International Archives of Medicine the Value of Minilaparotomy for Total Hysterectomy for Benign Uterine Disease: a Comparative Study with Conventional Pfannenstiel and Laparoscopic Approaches

Background: The aim of this paper is to review and compare the results obtained using the Pfannenstiel, laparoscopy and minilaparotomy approaches for total hysterectomy procedure in relation to benign uterine diseases.


Background
Currently gynaecologists have different options for the surgical treatment of benign uterine diseases [1]. For the total hysterectomy operation, one of the most common procedures in gynaecological practice, the laparoscopic procedure has been widely accepted as a better alternative to Pfannenstiel laparotomy.
However, the minilaparotomy procedure (a transverse abdominal incision into the pubic hair no longer than 6 cm in length in which it is possible to place a circular elas-tic retractor that enables a better exposure of the pelvic field) is another possible option [2][3][4] The aim of this study is to compare the results, in terms of morbidity, obtained following minilaparotomy, Pfannenstiel and laparoscopy approaches for total hysterectomy procedure.

Methods
A retrospective data analysis was performed on 165 patients who underwent total hysterectomy for benign diseases only (fibroids, adenomyosis, dysfunctional uterine bleeding and endometrial hyperplasia) during the period 2004 to 2006. 81 patients (49.1%) had undergone the minilaparotomy procedure, 46 (27.9%) the Pfannenstiel laparotomy procedure and 38 (22%) the laparoscopic procedure. The choice of the procedure was based on surgeon's decision according to their preference.
The variables reviewed in the study were as follows: 1. Demographic data: age, height, and weight, body mass index (BMI), previous pregnancies, previous deliveries, and previous abdominal surgeries.

Preoperative hemoglobin.
5. Intraoperative complications: Bladder, ureteral, bowel and vascular injuries and bleeding (measured as difference of preoperative and postoperative hemoglobin).
Three surgeons performed all surgical interventions at the Department of Obstetrics and Gynecology of the Clínica Universitaria de Navarra (Spain) with more than 10-year experience in all these techniques (only one surgeon for each surgical approach).

Surgical technique for the Minilaparotomy procedure
Under general anaesthetic, the patient was placed in the lithotomy position.
A Foley catheter was introduced within the bladder and a uterine manipulator was placed through the cervix for uterine mobilisation. Then a small transverse incision (3 to 6 cm in length) was made into the pubic hairline. A 6-cm incision creates a 28-cm 2 surgical area [3]. Once the pelvic cavity was reached, we placed a self-retaining abdominal retractor (Mobius, Apple Medical, Marlborough, MA) which is an elastic tubular device that isolates atraumatically the uterus from other pelvic organs ( Figure 1).

Figure 2 Minilaparotomy hysterectomy being performed with conventional open-surgical instruments (top-left).
Pelvic field exposed during surgery (top-right and down-left). Cosmetic outcomes after surgery (down-right).
Minilaparatomy access line measuring less than 6 cm Figure 1 Minilaparatomy access line measuring less than 6 cm. Large uterus shape is also drawn above (top-left). Introduction of the self-retaining abdominal retractor (top-right). Introduction of the self-retaining abdominal retractor (downleft). Isolation of the uterus from other pelvic organs, atraumatically (down-right).
The uterine ligaments and the vascular pedicles were ligated and cut with LigaSure (Valleylab, Boulder, CO) with the help of the second assistant who manipulates the uterine manipulator [4]. The first assistant presented the pelvic field using Sims and Deaver retractors when required. All hysterectomies were performed extra-fascially. If required, manual morcellation may help uterine abdominal extraction ( Figure 2).
The laparoscopic and Pfannenstiel techniques were performed according to standard techniques [6,7]. These procedures were also performed using the LigaSure vesselsealing system.

Statistical analysis
As this is a retrospective study we did not calculate statistical power according to sample size.
All data were presented using the mean value with standard deviation and 95% confidence intervals. A p-value < 0.05 was considered as statistical significant.
The continuous variables were compared using ANOVA with Bonferroni post hoc test or Kruskall-Wallis tests. The Chi-square test was used for comparing categorical varia-bles. All data analyses were performed using SPSS version 13.0 (SPSS, Inc., Chicago IL). The demographic and preoperative variables did not reveal significant association with regard to the surgical approaches (Table 2) Mean surgical time for the minilaparotomy approach was significantly shorter (73.4 minutes, SD: 25.1, range: 67.8 to 78.9) as compared with the Pfannenstiel (101.9 min-  Intraoperative bleeding and intraoperative complocations were similar for all three procedures analysed (Table 3) Postoperative complications were also similar for all three procedures (Table 4).

Discussion
In the present study we have found that total hysterectomy by minilaparotomy is faster than Pfannenstiel and laparoscopic approach. These results confirm previous data from by Sharma [8] and Hoffman-Lynch [9]. We also found the minilaparotomy procedure to be faster than the laparoscopic and Pfannenstiel procedures. Although the shortest hospital stay was for the laparoscopic approach.
Regarding intraoperative and postoperative complications we did not find any statistical differences, so all three technique are similarly safe, in agreement with other previous studies [8][9][10].
One relevant question is that a small surgical area provides better cosmetic outcome [10]. In addition, the minilaparotomy procedure offers the potential to leave the abdominal surface free from scars (lending further cosmetic value to the process). Nevertheless, a reduced surgical field may also generate some difficulties in respect of pelvic access (large fibroids, presence of adherences) or upper abdominal cavity exploration (routine in the laparoscopic approach). This situation makes advisable the presence of a second surgical assistant using the uterine manipulator, as with regard to the laparoscopic process too. As a matter of fact, our surgeons did not find minilaparotomic approach more difficult than laparotomic or laparoscopic approaches.
The minilaparotomy technique may be considered an "atraumatic procedure" [8] because neither fixed abdominal retractors nor pneumoperitoneum [10] are used,  which are both potential causes of postoperative pain (although this was not measured in our study).
Several studies have assesse the role of the minilaparotomy technique for the hysterectomy procedure, alone or in comparison with other abdominal or endoscopic approaches (Table 5) [1,3,8,9,11,12]. Most of these studies concluded that minilaparotomy may be an alternative to other approaches. However, it is difficult to compare the outcomes of these studies due to the heterogeneity of study designs, the different preoperative conditions and as well as the variables considered.
The only prospective randomized multicenter trial performed so far by Muzzi et al concluded that LAVH was a better option than minilaparotomy because a shorter stay and lower morbidity [12].

Conclusion
Minilaparotomy procedure may be considered a time saving technique for total hysterectomy for benign uterine pathology. It offers some of the advantages of a minimally invasive procedure (low morbidity, short hospital stay, good cosmetic results) and the benefits of open access (for example, shorter learning curve than laparoscopy).