Efficacy of laparoscopic subtotal hysterectomy in the management of menorrhagia: 400 consecutive cases

Transcription

1 DOI: /j x Gynaecological surgery Efficacy of laparoscopic subtotal hysterectomy in the management of menorrhagia: 400 consecutive cases J Erian, M Hassan, A Pachydakis, S Chandakas, I Wissa, N Hill Minimal Access Surgery unit, Department of Obstetrics and Gynaecology, Princess Royal University Hospital, Orpington, Kent, UK Correspondence: Professor J Erian, Minimal Access Surgery unit, Department of Obstetrics and Gynaecology, Princess Royal University Hospital, Orpington, Kent BR6 8ND, UK. john.erian@bromleyhospitals.nhs.uk Accepted 28 January Study objective To assess the safety and patient satisfaction of laparoscopic subtotal hysterectomy (LSH) using a standardised surgical technique. Design Prospective observational study. Setting Princess Royal University Hospital, Chelsfield Park Hospital and Sloane Hospital, Kent, UK. Patients and materials Four hundred consecutive women with menorrhagia underwent LSH. The procedure was performed using the Plasma Kinetic Bipolar Diathermy (Gyrus International Ltd, Berkshire, UK) for pedicle ligation and the Lap Loop system (Roberts Surgical Healthcare Ltd, Kidderminster, UK) to detach the cervix. An electromechanical morcellator (Morcellex; Ethicon Women s Health and Urology, Cincinnati, OH, USA) was used to remove the uterus from the abdominal cavity. Main outcome measures Patient satisfaction, morbidity rates and readmission rates. Results A total of 400 LSH were performed between February 2003 and November The principal clinical indication for hysterectomy was menorrhagia. The mean duration of surgery was 46.4 minutes. The mean operative blood loss was 126 ml. Concurrent surgery was performed in 141 women. Minor and major perioperative complications were encountered in 5% (n = 20) of women. The major complication rate was 1.2% (n = 5): three women (0.75%) with bladder perforation, two women (0.5%) with bowel injury and one woman (0.25%) with a vesicocervical fistula. Eight women (2%) suffered from cyclical vaginal bleeding postoperatively. Conclusions LSH is a safe and effective treatment for menorrhagia and other menstrual disorders when hysterectomy is indicated. Women appreciate the quick recovery period, reduced time off work and faster return to normal activity. Our data suggest that LSH can replace abdominal hysterectomy in selected cases. Keywords Laparoscopy, menorrhagia, subtotal hysterectomy. Please cite this paper as: Erian J, Hassan M, Pachydakis A, Chandakas S, Wissa I, Hill N. Efficacy of laparoscopic subtotal hysterectomy in the management of menorrhagia: 400 consecutive cases. BJOG 2008;115: Introduction Hysterectomy is one of the most commonly performed major surgical procedures with approximately operations performed in the UK each year. Traditionally, hysterectomy is performed using either the abdominal or the vaginal route. More recently, the laparoscopic technique has been used. 1 The laparoscopic approach for hysterectomy is an attractive and safe procedure for the management of benign gynaecological conditions. In particular, the laparoscopic subtotal hysterectomy (LSH) is associated with fewer complications and a more favourable outcome to women. However, the safety of the technique relies on the surgeon s experience, the ability to deal with laparoscopic complications as well as the availability of high technology equipment. 2 In a prospective randomised trial of endometrial ablation versus LSH, Zupi et al. concluded that for the treatment of menorrhagia, hysterectomy has the distinct advantage of being curative, but the disadvantage of being more invasive than hysteroscopic treatment. Patient satisfaction was higher in the LSH group, and surgical complications were not statistically different between the two groups. LSH preserved the curative effect of hysterectomy without the disadvantages of a laparotomy. 3 The first LSH was performed at the Princess Royal University Hospital in 2000, and the first 100 cases have 742 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

