Years ago, women with abnormal uterine bleeding, fibroids or other severe gynecological conditions had only one treatment choice: hysterectomy. Now there are many more surgical options that can preserve the uterus, such as endometrial ablation to control abnormal bleeding, or myomectomy or embolization to manage fibroids. But there's still a place for hysterectomy for certain patients, particularly women for whom other treatments have failed.

Nearly 70 percent of the 600,000 hysterectomies performed each year are total abdominal hysterectomies, in which the uterus and the cervix are removed through an abdominal incision. Vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy and laparoscopic hysterectomy (see "Types of Hysterectomy" on page 32) are all less invasive procedures, but they still involve removing the entire uterus. But now, we have the technology to make hysterectomy a safer, less complex, outpatient procedure by removing the uterus laparoscopically and leaving the cervix intact. This procedure, which I began performing in 1990, is called laparoscopic supracervical (also known as subtotal or partial) hysterectomy, or LSH.

Benefits of LSH
Most gynecological surgeons accept the fact that any laparoscopic procedure that has been compared to a corresponding open procedure has demonstrated lower morbidity. The number of laparoscopic or laparoscopically assisted hysterectomies will probably increase as more surgeons become comfortable with this approach. But the issue of whether to remove the cervix is somewhat controversial.

Based on our series of 1,500 LSH patients over the last 14 years, I believe supracervical hysterectomy offers four main benefits:

• Faster recovery time. I perform all LSH procedures in an outpatient surgery center where our average post-op stay is four hours to six hours. This is much faster than any comparable procedure, which nearly always require an overnight or multiple-night stay. Patients return to normal activities in about one week.
• A better safety profile. The surgery carries a low risk of injury to the ureter, the No. 1 injury in gynecological surgery. We've had very few complications: Febrile morbidity is less than 1 percent, our transfusion rate has been zero and reoperations have been .001 percent. The incidence of cuff cellulitis, a common complication in vaginal surgery, is also greatly reduced because there are no vaginal incisions.
• No increased risk of cervical cancer. One of the main arguments used to justify removing the cervix is that it eliminates the risk of cervical cancer. Studies show, however, that removing the cervix only shifts the risk of cancer to the vaginal vault - the risk of this happening is about 0.13 percent. Furthermore, the risk of developing cervical cancer after a subtotal hysterectomy is only 0.11 percent. As long as the patient continues to receive regular Pap smears, the chance of getting cervical cancer is minimal.
• Preservation of vaginal vault support, nerve network and blood flow. The peri-cervical ring serves as a keystone of support for the entire pelvic region. Leaving it intact may help to maintain pelvic organ support and maintain sexual and bladder function.

The only contraindications for LSH, I believe, are endometrial cancer and invasive cervical cancer, which comprise less than 1 percent of the total number of hysterectomy procedures performed. That means that 99 percent of women who require a hysterectomy are qualified candidates for LSH.

Critics of supracervical hysterectomy say that there is no clear evidence that the cervix provides pelvic organ support or helps maintain sexual function. Furthermore, some studies that have compared abdominal supracervical and total hysterectomy have shown that retaining the cervix doesn't decrease morbidity, which some surgeons regard as proof that you should take it out. In my opinion, if there's no benefit one way or another, and as long as there is no pathology in the cervix, you should opt for leaving it in. From a surgical standpoint, less is always more.

Two pairs of hands at the surgical site
When I started performing this procedure in the early 1990s, we struggled with acquiring just the right equipment, but the technology has progressed to the point where there are enough instruments designed for gynecological surgery to accommodate just about every surgeon's technique.

LSH requires a standard laparoscopic setup, an OR table with good Trendelenburg and good patient positioning equipment to avoid femoral nerve injuries. Required instrumentation includes a uterine manipulator/elevator, reliable vessel sealing electrosurgical instruments, a transecting instrument and an electromechanical morcellator.

It's important that your staff, including a circulating nurse, scrub nurse and anesthesia team, be familiar with these procedures and equipment. You also need two pairs of hands at the surgical site. Some surgeons prefer to work with another surgeon; I've been operating for 12 years with a surgical assistant who is an RNFA and a CNOR. Our anesthesia team, which includes anesthesiologists and CRNA extenders, know to minimize the use of opioids during general anesthesia, as the patient's recovery can be limited by post-op nausea and vomiting. Our anesthesia regimen uses a propofol induction with isoflurane maintenance. We administer a relaxant for intubation and use opioids only when necessary.

The procedure generally takes a little more than one hour and is comparable in complexity to a laparoscopic cholecystectomy. I generally use four trocars, one at the umbilicus and three slightly above the top of the uterus. Even for very large uteri, I don't require any more than six trocars. See "Step-by-Step Guide to Laparoscopic Supracervical Hysterectomy" on page 31 for the basic steps of the procedure and the equipment required to complete each step.

Pain control
A clear benefit of LSH over other hysterectomy procedures is less post-op pain. We begin pain control in the OR with 60mg of IV or IM Toradol (ketorolac). We also inject marcaine with epinephrine at the trocar sites. If the patient is particularly prone to PONV, we pretreat with Zofran (ondansetron). In recovery, if the patient needs it, we administer an NSAID as soon as she is able to take oral medications. We tell patients that they can use over-the-counter medications (Advil or Aleve, for example) for pain, and we also give them a prescription for hydrocodone, although it turns out to be unnecessary for many of our patients.

I strongly advise against using a PCA for these patients. There are many more effective ways to control pain for these procedures, and PCAs only ensure that the patient will stay in the facility longer.

Our patients generally stay in recovery for about four hours to six hours; they're ready to leave once their vital signs are stable and when they can eat, void and ambulate. Patients generally return to work in seven days to 10 days and resume intercourse in 14 days without pain.

Case costs and reimbursement
We've had very few issues with getting reimbursed. Our case costs, which are typically about $1,800 to $2,200, are lower than abdominal hysterectomy costs because of the lack of an inpatient stay. They're a little higher than vaginal hysterectomy if the patient goes home the same day (laparoscopic surgery has higher equipment costs), but are lower if the patient is hospitalized for a day or more, which is generally the case for vaginal hysterectomy procedures. A facility fee of at least $2,500 should ensure profitability for a surgical facility.

A few years ago, the American College of Gynecologists recommended that the abdominal hysterectomy rate (both total and supracervical) be reduced to 30 percent or less of the total number of procedures. ACG suggested that this was possible if more surgeons switched to a vaginal approach. I don't think that's a reasonable goal. The majority of gynecologists do less than 20 percent of their procedures using a vaginal approach because it's more complex than an abdominal approach. However, as we start to train physicians in LSH earlier in residency, as more gynecological surgeons become adept at laparoscopic surgery, as manufacturers continue to develop instrumentation and, most importantly, as women begin to demand more options for their healthcare, I believe LSH will become the preferred hysterectomy procedure.