What Is The Size Of A Uterus

Autops Case Rep. 2016 Jan-Mar; vi(1): 51–56.

Large uterus: what is the limit for a laparoscopic approach?

Beatriz H. Kehde

^aDepartment of Obstetrics and Gynecology - Santa Casa de Misericórdia de São Paulo, São Paulo/SP – Brazil.

^bEndoscopic Training Eye, Antwerp – Belgium.

Bruno J. van Herendael

^bEndoscopic Preparation Centre, Antwerp – Kingdom of belgium.

^cZiekenhuis Netwerk Antwerpen ZNA Stuivenberg – Sint Erasmus Section Gynecological Endoscopic Surgery, Antwerp – Belgium.

Benedictus Tas

^cZiekenhuis Netwerk Antwerpen ZNA Stuivenberg – Sint Erasmus Department Gynecological Endoscopic Surgery, Antwerp – Belgium.

Deepika Jain

^bEndoscopic Grooming Centre, Antwerp – Belgium.

^dDepartment of Obstetrics and Gynecology - Anand Infirmary, Beawar/Rajasthan – India.

Karine Helsen

^cZiekenhuis Netwerk Antwerpen ZNA Stuivenberg – Sint Erasmus Department Gynecological Endoscopic Surgery, Antwerp – Belgium.

Lisbeth Jochems

^cZiekenhuis Netwerk Antwerpen ZNA Stuivenberg – Sint Erasmus Section Gynecological Endoscopic Surgery, Antwerp – Kingdom of belgium.

Received 2015 Dec 28; Accepted 2016 Feb xi.

Abstruse

Hysterectomy is the most mutual surgical gynecologic procedure, which is oftentimes related to the treatment of leiomyoma. The laparoscopic hysterectomy is associated with a shorter infirmary stay, fewer infection rates, and a faster return to daily activities. Most gynecologists practice not recommend a hysterectomy via the vagina or a laparoscopic-assisted vaginal hysterectomy (LAVH) in the case of a uterus weighing more 300 thousand. This example report presents the case of an LAVH undertaken in a 43-year-old patient with a uterus weighing 2,800 thou. In that location are no definite guidelines concerning the procedure for a large uterus, and the literature is vague regarding the best surgical procedure for these cases. The size of the uterus does non seem to be an accented contraindication for endoscopic surgery. This procedure relies entirely on the surgeon's ability.

Keywords
: Hysterectomy, Vaginal, Uterus, Leiomyoma

INTRODUCTION

Hysterectomy is the near common gynecologic surgical procedure performed in the U.s., accounting for 600,000 procedures per twelvemonth.¹ The most common indication for a hysterectomy is aberrant uterine haemorrhage, which is oft caused by uterine leiomyoma,² which is nowadays in 25-50% of reproductive-anile women.ⁱⁱⁱ In 2003, approximately 66.1% of hysterectomies performed in the United states were via the abdomen; 21.8% were via the vagina; and eleven.8% were laparoscopically undertaken.^iv

A meta-assay by the Cochrane Library showed that both the vaginal and the laparoscopic hysterectomies were associated with a shorter hospital stay, fewer infections, and a more rapid return to normal activities compared with abdominal hysterectomies.^five Furthermore, the former is associated with less postoperative pain, a faster recovery, and a better cosmetic effect.⁶ Wattiez et al.⁷ concluded that "the rationale for hysterectomy is to convert intestinal hysterectomy into a laparoscopic procedure and thereby reduce trauma and morbidity."

In 1989, Reich and DiCaprio⁸ performed the first total laparoscopic hysterectomy (LH). Since and then, several authors have reported their experience with this operation, and so much that LH is currently accustomed as a condom procedure for the handling of benign uterine pathology.⁹

The term "big uterus" has been overused. In several publications, this term was used to define the weight of a uterus > 300 g or > 500 g.¹⁰ ^- ¹² Giant myomas unremarkably obstruct the pelvis and become extremely hard to be mobilized and manipulated, reducing the availability to identify the surrounding anatomic structures, and hampering the correct development of the spaces by the surgeon. In the study by Uccella et al.¹³ comprising more than than 1,500 hysterectomies, the prevalence of uteri weighing > i kg was five.seven%.

