Ureteral complications after gasless laparoscopic hysterectomy

Laparoscopic hysterectomy is becoming a more common operation. Gasless laparoscopy initially seems to be a better technique, reducing CO2 complications and allowing the use of conventional instruments rather than more expensive laparoscopic tools. We report our experience with 50 cases of laparoscopic hysterectomies, 5 of which were performed using a gasless technique. Of these five cases, there were two cases of ureteral stenosis. Ureteral injuries are common with hysterectomy, even in nonlaparoscopic procedures, and the literature is replete with recommendations to avoid this damage. In the gasless procedure, the ureters cannot be repositioned completely from the cervix after the hydrodissection. Extreme caution must be taken when applying bipolar or monopolar energy. The abdominal cavity shape does not allow complete avoidance of the ureters using the gasless technique. We have decided not to use a gasless technique with hysterectomy. We believe that the actual complication rate may be higher than reported, due to investigators' reluctance to report such complications. Our hope is that this report will encourage other investigators to help establish a more accurate rate of possible complications associated with this procedure.