Technique. Large uteri can be removed vaginally, depending on the surgeon’s technical ability and experience. A familiarity with the various methods of morcellation—hemisection, posterior fundal morcellation, intramyometrial coring, and myomectomy—is mandatory. It often is beneficial to use a combination of these techniques to accomplish the procedure vaginally, as opposed to a single means of morcellation. With any morcellation procedure, maintain a midline orientation to avoid dissection into the broad ligament. Continued caudal traction also is helpful in eliminating excessive blood loss during this prolonged procedure. Do not morcellate a uterus when endometrial carcinoma is suspected.
In a prospective observational study comparing vaginal morcellation to AH, Hoffman et al15 found the former to be safer. Other researchers also have demonstrated the procedure’s safety in retrospective reports16-18 and as subgroups in other series.14 Alternatively, preoperative treatment with a gonadotropin-releasing hor-Surgical Techniques mone (GnRH) agonist can reduce uterine size and result in a technically less challenging VH in some women.19,20
Also, whether or not the ovaries will be resected may influence the decision to perform a VH. While some surgeons believe that oophorectomy precludes the vaginal approach, the ovaries can be safely removed through the vagina in a large percentage of patients.21-23 In fact, Sheth24 and Kovac14 have published 95% and 97% success rates in 2 separate series in which vaginal oophorectomy was attempted in 740 and 142 women, respectively. However, do not attempt adnexal removal without adequate transvaginal access and visibility, as it increases the risk of hemorrhage and ureteral injury. In these cases, LAVH or mini-laparotomy AH may be preferable if oophorectomy is mandatory, i.e., in women who are predisposed to ovarian malignancies because of genetic mutations. However, when patients are appropriately selected, there are essentially no disadvantages to VH.
Advantages and disadvantages.VH has many advantages over AH. Minimal intraperitoneal manipulation and the avoidance of an abdominal wound lead to a shorter hospital stay and decreased recovery time, which is coupled with less cost. Patients also find the lack of an abdominal scar to be an attractive feature of VH. A disadvantage is reduced operative exposure, making it difficult to manipulate pelvic pathology and resect the adnexa.
Figure 2
Choose the vaginal route when pelvic support defects are present, but bear in mind that the course of the ureter changes due to prolapse.
Laparoscopic-assisted vaginal hysterectomy
Patient selection. When in doubt about which approach to use, turn to LAVH. The laparoscope allows the surgeon to thoroughly assess intra-abdominal pathology, which aids in the appropriate selection of a hysterectomy route. For example, if cancer is suspected based on the visual inspection, opt for an AH. On the other hand, if only extensive adhesions are noted, laparoscopic adhesiolysis can be performed to allow the hysterectomy to be completed vaginally. As previously noted, LAVH is appropriate in patients undergoing hysterectomy with prophylactic oophorectomy due to genetic or familial risk factors.
Technique. Bear in mind that the laparoscope does not permit all patients to undergo a VH. In fact, about 10% of attempted LAVHs will be unsuccessful.25,26 Some authors have reported failure during the laparoscopic portion,25,26 while others have attributed the lack of success to the vaginal portion of the procedure.27 Thus, it is important to be skilled at both laparoscopic and vaginal surgery in order to be successful with an LAVH.
LAVH requires three to five 5-to 10-mm abdominal incisions for port sites. An umbilical port is commonly used for the camera, and the remaining ports are used for operating. We typically use 3 ports and avoid most disposable instruments by using cautery on vascular pedicles, which helps minimize costs.3 Other alternatives include the use of endoscopic staplers, the Harmonic Scalpel (Ethicon Endo-Surgery, a Johnson & Johnson company, Cincinnati, Ohio), and suture ligatures with extra-or intracorporeal knot tying. Whichever instrument is used, familiarize yourself with all available equipment given the occasional malfunction encountered during laparoscopy.
Advantages and disadvantages. LAVH requires special equipment and expertise beyond that needed for an abdominal or vaginal hysterectomy. Additionally, this procedure increases operative time, cost, and morbidity (depending on the surgeon’s experience),4,27,28 while the postoperative recovery is similar to that of VH.
Although we use the laparoscope infrequently and believe there is little need to perform excessive laparoscopy at the time of routine hysterectomy, we do not wish to understate the role of the laparoscope. Its use in specific instances can certainly avoid a laparotomy or help determine when an AH is more appropriate.
Conclusion
Emergent situations and patients with excessively enlarged uteri, significant pelvic pathology, or cancer are obvious candidates for AH. On the other hand, VH is frequently chosen for the small uterus in a multiparous woman with a large pelvis and no prior pelvic inflammatory disease or surgery. The dilemma arises when determining the approach for those patients with moderately enlarged uteri or presumptive risk factors for serious pelvic disease.