Original Article

Laparoscopic Supracervical Hysterectomy with Transcervical Morcellation: Initial Experience Peter Rosenblatt, MD*, Gretchen Makai, MD, and Anthony DiSciullo, MD From the Division of Urogynecology and Reconstructive Surgery, Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts (all authors).

ABSTRACT Study Objective: To describe a novel method for morcellation at laparoscopic supracervical hysterectomy and to define its potential benefits. Design: Retrospective observational study (Canadian Task Force classification III). Setting: Hospital-based urogynecology and general gynecology practice and a single community teaching hospital of a university medical school. Patients: The first 51 women to undergo laparoscopic supracervical hysterectomy with transcervical morcellation at a single institution. Intervention: A novel surgical technique that uses a transcervical approach for morcellation of the uterine fundus after amputation from, and coring of, the cervix. Measurements and Main Results: Laparoscopic supracervical hysterectomy with transcervical morcellation was completed successfully in all 51 patients. Mean (SD) operating time for laparoscopic supracervical hysterectomy with transcervical morcellation alone was 64.3 (28.4) minutes, and median hospital stay was 1 day. There were no intraoperative or postoperative complications related to transcervical morcellation at a median (range) follow-up of 4.4 (1.6–11.7) months. Conclusion: Laparoscopic supracervical hysterectomy with transcervical morcellation is a feasible procedure that removes the cervical core and does not require enlarging an abdominal port site for introduction of the uterine morcellator. Journal of Minimally Invasive Gynecology (2010) 17, 331–336 Ó 2010 AAGL. All rights reserved. Keywords:

Laparoscopy; Supracervical hysterectomy; Transcervical morcellation

The number of hysterectomies performed in the United States has remained relatively constant at 600 000 per year for the last 10 years [1]. Despite improvements in laparoscopic instrumentation, optics, and insufflators, the percentage of hysterectomies performed laparoscopically is relatively low (15%), and abdominal hysterectomies continue to comprise most cases [2]. While many hysterectomies require an abdominal incision (e.g., advanced ovarian cancer,

The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Dr. Rosenblatt is a consultant for Ethicon Women’s Health & Urology and Gyrus ACMI. Dr. DiSciullo is a consultant for Gyrus ACMI. Presented as a video at the 37th Global Congress of Minimally Invasive Gynecology, October 28–November 1, 2008, Las Vegas, Nevada. Corresponding author: Peter Rosenblatt, 725 Concord Ave, Suite 3300, Cambridge, MA 02138. E-mail: [email protected] Submitted November 12, 2009. Accepted for publication February 3, 2010. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2010 AAGL. All rights reserved. doi:10.1016/j.jmig.2010.02.004

massive myomas), clearly many hysterectomies that are currently being performed through an open incision could be performed either vaginally or laparoscopically, with the commonly stated advantages to the patient such as decreased pain, shorter hospitalization and recovery, and improved cosmesis [3]. Laparoscopic supracervical hysterectomy (LSH) has grown in popularity as an alternative to laparoscopicassisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) in the last decade for several reasons. It may reduce complications such as bladder and ureteral injury, does not seem to disrupt the normal support of the vaginal apex, and is technically easier to perform than LAVH or TLH [4–6]. Herein, we present the initial results of a novel modification of LSH in which morcellation of the uterine corpus is performed transvaginally after laparoscopic amputation of the uterus and coring of the cervix. With this technique, there is no need to enlarge any of the abdominal port sites to accommodate the morcellator.