2 Laparoscopic subtotal hysterectomy previously been reported in This series of 400 consecutive LSH focuses on the complication rates and on the patient acceptability. Materials and methods Primary outcomes This prospective study was conducted to assess the patient satisfaction. Secondary outcomes Morbidity rates and readmission rates observed in 400 consecutive procedures. Inclusion criteria In this prospective study, from 2003 through 2006, 400 women planning to have LSH were recruited. Indications for LSH were different forms of menstrual disorder including menorrhagia resistant to medical treatment, dysfunctional uterine bleeding not responding to hormonal treatment, known symptomatic myomas or failed previous endometrial ablation (Figure 1). Exclusion criteria Abnormal cervical smear, endometrial hyperplasia, suspected endometrial carcinoma, suspicious adnexal mass, uterine prolapse and uterus clinically estimated to be larger than 20 weeks size. Previous pelvic surgery including caesarean sections, myomectomies, endometriosis surgery and midline incisions were not regarded as contraindications. All women included in the study were reviewed in the gynaecological outpatients clinic, fully counselled about the possible therapeutic options and given written information regarding the procedure and the alternative options. A transvaginal ultrasound scan was performed to confirm uterine size as well as the presence, size and location of any uterine or ovarian lesion. Clinical examination was performed to assess suitability for laparoscopic surgery and point of entry (intraumbilical or Palmer s point). A local anaesthetic hysteroscopy or pipelle endometrial biopsy was performed to ensure that the endometrium was normal before LSH was 39% 25% 1% 35% Figure 1. Previous treatment before LSH. 24% 11% Ablation Medical Hormone replacement therapy Hormonal Mirena performed. Informed consent was obtained from all women prior to the procedure in accordance with our local audit and the Royal College of Obstetricians and Gynaecologists guidelines, and the risks of infection, bleeding, anaesthetic, bowel or bladder injury, injury to vessels, thrombotic episode, haematoma, fistula and return to theatre were explained. Surgical technique All procedures were performed under general anaesthesia with the woman in the Lloyd-Davies position. Patient preparation included indwelling bladder catheterisation and placement of a Pelosi uterine manipulator (Apple Inc, Marlborough, MA, USA). The procedure was performed (as previously described by Erian et al.) 4 through a four-port operative laparoscopy: a 10-mm umbilical port for the camera, two 5-mm lateral ports and a suprapubic 12-mm port for the placement of the lap loop and the morcellator. The laparoscopic steps included coagulation and transection of the adnexae and the round ligament from the uterus. The broad ligament and uterovesical peritoneum were dissected with minimal downward displacement of the bladder. Coagulation of the uterine pedicles without transection followed. Dissection and haemostasis of all the pedicles was achieved using the Plasma Kinetic (PK) system (Gyrus International Ltd, Berkshire, UK). This system is composed of a PK generator, which delivers intermittent pulses of bipolar energy and automatically monitors tissue impedance to the current to adjust power levels, a 5-mm disposable PK laparoscopic bipolar cutting forceps (45 cm) designed with serrated jaws to grasp, coagulate and cut vascular pedicles and a reusable PK style connector cable. Supracervical separation of the uterus was performed using the Lap Loop system (Roberts Surgical Healthcare Ltd, Kidderminster, UK) after removal of the uterine manipulator. The uterus was then morcellated by drawing the specimen into the morcellator (Ethicon Women s Health and Urology, Cincinnati, OH, USA) while the trocar was stabilised by the assistant. The tip of the rotating electromechanical morcellator was always kept within 2 cm of the lower abdominal wall. The morcellator was advanced into the abdominal cavity for a short distance and the uterus was morcellated under direct vision to avoid inadvertent injury to the surrounding structures. After morcellation was completed, the peritoneal cavity was cleared of any collected blood and fragments of myometrium by irrigation with physiological saline solution followed by suction. Finally, the laparoscopic instruments and trocars were removed under direct vision, and the suprapubic port site was closed with a J-shape needle before deflation of the pneumoperitoneum. The women were discharged 8 10 hours postoperatively after having the Folley s catheter and drain removed after 4 hours. The women were advised to call the 24-hour nurseled helpline service if they experienced any symptoms. ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 743

