The AAGL Classification System for Laparoscopic Hysterectomy

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1 February 2000, Vol. 7, No. 1 The Journal of the American Association of Gynecologic Laparoscopists The AAGL Classification System for Laparoscopic Hysterectomy All portions in quotation marks are taken with permission from Munro MG, Parker WH: Classification of laparoscopic hysterectomy. Journal of Obstetrics and Gynecology, Vol. 82(4), , From the Classification Committee of the American Association of Gynecologic Laparoscopists David L. Olive, M.D., William H. Parker, M.D., Jay M. Cooper, M.D., and Ronald L. Levine, M.D. Reich first reported total laparoscopic hysterectomy in Since that time many variations of the procedure have been described, that vary principally by the relative portions of the surgery performed via the vaginal and laparoscopically directed routes. The variations have potential impact on clinical outcomes such as complication rates, and resource utilization outcomes such as the cost of surgical care. In addition, training and credentialing of surgeons may vary depending upon the type of laparoscopic hysterectomy performed. Unfortunately, critical and rigorous evaluation of the technique has been impaired by the varied and inconsistent nomenclature used in the gynecologic literature to describe the spectrum of operations that comprise laparoscopic hysterectomy, including laparoscopically assisted vaginal hysterectomy (LAVH), laparoscopic-directed hysterectomy, laparoscopic hysterectomy and laparoscopicallyassisted hysterectomy. In addition, the rediscovery of subtotal or supracervical hysterectomy and its adaptation to the laparoscopic route has introduced such terms as classic intrafascial Semm hysterectomy (CISH), laparoscopic assisted subtotal hysterectomy (LASH) and others. These procedures, while generally performed under laparoscopic direction, vary both by the amount of dissection performed and by the treatment of the columnar epithelium and the transformation zone of the cervix. These differences may have an impact not only on resource utilization and complications, but also on the long-term incidence of post procedural cervical neoplasia. Such information is important for patients, providers, and health care organizations. A historically useful solution to the problem is the creation of a classification system that is easily reproducible and capable of stratifying cases in a way that allows critical evaluation of procedures performed in different clinical environments by a variety of surgeons. Many attempts have been made to design a classification system for laparoscopic hysterectomy and each has been different in its approach. 2-5 Consequently, the goals of standardized classification have yet to be achieved. The AAGL believes that it is important to develop and support a standard nomenclature for the classification of laparoscopic hysterectomy. The AAGL Classification Committee was charged with designing an acceptable system, or selecting one that has been previously published. The result of the deliberation was the selection of a previously published system 2 accompanied by an abbreviated form of the same system designed for everyday use. The full system, reprinted here with permission, is designed principally for clinical and resource outcomes use by investigators but could be used in whole or in part by practitioners, investigators or provider organizations. It is detailed, From Dallas, Texas (Dr. Olive); Department of Obstetrics and Gynecology, University of California at Los Angeles, California (Dr. Parker); Department of Obstetrics and Gynecology, University of Tucson Health Sciences Center, Tucson, Arizona (Dr. Cooper); and Department of Obstetrics and Gynecology, University of Louisville, Louisville, Kentucky (Dr. Levine). Address reprint requests to the Journal of the American Association of Gynecologic Laparoscopists, E. Florence Avenue, Santa Fe Springs, CA 90670; fax Accepted for publication May 22,

The AAGL CJassification System for Laparoscopic Hysterectomy Olive et aj and, it is hoped, reproducible in a way that should enable investigators to accurately aggregate similar procedures for the