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Materials and Methods This study was a retrospective analysis of the first 51 patients undergoing laparoscopic supracervical hysterectomy with transcervical morcellation (LSH/TCM) over 18 months from January 2008 to June 2009. All patient care was given in a hospital-based urogynecology and general gynecology practice, and 1 community teaching hospital of a university medical school. All procedures were performed by a gynecologist or urogynecologist along with either an obstetrics and gynecology resident or a urogynecology or gynecologic laparoscopy fellow. The study was approved by the Institutional Review Board of Mount Auburn Hospital, Cambridge, Massachusetts. All patients received a single dose of preoperative prophylactic antibiotics. The LSH was performed with the PK bipolar cutting forceps (Gyrus ACMI, Inc.) in 47 patients (92.2%) and with the Ligasure 5-mm bipolar instrument (Covidien) in 4 (7.8%). The coring instrument used in the initial 6 patients was the Gynecare Morcellex (Ethicon, Inc.) with a 10-mm flat myoma screw, and subsequently the 15-mm CISH instrument set (WISAP GmbH) was used to perform the coring. Morcellation was performed in all cases using the 15.9-mm Morcellex. Cervical closure was performed using a fascial closure device in 12 patients (23.5%), with laparoscopic suturing in 22 (43.1%), and via the vaginal approach in 16 patients (31.4%). The method of cervical closure in 1 patient (2.0%) was not reported. The procedure begins with insertion of a uterine manipulator (Pelosi, Apple Medical Corp., Marlborough, Massachusetts, or Zumi, Zinnanti Surgical Instruments, Inc., Chatsworth, CA) and a transurethral catheter. After insufflation is performed in standard fashion using a Veress needle, a 5-mm trocar is placed through the umbilicus, and a 0-degree 5-mm laparoscope is placed through this port site. Two additional 5-mm trocars are placed into the right and left lower quadrants, lateral to the inferior epigastric vessels, after laparoscopic visualization of these vessels. In some early cases in which concomitant reconstructive procedures were performed, 11-mm trocars were placed in the lower quadrants bilaterally to facilitate suturing, and a suprapubic 5-mm trocar was also placed. In later procedures involving reconstructive surgery, only 5-mm trocars were used as mesh and needles were introduced and removed transcervically. Bipolar cutting forceps (Gyrus PK; Gyrus ACMI, Inc., Minneapolis, MN) were used in most cases. The LSH procedure is performed in standard fashion, with coagulation and transection of the round ligaments and development of the bladder flap. Either the infundibulopelvic or uterine-ovarian ligaments are coagulated and transected, and the posterior leaf of the broad ligament is incised to the level of the uterosacral ligaments. The uterine arteries are then skeletonized and coagulated, and transected only when the uterus becomes visually cyanotic, indicating successful bilateral occlusion of the uterine arteries. A bipolar spatula (Gyrus PlasmaSpatula; Gyrus ACMI, Inc.) is then used to transect the uterine corpus

Fig. 1. The 15-mm CISH instrument with central rod is placed against the cervix, and a core is removed using back-and-forth rotation of the serrated blade.

from the cervix at the level of the internal os. Any bleeding from the cervix is controlled using bipolar electrocautery. After complete transection of the uterine fundus from the cervical stump, the uterine manipulator is removed and 1 surgeon changes position to operate between the patient’s legs. The cervix is sounded to determine the axis of the cervical canal. In the initial 6 cases, a 10-mm flat myoma screw (Karl Storz GmbH & Co., Tuttlingen, Germany) was placed through the 15.9-mm morcellator (Gynecare Morcellex; Ethicon, Inc., Somerville, New Jersey) and then screwed into the cervix transvaginally until the myoma screw was visualized laparoscopically coming up though the cervix. The morcellator was then placed up against the cervix, and morcellation was initially performed to core out the endocervical canal and adjacent tissue. In the remainder of the cases, a 15-mm classic intrafascial supracervical hysterectomy (CISH) instrument set (Wisap GmbH, Munich, Germany) was used for coring of the cervix. A blunt rod is used to sound the cervix, and a serrated cylindrical blade is placed up against the cervix (Fig. 1). A cylinder with a central aperture that accommodates the blunt rod is placed within the outer serrated blade to maintain the proper axis for the cervical coring. Using a clockwise and counterclockwise motion, the cervix is manually cored, and the specimen is removed, along with the serrated CISH blade. Regardless of instrumentation, the entire coring procedure is performed with direct laparoscopic visualization of the pelvis to ensure no injury to internal organs. All specimens are tagged with a single suture at the ectocervix for pathologic orientation. When coring of the endocervix is complete, the serrated blade is removed and the morcellator is advanced into the pelvic cavity for removal of the uterus. Morcellation is performed using a 10-mm tenaculum placed through the morcellator. The laparoscopic assistant orients the specimen for the tenaculum in such a manner as to maintain the morcellator blade on the outer surface of the uterine corpus. Using the ‘‘core-guard’’ lip on the morcellator also facilitates this process. Morcellation may be made easier by using a reverse

