Laparoscopic Assistance After Vaginal Hysterectomy and Unsuccessful Access to the Ovaries or Failed Uterine Mobilization: Changing Trends

OBJECTIVES We conducted retrospective and prospective clinical studies at the Columbus Hospital of Rome to point out changes in choosing the route for performing hysterectomy; to evaluate the feasibility of vaginal hysterectomy (VH) and oophorectomy, even in commonly considered contraindications to the vaginal route; to describe a method of laparoscopic oophorectomy following vaginal hysterectomy; and laparoscopic assistance in impossible vaginal hysterectomies. METHODS From November 1999 to November 2001, 226 patients (age 46.1+/-4.6 years, range 35 to 58) underwent hysterectomy for benign pathologies: 22 (9.7%) underwent total laparoscopic hysterectomy for the presence of severe endometriosis, limited access to the fornices, or immobile uterus with no lateral mobilization; 204 (90.3%) underwent vaginal hysterectomy. Patients with uterine prolapse were excluded. Uterine size, previous cesarean deliveries, pelvic surgeries and the requirement of prophylactic oophorectomy were not considered contraindications to the vaginal approach. We retrospectively analyzed 509 hysterectomies performed in the previous 2 years from 1997 through 1998. RESULTS During vaginal hysterectomy, adnexectomy was possible in 90.6% of the cases in which it was indicated (unilateral in 21.8% because of adnexal pathology) and was technically impossible in 9.3%. In 4 patients (1.9%), it was not possible to complete a vaginal hysterectomy, owing to the presence of thick adhesions obliterating the cul-de-sac, to severe endometriosis, or to other unforeseen circumstances. In these few patients with difficult access to the ovaries (2.9% of all VH) or with difficulties in mobilizing the uterus, we resorted to laparoscopy. The pneumoperitoneum was achieved with an insufflation tube inserted via the vagina into the abdominal cavity and packing the vagina. Thus, the risks associated with the insertion of the Veress needle were avoided. In all but 2 patients in whom conversion to laparotomy was necessary, laparoscopy was successfully completed. No major complications occurred. In the retrospective analysis of 509 hysterectomies, we determined that 29% were vaginal, 43% abdominal, and 28% laparoscopic (mostly LAVH). In the following years, LAVH allowed the conversion of a significant number of abdominal or laparoscopic hysterectomies to a vaginal route, showing that the vaginal approach was possible in most of cases. CONCLUSIONS The vaginal approach is feasible in more than 90% of cases even if oophorectomy is required. In the few cases with difficult access to ovaries or difficulties in mobilizing the uterus, the laparoscopic route can easily be adapted by packing the vagina and obtaining a pneumoperitoneum without the risk and loss of time of the insertion of the Veress needle. In this way, it is possible to avoid a great number of LAVH, reducing operating time and the risks of a concomitant procedure.