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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.
Comparing
procedures
When three laparoscopic techniques for removing the uterus
were compared in several studies, the LASH received the
highest recommendations.2,3,6,8,9 The other two
procedures studied were laparoscopic-assisted vaginal hysterectomy
(LAVH) and TLH. The studies indicated that for certain gynecologic
disorders, LASH offers low morbidity, has a lower complication
rate than LAVH, and requires the shortest operating time
of the three procedures.3 The risk of intraoperative injuries
to the bladder, ureters, and intestines is also lower.
A TLH may be a more technically
difficult case than a LASH, leading to longer operative
times.6 However, laparoscopic surgery isn't without risk;
if any complications occur intraoperatively, the procedure
might be converted to open surgery, especially if there's
uncontrolled bleeding.
A 2006 study of 1,706 LASH
cases found conversion necessary in only 14 cases (0.82%).3
These conversions were necessitated by dense adhesions,
by the size and immobility of the uterus, or because of
intraoperative complications.
Overall, the advantages of
LASH include shorter operating time, minimal bleeding, fewer
risks of complications, quicker recovery, lower mortality,
and for some patients, the positive psychological impact
of retaining the cervix. Although this procedure isn't an
option for all women requiring a hysterectomy, there are
many reasons to recommend it to appropriate candidates.
As long as there's a thorough preoperative screening as
well as an in-depth discussion of the pros and cons of leaving
the cervix in place, the LASH procedure deserves strong
consideration as a surgical option.
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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.
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