Laparoscopic Surgery Classification Cost Indications and Contraindications

 


During the 1970s and 1980s, developed multiple minimally invasive gynecological procedures, leading to the development of laparoscopic-assisted vaginal hysterectomy. In 1985 he built the pelvi-trainer, as a training equipment for laparoscopic gynecological procedures. For minimally invasive surgery technique many of them have not received practical training with simulators resembling Ethicon Laparoscopic Trainer.

The first laparoscopic hysterectomy was performed in 1993. The first laparoscopic hysterectomy was performed in 2001, at Hospital. Regarding robot-assisted laparoscopic hysterectomy, it was first performed experimentally in animals. The first publication in humans was in 2002 and current evidence demonstrates the safety and effectiveness of robotics in gynecological surgery.

Concepts and Classification

- Laparoscopic-assisted vaginal hysterectomy:

These are patients in whom some procedure is performed laparoscopically, for example: lysis of adhesions, oophorectomy or salpingo-oophorectomy, then conventional vaginal hysterectomy is performed.

- Laparoscopic hysterectomy:

Involves laparoscopic ligation of the uterine vessels. After ligation, the rest of the surgery can continue laparoscopically or vaginally.

- Laparoscopic supracervical hysterectomy:

As its name implies, it involves leaving the cervical stump partially or completely. This technique leaves the cervix intact, preserving the uterosacral and cardinal ligaments. Some authors consider that sexual functionality is better protected by safeguarding the cervix and vagina. The uterus is removed by morcellation from above or below.

Much confusion has arisen due to the multitude of technical variants that this surgical procedure has presented and due to the terminology used. Therefore, classifications have been proposed to assess the technique used and the extent of the laparoscopic procedure.

One of Them Is the Clermont Ferrand Classification That Is Set Out Below:

Type I:

Includes hemostasis and sectioning of the adnexal pedicles and round ligaments, which frees the cusp of the broad ligament and facilitates the rest of the maneuvers vaginally.

Type II:

Associated with uterine-vesical detachment and hemostasis of the uterine pedicles.

Type III:

Performs the dissection of the cervix intrafascially, the hemostasis of the cervicovaginal pedicles and begins the vaginal opening.

Type IV:

Consists of performing the entire hysterectomy laparoscopically, including vaginal opening and closure. The only moment of vaginal use is the extraction of the piece.

Cost with Laparoscopic Techniques

Controversies begin to arise when analyzing the benefits in terms of cost. In general, studies to date show a higher cost with laparoscopic techniques. The economic implications depend on local factors and the type of technique adopted. The use of disposable instruments greatly influences costs. Laparoscopic hysterectomy can be performed at the same or lower cost than conventional surgery, as long as techniques with reusable equipment are used.

The abdominal route is the traditional method of performing hysterectomy plus bilateral salping oophorectomy, and in this sense, adnexectomy has been considered another advantage of laparoscopic hysterectomy. The operative time has been considered a weak point of laparoscopic hysterectomy. The Clermont Ferrand series reached an average duration of 97.4 +/- 37.9 minutes. Other authors do not report significant differences between the abdominal and laparoscopic routes.

Indications and Contraindications of Laparoscopic Hysterectomy

Indications

When there is a benign disease in which an abdominal approach is usually required and when vaginal hysterectomy is contraindicated, as in the case of a narrow pubic arch, narrow vagina without prolapse or arthritis that prevents the patient from being placed in the lithotomy position, to sufficiently expose the vagina.

In relation to the size and weight of the uterus, many authors consider that uteri of more than 700 grams should not be approached laparoscopically, although the range of acceptance of different series ranges from those that place the limit between 200-500 g to those who accept estimated weights of 1000 g or more, and those who recommend the use of different methods to reduce the size of the organ and then proceed to surgery.

In the case of large fibroids, the indication for laparoscopic hysterectomy depends on many factors: the shape and diameter of the uterus, its mobility in the pelvis, the location of the fibroids, the width of the patient's pelvis, height and surgical field, the instruments available and the experience of the surgical team.

Contraindications

Uterine dimensions and weight greater than those described above, patients with stage IV endometriosis with extensive involvement of the cul-de-sac of Douglas, unless the surgeon has the ability and time to resect all fibrotic endometriosis from the vagina, ligaments uterosacros and rectus anterior.

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