УДК 61

The hystory of the formation of hysterectomy

Артемьева Светлана Дмитриевна – студентка Лечебного факультета Пермского государственного медицинского университета им. академика Е.А. Вагнера

Архипов Данил Олегович – студент Лечебного факультета Пермского государственного медицинского университета им. академика Е.А. Вагнера

Сапегина Фаниса Зуфаровна – кандидат медицинских наук, доцент, профорг кафедры Нормальной, топографической и клинической анатомии, оперативной хирургии Пермского государственного медицинского университета им. академика Е.А. Вагнера

Некрасова Людмила Владимировна – кандидат медицинских наук, доцент, ответственная за работу студенческого научного кружка на кафедре Нормальной, топографической и клинической анатомии, оперативной хирургии Пермского государственного медицинского университета им. академика Е.А. Вагнера

Abstract: Hysterectomy is one of the most commonly performed surgical procedures on women, mostly for the treatment of benign and malignant tumors. From ancient times to the present, it is possible to see how the technology of this surgical procedure has changed and improved. In the nineteenth century, vaginal hysterectomy was replaced by abdominal surgery, and with the introduction of endoscopic technology in the twentieth century, massive laparotomy access was replaced by microscopic incisions, reducing the risk of complications. Hysterectomy can now be conducted with minimum human intervention thanks to advances in robotic technology.

Keywords: hysterectomy, operative access, laparoscopy, robotization.

Operations for the removal of the uterus originate from ancient times [17]. The first mention of hysterectomy in history dates back to 120 BC. Soranus in Greece, by removing an inverted uterus that had become gangrenous, made the world's first attempt at this type of surgical intervention. After 70 years, the experience of a Greek surgeon was tried to repeat in Athens by Feminis.

The 11th century saw the writing of the first books in our era's history that were specifically on the uterus' extirpation. According to the Arab physician Alsacharavius, surgery should be performed to remove the uterus if it has slipped out and cannot be reinserted [18]. These procedures were only done in rare instances due to uterine prolapse or inversion, and they frequently resulted in bladder injury, which increased mortality. The technique was turned down because of the high death rate connected with it and the doctors' lack of understanding of the anatomy of the female reproductive system.

It took four centuries for the first recorded vaginal hysterectomy cases to surface. Italian anatomists Berengario da Carpi from Bologna in 1507, Andereas da Cruz from 1560, and German surgeon Valkaner from Nuremburg in 1675 carried out this urgent surgical surgery [19]. Nevertheless, none of them were effective, all of the patients passed away from complications such as diffuse peritonitis and sepsis a few days following the procedure.

The procedure was totally abandoned in the 17th century due to the significant death rate associated with vaginal hysterectomy, both during the procedure and in the aftermath. In the early 19th century, only the most skilled surgeons started taking on more responsibility and removing the entire uterus. Hysterectomy was the only emergency procedure available until 1813, and it was only used to treat uterine prolapse. Konrad Langenbeck performed the first elective vaginal hysterectomy in history, which altered the course of events. This incident sparked a widespread uproar. Even though the woman recovered well and showed no evidence of problems, Legenbeg's achievement was not acknowledged until 30 years later, following his patient's death from old age [3].

Even with the early successes, there was still a very high death rate following a hysterectomy. It was 90% even by the end of the 18th century [13]. At that time, the majority of doctors declined to perform the most complex vaginal hysterectomy because they believed that a woman's chances of survival were low. For this reason, the majority of the earliest surgical treatments made in the 19th century to cure cervical cancer and uterine prolapse involved removing the cervix and the bottom portion of the uterus.

In the USA, Ephraim McDowell made the first deliberate abdominal cavity incision in 1809 to remove a 10-kg ovarian tumor, while the development of the vaginal hysterectomy was happening in Europe. A hysterectomy from the abdomen was made possible by this procedure. Thus, in Manchester, England, Charles Clay carried out the first abdominal hysterectomy in 1843. But during the first several hours following surgery, the patient passed away from severe bleeding [5]. In Lowell, Massachusetts, in 1853, the success occurred. Walter Burnham removed a patient's uterus by ligating both uterine arteries during an autopsy on a patient who had uterine fibroids from the sternum to the pubis.

Even in 1880, subtotal hysterectomy was the only procedure used to remove the uterus. It was done without anesthetic and carried a very high risk of death [19]. Because of this exceedingly undesirable mortality, abdominal hysterectomy was officially condemned by the Medical Academy in Paris in 1872.

