invasive than an open procedure, minimizes blood loss, and leads to a shorter recovery time frame. Postoperative complications associated with an abdominal incision include the increased possibilities of a surgical site infection, increased pain necessitating more potent analgesic medication with more potential side effects, longer hospital stay, and additional time lost away from work and family.3 Once a woman and her surgeon decide that based on symptoms, a hysterectomy procedure is warranted, the most appropriate procedure will be chosen.

Surgeons are beginning to study the benefits and drawbacks of the different methods of performing a hysterectomy when one is indicated, and the laparoscopic-assisted supracervical hysterectomy (LASH) is demonstrating some advantages over other methods.

LASH procedures
LASH may offer cost savings for the hospital, as well as some advantages for the patients. There's a 30% savings overall when comparing LASH with a total laparoscopic hysterectomy (TLH).⁵ When a hospital begins to offer LASH procedures, there may be an initial expense of purchasing a morcellator, essential to the procedure. Over time, the equipment will recoup its expense.³

Mortality is another consideration when deciding to proceed with a LASH. Data published in 2007 indicates a 2% to 3% mortality for these patients, compared with a 10% mortality for total vaginal hysterectomies and 25% mortality with total abdominal hysterectomies.⁶

The decision to leave or remove the cervix isn't always clear. If a patient wishes to preserve her cervix when the uterus is removed, the surgeon must determine preoperatively whether the cervix is normal or whether it contains disease of any kind. A diseased cervix should be removed during hysterectomy to avoid the potential for future illness or surgery.

Leaving the cervix requires that it appear grossly normal on examination. Cervical papilloma, which are potentially precancerous, can't be present. If malignancy is suspected, there needs to be verification that no malignancy exists within the cervix. This can be achieved with cytologic cervical testing and possibly a lab analysis of endometrial tissue obtained from dilatation and curettage of the uterus.^1,2 A thorough family history should be obtained to determine the potential risk of uterine cancer.

Some studies recommend retaining the cervix if the pelvic floor is weak to provide additional stability.⁶ Other surgeons claim there's no such advantage to leaving the cervix.⁷

Disadvantages
There are some drawbacks to leaving the cervix, even if it's healthy. One is the possibility of adhesions leading to chronic pelvic pain. There could also be cervical bleeding or postoperative infection of the cervical stump due to infection from the cervical canal.³ Any of these circumstances could lead to morbidity or an additional procedure to remove the cervical stump.

A very common argument for a woman to keep her cervix focuses on the possibility of diminished sexual pleasure if it were to be removed. There's no convincing evidence either to support or refute this claim. Studies in the United States and Denmark reported no difference between preoperative and posthysterectomy sexual response, regardless of whether the cervix had been removed or not.² A recent study in Atlanta, Georgia exhibited the same results,⁶ as did a 2-year follow-up of hysterectomy patients in Tucson, Arizona.⁸

However, in another study of 100 women in Barcelona, Spain, in which half underwent TLH and the other half the supracervical procedure, the results differed. The women in the group who didn't have their cervices removed had significantly better clinical outcomes, and stated they felt less castrated than the women who received TLH.⁹

A woman's personal feelings, cultural background, and self-image must be considered when deciding whether to remove the cervix. No data can predict an individual's emotional reaction postoperatively, especially if she has already formed a firm opinion of what will happen. The surgeon is obligated to explain the benefits and risks of leaving or removing the cervix, including the potential for additional future surgery. Agreement can be reached when all of the above factors are reviewed.

Factors to consider
Several factors are pertinent when deciding which hysterectomy technique will achieve the best outcome. Although laparoscopic surgery has many advantages over an open procedure, not all patients are candidates. Adhesions resulting from prior surgery might preclude laparoscopy. The uterus might be too large to be removed via laparoscope. Disease or congenital abnormalities may have distorted the internal anatomy, making trocar insertion dangerous. An open procedure would be the safest choice in these circumstances.

