Novel Ligament-Sparing Hysterectomy Associated With Less Morbidity

Peggy Peck

April 29, 2003

April 29, 2003 (New Orleans) — Results from a small comparative study suggest that a novel technical approach — intrastromal abdominal hysterectomy — may decrease morbidity associated with traditional abdominal surgery by shortening length of stay and decreasing blood loss.

The results were presented here Monday at the 51st annual meeting of the American College of Obstetricians and Gynecologists (ACOG).

Daryoosh Samimi, MD, medical director of the US Women Institute in Fountain Valley, California, told Medscape that he developed the procedure as a means of "preserving the integrity of the ligature" supporting the uterus. He said that he has used the technique successfully in 43 hysterectomies, in women with benign, symptomatic disease.

In the paper presented at the ACOG meeting, he compared outcomes in a series of 40 women: 20 were randomized to the intrastromal procedure and 20 to traditional hysterectomy. The women ranged in age from late 30s to mid 60s.

"I use a standard bikini incision but after cutting the uterine artery, I do not cut either the cardinal ligament or the uterosacro cardinal ligament complex," he explained. Sparing the ligaments reduces intraoperative blood loss, he said. In this series the average hemoglobin loss was 1.0 g/dL for women who underwent intrastromal surgery compared with 1.4 g/dL for women who had traditional surgery. This difference was significant (P = .001).

The difference in hospital stay length was 2.7 days for women undergoing intrastromal surgery and 3.15 days for traditional surgery (P = .005).

Dr. Samimi said the procedure is safe; there were no postoperative infections, ureter injury, vaginal vault prolapses, or posthysterectomy fistula in either arm.

The procedure can be performed without regard for uterus size, which makes it a more universal option than vaginal hysterectomy. In fact, Dr. Sumimi said that in his practice, "I am no longer offering vaginal hysterectomy. I just do this procedure because it is a scientifically better operation."

Others are less convinced. Bryan D. Cowan, MD, professor and chairman of obstetrics and gynecology at the University of Mississippi in Jackson, told Medscape that "twenty patients are just not enough to make this claim. You need at least 60 patients in each arm to really show a difference." In addition, a well-designed study would "call in other centers, maybe three centers in all, to broaden the results," Dr. Cowan said.

Moreover, Cowan maintains that the hospital stay numbers are subject to bias. "A determined physician and a working woman who really needs to get back to that job," can combine to produce "really impressive [length-of-stay] numbers."

He added that while it seems technically possible to remove the uterus in the way described by Samimi, "most surgeons prefer to cut the ligaments so that we have a good open field for surgery."

But despite his skepticism, Dr. Cowan said, "I'm glad he [Samimi] is doing this because we need more innovative approaches." Gynecologic surgeons are constantly searching for ways to reduce the morbidity associated with surgery. "I'm just not buying this approach," he said.

ACOG 51st Annual Clinical Meeting: Poster 40. Presented April 28, 2003.

Reviewed by Gary D. Vogin, MD

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