There have been several new medical breakthroughs in the 20th century. The first antibiotic was discovered by Alexander Fleming in 1928, and blood group discoveries by Landsteiner in 1900 contributed to a considerable decline in surgical mortality and postoperative mortality from infectious complications. Comparable surgical fatality rates of 2-3% were reported in 1920 for both vaginal and abdominal hysterectomy [18]. Because gynecology was still developing as a separate branch of medicine during this time, many hysterectomies were carried out by general surgeons who preferred the abdominal approach because they were not comfortable with vaginal surgery. This was the rationale behind the adoption of the whole hysterectomy approach as opposed to the more common subtotal one. Additionally, Johannes Pfannenstiel created the transverse incision, which represents a significant advancement in abdominal hysterectomy technique, in 1900. With fewer surgical problems, this surgical strategy produced the best cosmetic outcome [15].

The development of endoscopic surgery and Harry Reich's 1988 laparoscopic hysterectomy in Kingston, Pennsylvania, marked the beginning of the practice of minimally invasive gynecological procedures [20].

With the advent of endoscopic tools in hysterectomy practice, many surgeons who preferred a more straightforward method went back to doing subtotal hysterectomy. Semm created an intrafascial laparoscopic supracervical hysterectomy in 1993 [12], utilizing a technique that involved removing both the uterine core and the transformation zone core. This surgery lowers the risk of an ascending infection and helps to prevent injury to the ureter. She also put forth a plan in 1994 to use a Nd:YAG laser for coagulation or an electrosurgical loop to remove the transformation zone. As a result, there is a lower chance of cervical cancer.

The endoscopic hysterectomy is gaining popularity as a substitute for conventional intervention techniques in the late XX and early XXI centuries. There are numerous advantages of switching from extensive laparotomy, including lower patient risks [1, 2]. This shift is now widely acknowledged. Because the patient has less trauma during the laparoscopic treatment, she recovers more quickly and can resume her regular life [6]. But this method has advantages beyond just helping patients. Surgeons have a rare opportunity to obtain a comprehensive understanding of the anatomy and pathology of the pelvis thanks to modern laparoscopes, particularly in areas of the deep pelvis that are difficult to access, such as the anterior Retzius cave and the side walls of the pelvis [7]. An enhanced visual aid enables the surgeon to carry out more accurate procedures.

The hysterectomy procedure is still getting better today. The surgical community started thinking about how cutting-edge technology might be incorporated into time-honored surgical techniques.

Therefore, the ability to perform transluminal endoscopic procedures through natural openings, such as the vagina, as opposed to the more conventional access through the abdominal cavity, is one of the most alluring aspects of gynecological surgery. This creative method saves patient expenses by avoiding more intrusive procedures.

The integration of endoscopic procedures via the vagina into gynecological surgery for hysterectomy has created significant opportunities to enhance patients' overall health and well-being. Thus, the work of a group of gynecologists from Russia on the application of v-NOTES, or transvaginal transluminal endoscopic surgery, in gynecology was published in 2023. Fourteen patients underwent surgery using this technology: eleven had apical prolapse of the pelvic organs, and three had malignant uterine malignancies. According to the statistics, vNOTES may lessen the chance of prolapse following a hysterectomy.[22]

Laparoscopic single-port, or minimally invasive, surgery is another advancement in surgical gynecology. It is also known as laparoendoscopic single-site (LESS) surgery. The main difference is that laparoscopic trocars are inserted through either a single tiny incision made in conjunction with the use of a specialized equipment (single-port) or many small incisions made in one location (single-incision). Consequently, it's possible that the term "single-port laparoscopy" is inaccurate and misrepresents the procedure. Nevertheless, following this treatment, the patient always has a single scar in the navel region, which is often no more than 2 cm [7].

The use of surgical robots for hysterectomy procedures is the most recent advancement in the area [4]. Their application creates entirely new opportunities in the surgical field. Recognizing the shortcomings of the laparoscopic technologies available at the time, scientists and developers of the previous century worked to find novel and cutting-edge ways to get around these challenges [14].

Robots have been around since the Puma 560, which was first utilized in 1985 to do stereotactic brain biopsies [11] and more precisely excise the thalamus' astrocytoma. Gynecology has only lately seen the introduction of automated equipment. In 1994, Lung Wang developed a robotic arm equipped with an endoscope that the surgeon used voice commands to operate on during a hysterectomy. He dubbed his creation the AESOP, or automated endoscopic system for optimal placement.