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image unit (Karl Storz GmbH & Co.) connected to an accessory monitor, placed at the head of the bed. This monitor provides a mirror image of the pelvis and is used by the vaginal surgeon to direct morcellation. When the specimen has been completely removed, the defect in the cervix is closed to prevent herniation of bowel or adnexa through the cervix. In early cases, a fascial closure device (Grice needle; Covidien, Mansfield, MA) was used to close the defect. The needle, loaded with 0 polyglactin 910 absorbable suture (Vicryl; Ethicon, Inc.), is introduced vaginally and inserted into the ectocervix at approximately the 12-o’clock position. The needle is advanced parallel to the core defect, the length of the cervix, until it reaches the peritoneal cavity at the level of the internal os (cut edge of the cervix). The end of the suture is grasped with a laparoscopic instrument, and the fascial closure device is withdrawn from the cervix. A second pass with the needle is then performed at the 6-o’clock position on the cervix, and the suture is retrieved from the abdominal cavity and brought out vaginally. The suture is then tied down vaginally, bringing the walls of the cervical canal together and closing the cored defect. In some later cases, closure of the cervical defect was performed with laparoscopic suturing using an interrupted absorbable 0 suture (Vicryl) and an extracorporeal knottying technique. In other cases, closure of the cervix was performed using a vaginally placed purse-string suture of 2-0 absorbable suture (Vicryl). Data are given as mean (SD, 95% CI), median (interquartile range), or percentage, as appropriate. Some percentages may not sum to 100% because of rounding. Results In this series, mean (SD) age of patients undergoing LSH/ TCM was 50.2 (9.5, 47.5–52.9) years, body mass index (calculated as weight in kilograms divided by height in meters squared) was 26.1 (5.3, 24.6–27.7), and median (range) parity was 2.0 (2.0–3.0). Most of the women (52.9%) were premenopausal, 33.3% were postmenopausal, and 13.7% were perimenopausal. Indications for hysterectomy included myomas (n 5 24), menorrhagia (n 5 17), prolapse (n 5 27), and pain (n 5 11). All patients with abnormal uterine bleeding underwent preoperative endometrial biopsy. In 10 women (19.6%), LSH/TCM was the only procedure performed, whereas concomitant procedures were performed in the other 41 (80.4%) (Table 1). Mean (SD) time for the LSH/TCM procedure was 64.3 (28.4, 55.5–73.0) minutes. Operative time is defined as the time from first incision to completion of cervical closure, and does not include time for closure of any abdominal incisions. In patients who underwent additional procedures, LSH/TCM time was calculated using the raw LSH time and adding cervical coring, morcellation, and cervical closure times. Mean total operating time was 220.6 (79.0, 198.1–243.0) minutes because 80.4% of women underwent concomitant procedures. Individual steps in the procedure were defined and timed as follows:

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Concomitant procedures Procedure

No.

Bilateral salpingo-oophorectomy Unilateral adnexal surgery Sacrocervicopexy Perineorrhaphy Suburethral sling Anterior or posterior repair Cystoscopy Other

7 5 27 10 25 3 33 5

(1) LSH, that is, time from initial abdominal incision to transection of the uterine corpus from the cervix, 46.6 (19.4, 40.6– 52.6) minutes; (2) cervical coring, time from introduction of the coring instruments in the vagina to removal of the core specimen, 3.6 (2.3, 2.5–4.6) minutes; (3) uterine morcellation, time from first activation of the morcellator to removal of the last piece of specimen or ‘‘chip,’’ 12.8 (14.4, 8.4–17.1) minutes; and (4) cervical closure, time from initiation of cervical closure until last knot is secured and cut, 4.2 (4.3, 2.9–5.6) minutes. During follow-up of median (range) duration 4.4 (1.6–11.7) months, there were no major intraoperative complications related to transcervical morcellation. In 1 patient, bleeding was noted from a vessel, presumably the uterine artery, during insertion of the fascial closure device to close the cervical defect. This was easily controlled with laparoscopic bipolar electrocoagulation. Four other intraoperative complications occurred in our series: 2 patients had corneal abrasions; 1 patient had subcutaneous emphysema that required intubation in the postanesthesia care unit, after which extubation was successful; and 1 patient had subcutaneous emphysema that required intubation for less than 24 hours. Postoperative complications included readmission of 3 patients, none of whom experienced long-term sequelae. One woman who underwent LSH/TCM only was readmitted 1 week postoperatively because of right-sided colitis diagnosed at computed tomography (CT), which resolved spontaneously in days. Another patient, who underwent LSH/TCM with sacrocervicopexy and transobturator suburethral sling, was readmitted on postoperative day 3 because of fever, nausea, and constipation. Physical examination was unremarkable; however, workup revealed a white blood cell count of 14 600/mL, and intravenous antibiotics were administered overnight. Defervescence occurred within 24 hours, and all follow-up studies (urine culture, blood culture, chest radiography, and CT of the abdomen and pelvis) yielded normal findings. The patient was discharged to home on hospital day 2 without antibiotic therapy, and recovered without further issues. A third patient was readmitted on postoperative day 2 after LSH/TCM, sacrocervicopexy, and transobturator suburethral sling, for which she had been in surgery for more than 4 hours. At readmission, she reported nonspecific symptoms but was found to have hypoxemia (room-air oxygen saturation, 88%) and hyponatremia (blood sodium concentration, 134 mEq/L). Hypoxemia resolved within 48 hours with supportive