Studies involving the laparoscopic procedure for the treatment of a uterus weighing > 1 kg are scanty and involve a small number of patients,¹⁴ ^- ^sixteen and the procedure via the vagina has been express to sporadic reports.¹⁷ The case reported herein presents the removal of a 2,800 g uterus via laparoscopic-assisted vaginal hysterectomy (LAVH) by skilled surgeons using minimally invasive techniques. The report was canonical by the ethics committee of the hospital (ZNA Stuivenberg/ Antwerp - Belgium), and was formally consented by the patient. This intervention was part of a routine treatment–hysterectomy–-hysterectomy. The informed consent had been obtained from the patient.

CASE REPORT

A 43-twelvemonth-old adult female born in the Middle East presented to the medical facility complaining of a "big brawl" in the abdomen for two years, which was associated with nocturia. She denied abnormal uterine bleedings, just somewhen presented hurting. She was obese (body mass alphabetize = 34.5kg/grand^two) only no other comorbidity was present. Physical exam revealed a mobile, painless, pelvic-abdominal mass extending 3 cm above to the omphalos.

Intestinal and vaginal ultrasonography was performed showing a large mass in the uterine topography that was scarcely vascularized and sized 13.9 × 16.four cm.

The magnetic resonance images showed a mass with areas of hyperintense signal intermingled with areas of hypointense signal in T2 in the fundus and the posterior wall of the corpus uteri partially subserous and intramural. The mass measured 18.seven × 16.iii × 21 cm. The endometrial cavity was normal (Figure ane). These findings were consistent with the diagnosis of uterine myomatosis without whatsoever sign of malignancy.

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Magnetic resonance of the abdomen. T2 weighed images showing a uterine nodule partially subserous and partially intramural. A - Sagittal airplane; B - Coronal aeroplane.

The patient was submitted to LAVH. To accomplish the pneumoperitoneum a Veress needle was placed in the Palmer indicate. Via an incision of ane.5 cm, a 5 mm trocar was inserted followed past a five mm nix caste laparoscope (Karl Storz GmbH & Co., Tuttlingen, Germany). The inspection of the abdominal cavity with mobilization of the uterus disclosed a very large uterus. A xxx-degree optic was and so introduced to optimize the visualization (Figure 2A). A second and third trocar were inserted at the level of the vascular pedicle, and the 4th was inserted in the navel. Dissection and sealing of the parametria, the round ligaments, and the ligament ovaria propria followed by the uterine vessels was performed with LigaSure (LigaSure™ 5 mm Edgeless Tip, Covidien Belgium BVBA, Mechelen, Belgium). The get-go morcellation was performed with a cold laparoscopic pocketknife (Chardonnens morcellation pocketknife, Karl Storz GmbH & Co.) (Effigy 2B).

An external file that holds a picture, illustration, etc. Object name is autopsy-06-01051-g02.jpg

A - Large uterus. It is impossible to come across it completely via a panoramic view; B - Morcellation with the cold laparoscopic knife.

The vaginal process started with opening the vagina with a circular incision around the neck, dissecting the bladder, and opening the posterior fornix. Clamps were used on the sacro-uterine ligaments. Then, the morcellation was started using a knife and a tenaculum clamp. This maneuver took around two-thirds of the operating time. The vaginal cuff was closed and attached to the sacro-uterine ligaments. In that location were no complications and the operating time was 270 min. The claret loss was 900 mL and no blood transfusion was required. The surgical specimen weighed 2,802 g and the pathologic assay resulted in benign leiomyoma. The patient was discharged in the 2nd postoperative day.

DISCUSSION

It is non uncommon for a surgeon to be able to perform the entire laparoscopic histerectomy using 3 5-mm ports and and then a larger abdominal incision to remove the surgical specimen.¹⁸ Most of the gynecologic surgeons will not remove a uterus weighing > 300 g either via the vagina or past the LAVH technique.^vii Uteri > 300 g are hard to pull out through the vagina without whatsoever incision.^nineteen

Wattiez et al.⁷ first introduced several modifications to the current technique for LH for large uterus. The primal modifications consisted of a higher insertion of the optic cannula with consideration of an open abdominal entry to minimize the take chances of lacerating the uterus, and the 30-degree optic can ensure meliorate visualization of uterine pedicles.⁷ The same technique was used in this case report.

