Well over 95% of the conditions that warrant hysterectomy do not require removal of the cervix. The only absolute pathologies that mandate cervical removal are invasive cervical cancer and endometrial cancer. Using a standardised technique, with reasonable individual surgeon differences, the laparoscopic supracervical hysterectomy (LSH or LASH) procedure can be used safely. The most common reported morbidity is recurrent cyclic bleeding (incidence ranging from 1 to 25% depending upon the study). Our experience suggests that this is a technical issue and a problem not with the operation but rather with the operator. However, where a long intravaginal portion of cervix presents, some residual endometrium may be left. To this end HRT should be used with caution and may require additional progestogens or the equivalent, with all of the attendant complications that may ensue. Urinary tract injury (the most common major injury reported in pelvic surgery) is extremely rare in supracervical hysterectomy. Urinary tract infection is very unlikely. When examined in randomised control trials (Thakar et al. N Engl J Med 2002;347:1318–25) there has been no evidence that the total approach is superior to the subtotal approach with regard to morbidity factors. Studies have demonstrated clearly that the supracervical approach remains an economically sound alternative with a similar procedural cost. The shortened post-operative recovery period with LSH resulted in decreased overall cost compared with total hysterectomy and even in comparison with endometrial ablation. Nainani et al. (J Minim Invas Gynecol 2005;12:20–1) further demonstrated significant intangible cost savings with a rapid return to normal activity and job performance, and the eVALuate trial (2004) in the UK demonstrated similar findings (unpublished data). The versatility, reliability, safety, and effectiveness have been demonstrated in a series of over 1500 procedures over 14 years. Conditions treated included uterine fibroids (up to 2800 g), severe endometriosis, severe adhesive disease, and pelvic floor relaxation. The average duration of stay was 8.5 hours and return to work was achieved in 7–10 days. Febrile morbidity was <1%, transfusion rate 0%, re-operation rate <0.001%, and cyclic bleeding occurred in <1%. Similar experiences by other surgeons have been reported. There are randomised controlled trials comparing subtotal hysterectomy to total hysterectomy (Thakar et al. N Eng J Med 2002; 347:1318–26; Engh et al. Acta Obstet Gynecol Scand 2010;89:65–70). In all of these studies no statistically significant differences were noted between the two groups, although some superiority in recovery was noted in the LSH groups. These studies, therefore, don't in any way prove that a patient should have their cervix removed. Many studies have demonstrated the efficacy of LSH and the superiority of this technique over TLH, LAVH, TAH, and TVH, and many have demonstrated the superiority of LSH in one or more of the areas in question, i.e. efficacy, versatility, safety, efficiency, and cost effectiveness. When the classic data of Dicker et al. is compared with current data on LSH from Lyons, the clear advantage over the abdominal approach in particular is seen. For TAH the morbidity was 25% and the mortality ×10. For TVH the morbidity was 10%, and mortality ×1. For LSH (in current data) the morbidity was 2–3%, and mortality 0. Difficult pelvic floor support procedures such as sacral culpopexy have been demonstrated to have lower morbidity when the vaginal vault remains closed, thus demonstrating further versatility of the LSH procedure. My goal in developing LSH has been to provide a choice for patients, with a technique that could be performed by the majority of gynaecological surgeons in order to provide a lower morbidity alternative to abdominal hysterectomy. On all counts, LSH accomplishes this task. For that reason I believe that LSH should be the standard for hysterectomy in patients without indications for cervical removal. None to declare.
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Jan 1, 2016
Helen Jefferis + 2
Open Access