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treatment (supplemental oxygen and bedside incentive spirometry). The chest radiograph showed bilateral pleural effusions but no evidence of pneumonia, and CT ruled out pulmonary embolus. The cause of the hyponatremia was never elucidated; however, the sodium concentration slowly improved over 3 days of hospitalization. Initially, in patients in whom laparoscopic sacrocervicopexy was performed after LSH/TCM, 11-mm trocars were used in the right and left lower quadrants. These ports were used for insertion and removal of mesh and suture needles. As our experience with cervical access increased, however, our method changed so that only 5-mm trocars were used abdominally. Polypropylene mesh and needles were introduced and removed through the Morcellex trocar, which was left in the cervix once morcellation was completed. Laparoscopic instruments were placed through this trocar to deliver and retrieve these devices from the peritoneal cavity. Patients were asked on postoperative day 1 to score their level of pain on a scale of 0 (no pain) to 10 (worst imaginable pain). The median (range) reported pain score was 3.0 (2.0–4.0). Mean length of stay was 1.0 (1.0–1.0) days (overnight but less than 24 hours). No patients had immediate or delayed postoperative vaginal bleeding, and none reported postoperative cyclic bleeding. Median (range) uterine specimen weight, available for 45 of 51 patients, was 124.0 (86.0–180.0) g, with a minimum weight of 37.0 g and a maximum of 1800 g. Uterine pathologic findings were benign in all patients but 1, in whom mild atypia of the endometrium was identified. At 1 year after surgery, there was no evidence of disease, and no further follow-up was planned other than routine Papanicolaou tests (Pap smears). Pathologic analysis of the cervical core revealed an unexpected low-grade squamous intraepithelial lesion in 1 patient, who had no history of abnormal Pap smears. The postoperative Pap smear was normal, and the patient will be followed up with routine cervical cytologic analysis. All other cervical core pathologic findings were benign. Discussion Laparoscopic supracervical hysterectomy is an option in women with abnormal uterine bleeding, symptomatic uterine myomas, or other benign conditions indicative for hysterectomy who have no history of recent or current cervical dysplasia. Before 1950, approximately 95% of all hysterectomies were performed supracervically [4]. This approach was used for several reasons including shorter operative time (and, therefore, anesthesia time) decreased blood loss and visceral injury, and avoidance of vaginal entry in an attempt to decrease postoperative vaginal cuff cellulitis. With improved anesthesia and surgical techniques, and the widespread use of prophylactic antibiotic therapy, supracervical hysterectomy fell out of favor. More recently, there has been renewed interest in supracervical hysterectomy, specifically