3 J Erian et al. The main outcome measures were operative time, complication rates, intraoperative blood loss and readmission rates. The operative time was calculated from the introduction of the CO 2 pneumoperitoneum until the closure of the laparoscopic ports. The intraoperative blood loss was estimated from the volume of blood collected by suction before pelvic irrigation. The study was performed as a continuous prospective audit of clinical practice after obtaining research and development committee approval. Participants were reassured of the adherence to the Data Protection Act 1998 and informed that only anonymised information would be disclosed within a research and publication context. Follow up All women were reviewed in the outpatient clinic 12 weeks postoperatively. At follow up, they had a symptoms review, enquiring about return to regular activity and work and resumption of sexual activity. Abdominal examination was performed, and emphasis was placed on the importance of continuous cervical screening. Results A total of 400 LSH were performed in the period from February 2003 to December Patients demographic characteristics, previous abdominopelvic surgery, indication for hysterectomy and operative variables are outlined in Table 1. Patient characteristics The principal clinical indication for hysterectomy was menorrhagia (96% of women). In addition to menorrhagia, 85% of women complained of dysmenorrhoea, 11% of dyspareunia, 8.5% of pelvic pain and 6% perimenopausal bleeding without endometrial pathology. On preoperative clinical examination, 79.5% of women had uterine size equivalent to 6 12 weeks size and 20.5% had >12 weeks size. 42.7% of women had fibroids identified on ultrasound scan. Procedure characteristics Concomitant surgery was carried out in 35.25% (n = 141) of women (Table 1) % (n = 81) of women had bilateral salpingo-oophorectomy, 10.5% (n = 42) had unilateral salpingo-oophorectomy, 3% (n = 12) had adhesiolysis, 0.5% (n = 2) had ovarian cystectomy, while 0.05% (n =2)of women had pelvic endometriosis treatment using the Helica Thermablator (Helica Instruments Ltd, Edinburgh, UK). The mean duration of surgery was 46.4 minutes (SD 16.1, median 42 minutes). The Spearman s correlation coefficient between uterine weight and duration of surgery was calculated, r = (P < 0.05), showing a weak positive correlation between the uterine size and the duration of the procedure (Figure 2). Table 1. Patients characteristics Mean (SD) Median Age, years 45.2 (6.2) 45 (26 68) Parity 2 (1.2) 2 (0 4) Body mass index, kg/m (4.2) 28 (18 42) Previous pelvic surgery, n 174 Duration of symptoms, years 4 (3) 3 (1 16) Previous treatment n (%) Medical hormonal 171 (42.7) Mirena intra-uterine system 39 (9.7) Endometrial ablation/resection 48 (12) Preoperative examination n (%) of the uterus Uterine size on pelvic examination 6 12 weeks 318 (79.5).12 weeks 82 (20.5) Fibroids on ultrasound scan 171 (42.7) Indication for LSH n (%) Menorrhagia/dysfunctional 400 (100) uterine bleeding Dysmenorrhoea 340 (85) Pelvic pain 34 (8.5) Dyspareunia 44 (11) Perimenopausal bleeding 24 (6) without endometrial pathology Operative variable Mean (SD) Median Weight of uterus (g) 138 (76) 119 (21 383) Operative time (minutes) 46.4 (16.1) 42 (15 90) Estimated blood loss (ml) 126 (116) 100 (20 900) Previous pelvic surgery n Laparoscopy plus treatment 69 of endometriosis Laparoscopic ovarian cystectomy 21 Laparoscopic sterilisation 63 Caesarean section (one or more) 58 Others 43 Concomitant surgery n Bilateral salpingo-oophorectomy 81 Unilateral salpingo-oophorectomy 42 Pelvic adhesiolysis 12 Ovarian cystectomy 3 Cystoscopy 2 However, such a correlation was not shown between uterine size and blood loss (correlation coefficient r = 0.28 [ no correlation]) (Figure 3). The mean operative blood loss was 126 ml (range ml; SD 116, median 100 ml). Two hundred and ninety-nine cases (74.7%) were performed as a day case (less than 12 hours stay), which represents all the cases performed in the NHS setting. 1.5% of women (n = 6) required overnight admission. One hundred and one cases were performed in the private sector and were planned to stay for 1 or 2 days in the hospital because of patient s choice. 744 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

