SUMMARY AND CONCLUSIONS

Laparoscopic hysterectomy was performed for the first time in 1988 in the United States and in 1992 in Finland. To evaluate how soon a gynecologist experienced in laparoscopic surgery can learn a new technique from the beginning, the first one hundred laparoscopic hysterectomies performed by a single senior gynecologist were analyzed. Laparoscopic removal of the uterus succeeded in all cases and the operating time was on average 109 minutes and the mean operating time was reduced to half after 80 operations. The average hospital stay was 1.3 days, sick leave 10.9 days and complications occurred in 10% of cases. In addition, the nationwide outcome of laparoscopic hysterectomy was evaluated and a national register was founded for a prospective multicenter survey. From 1993 through 1994, 1165 procedures were performed by 68 gynecologists at 30 hospitals. Most of the operations were carried out because of fibroids and the mean operating time was 132 minutes. The patients stayed in hospital for an average of 3.3 days, and the mean sick leave was 17.9 days. Complications occurred in 10.2% of the procedures: infections in 5.6%, vascular injuries in 1.2%, urinary tract injuries in 2.7% and bowel injuries in 0.4%.

Laparoscopic hysterectomy has been said to be a substitute for abdominal hysterectomy, not necessarily for vaginal hysterectomy. Laparoscopic hysterectomy was compared with abdominal hysterectomy in one study. The mean operating time and anesthetic time were significantly longer in the laparoscopic group. On the other hand, there was less blood loss, and the times of hospital stay and sick leave were significantly shorter in association with laparoscopic hysterectomy. There were no significant differences in complications between the study groups. Postoperative tissue trauma was evaluated by assay of serum IL-6, CRP, TATI and CA 125. Postoperative increases in the concentrations of all these markers were seen in laparoscopic and abdominal hysterectomies but the increase was more marked in the abdominal group suggesting more tissue trauma.

To compare complications of laparoscopic hysterectomy with those of other laparoscopic procedures, data files of both the Finnish Hospital Discharge Register and Care Register and the National Patient Insurance Association were used. The incidence of major complications was low in diagnostic and sterilization laparoscopies but it increased steeply in the 1990s in operative laparoscopies. Eighty-two percent of major complications occurred in operative laparoscopies and 69% of these were in laparoscopic hysterectomies. The incidence of major complications in laparoscopic hysterectomies decreased from 4.9% in 1993 to 1.4% in 1998. Half of the major complications were ureteral injuries, occurring on average in 1% of procedures. However, this incidence also decreased, from 1.9% in 1993 to 0.7% in 1998. As laparoscopic hysterectomies were the main source of laparoscopic ureteral complications in Finland, urinary tract injuries among all types of hysterectomy were analyzed. The rate of ureteral injury was low after vaginal, supracervical abdominal and total abdominal hysterectomy, but high after laparoscopic hysterectomy. In addition, bladder injuries were rare after vaginal and supracervical hysterectomy, but more common after total abdominal hysterectomy. Again, bladder injuries were most common after laparoscopic hysterectomy.

In conclusion, laparoscopic hysterectomy offers many advantages over abdominal hysterectomy, with minimal operative blood loss and pain and a short hospital stay and recovery time. The incidence of ureteral injuries has been unacceptably high. Although the incidence is decreasing it is mandatory to obtain proper experience before performing laparoscopic hysterectomies independently. Laparoscopic and vaginal hysterectomy should be the preferred techniques and the gynecologist's skills and experience influence the choice between these methods.