With good reason, the Da Vinci S and SI systems are regarded as one of the most exciting gynecological surgical initiatives [16]. These kinds of operating systems have an extra benefit: they include special dual optics that enable the operator to completely immerse himself in the three-dimensional operational field. Furthermore, the overview of the pelvic area can be greatly increased by varying the system's magnification. When F. Smalley R. Yang started Intuitive Surgical in 1995, he modified the telepresence surgical system developed by Phil Green of SRI into an inventive robotic system. This resulted in the first prototype of the system.

Belgium achieved a significant milestone in 1997 when they executed the first da Vinci surgical procedure successfully [8]. Furthermore, five years later, in 2002, Diaz-Arrastia added to the body of work by revealing several successful robotic laparoscopic hysterectomies [21]. These developments have ushered in a new era in medicine by making it possible to carry out intricate procedures with greater accuracy and efficiency.

In retrospect, a comparison between total laparoscopic hysterectomy and robot-assisted hysterectomy was made. When compared to traditional laparoscopic procedures, the early outcomes of using robots in hysterectomies indicated a decrease in the incidence of both early and late problems after the treatment.

Positive findings were obtained from the analysis of robot-assisted hysterectomies in 2022. Twenty-four patients between the ages of 41 and 80 had robotic hysterectomy at the Novosibirsk Center for New Medical Technologies in 2022. A set of requirements was set for the robotic procedure: the tumor had to be a minimum of 3 cm in size, and it had to be among the most frequent histological types, provided there were no underlying medical issues that would prevent the procedure. Every operation was carried out utilizing the DaVinchi apparatus. Furthermore, the potential of this operation was unaffected by prior abdominal organ procedures, and a histological study was always conducted to confirm the diagnosis prior to the procedure. The procedure took roughly ninety minutes on average. Between 50 and 100 milliliters of blood were lost during the surgical procedure. Patients were released from the hospital on days three and four, with no evidence of intraoperative or postoperative problems [10].

Robotic helpers are not ignoring the field of oncogynecology. The first studies by Reynolds and Advincula were published in 2006, and this led to a widespread adoption of robotic hysterectomy for benign illnesses [16]. Their research looked at 16 consecutive cases where they eliminated the need for a laparotomy while still achieving the same rate of complications as traditional laparoscopic surgery.

The experience of employing robotic technologies for the surgical treatment of cervical and endometrial cancer has gained relevance in recent years. Comparing the incidence of complications following robotic versus open radical hysterectomies for cervical cancer at Brigham and Women's Hospital between August 1, 2004 and August 1, 2007, Emily M. Ko and Michael J. Muto conducted a study in 2008. The data gained indicates that there is a comparable rate of intraoperative and postoperative problems; however, robotic radical hysterectomy results in less blood loss and a shorter hospital stay [9].

A relatively new field that is quickly gaining popularity is robotic surgery. Although it has a lot of benefits, there are a few drawbacks that should be taken into account. The high expense of robotic surgery is one drawback. This is because personnel training and specific equipment are needed for these kinds of systems. Furthermore, the lack of tactile feedback in robotic surgery can be problematic for certain difficult procedures. The inability to enter the vagina is another drawback. A trocar, which is larger than conventional instruments, is needed when using a robotic surgical instrument. This may limit the surgeon's ability and cause discomfort. It is also important to note how heavy the equipment is. Specialized robots and support systems are needed for robotic surgery, and these take up a lot of room in the operating room. Small clinics with little space may find this to be an issue. An additional consideration is the time needed to assemble the robot. It may require some extra time to set up and test the robot's functionality before beginning the operation.

Its inability to carry out more accurate and minimally invasive procedures is a drawback of robotic surgery. However, further efforts to remove these drawbacks and lower east cost are required for the technology to be implemented successfully.

In conclusion. One of the most common gynecological procedures, hysterectomy, has historical roots. Her narrative is entwined with the lives of well-known individuals, many of whom had doubts about other medical authorities.

The hysterectomy procedure has undergone continuous technical advancements since its inception. The operation's historically high death rate has dramatically dropped as a result of the use of anesthesia, blood transfusion techniques, antibiotics, and antiseptics. This considerably decreased the likelihood of any issues, increasing the procedure's safety.

There are currently three primary surgical methods for removing uteruses: laparoscopic, abdominal, and vaginal. Endoscopic access is gradually replacing wide laparotomy access, and robotic surgery has made it possible to perform procedures with less involvement from the physician. In the last ten years, this technology has progressed from basic mechanical devices to intricate robotic systems that are effectively employed in medical practices worldwide.

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