4 Laparoscopic subtotal hysterectomy Minutes Grams Figure 2. Spearman s correlation coefficient between uterine weight and duration of surgery. Complications Two women required a transfusion because of preoperative anaemia due to menorrhagia (Table 2). No women required postoperative transfusion due to excessive blood loss. No women returned to theatre because of postoperative bleeding complications. One woman had port-site bleeding in the first postoperative day, which was controlled with suturing under local anaesthetic infiltration. Three women (0.75%) sustained bladder entry that was repaired laparoscopically. All these women had multiple caesarean sections that were not considered a contraindication. Two of these women had four previous caesarean sections and one had three previous caesarean sections. Following a change in the technique of bladder dissection (each operator reflecting one side of bladder), there have been no bladder injuries. A follow-up cystogram was normal in all women. Bowel injury occurred in 0.5% (n = 2) of the cases. One was recognised intraoperatively. This was in a woman who suffered a tear in the serosal layer of the sigmoid colon as a result of trocar insertion injury, which was repaired laparoscopically using interrupted 2-0 Vicryl and made an uneventful recovery. The second woman was readmitted with abdominal pain and distension 10 days postoperatively. Clinically, the impression was of bowel perforation; therefore, a laparotomy was performed. A 3-mm hole was found in the small bowel, which was repaired. The woman made a complete recovery. One woman was readmitted after hospital discharge because of transient intestinal ileus that was managed conservatively. Seven women (1.7%) suffered from postoperative infection; all seven women were managed expectantly successfully, three of these were readmitted for intravenous antibiotic treatment. Four women (1%) had urinary tract infection between the first and the second postoperative weeks, which was treated with oral antibiotics. A vesicocervical fistula occurred on a woman in whom a large loop excision transformation zone (LLETZ) was performed at the time of LSH. This woman experienced urinary leakage 2 weeks after surgery. After urology review, the woman underwent a surgical excision of the cervical stump and primary repair of the fistula vaginally. The overall major complication rate in all women was 1.5% (6/400) including three bladder injuries, two bowel injuries and one fistula. Eight women (2%) suffered from cyclical vaginal bleeding for variable duration postoperatively. Five of these women needed removal of the cervix because of persistence of symptoms. This was performed laparoscopically. On histopathological examination of the 400 specimens, leiomyomata was the most common tissue diagnosis in Figure 3. Correlation between uterine weight and blood loss. ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 745

5 J Erian et al. Table 2. Complications and readmission Perioperative Bleeding 1 Bladder injury 2 Bowel injury 2 Vascular injury 0 Unintended laparotomy 0 Late postoperative Pelvic infection 7 Urinary tract infection 4 Anaemia (needed transfusion) 2 Bleeding from port site 1 Subacute intestinal obstruction 1 (readmitted) Fistula 1 Laparotomy 1 Cyclical vaginal bleeding 8 Readmission % of the cases, adenomyosis in 21.5% of cases and both conditions in 6.7% of cases. Endometrial hyperplasia without cytological atypia was detected in one specimen. The mean weight of uteri was 138 g (range g; SD 76, median 119 g). Follow up All women had attended a follow-up appointment at 12 weeks after surgery. None of the women experienced tenderness on abdominal examination. Ninety-eight percent of women were satisfied with the operation, and the same number would recommend this procedure to a friend. The mean time to return to work was 2 weeks. The short recovery time and reduced time off work have been the most common advantages highlighted by the women. The majority of women resumed sexual activity in 3 4 weeks after surgery. As a long-term follow up, all the women are going to have a 2-year follow up as well as quality-of-life questionnaire. A follow up of cases performed till the end of year 2005 is under way. Discussion Since Harry Reich first described total laparoscopic hysterectomy in 1988, the use of laparoscopic hysterectomy as an alternative to abdominal hysterectomy is increasingly being reported. 