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LSH, for several reasons. First, LSH may decrease the risk of bladder and ureteral injury because the dissection need not extend as far inferiorly on the cervix and vagina as with total hysterectomy [5]. Second, by retaining the cervix, the natural support of the vagina to the uterosacral ligaments is not compromised, which may reduce the risk of future vaginal prolapse. While this is theoretically an attractive argument, there is no literature to support this assertion [4]. In addition, total hysterectomy may lead to vaginal foreshortening, which does not occur with cervical preservation. Most gynecologists find that LSH is technically easier to perform than either LAVH or TLH. It has also been demonstrated that compared with LAVH, LSH results in shorter operating time, shorter hospital stay, and less morbidity [7]. Innovations in instrumentation such as bipolar cutting instruments, ultrasonic coagulation, and electromechanical morcellation have made LSH safer and more efficient to perform. Critics of supracervical hysterectomy point to several disadvantages of retaining the cervix, such as the potential for developing postoperative cyclic bleeding from hormonally active cells being left behind in the specimen [7]. This has been reported to occur in 5% to 20% of patients undergoing LSH [8–10]. In addition, preservation of the cervix results in the potential for development of cervical cancer. Although PAP smears are effective in detecting cervical dysplasia and squamous cell carcinoma, adenocarcinoma of the endocervix is more difficult to detect, and is actually increasing in the United States, for unknown reasons [11]. Finally, morcellators range in size from 15 to 20 mm, which requires that 1 of the laparoscopic port sites needs to be enlarged to accommodate the instrument, which increases postoperative pain secondary to the enlarged incision, requires suture closure of the fascial defect, and is associated with an increased risk of postoperative herniation [12]. The American College of Obstetricians and Gynecologists [13] published a Committee Opinion on Supracervical Hysterectomy in November 2007. According to this review of the literature, there is no benefit to retention of the cervix in an effort to reduce adverse effects on sexual and urinary function. In 2 trials, there was no difference in postoperative development of stress or urge incontinence, urinary frequency, or incomplete bladder emptying in patients who underwent total abdominal hysterectomy compared with supracervical hysterectomy. Although it has been suggested that women experience less sexual dysfunction with conservation of the cervix, controlled prospective studies have failed to support this proposition [14]. In a US study by Kupperman et al [14], there were no differences in sexual function between women who underwent total vs supracervical hysterectomy, when sexual function was measured by sexual desire, frequency and quality of orgasm, and body image 2 years after surgery. In a European study, Gimbel et al [10] reported no difference in sexual satisfaction in preoperative and postoperative questionnaires, irrespective of the type of hysterectomy performed (total or supracervical). Similar results were

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reported in another European study by Thaker et al [9], with no differences found between preoperative and postoperative frequency of intercourse and orgasm, regardless of whether total or supracervical hysterectomy was performed. To our knowledge, no randomized studies have compared LSH with either TLH or LAVH. In 1993, Semm et al [15] described the CISH procedure, in which a hollow serrated blade is used to core out the cervix and endometrium via a transvaginal approach before LSH is performed. Pneumoperitoneum is maintained by placing Endo-loops around the upper cervix before the coring device is removed. By removing the endocervical canal, the CISH procedure addressed the issue of postoperative cyclic bleeding and potential for carcinoma of the endocervix. The traditional CISH procedure, when applied to laparoscopic hysterectomy, still requires laparoscopic morcellation; thus, 1 of the abdominal port sites must be enlarged to accommodate the morcellator device. The LSH/TCM procedure shares some similarities with the CISH procedure in that the cervix is cored, thereby reducing or eliminating the possibility of development of postoperative cyclic bleeding or adenocarcinoma of the cervix. The LSH/TCM procedure has an additional advantage in that it eliminates the need to enlarge an abdominal port site for morcellation. The present retrospective study demonstrates the feasibility of LSH/TCM. What are the potential advantages of this approach compared with established techniques of laparoscopic hysterectomy? Laparoscopic-assisted vaginal hysterectomy requires that surgeons change their surgical approach intraoperatively before all vascular pedicles have been secured. It also requires removal of the cervix, which, in theory, may weaken the vaginal supports, specifically the uterosacral ligaments, and may also lead to vaginal foreshortening. Total laparoscopic hysterectomy requires no vaginal surgery but similarly interrupts natural vaginal supports. In addition, TLH requires that the surgeon perform deeper dissection of the bladder and uterine vessel pedicles and possess laparoscopic suturing skills to close the vaginal cuff. Traditional LSH addresses most of these issues but requires a larger abdominal port-site incision for morcellation, and the subsequent need for fascial closure, and does not address the potential for cyclic bleeding or development of adenocarcinoma of the cervix. The LSH/TCM procedure, in which a core of the endocervical canal is removed, potentially addresses all of these issues. The potential advantages of cervical preservation are maintained, such as retention of vaginal apical support and depth, and fewer surgical complications such as bladder and ureteral injury. The need for laparoscopic suturing is eliminated with LSH/TCM because, in our experience, the cervix can be closed easily with a vaginal purse-string suture. Perhaps most important, transcervical morcellation obviates the need to enlarge 1 of the laparoscopic port sites, which decreases incisional pain and, in theory, decreases the likelihood of port site hernias. As an additional benefit to LSH/TCM, we have found that while transabdominal morcellation may result in uterine ‘‘chips’’

