A Modified Technique for Laparoscopic Assisted Vaginal Hysterectomy

Introduction: Vaginal hysterectomy can be the standard procedure for removing the uterus, but surgical skills and indications to vaginal surgery are variable. Laparoscopic assistance to vaginal hysterectomy is a way to change the approach to hysterectomy. In this paper we describe our retroperitoneal technique for laparoscopic securing of the uterine pedicles. Materials and methods: 24 patients with uteri above 500 gr, who would have been candidats for abdominal hysterectomy, underwent laparoscopic assisted vaginal hysterectomy. The charts of the procedures performed at the Department of Ginecologic Oncology from May 1999 to May 2001were retrospectively reviewed. Technique: The retroperitoneum was accessed through the lateral leaf of the broad ligament and the ureter isolated at the pelvic brim. The ureter and the internal iliac artery were then dissected to the origin of the uterine artery, delimiting the pararectal fossa. At this point, the uterine artery was coagulated, previous checking of the ureter. Only at this step the infundibulo-pelvic ligaments or the utero-ovarian ligaments were severed. Section of the uterosacral ligaments, preparation of the bladder flap and opening of the vagina were performed according to the difficulty of the vaginal procedure. Results: 23 out of 24 laparoscopic assisted vaginal hysterectomies were carried out (95.8%). One patient had laparotomy. The median weight of the uteri was 650 gr (range 500-1100). The median time for the procedure was 100 minutes (range 80-180). We did not observe postoperative complications. Discussion: Few authors have described the retroperitoneal approach as the standard technique for laparoscopic securing of the uterine pedicles. The advantages of this approach to laparoscopically assisted vaginal hysterectomy are discussed. Introduction Vaginal hysterectomy (VH) can be the standard procedure for removing the uterus in most patients (Darai et al,2001; Harris and Olive, 1992; Magos et al,1996; Richardson et al,1995). However, the surgeon's individual skills and capabilities in vaginal surgery vary widely and indications or contraindications to VH are not unequivocal. Although an uterus larger than 13 weeks of pregnancy can be vaginally removed, the procedure may be difficult and sometimes challenging. Many different techniques for laparoscopic assistance to VH have been described (Aubard et al,1996; Ferrari et al,2000; Hur et al,1995; Nezhat et al,1992; Redwine, 1995; Reich et al,1989; Shwayder,1999; Summitt et al,1998) and classifications for laparoscopic assisted vaginal hysterectomy (LAVH) have been proposed (Mage et al,1995; Munro and Parker,1993). Most of these papers do not describe or take in account a modified retroperitoneal procedure with isolation of the ureter and uterine artery which allows total control of the operative field. Only Kadar (1995) describes in details the retroperitoneal hysterectomy and Schneider (1997) cites this technique for the large uterus In this paper, we describe our experience and technique for retroperitoneal dissection of the ureter and the uterine pedicles during the laparoscopic assistance to VH in cases of uterus above 500 gr.