2 The AAGL CJassification System for Laparoscopic Hysterectomy Olive et aj and, it is hoped, reproducible in a way that should enable investigators to accurately aggregate similar procedures for the purpose of clinical and cost outcome studies. It is recognized that its complexity renders it less desirable for routine use by the practicing clinician. For this reason, the abbreviated scheme has been derived from the fully constituted system. As with any health care research or classification system, the collection and analysis of data may reveal that revision of the system is necessary. The AAGL Classification Committee feels that it is important to periodically review each system for its utility, and, if necessary, to modify it to meet the requirements of investigators and clinicians. Goals of Classification A good classification system should allow investigators and clinicians to compare different outcomes among and between the existing types of procedures. In considering the optimal classification system, the following goals were considered to be important: 1. The AAGL classification system should more clearly define what is meant when a laparoscope is included as a tool to accomplish hysterectomy. 2. One generic name should be selected that encompasses all of the hysterectomy procedures performed partly or totally under the guidance of the laparoscope. 3. The system should be linked to clearly defined anatomic landmarks eliminating, as much as possible, subjective interpretation. 4. The system should allow detailed subclassification of the different components of laparoscopic hysterectomy for investigative purposes, but possess the capacity of abbreviation for day-to-day use. The scheme should be specific enough so that as data become available they can be aggregated or stratified as needed to maximize useful information. 5. While it is recognized that certain pathological conditions, by virtue of their type or extent (e.g., leiomyomas, endometriosis) may affect the difficulty of a surgical case, incorporation of such information into the system was not deemed appropriate. Instead, investigators should be encouraged to utilize the system to facilitate evaluation of different types of hysterectomy in specific disease states, or the use of different instrumentation and/or techniques to accomplish the procedure under laparoscopic direction. The Committee's Decision The Classification Committee determined that the term "laparoscopic hysterectomy" should be used to generically describe any total hysterectomy performed in whole or in part under laparoscopic guidance. The abbreviation for laparoscopic hysterectomy would be "LH." In addition, the term "laparoscopic subtotal hysterectomy," "LSH," would be used to describe any procedure where the uterine corpus was removed, with the retention of some of, or the entire cervix. This decision was made over the term "laparoscopic supracervical hysterectomy" because some variants of the procedure remove a substantial portion of the uterine cervix. The committee will recommend to the editorial board that this terminology be required for all papers published in the Journal of the American Association of Gynecologic Laparoscopists. The Laparoscopic Hysterectomy Classification System "The proposed system describes the portion of the procedure completed under laparoscopic direction, with four types of hysterectomies (types I-IV) arranged according to increasing laparoscopic intervention (Table 1, Figure 1). Type "O" denotes those cases where the laparoscope is used solely to visualize the pelvis prior to vaginal hysterectomy or to perform adjuvant procedures like vaporization of endometriosis or adhesiolysis prior to performing vaginal hysterectomy. The anatomic landmarks used to determine the type of hysterectomy performed are the ovarian arteries (either the infundibulopelvic ligament or the "triple pedicle" between the ovary and the uterus), the uterine arteries, and the cardinaluterosacral ligament complex. The required dissection must be accomplished on at least one side. "The complete system further stratifies each type of LH into subgroups by virtue of laparoscopic dissection of the bladder and the posterior cul-de-sac. Subgroup "A" denotes cases limited to the division of the pedicle(s) containing ovarian or uterine _artery(ies). Subgroup "B" indicates dissection of the bladder, and is further substratified (bi-iii) according to the amount of the dissection. Subgroup "C" denotes the performance of a posterior culdotomy. Subgroup "D" refers to dual dissection of the bladder and the performance 10

