LAVH

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LAVH

~ LAVH ~

§ Classification of laparoscopic hysterectomy:

　

Type

Procedure

DL + VH

Diagnostic laparoscopy prior to a vaginal hysterectomy, to verify the absence of contraindications of vaginal hysterectomy.

LAVH

The laparoscopic component of the operation is completed above the uterine vessels, which are subsequently secured by the vaginal route.

LH

The uterine vessels are secured laparoscopically.

TLH

In addition to the uterine vessels, the uterosacral and cardinal ligaments are secured laparoscopically and the cervix completely freed from the vagina.

ø DL: diagnostic laparoscopy

ø VH: vaginal hysterectomy

ø LAVH: laparoscopic-assisted vaginal hysterectomy

ø LH: laparoscopic hysterectomy

ø TLH: total laparoscopic hysterectomy

ø Contraindications of vaginal hysterectomy:

j Uterine size greater than 280 g

k Previous pelvic surgery

l History of PID

m Moderate or severe endometriosis

n Concomitant adnexal mass

o Indication for adnexectomy in nulliparity with lack of uterine descent

p limited vaginal access

(Vaginal hysterectomy is usually planned in women with mobile uteri not greater than

280g, especially if there is some uterine descent.)

　

§ LAVH technique:

è Laparoscopic phase:

j Single-dose antibiotic for prophylaxis

k Preparation and setting of laparoscope

l Evaluate accurately the pelvis and upper abdomen, and if possible, treat any pathological

findings.

m When ovaries are to be conserved, use bipolar forceps and scissors to resect the round

ligaments , utero-ovarian ligaments, and fallopian tubes. For adnexectomy, use bipolar forceps

and scissors to resect the round ligaments, infundibulo-pelvic ligaments, mesosalpinx, and

mesoovarium.

n Opening of the bladder flap

è Vaginal phase:

j Circular incision of the vagina

k Bladder dissection to the laparoscopically-operned bladder flap

l Entry into the posterior cul-de-sac

m Clamping, transecting, and suture-ligating of uterosacral ligaments, base of cardinal

ligaments, and uterine vessels

n Peritoneal closure with exteriorization of the pedicles

o Closure of the vaginal vault, which is anchored to the uterosacral and cardinal ligaments

ø Securing the uterine vessels is the most difficult and critical step of the procedure, and is

best performed during the vaginal phase.

　

§ LAVH vs. ATH:

	LAVH	ATH
Operating time	No significant difference	No significant difference
Blood loss	Significantly less	Significantly more
Postoperative pain	Significantly less	Significantly more
Postoperative hospital stay	Significantly shorter	Significantly longer
Total major complication rate	No significant difference	No significant difference
Adnexectomy	Not technically difficult	Not difficult
Cost	Increased?

　

§ Conclusion:

è When vaginal hysterectomy is feasible, it is the first choice.

è LAVH may be used to extend the applications of a vaginal route, particularly

in allowing safe utilization of a vaginal approach in patients for whom VH

may be contraindicated according to conventional standards.

　

§ References:

1. A practical technique for laparoscopically assisted vaginal hysterectomy. Riccardo Marana,

MD, Ludovico Muzii, MD, and Giovan Fiore Catalano, MD. Contemporary OB/GYN March

2000:60-68

Filename: LAVH