Observational studies showed that outcomes for robotic-assisted hysterectomy can be similar to laparoscopic hysterectomy but with less blood loss and possibly fewer conversions to laparotomy (55,56). The learning curve to stabilize operative times for skilled laparoscopic surgeons is about 50 cases (57). Although these case series demonstrated equivalent operative times, an analysis of the Premier hospital database of over 36,000 laparoscopic or robotic hysterectomies demonstrated longer surgical times and higher costs with the robot-assisted procedures compared with conventional laparoscopy with little difference in perioperative and postoperative outcomes (58). Robotic-assisted laparoscopic hysterectomy is associated with delayed vaginal cuff dehiscence around 7 to 8 weeks after hysterectomy, although one case series showed an increased frequency with conventional laparoscopy (59,60). The frequency of other complications is similar to conventional laparoscopy. A more complete discussion of this subject is in Chapter 25.
Another modification of laparoscopic hysterectomy is the introduction of laparoendoscopic single-site surgery or single-port surgery. Because some surgeons use multiple ports at one site, laparoendoscopic single-site surgery is probably the best term. The role of single-site access to hysterectomy is unclear, and there are only case reports (61). Specifically designed umbilical port systems that admit multiple instrument access have enabled the development of this technique. The availability of ﬂexible instruments and ﬂexible tip laparoscopes allows the surgeon to perform a hysterectomy by reducing instrument crowding and clashing at the umbilicus. The basic hysterectomy steps are the same.
Intraoperative Complications: Laparoscopic Hysterectomy
The intraoperative complications of a laparoscopic hysterectomy are similar to an open hysterectomy. These are injury to the ureter, bladder, and bowel and hemorrhage. Recognition and management are similar. Because there is an increased frequency of injury to the ureter and bladder, a cystoscopic evaluation after injection of intravenous indigo carmine dye is recommended (62).
Intraoperative bleeding during a laparoscopic procedure is handled by use of a bipolar instrument. The same principles apply as with an open case. Cautery should not be used without proper localization of the ureters. If it is not apparent where the bleeding is occurring, the procedure should be converted to an open one.
Many surgeons remove the bladder catheter at the end of the laparoscopic hysterectomy. Patients can resume a regular diet the same day as the surgery. Transition to oral analgesics can be made the same day.
Postoperative Complications of Hysterectomy
A comprehensive discussion of postoperative complications after gynecologic surgery is presented in Chapter 22.
Hemorrhage Immediately after hysterectomy, hemorrhage may become apparent in one of two ways. Bleeding from the vagina may first be noted by the nursing staff or physician within the first few hours after surgery. Second, the patient may be noted to have little bleeding from the vagina but deteriorating vital signs manifested by low blood pressure and rapid pulse, falling hematocrit level, and ﬂank or abdominal pain. The first presentation is in the form of bleeding from the vaginal cuff or one of the pedicles. The second presentation may be a retroperitoneal hemorrhage. Each situation is approached differently in its evaluation and treatment, but both involve the same general principles of rapid diagnosis, stabilization of vital signs, appropriate ﬂuid and blood replacement, and constant surveillance of the patient’s overall condition.