3 February 2000, Vol. 7, No. 1 The Journal of the American Association of Gynecologic Laparoscopists TABLE 1. Classification System for Laparoscopic Hysterectomy Type 0 Type I* Type I1" Type II1" * Laparoscopic-directed preparation for vaginal hysterectomy Dissection up to but not including uterine arteries Type IA Ovarian artery pedicle(s) only Type IB + I A + anterior structures Type IC I A + posterior culdotomy Type ID + I A + anterior structures and posterior culdotomy Type I + uterine artery occlusion and division, unilateral or bilateral Type IIA Ovarian artery(ies) and uterine artery(ies) occlusion and division only Type lib + II A + anterior structures Type IIC II A + posterior culdotomy Type lid + II A + anterior structures and posterior culdotomy Type II + portion of cardinal-uterosacral ligament complex only, unilateral or bilateral Type IliA Uterine and ovarian artery pedicles with portion of the cardinal-uterosacral complex only, unilateral or bilateral Type IIIB t [11 A + anterior structures Type IIIC III A + posterior culdotomy Type IIID t III A + anterior structures and posterior culdotomy Type II + total cardinal-uterosacral ligament complex, unilateral or bilateral A Uterine and ovarian artery pedicles with complete detachment of the total cardinaluterosacral ligament complex only, unilateral or bilateral Type I VB f IV A + anterior structures C IV A + posterior culdotomy D t IV A + anterior structures and posterior culdotomy E Laparoscopically directed removal of entire uterus The system describes the portion of the procedure completed laparoscopically. * A suffix "o" may be added if unilateral or bilateral oophorectomy is performed concomitantly (e.g., type IoA). 4- The B and D subgroups may be further subclassified according to the degree of dissection involving the bladder and whether an anterior culdotomy is created: (1) incision of vesicouterine peritoneum only, (2) dissection of any portion of bladder from cervix, (3) creation of an anterior culdotomy. (With permission from the Journal of Obstetrics and Gynecology, Vol. 82(4), pp 625). of the posterior culdotomy, with substratification determined by the amount of dissection as for subgroup B. Finally, the subtype "E" is used only in type IV procedures, when the entire uterus is removed under laparoscopic direction. The suffix "o" is used to denote the performance of either unilateral or bilateral _oophorectomy. Type 0 "This type includes those procedures for which the laparoscope is used, for example, to direct the division of adhesions or the surgical treatment of endometriosis before an otherwise standard vaginal hysterectomy. The designation should not be applied if only a diagnostic laparoscopy is performed or if the laparoscopic portion of the procedure does not contribute materially to the hysterectomy. Type I "At least one of the ovarian artery pedicles, the infundibulopelvic ligament o1 the pedicle including the fallopian tube, the round ligament, and the ovarian artery, is occluded and divided under laparoscopic direction. The dissection may be carried farther along the broad ligament but does not include the uterine artery. Subgroups denote dissection of anterior structures related to the bladder, the formation of a posterior culdotomy, or both. "Type IA procedures include unilateral or bilateral occlusion and division of the ovarian artery(ies), either medial or lateral to the ovary(ies), with or without dissection of the adjacent broad ligament under laparoscopic guidance. "Type IB procedures must meet the criteria necessary for type IA and also include dissection of 11

4 The AAGL Classification System for Laparoscopic Hysterectomy Olive et a[ IA IAo : ~ Urger Type! " '% Type!1 ~ -.,,,A Type II! IVA IVAo e.~ o~176 9 IVE - Entire uterus removed *B & D Subgroups % "%... FIGURE 1. Total laparoscopic hysterectomy classification system. Subgrouping is similar for each type. "A" generally refers to major arterial pedicles only; "B" relates to bladder and bladder-associated dissection; "C" always describes posterior culdotomy; "D" denotes a combination of B and C or dual dissection; "E" reflects removal of the entire uterus. *Bladder-related dissection in groups B and D is further classified according to extent: 1. vesicouterine peritoneum, 2. bladder in whole or in part, and 3. anterior culdotomy. (With permission from the Journal of Obstetrics and Gynecology, Vol. 82(4), pp 626). structures located anterior to the uterus. Incision of only the vesicouterine peritoneum constitutes type IB(1), whereas separation of the bladder from the uterus, in whole or in part, is classified as type IB(2). Performance of an anterior culdotomy under laparoscopic direction is a type IB(3) procedure. "Type IC operations also include a posterior culdotomy fashioned from within the peritoneal cavity under laparoscopic direction. "Type ID procedures combine a posterior culdotomy with the anterior dissection of type IB under laparoscopic guidance. The operations are defined as 12

February 2000, Vol. 7, No. 1 TheJournd of the American Association of Gynecologic Laparoscopists in subgroup B, according to the degree of anterior dissection.