5 However, over two-thirds of hysterectomies performed in the UK are still performed through the abdominal route. 4 The laparoscopic approach for hysterectomy in its different forms is an attractive and safe procedure for the management of benign gynaecological conditions. In particular, the LSH approach is safe, well tolerated by women, with relatively shorter theatre time and minimum complications. It is associated with a shorter hospital stay and an early return to normal activity and work. The recent National Institute for Clinical Excellence guideline is advocating vaginal hysterectomy as the most cost-effective procedure for menorrhagia. However, LSH allows earlier return to work, thus reducing disability, replacement worker and lost productivity costs, which may actually make it more efficient. The preferred method of laparoscopic hysterectomy will depend on various factors, such as the indication for surgery, associated comorbidity, surgeon s experience, the ability to deal with laparoscopic complications and availability of equipment and technology. 2,5 Preoperative clinical assessment to decide feasibility of laparoscopic surgery according to surgeon s experience and route of entry is important. This cannot be replaced by any imaging modality as the scan is a dynamic investigation heavily related to the operator s perception, and the human pelvis shows great variation in shape and therefore operating space. To the best of our knowledge, this is the largest series of LSH using this technique: the PK and the Lap Loop systems as well as the use of electromechanical morcellator. Owing to this technique, the rate of complications is low and compares favourably with other studies. 6 The introduction and use of the new PK vessel-sealing system have minimised to a great extent one of the major complications: the intraoperative or postoperative haemorrhage, which can result from unsecured ovarian or uterine blood vessels. The PK vessel-sealing system has the ability to seal vessels up to 7 mm in diameter and causes minimal lateral thermal spread ranging from 1.5 to 3 mm depending on the vessel size. 7 Also, it eliminates the need for using laparoscopic scissors or changing instruments, 8 which significantly reduces operating time. The use of the Lap Loop system allows safe, fast transection of the uterus from the cervix. 9 To enhance safety, a large portion of the loop is electrically isolated and the loop retracts back into the introducer as cutting proceeds to further reduce the risk of damage to adjacent organs. In addition, the loop system allows the supracervical separation of the uterus at or above the level of the coagulated uterine vessels, therefore minimising the risk of slippage or retraction of the vessels. 4 The lap loop eliminates the disadvantage of using straight rigid laparoscopic instruments to detach the uterus from the cervix regardless of the uterine size, and therefore, it is preferable. 9 The use of electromechanical morcellators has revolutionised the laparoscopic removal of the uterus. The X-Tract Morcellator, distributed by Ethicon Women s Health and Urology, consists of a motor drive and a disposable morcellator with a cutting blade 15 mm in diameter. The disposable morcellator used in the study is a quick system, provides a significant saving in operating theatre time (the capacity 746 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

