Past and Present
Laparoscopic Assisted Vaginal Hysterectomy (LAVH) is not your mother’s hysterectomy. In the old days, you stayed in the hospital for 4-6 days, didn’t return to work for 6 weeks, and were left with a large scar. Today, there are a number of new options that do away with those problems and more. New procedures feature shorter or no hospital stays, less post-operative pain, negligible scars, and a quick return to normal activity and work.
The Laparoscopic Revolution
Laparoscopy was pioneered by gynecologists in the early 1960s, and has been widely used in a range of procedures, including tubal ligation, the removal of ovaries and fibroids (benign fibrous tumors of the uterus), and the treatment of tubal pregnancies.
If you’re concerned that laparoscopic hysterectomy is relatively new, remember that gynecologists have been using laparoscopy for the past three decades. More than 95 of all gallbladder surgery is now performed using this technique. Similarly, LAVH is rapidly gaining acceptance among gynecologic surgeons and their patients. The first laparoscopic hysterectomy in the world was performed by gynecologist Dr. Harry Reich in 1989. Dr. Lyndon Taylor at Healthcare for Women has been performing this procedure since 1991.
Procedure Description
LAVH combines laparoscopy and hysterectomy. Laparoscopy is used to look into the abdomen at the reproductive organs. Hysterectomy is surgery to remove the uterus. The uterus can be removed in two ways. When it is removed through a large cut (incision) in the abdomen, the procedure is called an abdominal hysterectomy (the past). Today, LAVH involves the use of a small, telescope-like device called a laparoscope. The laparoscope is inserted into the abdomen through a small cut. It brings light into the abdomen so that your doctor can see inside. Tiny instruments are also inserted to perform the procedure. Ligaments that support the uterus are cut with these instruments, and the uterus is removed vaginally. The benefits of LAVH include a short post-operative recovery time, which can be as little as a few hours after the surgery, to a day or two depending on your condition. Also, many patients can return to work and normal activities within 1 to 2 weeks. Most patients appreciate that LAVH has better cosmetic results, with only tiny scars.
What To Expect
LAVH may be performed on an out-patient basis. This means that you may be going home the same day. The surgery typically lasts from 1 to 2 hours, with a 4- to 8-hour post-operative recovery period, depending on your condition.
Pre-procedure
A complete history and physical exam including a pap smear and a vaginal ultrasound are performed at the time of the first visit, with other pre-surgical testing depending on your condition. You do not qualify for LAVH if you have advanced cancer.
Post-procedure
Recovery from laparoscopic surgery is significantly faster and less painful than recovery from traditional surgery. After LAVH, you will no longer have any vaginal bleeding. There wil be no hormonal changes when the ovaries are preserved. Most women say that sex is unchanged, or even improves because of the elimination of bleeding and pain. You may experience some vaginal dryness, which can be treated with estrogen cream and lubricants (we recommend Astroglide).
Hysterectomy (removal of the uterus) is one of the most common surgical procedures performed in the United States . Over 700,000 women undergo this procedure each year for the following indications:
LAVH Indications
- Pelvic Prolapse
- Fibroids
- Endometriosis
- Central Chronic Pelvic Pain/Adhesions
- Heavy Vaginal Bleeding (Periods)
There are three major approaches to remove the uterus: through the abdomen (abdominal hysterectomy – AH), through the vagina (vaginal hysterectomy – VH), or through the vagina with the aid of a laparoscope (laparoscopic assisted vaginal hysterectomy – LAVH). The majority of physicians perform the abdominal hysterectomy through a large transverse or vertical incision, despite the fact that the vaginal hysterectomy has fewer complications and has a shorter overall recovery period due to the lack of a large incision. The physicians also add numerous factors to lean toward the abdominal approach to include: uterine size (greater than 12 week size), previous pelvic surgery to include cesarean sections, history of pelvic infections, endometriosis, ovarian cysts, and lack of vaginal deliveries. As pioneers in advanced laparoscopic surgery, Drs. Miklos and Moore believe the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) is the most beneficial way of removing the uterus if these symptoms are present while addressing any coexisting problems. They agree with a recently published study by Marana et. al., which demonstrated that a laparoscopic hysterectomy may replace abdominal hysterectomy in most patients who require a hysterectomy and have contraindications to Vaginal Hysterectomy, with all the benefits associated with the vaginal route.
Advantages of LAVH
- Miniature Abdominal Incisions (< 1.2 cm)
- Decreased Post Operative Pain
- Shortened Post Operative Recovery
- Fewer Post Operative Infections
- Fewer Adhesions
- Shortened Hospitalization (< 24 hours)
- Access To Advanced Pelvic Reconstruction Procedures
Technique
Our doctors incorporate an alternative approach to the Laparoscopic Assisted Vaginal Hysterectomy (LAVH), which allows better operative exposure, decreased blood loss, and decreased operative time called the Laparoscopic Doderlein Hysterectomy (LDH). Dr. Miklos published an article in Contemporary OBGYN describing the technique for a laparoscopic hysterectomy in 1997. A recently published article in the Journal of Pelvic Surgery in 2001 supports Dr. Miklos's addition of the laparoscope to the Doderlein procedure. All of the benefits of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) apply to Laparoscopic Doderlein Hysterectomy (LDH) with the added advantages listed below:
Advantages of a Laparoscopic Doderlein Hysterectomy
- Existing Advantages of Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
- Better Surgical Exposure
- Decreased Blood Loss
- Decreased Operative Time
- Access to Apical Cystoceles (Transverse Defects)
Contraindications
Many of the published contraindications to Laparoscopic Assisted Vaginal Hysterectomy (LAVH) and Vaginal Hysterectomy are outdated. They include previous pelvic surgery, history of pelvic infection, endometriosis, benign appearing adnexal (ovarian) masses, and nulliparity (women without a vaginal delivery) without uterine prolapse. We at the Atlanta Urogynecology Center experience successful surgical outcomes with total laparoscopic hysterectomy in patients with these outdated contraindications. The contraindications would be if the uterus is greater than 16-week size or if you have a serious medical condition that would not be safe to undergo anesthesia. In the first situation, the safest approach would be through an abdominal incision. If you have any medical conditions, we would consult an Internal Medical physician to address the severity of your medical condition.
Results and Complications
With our approach to the laparoscopic hysterectomy, our patients achieve excellent outcomes with minimal pain and blood loss. The usually go home the next day and often require minimal pain medication. Laparoscopic assisted vaginal hysterectomy, like any surgical procedure, carries a risk of complications. Because of Drs. Miklos and Moore's vast experience in laparoscopic and advanced pelvic surgery, they have a complication rate lower to what is in the published literature of 3.6%. If an injury occurs, it is more important for the physician to recognize the injury at the time of surgery rather than after. The reported complications in the literature include:
Surgical Complications
- Bleeding
- Bladder Injury
- Ureter Injury
- Nerve Injury
- Intestinal Injury
Comparison of Laparoscopic-assisted Vaginal Hysterectomy, Total Abdominal Hysterectomy and Vaginal Hysterectomy :
Source :
http://www.chicagolavh.com
http://www.miklosandmoore.com/lap_proc2.php
http://www.wdxcyber.com/nbleed7.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891794/pdf/umj7501-054.pdf
