You need to log in to watch this media!

Click here to log in.

Laparoscopically assisted vaginal hysterectomy

Authors

Abstract

The description of the laparoscopically assisted vaginal hysterectomy (LAVH) covers all aspects of the surgical procedure used for the management of uterine pathology.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure/Incision, ovarian vessels, bladder dissection, uterine vessels, uterus removal, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.

Media type

Publication

2002-07

Popular

Favorites

Audio

E-publication

WeBSurg.com, Jul 2002;2(07).
URL: http://www.websurg.com/doi-ot02en281.htm

Laparoscopically assisted vaginal hysterectomy

1. Introduction

Laparoscopically assisted vaginal hysterectomy (LAVH) was introduced in the early 1990s as an alternative to abdominal hysterectomy. In a recent large hospital survey in Ohio, USA, only 8% of all hysterectomies were performed with laparoscopic assistance (Weber and Lee, 1996). LAVH is a safe alternative to abdominal hysterectomy when a vaginal hysterectomy is contraindicated. A randomized clinical trial showed that vaginal hysterectomy and LAVH were associated with similar hospital stays, and similar intraoperative and postoperative morbidity. Operative times and costs were higher in the LAVH group (Summitt et al., 1992).

In several prospective randomized clinical trials of LAVH versus total abdominal hysterectomy, the former was associated with less postoperative pain, shorter hospital stays and a more rapid return to normal activities (Summit et al., 1998; Marana et al., 1999; Falcone et al., 1999; Ferrari et al., 2000). Several studies have shown that the costs of LAVH were similar to (Summitt et al., 1998; Falcone et al., 1999) or less than (Ellstrom et al., 1998) the costs of total abdominal hysterectomy.

There are several classifications of laparoscopic hysterectomy. The laparoscopic ligation of the uterine artery appears to be the critical step that differentiates a laparoscopic procedure from LAVH. In fact this division is arbitrary. In practice, the procedure is continued laparoscopically until the surgeon is confident that the procedure can be completed vaginally. However in some cases, the anatomy does not permit any portion to be performed vaginally and the whole procedure is carried out laparoscopically.

2. Anatomy

• Topographic anatomy

1. Uterus
2. Round ligament
3. Utero-ovarian ligament (proper ovarian ligament)
4. Uterosacral ligament
5. Ovary
6. Suspensory ligament of the ovary
7. Ureter

• Vasculature

1. Umbilical artery
2. Ureter
3. Uterine artery
4. Internal iliac artery
5. Ovarian artery
6. Common iliac artery
7. Utero-sacral ligament

3. Indications

Indications for laparoscopic access for hysterectomy:
- same indications as hysterectomy by laparotomy;
- a vaginal hysterectomy is not feasible;
- need to evaluate other intraperitoneal tissue or organs.

Contraindications to hysterectomy:
- desire to maintain future fertility,
- known medical or psychological risks that exceed the benefits.

Contraindications to laparoscopic access:
- inexperienced surgeon;
- bowel obstruction;
- ileus;
- peritonitis, unless it is to assess pelvic inflammatory disease or a tubo-ovarian abscess;
- hemorrhage in an unstable patient;
- diaphragmatic hernia;
- severe cardiorespiratory disease.

4. Preop period

The patient takes a preparation to cleanse the bowel the day before the procedure. We do not use oral antibiotics. We do not routinely order any preoperative testing unless there is a specific history, such as excessive vaginal bleeding, in which case a complete blood count is required. Potential complications, possible conversion to a laparotomy and the need for autologous blood transfusion are discussed with the patient.

5. Operating room set-up

• Patient

- general anesthesia;
- dorsal lithotomy;
- Trendelenburg is not used until after the introduction of the primary cannula;
- the legs are placed in foam-padded leg stirrups where the calves and heels are supported and can be elevated for the vaginal portion. They are fixed with adhesive tape.
- pneumatic compression stockings are placed on the calves;
- both arms are tucked alongside the body;
- an orogastric tube is placed if there is a left upper quadrant trocar inserted or if stomach distension is suspected;
- examination under anesthesia is performed;
- a urinary catheter is inserted;
- an intrauterine manipulator is inserted.

• Team

1. The surgeon's position is on the left side of the patient if he or she is right-handed. The reverse is true for left-handed surgeons.
2. The assistant is on the opposite side of the surgeon.
3. The scrub nurse stands between the patient's legs so that the uterus can be mobilized appropriately.

• Equipment

1. Monitor
2. High-flow insufflator
- camera control unit and camera (3-chip camera);
- electrosurgical unit (unipolar and bipolar systems: the unipolar system should generate both non-modulated and modulated currents);
- image-recording device;
- light source (xenon light source).

6. Trocar placement

The trocars are placed as follows:
A: A 10 mm trocar is placed in the umbilicus.
B and C: Two other trocars are placed in the lower abdomen, at the level of the anterior superior iliac spine, lateral to the rectus abdominis muscle. These may be reusable 10 mm trocars if no laparoscopic suturing is anticipated. If the vaginal cuff is closed by laparoscopy, one of the trocars will be a 10 mm disposable trocar.
D: Finally, in particularly difficult cases, a 5 mm reusable trocar may be placed at the level of the umbilicus, lateral to the rectus abdominis muscle.