6 Laparoscopic subtotal hysterectomy of morcellator is 15 g/minute). For safety, the morcellator was only inserted through the midline into the abdominal cavity for a short distance and the uterus was drawn into the morcellator under direct vision to avoid injury to the surrounding structures. The tip of the rotating electromechanical morcellator was always kept within 2 cm of the lower abdominal wall. 2,4 The morcellator was equipped with a blade guard that further reduced the risk of injuries. In our series, we had no morcellation-related visceral injury. In our series, the size of the uterus showed only a weak (0.70 > r = > 0.30) correlation with the duration of surgery, and this is reflecting the effect of the new technology in the procedure characteristics. This weak correlation was attributed to the duration of morcellation. As this is not the case in open surgery, one might advocate that for uterine sizes were laparoscopic surgery is feasible then this may be the preferred route since the blood loss is not correlated with the uterine size (0 < r = 0.28 < 0.30). This again is reflecting the operator s experience and the quality of the technology as it allows large uteri to be removed without increased blood loss. The overall complication rate in present study was 3.5%, six (1.5%) of these complications were major ones and the rest were minors. The six cases of major complications were: three cases of bladder entry that was repaired laparoscopically with no residual problems. Two women had a bowel injury: one was repaired laparoscopically and the other required a laparotomy. One woman had a cervicovaginal fistula after a loop excision of the transformation zone was excised after the uterus has been removed. The injury to the bladder probably resulted from thermal spread. The cervix was removed vaginally and the fistula repaired as a primary procedure. All bleeding complications (haematoma, pelvic collection and transfusion) happened in the first 81 cases, and this is reflecting the duration of the learning curve. However, this is not the case with visceral injuries as they occurred later as well, probably reflecting the confidence to undertake more difficult cases with complex previous surgical history (Figure 4). These are in accordance with previous studies. 10 The reported intraoperative complication rate in different studies of LSH varies widely from 0 to 40%, however, the largest trials report rates of approximately 2%. 14,15 Comparative complication rates for vaginal hysterectomy (VH), laparoscopic assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH) in women with similar indications are 5.3, 3.6 and 9.3%, respectively. 16 Recently, a study of outpatient laparoscopic supracervical hysterectomy was published. 9 The overall complication rate was 19%. The Value study prospectively analysed a series of women undergoing hysterectomy in UK during a 12-month period; 67% of procedures were abdominal, 30% vaginal and 3% laparoscopic. Operative complications occurred in 6% of laparoscopic procedures, significantly greater than vaginal (3.1%) or abdominal (3.6%). No significant differences was noted in Cure Number Bladder Bleeding lateral port Trasnfusion Pelvic collection Pelvic collection Trasnfusion Figure 4. Timing of major complications. Fistula Bladder Bleeding lateral port Bowel Bowel Bladder the rate of bladder or ureteric injury between the three techniques. 17 The Evaluate trial showed a difference in overall complication rates, with a higher rate for abdominal hysterectomy (11.1 versus 6.2%). 18 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 747

7 J Erian et al. Persistent vaginal bleeding after LSH has been reported to occur in % of women, with most series reporting a rate of 5 10%. Donnez et al. 15 and Lyons 14 describe vaginal bleeding rate of <2%. In the present study, eight women (2%) complained of irregular or cyclical vaginal bleeding/ spotting. We believe that the relatively low rate of cyclical bleeding is attributed to the appropriate transection at the level of isthmic portion of the uterus made possible by the Lap Loop system and also because the entire endometrium was excised and the lining of the cervical stump was dessicated using the PK forceps. 4 Published reports have varied in the handling of the remaining cervical stump and, more specifically, the treatment of the endocervical canal. Most authors recommend either ablation of the endocervical canal at the end of the procedure or no treatment. Others advocate reverse cervical conisation or removal of the entire endocervical canal. Currently, there is no definite evidence that one method is clearly superior to another. 