Wattiez et al.⁷ reported that LH can exist successfully carried out in most women with an enlarged uterus (ranging from 500 thou to 1230 g). Thirty-four women with a uterus weighting more than than 500 g were compared with 68 women with a uterus weighting ≤ 300 g; both groups submitted to total LH. No departure was observed apropos the complication rate among both groups. The operative fourth dimension was significantly higher (p < 0.001) in women with a very enlarged uterus compared with those with a smaller uterus. The rates of intraoperative and postoperative complications and the length of hospital stay were independent of the uterus size.¹³

Different laparoscopic techniques were adult for removing large uteri, including (i) intra-abdominal cutting of the uterus into pieces; (ii) morcellation (electromechanical,²⁰ in situ,¹⁴ or with a bowel handbag technique for pelvic mass isolation, and so morcellation vaginally²¹); (iii) electrosurgery; and (iv) supracervical amputation followed past traquelectomy.²² The morcellation of a huge surgical specimen represents the limiting cistron in reducing the operative fourth dimension in LH.²³

An assay of more than than 6,000 laparoscopic hysterectomies from a multicenter series showed shorter operating times in LAVH compared with LH. This is consequent with previous reports, which as well demonstrated reduced operative times in LAVH procedures.²⁴ ^, ²⁵ The difference is mainly due to the size of the uterus and the morcellation time.²⁶

Each morcellation type has pros and cons. In our case, the vaginal morcellation with the knife and tenaculum clench technique was chosen to avert the spread of myomatous cells in the abdominal crenel, despite the mass not showing malignant characteristics.

The vaginal fragmentation of a large uterus allows minimization of the spillage of surgical debris inside the abdominal cavity and avoids the enlargement of the coincident ports to insert a ten-20 mm endoscopic morcellator.²³ The transvaginal closure of the vaginal stump was previously reported equally a prophylactic procedure.²⁷ The reduced abdominal incisions not only offer cosmetic advantages merely also reduce the incidence of incisional hernia, which occurs in upward to 3% using 12 mm trocars, but 0% using v mm trocars.²⁸

Walid and Heaton,²⁹ in a example study of a hysterectomy of a 3,000 g uterus, presented an operation fourth dimension of 357 min and the estimated claret loss of 800 mL. Wattiez et al.⁷ showed a case in which the estimated blood loss was < 100 mL and the whole surgical time was 300 min. In this study, the operating time was 270 min and the blood loss was 900 mL. The operative fourth dimension is longer compared to uteri of a smaller size⁷ or a laparotomy approach.^xxx However, the time was similar to other studies with a big uterus because of the morcellation. The blood loss was higher than in the literature.^vii ^, ²⁹ These parameters are probably because of the experience of surgeons and the characteristics of the uterus.

There are no definite guidelines about the meliorate surgical approach for the treatment of a large uterus. It is still commonly accepted almost worldwide, that in everyday practice when the fundus of the uterus reaches the umbilicus the treatment of choice is open up intestinal hysterectomy.²³

Skilled operators trained appropriately in endoscopic techniques with a delivery to reducing unnecessary open procedures is of utmost importance to obtain better results. The uterus size itself does not seem to be an accented contraindication to endoscopic surgery, and the acquisition of adequate surgical skills to perform LH in cases of large uteri seems to exist tightly connected to the policy and orientation of the medical eye.^xiii

In conclusion, this case shows that the size of the uterus does not forbid the laparoscopic approach for hysterectomy. More randomized and multicenter studies are necessary before this technique can become routinely preconized.

Footnotes

Kehde BH, van Herendael BJ, Tas B, Jain D, Helsen K, Jochems L. Large uterus: what is the limit for a laparoscopic approach? Dissection Instance Rep [Internet]. 2016;6(1):51-56. http://dx.doi.org/ten.4322/acr.2016.025

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