Laparoscopy-Assisted Vaginal Hysterectomy

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Laparoscopy-Assisted
Vaginal Hysterectomy

There are two reasons for performing a laparoscopy-assisted vaginal hysterectomy. The first is to attempt to make vaginal hysterectomy with its advantages available to those women whose surgeons feel uncomfortable with a regular vaginal hysterectomy and who have a tendency toward performing the hysterectomy through the abdominal route with its disadvantages of postoperative pain, need for hospitalization, and reduced time for return to full activities and/or employment. The second is a significant reduction in length of stay in the hospital with this procedure than with an abdominal hysterectomy. It was originally thought that routine vaginal hysterectomy required 5-6 days of hospitalization. Recently, this has been shown to be untrue. It was originally thought that there would be a cost savings from laparoscopy-assisted vaginal hysterectomy compared with a regular vaginal hysterectomy. Several evaluations have shown that because of the high cost of the instruments needed and the length of operating time needed for laparoscopy-assisted vaginal hysterectomy, this procedure is more expensive than a regular vaginal hysterectomy. If the patient's surgeon feels uncomfortable with a regular vaginal hysterectomy and would convert these operations to abdominal hysterectomy, however, there is a definite advantage for the laparoscopy-assisted vaginal hysterectomy in the length of stay, cost, and recovery.

The typical patient on whom a surgeon would be tempted to perform a laparoscopy-assisted vaginal hysterectomy would be one with myomata uteri, a history of pelvic inflammatory disease, a history of previous pelvic surgeries such as cesarean section, or significant endometriosis with adhesions to bowel. The hypothesis is that with laparoscopy these variables can be managed in a safer manner than with the traditional vaginal hysterectomy.

Physiologic Changes. The predominant physiology is the loss of the uterus and the offending signs and symptoms that require the uterus to be removed. If it is a bleeding disorder, the bleeding will stop. If it is chronic pain caused by the uterus, the pain should be eliminated. If it is an ovarian-masking problem, the ovaries would now be free and could be felt on routine examination. If there is carcinoma in situ or significant cervical intraepithelial neoplasia, then that would be removed.

Points of Caution. Laparoscopy is not a completely complication-free operation. Bowel injuries, urinary tract injuries, and hemorrhage are reported sequelae of laparoscopy. Clinical experience in intra-abdominal laparoscopy as well as vaginal hysterectomy must be obtained prior to initiating this procedure.

Technique

Usually, there are five sites of puncture required for the insertion of the laparoscopic trocar and sleeves. First, a 12-mm incision is made in the inferior rim of the umbilicus for insertion of the observation laparoscope. Second, two 12-mm incisions, one in the left lower quadrant and one in the right lower quadrant, are needed. These incisions should be lateral to the rectus abdominis muscle to avoid injury to the epigastric vessels. Third, an incision is required for grasping forceps, dissection scissors, and irrigation and suction instruments. Fourth, a 5-mm suprapubic incision is needed for additional surgical instrument.

This laparoscopic view of the pelvis shows the bladder (B) at the 12-1 o'clock position and the fundus at the 4-5 o'clock position with the intra-vaginal and cervical instrument manipulating the uterus so the infundibulopelvic ligament can be exposed. A grasping forceps has been used to remove the ovary and Fallopian tube medially, further exposing the infundibulopelvic ligament. The ureter must be clearly identified prior to placing the Endo-GIA (gastrointestinal anastomosis) stapler on the infundibulopelvic ligament. First, the size and thickness of the infundibulopelvic ligament must be known. This can be best done by placing an Endo Gauge 30-mm instrument across the infundibulopelvic ligament, measuring the thickness. This allows for the appropriate Endo-GIA stapler to be placed. The Endo-GIA stapler is placed across the infundibulopelvic ligament as well as the round ligament. Care must be taken to ensure that the ureter is not included in this grasp and is out of danger from being transected and stapled.

The fundus of the uterus is at the 5 o'clock position, the tube and ovary have been removed medially by the Endo Grasp instrument, the bladder is at the 2 o'clock position, and a second application of the multiple-fire Endo-GIA 30 stapler is applied to the upper broad ligament. At the 7 o'clock position, the previously stapled and incised left infundibulopelvic ligament can be seen. The round ligament and the upper portion of the broad ligaments are included in this second bite of the Endo-GIA 30 stapler.

This endoscopic view shows the fundus of the uterus at the 9 o'clock position, the bladder at the 12 o'clock position, and the right infundibulopelvic ligament exposed by manipulating the intra-vaginal cervical manipulator as well as the grasping forceps, moving the tube and ovary medially. The round and infundibulopelvic ligaments can also be seen. The right ureter must be clearly identified before the Endo-GIA stapler is placed on the infundibulopelvic ligament.

This laparoscopic view shows the bladder at the 12 o'clock position and the right and left infundibulopelvic ligaments stapled and transected. The round and broad ligaments have been stapled and transected down to a point approximately 0.5 cm above the ureter and uterine artery. Endo Shears are used to transect the peritoneum over the anterior uterine segment.

The vesicoperitoneum is grasped with an endo-grasping forceps and elevated. The Endo-GIA stapler is placed adjacent to the lower uterine segment on the lower broad ligament but superior to the uterine artery.

To distinguish the anterior from the posterior surface of the uterus, the midline of the uterus from the fundus down to the lower uterine segment is slightly coagulated with electrocoagulation forceps.

The surgeon goes below, leaving the laparoscope in the hands of an assistant, and transects circumferentially the vaginal mucosa immediately adjacent to the cervix. The cervix is grasped with a Jacobs tenaculum, and the anterior vaginal cuff is dissected caudally until the peritoneal cavity is entered through the previous dissection of the vesicoperitoneal fold seen in Figure 5.

A Lahey thyroid tenaculum is placed into the anterior cul-de-sac and pulls the uterine fundus through the anterior cul-de-sac. Traction is maintained on the cervix with the Jacobs tenaculum.

The tenaculum on the cervix is released, allowing the uterus to be flipped forward; additional tenacula are placed on the anterior uterine wall, progressively pulling the fundus forward and outward as the uterus begins to emerge from the anterior cul-de-sac opening.

The uterine artery on both sides is clamped, ligated, cut, and tied with synthetic absorbable suture. The uterus and adnexa are delivered through the anterior cul-de-sac wound.

The posterior surface of the uterus from the fundus to the lower uterine segment can be identified because its lacks the burn stripe previously applied to the anterior surface. The vaginal mucosa is identified on both sides; clamped and incised. The clamp is placed slightly above the uterosacral ligaments. The line of amputation of the cervix and uterus is shown.

The vaginal cuff has been reefed with running 0 synthetic absorbable suture.

The vagina is closed and returned to its proper position. The ties are seen on the uterosacral ligaments. They are plicated in the midline for enterocele prophylaxis and vaginal cuff suspension.