In addition to preserving the vaginal and uretero-sacral ligaments and the cervix, the goals of performing LASH are to minimize blood loss, reduce the size of the incision, and shorten the length of hospital stay. Overall, LASH can result in fewer complications than an open procedure, including adhesions and bladder or ureteral injury.³

The day of surgery
A woman scheduled for a LASH procedure receives preadmission screening, as per hospital protocol. The perioperative nurse would review her chart, and then introduce herself and verify the patient's identity. Information regarding what will happen when the patient enters the OR should be offered, as well as the opportunity for questions or clarifications.

Once the patient enters the OR, she should be introduced to the rest of the surgical team. The atmosphere should be calm and quiet as vital signs are checked and the safety strap placed across the patient. When anesthesia has been administered and the airway is secure, an indwelling urinary catheter is inserted to decompress the bladder. This allows improved visualization of the uterus. Also, any sign of blood in the urinary drainage bag might alert the surgical team to an intraoperative injury to the bladder.

As with many laparoscopic procedures, the abdomen is inflated with CO₂ (pneumoperitoneum) to increase the safety of trocar introduction. The uterus is mobilized and then pulled upward with a monopolar hook. At this point, it has been completely dissected away from the cervix and any ligaments and arteries.³ The cervical canal is coagulated to minimize the introduction of its contents into the field.

The uterus is then removed with the assistance of an electric morcellator. The morcellator allows the uterus to be removed via a trocar site by cutting it into long cylindrical strips that can easily fit through the port. Large amounts of tissue can be extracted at one time, which minimizes operating time. Smaller pieces of tissue can be removed with graspers.

Postoperative care
Hemorrhage is a major postoperative risk after a LASH procedure. Although the surgery is performed via abdominal laparoscopy, PACU nurses must also check the vaginal area (or a peripad if one is in place) for signs of bleeding. BP must be monitored carefully to detect possible internal hemorrhage.

The patient may be allowed to return home the day of surgery or the following day. Discharge instructions include recommendations to rest, maintain her fluid intake, and take analgesics, as necessary.

Return to preoperative activities will vary, depending on the patient's physical condition. The recovery period following the laparoscopic procedure is al-most always shorter and simpler than the recovery following an abdominal incision and an open procedure.

References
1. Munro MG. Uterine surgery: The evolving landscape. Clin Obstet Gynecol. 2006 Dec: 49(4):713–721.
2. Supracervical hysterectomy. ACOG Committee Opinion No. 388. American College of Obstetricians and Gynecologists. November 2007; 110.1215–1217.
3. Bojahr B, Raatz D, Schonleber G, et al. Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique. J Minim Invasive Gynecol. 2006 May-Jun;13(3): 183–189.
4. Hur HC, Guido RS, Mansuria SM, MD, et al. Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. J Minim Invasive Gynecol. 2007;14:311–317.
5. Morin CR, Perez-Villa AMJ, Rodriguez I, et al. Supracervical laparoscopic hysterectomy (SCLH). J Am Assoc Gynecol Laparoscopists. August 1994; 1(4) Part 2: S24.
6. Lyons T. Laparoscopic supracervical versus total hysterectomy. J Min Invasive Gynecol. 2007; 14: 275–277.
7. Rahn DD, Marker AC, Corton MM, et al. Does supracervical hysterectomy provide more support to the vaginal apex than total abdominal hysterectomy? SGS Meeting Papers. Am J Obstet Gynecol. 2007: 650e1-650e4.
8. Kuppermann M, Summitt RL, Varner RE, et al. Sexual functioning after total compared with supracervical hysterectomy: A randomized trial. Obstet Gynecol. 2005; 105:1309–1318.
9. Rene AMJ, Morin C, Rodriguez J, et al. Supra-cervical laparoscopic hysterectomy (LH): A comparative post-operative study. J Am Assoc Gynecol Laparoscopists. August 1994; 1(4) Part 2: S30.

Source: OR Nurse. July 2008.