Nicola Gasbarro

INTRODUCTION
The abdominal hysterectomy is still the operation more frequently performed by the gynaecologist. About 600,000 hysterectomies are carried out in the United States each year, and 400,000 of them are total abdominal hysterectomies (17). The first abdominal hysterectomy was performed by Charles Clay in Manchester, England, in 1843; unfortunately the patient died in the immediate postoperative period. It was not until 1853 that Ellis Burnham from Lowell, Massachusetts, achieved the first successful abdominal hysterectomy. These early procedures, as well as the following pioneeristic operations, were supracervical hysterectomies. The mortality rate was of about 70%, mainly due to haemorrage, peritonitis and sepsis. Infections, in particular, were very common, because it was customary to leave a long ligature to promote the drainage of fluid from the vagina. Thomas Keith from Scotland, perceiving the risks of this practice, condemned it. He also introduced the cauterization of the cervical stump, thereby bringing the mortality down to about 8% (23). Hysterectomy became safer with the introduction of anaesthesia and proper antisepsis. During the 1930s, Richardson introduced the total abdominal hysterectomy, by distinguishing between the intrafascial and extrafascial procedure, according to a technique that has been employed until now (21). However, up to the 1960, the supracervical hysterectomy has been the standard technique for the removal of the uterus in presence of benign lesions. The procedure is relatively simple. It significantly reduces the risks of injuries to the urinary tract and minimizes the blood loss and the infections (10). Furthermore, the topography of the pelvic floor is maintained. Because of the subsequent reports of cervical stump cancers, with an incidence of 0.3 - 1.9 %, in a largely unscreened population, it was then recommended that the total hysterectomy would have to be preferred to the supracervical one (25). There was little advance in the hysterectomy techniques until the performance of the first laparoscopic hysterectomy, in 1988, by Harry Reich in Kingston, Pennsylvania, who actually performed a laparoscopically assisted vaginal hysterectomy (LAVH) (20). As the LAVH gained popularity (in some areas of the USA it accounts for the 30% of the hysterectomies (4) ), a passionate debate raised on the better way to performe the hysterectomy (14, 15). In our opinion, the advent of the laparoscopic hysterectomy has favoured the developement of a minimally invasive approach also in the laparotomic surgery. However, this approach has not to be confined to the length of the skin incision, but it should avoid the estirpation of healthy organs. In this setting, the minilaparotomic intrafascial hysterectomy accomplishes the principles of the minimally invasive and organ preserving surgery, by preventing the cervical cancer and by preserving the pelvic support.

BASIC ELEMENTS OF PELVIC FUNCTIONAL ANATOMY (12) According to the classical anatomic description, the pelvic connettive tissue condensates around the pelvic viscera and the neurovascular structures to form adventitial layers that represent the visceral fasciae (vesical, vaginal, cervical and rectal fascia) and the neurovascular connective bands (cardinal ligaments, utero-sacral and pubo-cervical ligaments). The visceral fasciae are irregularly developed and in some areas they result very thin and difficult to isolate. However, they appear very strong where the viscera go in contact, as it occurs between the bladder and the cervix or between the rectum and the vagina. Here, we focus on the cervical fascia, that surround the cervix. The cervical fascia is well developed either anteriorly, where it goes in contact with the vesical fascia, either posteriorly, where it lies separate from the rectal fascia by the pelvic connective tissue.To the cervical fascia are attached, laterally, the cardinal ligaments (Mackenrodt’s ligaments or lateral parametrium), anteriorly, the vesical-cervical band of the pubocervical ligament (anterior parametrium), posteriorly, the uterosacral ligaments that all provide a supportive meshwork for the uterus and the superior vaginal third (Fig. 1).

The anterior parametrium has considerable surgical importance because it is crossed from the terminal tract of the pelvic ureter, which, approaching the bladder, crosses under the uterine artery: this is the hazardous angle of the hysterectomy, because of the injurie risks to the ureter when the uterine vessels are clamped.

ADVANTAGES OF THE INTRAFASCIAL TECHNIQUE
The rationale for the employement of the intrafascial hysterectomy relies upon these anatomo-functional basis. By the intrafascial technique the cervical fascia is circumferentially incised around the cervix and it is detached from the underlying muscular tissue to obtain a fibrous cuff, by which the connexions to the endopelvic fascia are preserved. Furthermore, the cervical and vaginal branches of the uterine artery are spared, because they are positioned laterally to the cuff, as well as the ureter is less frequently injured, because of a greater distance from the surgical plane of dissection. The advantages will follow are summarized in this table:

Advantages of the intrafascial technique

Preservation of the connexions between the endopelvic fascia and the superior vaginal third (prevention of the vaginal vault prolapse)

Preservation of the vaginal length and axis, that favours the pelvic support and, probably, the sexual function

Preservation of the cervico-vaginal branches of the uterine artery (better irroration of the vaginal mucosa)

Less probability of vesical and ureteral injuries

Less vesico-uterine dissection (less bleeding, less dead spaces, less infectious morbidity)