5 February 2000, Vol. 7, No. 1 TheJournd of the American Association of Gynecologic Laparoscopists in subgroup B, according to the degree of anterior dissection. Type H "The type II operations follow a classification scheme similar to the class I procedures, with the addition of either unilateral or bilateral occlusion and division of the uterine artery(ies) under laparoscopic direction. Type III "To qualify as a type III procedure, a portion, but not all, of at least one uterosacral-cardinal ligament complex must be dissected from the uterus under laparoscopic direction. The subgroups are defined in a fashion identical to that for types I and II procedures. "The type IV operations differ from type III in that the entire uterosacral-cardinal ligament complex is detached on a least one side under laparoscopic guidance. The remaining subgroups are defined as for the other types except for the addition of type IVE, which describes those instances in which the entire uterus is detached under laparoscopic guidance." The Abbreviated Laparoscopic Hysterectomy Classification System A simplified version of the above classification scheme was designed for practical, everyday use (Table 2). This system eliminates all subtypes from the original scheme, instead breaking down all laparoscopic hysterectomies into five types: Type 0 This is identical to that in the research scheme: use of laparoscopy to perform ancillary dissection of pathology before an otherwise standard vaginal hysterectomy. Type I Occlusion and division of at least one ovarian artery pedicle, either lateral or medial to the ovary, under laparoscopic guidance. Type I does not involve occlusion and division of the uterine artery(ies). Type H The same as type I, with the addition of occlusion and division of the uterine artery, either unilateral or bilateral, under laparoscopic guidance. Type III Type III procedures include dissection of a portion, but not all, of at least one uterosacral-cardinal ligament complex under laparoscopic direction. The type IV operations differ from type III in that the entire uterosacral-cardinal ligament complex is detached on a least one side under laparoscopic guidance. The Laparoscopic Subtotal Hysterectomy (LSH) Classification System "Laparoscopic subtotal hysterectomy (Tables 3 and 4, Figure 2) is distinguished from total hysterectomy by using the abbreviation LSH (e.g., LSH II). The operations are stratified according to the management of the uterine artery(ies), in that it is not necessary to divide the uterine arteries to complete the procedure. Although specifically securing control of the uterine vessels is generally thought to reduce bleeding, procedures have been described without such an approach. Furthermore, it is not clear whether occlusion of the uterine vessels alone, versus occlusion and division differs significantly with regard to operating times or morbidity. Subgroups of LSH are based on management of the cervix in an attempt to determine the potential influence on the subsequent development of cervical neoplasia. If an TABLE 2. Abbreviated Classification System for Laparoscopic Hysterectomy Type O Type I Type II Type III Laparoscopic-directed preparation for vaginal hysterectomy Occlusion and division of at least one ovarian pedicle, but not including uterine artery(ies) Type I plus occlusion and division of the uterine artery, unilateral or bilateral Type II plus a portion of the cardinal-uterosacral ligament complex, unilateral or bilateral Complete detachment of cardinal-uterosacral ligament complex, unilateral or bilateral, with or without entry into the vagina 13