7. Instrumentation

• Instrument table

1. Laparoscopes: 3 sizes (2-3 mm, 5 mm and 10 mm); 0° lens
Graspers and dissectors:
2. Atraumatic graspers
3. Soft bowel clamps
4. Maryland dissectors
5. Scissors
6. Needle holders
7. Bipolar forceps and cord
8. Endoloop
9. Aspiration-suction device
Tissue morcellator for large uterus

• Vaginal instrument table

1. Single tooth tenaculum
2. Allis graspers
3. Dilators
4. Uterine manipulator
5. Cohen cannula (alternative uterine manipulator)
Speculum
Urinary catheter (Foley catheter)

8. Major principles

Trocars are introduced, and a view of the peritoneal cavity is systematically obtained.
The round ligament is electrocoagulated and transected.
The incision from the round ligament is continued cephalad to open the retroperitoneal space lateral to the ovarian vessels and caudad to incise the bladder peritoneum.
The ureter is identified and kept in view.
The ovarian vessels are grasped and electrocoagulated.
The uterine artery is identified and electrocoagulated.
The process is repeated on the opposite side.
The bladder peritoneum is dissected downwards until the vagina is identified.
A sponge forceps is placed in the vagina in the anterior fornix and the vagina is tented upwards.
An incision is made circumferentially around the vagina.
The vault is sutured with 0 polyglactin.

9. Exposure/Incision

• Retroperitoneal space

1. Uterus
2. Lateral retroperitoneal space
If the ovaries are to be removed, the round ligament is grasped mid-segment and, using a bipolar electrocoagulating/cutting device that is set at 50 W pure cut, electrocoagulated and cut. The retroperitoneal space lateral to the ovarian vessels and medial to the external iliac artery is dissected.

• Round ligament incision

1. Electrocautery of the round ligament
2. Left side: ureter identified on the peritoneum
The incision from the round ligament is continued cephalad lateral to the ovarian vessels. The ureter is then identified on the medial leaf of the broad ligament.
If the ovaries are to be retained, the round ligament, utero-ovarian ligament and tube are grasped near the uterus and electrocoagulated and cut. A stapling device can also be used.

10. Ovarian vessels

1. Visualization of the right ureter
2. Open retroperitoneal space
3. Electrocautery of the left ovarian vessels
Occlusion of the ovarian vessels:
The ureter with the uterine artery running parallel to it is clearly seen. The ovarian vessels are then grasped, electrocoagulated and cut.
This is then repeated on the other side.

11. Bladder dissection

1. Bladder peritoneum
2. Uterus
3. Vagina
4. Bladder
Dissection of the bladder:
The incision from the round ligament is carried anteriorly towards the bladder. The bladder peritoneum is grasped with an Allis forceps and raised towards the anterior abdominal wall. The bladder peritoneum is incised and dissected caudad. The correct dissection plane is identified by an avascular space. Sharp dissection is used. During the procedure, the uterus is pushed cephalad and in the midline.

12. Uterine vessels

• Identification

1. Right uterine artery
2. Right ureter
3. Vagina
The uterine artery is identified at its origin as the umbilical artery branches from the internal iliac artery and courses anteriorly. The uterine artery then runs parallel to the ureter for a short course before crossing over it.

• Division

The uterine artery is grasped at the cervico-uterine junction with a bipolar device. It is then electrocoagulated and cut.

13. Uterus removal

• Incision

1. Vaginal incision
A sponge on a ring forceps is placed in the vagina in the anterior fornix. The vagina is tented with the sponge on the ring forceps and entered using electrocautery on pure cut (50 W). If a uterine manipulator is in place, the plastic section is used as a guide for the vaginal incision. The incision on the vagina is started anteriorly and continued circumferentially. Once the anterior fornix is entered the peritoneal gas will escape. The vagina can be packed or the balloon of the uterine manipulator inflated to prevent gas leak.

• Uterus removed

1. Morcellated uterus
The uterus is then removed vaginally. If it is too large, a morcellator is used from one of the trocars and it is removed in pieces.

• Vaginal vault closure

The vaginal vault is sutured laparoscopically with 0 polyglactin. The knots are tied extracorporeally.

14. End of procedure

At the end of the procedure, an ampule of indigo carmine dye is given and a cystoscopy is performed to make sure there is no bladder damage and that the ureters are patent. The fascia of all trocars over 5 mm are closed. A subcuticular suture is used for the skin.

15. Postop period

The urinary catheter is left in overnight. Intravenous narcotics are used. The patient is allowed a regular diet, as tolerated. The patient is discharged as soon as the following criteria are met (usually within 24 hours):
- afebrile with stable vital signs and hematocrit;
- able to void without difficulty;
- ambulates on his or her own;
- tolerates oral analgesics;
- tolerates at least a clear liquid diet.

16. Reference

Ellstrom M, Ferraz-Nunes J, Hahlin M, Olsson JH. A randomized trial with a cost-consequence analysis
after laparoscopic and abdominal hysterectomy. Obstet Gynecol 1998;91:30-4.
Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted
vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol 1999;180:955-62.
Ferrari MM, Berlanda N, Mezzopane R, Ragusa G, Cavallo M, Pardi G. Identifying the indications for
laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal
hysterectomy in patients with symptomatic uterine fibroids. Bjog 2000;107:620-5.
Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano GF. Laparoscopically assisted vaginal
hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J
Obstet Gynecol 1999;180:270-5.
Summitt RL, Jr., Stovall TG, Lipscomb GH, Ling FW. Randomized comparison of laparoscopy-assisted
vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol
1992;80:895-901.
Summitt RL, Jr., Stovall TG, Steege JF, Lipscomb GH. A multicenter randomized comparison of
laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy
candidates. Obstet Gynecol 1998;92:321-6.
Weber AM, Lee JC. Use of alternative techniques of hysterectomy in Ohio, 1988-1994. N Engl J Med
1996;335:483-9.

Username
Password
	Remember me (needs cookies)