Textbook of Simplified Laparoscopic Hysterectomy:
Practical, Safe and Economic Methodology
 

Chapter 3

Patient Selection

Selection of patients is crucial for successful TLH. Initially, the authors suggest selecting patients with normal uteri, preferably confirmed with ultrasound scans. This will build confidence. As the number of operated patients increases, one can start operating on larger uteri or those with anatomic variations, again progressing from the simple to the complex.

Patients who challenge performance of laparoscopic hysterectomy include extremely obese women (morbidly obese or BMI 45 and above, especially those with a small atrophic uterus) and those who have had two or more previous laparotomies or cesarean sections. In all such instances, including those patients thought not to pose potential problems, the authors strongly suggest examining the patient bimanually under anesthesia before proceeding with laparoscopic hysterectomy. If during surgery, it can be seen that the steps of the TLH are not working, then hysterectomy can be completed through traditional routes (abdominal or vaginal).

The selection criteria for laparoscopic hysterectomy should be strictly observed. At the end of the procedure, the surgeon should be satisfied with his/her performance. If a beginner selects a case of a large uterus with previous laparotomy for endometriosis, technical difficulties may occur for which the surgeon may not be mentally prepared and which may affect the operative performance. This results in prolongation of the operating time and makes the patient vulnerable to complications. Such complications often relate to anesthesia or the use of carbon dioxide for insufflation; both circumstances increase patient morbidity. Not only would improper patient selection violate the principles of minimal access surgery, but it would also do so at the cost the patient’s health.

The following points should be kept in mind while proposing the laparoscopic route for hysterectomy.

1. Age: In authors’ opinion, patients aged 60 or more should be operated on in a tertiary care hospital where a multi-speciality approach is possible. The anesthesiologist should be aware of the hemodynamic changes common in this age group secondary to carbon dioxide insufflation along with Trendelenburg position and prolonged surgery. In particular, changes occur in intracranial pressure owing to thoracic and lumbar venous congestion related to pneumoperitoneum. Elderly patients may not tolerate such changes.
2. Parity and the age of children: Posthysterectomy regret is more likely if patient age, parity and the respective ages of living children are low, as the morbidity and mortality of children under age five is unpredictable. Accordingly, patients should be appropriately counseled, and the permanent nature of the operation should be stressed. This is also true if the patient is nulliparous. If children are very young, the patient can be offered another more conservative type of management. Nulliparous patients present an additional problem if their hymen is still intact and they wish it to remain so. In such instances, patients should be counseled about the potential alteration of vaginal anatomy during the course of surgery and informed that the specimen may have to be retrieved by the way of morcellation.
3. History of previous cesarean delivery: Intra-abdominal adhesions vary from simple omental adhesions to complete plastering of the surface of the uterus and bowel to the anterior abdominal wall. In the presence of a history of laparotomy for myomectomy, endometriosis or intestinal surgery, bowel adhesions to the abdominal scar as well as the uterine scar are common. Knowledge of prior surgical history helps the surgeon prepare to face technical difficulties while contemplating the operation at hand.

As the number of TLH performed increases, then one can start operating on larger uteri. The beginner should not start to operate on patients where two or three pathologies co-exist in the pelvis (endometriosis and adhesions, myomata and prior cesarean sections(s), obliteration of the pouch of Douglas from prior infection or intra-abdominal abscess, etc.), but rather progress to these as experience is gained. As surgical experience is accumulated, so is operative confidence.

Common relative contraindications to TLH include:

• BMI 45 and above (morbid obesity)
• Compromised cardiorespiratory/renal system
• Uterine size >26 weeks
• Multiple laparotomies for surgical disease
• Deranged coagulation profile.