Route of Hysterectomy: “Straight-Stick” Laparoscopy

The laparoscopic, or “straight-stick” approach to hysterectomy accounts for ∼30% of hysterectomies performed. Enhanced magnification and visualization, decreased blood loss, and fewer complications have made laparoscopic hysterectomy a preferred approach and the modality recommended by the American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists when vaginal hysterectomy is not possible. Laparoscopic hysterectomy is ideal for managing fibroids, adnexal masses, and endometriosis by providing excellent visualization of the pelvis while offering the benefits of minimally invasive surgery. Large pathologies, such as fibroids or adnexal masses, can be navigated safely using an angled laparoscope. In patients undergoing surgery for pelvic pain, laparoscopy allows the surgeon to inspect the abdomen fully to determine if anatomical abnormalities or pathology are present. The laparoscopic approach is useful for patients who desire supracervical hysterectomy and for those having concomitant pelvic support procedures such as sacrocolpopexy. Advantages of laparoscopic hysterectomy include the ability to allow same-day discharge with no increase in intraoperative or postoperative complications, readmission rates, or 30-day morbidity, compared with patients admitted to the hospital. Patients are able to return to normal activities sooner and experience decreased postoperative pain, compared to patients who undergo abdominal hysterectomy. Shorter hospitalization and decreased complications have also enabled the laparoscopic approach to become more cost-effective than the abdominal approach. To facilitate a safe and effective laparoscopic hysterectomy regardless of surgical complexity, the surgeon must be comfortable with adhesiolysis, retroperiteoneal dissection, and suturing. There are several limitations to laparoscopy, including numerous prior surgeries, extensive pathology, comorbidities, and concern for malignancy. In these cases, an alternative route to hysterectomy may be preferred. Many of these challenges may be overcome with alternative entry points, modifications to trocar placement, an angled lens, and appropriate instrument selection. Surgeons who perform laparoscopic hysterectomy must anticipate potential concerns and consider patient-specific characteristics carefully when choosing this route of surgery. Surgeon skillset and expertise is essential to performance of straight-stick hysterectomy