4 In our opinion, counselling of women is of paramount importance. The woman should be informed of the almost 100% rate of treatment of menorrhagia; however, a small percentage of women will experience cyclical bleeding. Treatment of menorrhagia is the outcome measure as opposed to complete amenorrhoea. In our experience, women who realise this fact are less likely to request a trachelectomy for cyclical bleeding. The Evaluate group, in a separate paper, found that laparoscopic hysterectomy (LH) costs more than VH with no differences in quality-of-life outcomes. LH was also more expensive than abdominal hysterectomy (AH) but LH was associated with better short-term quality-of-life scores at 6 weeks. 19 Garry 20 stated that the overall costs in terms of patients loss of productivity by requiring a greater period of time for overall recovery after AH were not taken into account. Ellstrom et al. 21 noted that when indirect costs such as loss of productivity by the woman are taken into account, these lead to an overall cost saving in favour of LH. In balance, the cost of the morcellator use in this procedure is justified taking in consideration the cost of the operative time and hospital stay in addition to the patient and society benefits from quicker recovery and a lower complication rate. 2 Conclusion LSH is a safe and effective procedure for treating menorrhagia. It is now routinely performed as a day case in our unit, increasing the surgeon s productivity and reducing the collateral cost from patient s postoperative disability. Patient selection and surgeon s continuing experience are the main factors affecting the outcome. j References 1 Clayton RD. Hysterectomy. Best Pract Res Clin Obstet Gynaecol 2006; 20: Mettler L, Ahmed-Ebbiary N, Schollmeyer T. Laparoscopic hysterectomy: challenges and limitations. Minim Invasive Ther Allied Technol 2005;14: Zupi E, Zullo F, Marconi D, Sbracia M, Pellicano M, Solima E, et al. Hysteroscopic endometrial resection versus laparoscopic supracervical hysterectomy for menorrhagia: a prospective randomised trial. Am J Obstet Gynecol 2003;188: Erian J, El-Toukhy T, Chandakas S, Theodoridis T, Hill N. One hundred cases of laparoscopic subtotal hysterectomy using the PK and Lap Loop systems. J Minim Invasive Gynecol 2005;12: Reich H. Laparoscopic hysterectomy. Surg Laparosc Endosc 1992;2: Jenkins TR. Laparoscopic supracervical hysterectomy. Am J Obstet Gynecol 2004;191: Carbonell AM, Joels CS, Kercher KW, Matthews BD, Sing RF, Heniford BT. A comparison of laparoscopic bipolar vessel sealing devices in the hemostasis of small-, medium-, and large-sized arteries. J Laparoendosc Adv Surg Tech A 2003;13: Dequesne J, Schmidt N, Fryman R. A new electrosurgical loop technique for laparoscopic supracervical hysterectomy. Gynaecol Endosc 1998;7: Lieng M, Istre O, Langebrekke A, Jungersen M, Busund B. Outpatient laparoscopic supracervical hysterectomy with assistance of the lap loop. J Minim Invasive Gynecol 2005;12: Wattiez A, Soriano D, Cohen SB, Nervo P, Canis M, Botchorishvili R, et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc 2002;9: Okaro EO, Jones KS, Sutton C. Long term outcome following laparoscopic supracervical hysterectomy. BJOG 2001;108: van Wijngaarden WJ, Filshie GM. Laparoscopic supracervical hysterectomy with Filshie clip. J Am Assoc Gynecol Laparosc 2001;8: Morrison JE, Jacobs VR. 437 Classic intrafascial supracervical hysterectomies in 8 years. J Am Assoc Gynecol Laparosc 2001;8: Lyons TL. Laparoscopic supracervical hysterectomy. Baillieres Clin Obstet Gynaecol 1997;11: Donnez J, Nisolle M, Smets M, Polet R, Bassil S. Laparoscopic supracervical (subtotal) hysterectomy: a first series of 500 cases. Gynaecol Endosc 1997;6: Kovac SR. Hysterectomy outcomes in patients with similar indications. Obstet Gynecol 2000;95: McPherson K, Metcalfe MA, Herbert A, Maresh M, Casbard A, Hargreaves J, et al. Severe complications of hysterectomy: the VALUE study. BJOG 2004;111: Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, et al. The evaluate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004;328: Sculpher M, Menca A, Abbott J, Fountain J, Mason S, Garry R, et al. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ 2004;328: Garry R. The future of hysterectomy. BJOG 2005; 112: Ellstrom M, Ferraz-Nunes J, Hahlin M, Olsson JH. A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol 1998;91: ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology