Laparoscopic Hysterectomy

Laparoscopy is done using a lighted telescope for viewing and additional surgical instruments for cutting. All these instruments are passed into the abdominal cavity through relatively small incisions in the abdominal wall. The technique has been known for decades, but the miniaturization of equipment has expanded its role and its possibilities. Most frequently, laparoscopy is used to assist with a vaginal hysterectomy (laparoscope-assisted vaginal hysterectomy, or LAVH), but hysterectomy can also be done in entirety through a laparoscopic procedure (laparoscopic hysterectomy, or LH).

Surgeons began using laparoscopy to assist in vaginal hysterectomy in the late 1980s. In performing laparoscope-assisted vaginal hysterectomy, your doctor can combine the advantages of vaginal hysterectomy with the enhanced visualization of the pelvic organs that the laparoscope provides. LAVH is done today to treat many conditions that would have required an abdominal hysterectomy in the past, including uterine fibroids and endometriosis.

LAVH does not replace vaginal hysterectomy. Vaginal hysterectomies are still common and preferred whenever possible because they have the advantage of requiring no abdominal incision at all. LAVH is best suited for conditions in which the surgeon's ability to perform a total vaginal hysterectomy is made difficult by certain disorders (for example, en-dometriosis, tubal infection, or tubo-ovarian abscess) or because the woman has not given birth vaginally.

There are a number of variations in how the laparoscope is used to assist vaginal hysterectomy. They are classified into four types:

• Type 1—A laparoscope is placed to evaluate the condition of the pelvic organs and to determine whether vaginal hysterectomy is possible. In this case, the laparoscope is used only for visualization and diagnosis.

• Type 2—The laparoscope finds pelvic pathology such as adhesions or endometriosis. Your surgeon will treat these conditions through the laparoscopic incisions and then perform a vaginal hysterectomy.

• Type 3—Your doctor does part of the hysterectomy procedure through the laparoscope, a procedure called operative laparoscopy. For example, ligaments are cut or the blood supply to the uterus is sutured through the laparoscopic incisions. The vaginal hysterectomy is thus facilitated by the laparoscope.

• Type 4—The entire hysterectomy is performed using operative la-paroscopy. The uterus is removed through the vagina, but the vaginal incision is sutured from above using the laparoscopic ports (small incisions) in the abdomen and laparoscopic instruments.

The first three options differ significantly from the fourth. They truly qualify as vaginal hysterectomy with laparoscopic assistance (LAVH), whereas type 4 is a complete laparoscopic hysterectomy (LH). In another variation, the surgeon uses a process called morcellation, which means "to divide into small pieces and remove." With laparoscopic instruments the uterus is surgically divided into small fragments, and these pieces are removed through the laparoscopic incisions. This approach requires no vaginal incision at all. However, because the bowel or other vital tissues can inadvertently be injured during morcellation, do not consider having this procedure done except by a surgeon who is very experienced with it.

Possible complications from the LAVH procedure include bleeding and injury to other organs. Since the laparoscopic instruments must be inserted through multiple small incisions into the abdominal wall (fig. 11.3), bleeding from the epigastric artery, one of the major blood vessels in the abdominal wall, can occur. Another potential complication is infection from the incision that is placed just below the navel. The medical term for this infection is cellulitis. More serious possible complications involve injuries to the bladder, ureters, or intestinal tract by the sharp instruments, electrocautery, or suturing techniques. Complication rates appear to be lower for LAVH than for abdominal hysterectomy but comparable for LAVH and vaginal hysterectomy.

Laparoscopic surgery has distinct advantages over an abdominal approach. It involves minimal manipulation of the intestinal tract, and bowel function usually returns promptly after surgery. The laparoscopic approach also decreases the formation of adhesions within the abdomen. Following laparoscopy, the woman is usually discharged earlier than with an abdominal hysterectomy. The recuperative phase at home is shortened, allowing a woman to resume her customary activities within two weeks.

LAVH or LH may cost more than other types of both vaginal and abdominal hysterectomy because of the expense of the specialized instruments and equipment used (many of which cannot be reused) and the longer anesthesia time. Although you will have a shorter hospital stay with LAVH, the actual surgical procedure takes longer than a vaginal hysterectomy that is not done with laparoscopic assistance. The more skilled and experienced your surgeon, the shorter the duration of the operation.

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