6 The AAGL Classification System for Laparoscopic Hysterectomy Olive et al TABLE 3. Classification System for I aparoscopic Subtotal Hysterectomy Type LSH I* Typ~ LSH II *r Type LSH III *f Occlusion and division of at least one ovarian artery with or without dissection to, but not including, uterine arteries A Without cervical canal excision or ablation B With cervical canal ablation C With cervical canal excision LSH I plus occlusion of uterine artery(ies) LSH II plus division of uterine artery(ies) * A suffix "o" may be added if unilateral or bilateral oophorectomy is performed concomitantly (e.g., type LSH IoA). t Types LSH II and LSH III have subgroups (A, B, and C) in a fashion identical to that for LSH I procedures. (With permission from the Iournal of Obstetrics and Gynecology, Vol. 82(4), pp 627). TABLE 4. Abbreviated Classification System for Laparoscopic Subtotal Hysterectomy Type LSH I* Type LSH II *t Type LSH III *t Occlusion and division of at least one ovarian artery with or without dissection to, but not including, uterine arteries LSH I plus occlusion of uterine artery(ies) LSH II plus division of uterine artery(ies) oophorectomy is performed, the "o" suffix is used as for total hysterectomy (e.g., Type LSH IIo). Type LSH I "The pedicle containing the ovarian artery, either medial or lateral to the ovary, is occluded and divided under laparoscopic direction, unilateral or bilateral. Dissection may continue down to, but does not include, the uterine artery(ies). The subgroups are determined by management of the cervical canal. There is no attempt to excise or ablate the canal in subgroup A procedures. Subgroup B operations include ablation of the canal, usually by means of electrosurgical or laser energy. The canal is totally excised in subgroup C. The method of such excision, and whether it is performed by the vaginal or laparoscopically directed route, is unspecified. Type LSH H "At least one uterine artery is occluded by any of a number of techniques including electrosurgery, staples, surgical clips, or suture ligation under laparoscopic guidance. The subgroups for type LSH II operations are identical to those for type LSH I. Type LSH III "Occlusion and division of at least one uterine artery is necessary. The subgroups for these cases are identical to those for types LSH I and LSH II." Discussion Both laparoscopic hysterectomy and laparoscopic subtotal hysterectomy have the potential to replace more invasive surgery with the benefit of shorter hospital stay and faster recovery. However, to date a number of issues remain unclear regarding complications, cost, and the training required to accomplish this goal. Gynecologists have a responsibility to ensure that these procedures are safe and cost-effective. A standard classification system, used to evaluate the components of the procedure, may help to better define areas of surgical concern. It may become apparent that some of the subgroups do not distinguish a cohort of procedures that are distinct from a morbidity, educational, or economic perspective. On the other hand, important categories may evolve that will require integration into this system. We hope that by monitoring and evaluating what we do, we will continue to improve the care we offer our patients. 14

7 February 2000, Vd. 7, No. 1 The Journal of the American Association of Gynecologic Laparoscopists Type ST I Type ST!! - /.J,...-" Ligature 9 ]/ / [ 9 Ureter Type ST!11 Sub-Groups A B C FIGURE 2. Subtotal laparoscopic hysterectomy classification system. This classification is based on treatment of the uterine artery, with subgroups determined by management of the cervical canal. In type I, neither uterine artery is taken; for type II, at least unilateral occlusion is performed without division; type III cases require that at least one uterine artery is divided. Subgroup A cases have no treatment of the cervical canal; ablation is performed in subgroup B; excision of the entire canal is necessary to be classified as subgroup C. (With permission from the Journal of Obstetrics and Gynecology, Vol. 82(4), pp 627). Copies of the AAGL classification system for laparoscopic hysterectomy may be obtained by sending $2.00 per reprint to the Journal of the AAGL, E. Florence Avenue, Santa Fe Springs, CA References 1. Reich H, DeCaprio J, McGlynn F: Laparoscopic hysterectomy. J Gynecol Surg 5: , Munro MG, Parker WH: Classification of laparoscopic hysterectomy9 Obstet Gynecol 82: , Garry R, Reich H, Liu CY: Laparoscopic hysterectomy-- Definitions and indications [editorial]. Gynaecol Endosc 3:1-3, Johns DA, Diamond MP: Laparoscopically assisted vaginal hysterectomy. J Reprod Med 39: , Kesteloot K, Deprest J, Depratere R, et al: A comparison of hospital costs for laparoscopic, abdominal and vaginal hysterectomies in Belgium. American Association of Gynecologic Laparoscopists, abstract book, San Francisco, November 10-14, 1993, p

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