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being spread throughout the abdominal cavity, transcervical morcellation tends to limit any spread of these chips to the cul-de-sac, where they are easily retrieved. Mean time required for morcellation in our series was 13 minutes, which suggests that this approach to morcellation does not extend the time of LSH. While coring of the cervix and subsequent closure of the cervical defect are required with this approach, the mean times required for these steps did not seem excessive. We are encouraged that none of our study patients demonstrated immediate or delayed postoperative hemorrhage from the cervix despite mechanical coring of the cervix. We believe that coagulation of the uterine arteries, pressure from the morcellator sleeve on the raw surface area of the endocervix, and cervical closure with absorbable suture may all contribute to prevention of this complication. Transcervical coring may be accomplished using one of several tools, including the Morcellex and the hand-held CISH instruments. More recently, we have used an electromechanical model of the CISH instrumentation, which we have found improves the consistency of the core specimen and decreases the coring time. We have applied the transcervical access techniques described in the present study to concomitant laparoscopic surgical procedures in which the surgeon would usually need to use larger port sites for introduction of materials such as suture needles and mesh. When performing LSH with sacrocervicopexy for treatment of uterine prolapse, the transcervical trocar is kept in place after morcellation of the uterine fundus. The mesh and all needles are inserted 1 at a time through the morcellator trocar using laparoscopic instruments, and are received in the peritoneal cavity by abdominally inserted laparoscopic instruments. After each suture placement, needles are retrieved though the cervical trocar in reverse fashion. We have also performed singleincision LSH with transcervical morcellation. In such cases, we have been able to minimize the size of the umbilical incision, which otherwise would have to be enlarged to accommodate the morcellator in addition to the laparoscope and grasper. Conclusion Laparoscopic supracervical hysterectomy with transcervical morcellation is a novel technique that has several real and theoretical advantages including minimizing laparoscopic port site size, reducing the chance of postoperative cyclic bleeding, and potentially decreasing the likelihood of cervical adenocarcinoma. Further studies are needed to evaluate such potential long-term benefits of removal of the cervical core. Nonetheless, immediate benefits are evident. Transcervical morcellation provides a useful access port for introducing and removing surgical devices such as mesh and suture needles, and can also be used to remove a variety of specimens from the pelvis. Laparoscopic supracervical hysterectomy with transcervical morcellation enables

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a variety of surgical procedures to be performed, keeping the size of laparoscopic incisions to a minimum, without increased risk of injury or infection.

Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jmig.2010.02.004. References 1. Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110:1091–1095. 2. Abenhaim HA, Azziz R, Hu J, et al. Socioeconomic and racial predictors of undergoing laparoscopic hysterectomy for selected benign diseases: analysis of 341 487 hysterectomies. J Minim Invasive Gynecol. 2008; 15:11–15. 3. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomized controlled trials. BMJ. 2005;330:1478. 4. Jenkins TR. Laparoscopic supracervical hysterectomy. Am J Obstet Gynecol. 2004;191:1875–1884. 5. Lyons T. Laparoscopic supracervical hysterectomy versus total hysterectomy. J Minim Invasive Gynecol. 2007;14:275–277.

Journal of Minimally Invasive Gynecology, Vol 17, No 3, May/June 2010 6. Milad MP, Morrison K, Sokol A, Miller D, Kirkpatrick L. A comparison of laparoscopic supracervical hysterectomy vs laparoscopically assisted vaginal hysterectomy. Surg Endosc. 2001;15:286–288. 7. Richards RS, Simpkins S. Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc. 1995;2:431–435. 8. Learman LA, Summitt RL Jr, Varner RE, et al. Total or Supracervical Hysterectomy (TOSH) Research Group. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Obstet Gynecol. 2003;102:453–462. 9. Thakar R, Ayers S, Clarkson P, et al. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med. 2002;347:1318–1325. 10. Gimbel H, Zobbe V, Andersen BM, et al. Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. BJOG. 2003;110:1088–1098. 11. Herzog TJ, Monk BJ. Reducing the burden of glandular carcinomas of the uterine cervix. Am J Obstet Gynecol. 2007;197:566–571. 12. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg. 2004;139:1248–1256. 13. ACOG Committee Opinion: supracervical hysterectomy. Obstet Gynecol. 2007;110:1215–1217. 14. Kuppermann M, Summitt RL Jr, Varner RE, et al. Sexual functioning after total compared with supracervical hysterectomy: a randomized trial. Obstet Gynecol. 2005;105:1309–1318. 15. Semm K. CISH (pelviscopic intrafascial hysterectomy, without colpotomy), TUMA (total uterine mucosa ablation) and IVH (intravaginal vaginal hysterectomy) [in German]. Gynakologe. 1993;26:378–384.