First, the connexions between the endopelvic fascia and the superior vaginal third are preserved, thus preserving the support of the vagina and preventing the vaginal vault prolapse. The mean incidence of this complication reported in the literature is 0.4%. However, the data are often confused by the mixture of abdominal and vaginal hysterectomies and by the mixture of operations performed for genital prolapse as well as for other diseases. In a recent and accurate study the incidence of the vault prolapse after abdominal hysterectomy performed for other indications than genital prolapse was 2%, thus showing that this complication is often underestimated (18). According to the abovementioned principles, the vaginal vault prolapse after the intrafascial abdominal hysterectomy occurs only in 0.1-0.4% of cases and, in some study, it is completely absent (2, 3 , 8, 11). Moreover, by the intrafascial techniqe, not only the support of the vagina is preserved, but also its configuration, its length and its axis, as studies on vaginal casts, performed prior and after the operation, have demonstrated (8, 9). By contrast, the extrafascial technique often causes a shortening of the vagina and modifies its axis because of the anchorage of the vaginal cuff to the cardinal, utero sacral and round ligaments in such a way that the pelvic support and the sexual function can be negatively affected. Although the influence of the abdominal hysterectomy on sexual activity and satisfaction is contoversial, and probably not very important (26), it can be hypothesized a more favourable otcome when the anatomic principles are respected. Similarly, the preservation of the cervicovaginal branches of the uterine arteries can positively affect the irroration of the vaginal mucosa as well as the sexual activity. For the same reasons, the bladder and the ureters are less frequently injured. The literature data show that the abdominal hysterectomy is the first cause of the urinary tract injuries: it accounts for the 80-99% of all ureteral lesions that occur in the 0.5% of all abdominal hysterectomies (6, 19, 24). Regarding the bladder injuries it is estimated a 0.8% incidence and in 20% of cases the lesion goes undetected during the operation or the primary repair fails thus producing a fistula (6). On the contrary, data from the greater studies on the intrafascial technique report 0.1% of ureteral injuries and 0.4% of vesical lesions (2, 3, 16). These results come not only from the greater distance between the urinary tract and the surgical dissection plane, but also from the less dissection that is required for the removal of the uterus. This, also, involves less bleeding, less dead spaces and, last but not least, less postoperative infectious morbidity (16). INDICATIONS Basically, the indications for the minilaparotomic intrafascial hysterectomy are the same as for the extrafascial one, unless the endometrial and cervical malignancies. There is no controindication to treat by this way the cervical preinvasive lesions (H-SIL), for which total hysterectomy is judged today an overtreatment, but that, in selected cases, can result a more appropriate treatment than the cold knife conization or than the loop electrical excision procedure (LEEP). To further select the patients, some Author advises that the uterus should be not more than 12 weeks and not fixed (7). However, as for the vaginal hysterectmy, the presence of a more enlarged and/or fixed uterus does not absolutely contraindicate this procedure. On the contrary, the minilaparotomic approach makes everyone capable of performing the two-valves section of the uterus (Doderlein procedure) or the coring technique, that only the more skilled surgeons can employ in the vaginal approach. Furthermore, it is possible, in the more difficult cases, a combined laparoscopic-minilaparotomic approach (27), with the gasless technique, without pneumoperitoneum, by which the surgical field is simultaneously under the laparoscopic and laparotomic. This approach results very useful when a large posterior or infraligamentary myoma has to be removed by morcellation or when an adhesiolisis has to be performed (5).

OUR EXPERIENCES
In this study we retrospectively evaluate 211 patients who, from January, 1, 1995, to April, 2, 2002, underwent a minilaparotomy intrafascial hysterectomy, 112 of them with bilateral salpingooophorectomy and 99 with adnexa preservation, at our Department. The admission diagnoses for hysterectomy were: sintomatic uterine myomas in 182 patients, endometrial hyperplasia in 11, adenomyosis in 15, and tuboovarian abscess in 3. The mean age of the patients was 46 years (range 37 - 64 years) and the body mass index resulted 28.8 (range 22 - 34). The mean uterine weight was 280 gr. (range 98 - 630 gr.). The mean operative time resulted 34 minutes (range 28 - 45). Regarding the intraoperative complication rate, only one vesical injurie occurred, promptly repaired. Neither ureteral injuries, nor bowel perforations, nor haemorrage have occurred. In 8 patients postoperative fever has developed; the causative factor was the wound infection in 3 patients and a supravaginal fluid collection in 2, that do not required further surgical procedures. The mean hospital stay was 2 days. At present, no case of vaginal vault prolapse has occurred.

CONCLUSIONS
Nowadays there are four ways an hysterectomy can be performed: by laparotomy and by minilaparotomy, vaginally and laparoscopically. For each of them three techniques can be employed: the supracervical one, the extrafascial and the intrafascial. An hysterectomy can also be carried out by a combined approach: laparoscopic and vaginal, minilaparotomic and vaginal (13), laparoscopic and minilaparotomic (27). These innovations were not universally appreciated and many Authors state that the 80-90% of all hysterectomies could be performed in a shorter and cheaper manner vaginally (22). By contrast, we believe that by these new approaches the more common gynecological operation can be tailored according to the principles of the minimally invasive and organ preserving surgery. In particular, the minilaparotomy intrafascial hysterectomy represents, unlike the laparoscopic one, a chance within the capability of all pelvic surgeons, when the uterus has to be removed for a benign desease. Furthermore, the minilaparotomy, equals with the laparoscopy the advantages of less tissue trauma, less morbidity, and less postoperative pain. On the other hand, the intrafascial technique does preserve the connexions between the superior vaginal third and the endopelvic fascia, thus achieving the best prophylaxis against the vaginal vault prolapse and many others abovementioned benefits.

Translated by Interpres sas

N. Gasbarro M. Brusati P. Lupo, A. Togliani
Regione Piemonte ASL 7 - 10034 Chivasso (TO) Ospedale Civico. U.O. di Ostetricia e Ginecologia (Direttore: Dr. N. Gasbarro)