Transvaginal hysterectomy or laparoscopically assisted vaginal hysterectomy for nonprolapsed uteri

BACKGROUND: To define a rational guideline for the use of either laparoscopically assisted vaginal hysterectomy (LAVH) or transvaginal hysterectomy in dealing with a nonprolapsed uterus. METHODS: A total of 452 patients receiving LAVH or transvaginal hysterectomy were retrospectively studied between October 2002 and October 2004. The operative time, estimated blood loss, uterine weight, and complications were all recorded for analysis. RESULTS: Significant linear correlations of uterine weight with operative time and estimated blood loss could be seen only in the transvaginal hysterectomy group. Transvaginal hysterectomy required significantly shorter operative time, but longer duration when the uterine weight exceeded 350 g. These 452 patients were stratified into 4 subgroups according to the uterine weight and hysterectomy procedure. Data are expressed as the mean +/- standard deviation. For uterine weight less than 350 g, transvaginal hysterectomy had significantly shorter operative time than LAVH (80 +/- 27 minutes compared with 118 +/- 21 minutes, P < .05) but similar blood loss (70 mL compared with 74 mL). For uterine weight 350 g or less, transvaginal hysterectomy had not only significantly longer operative time (139 +/- 30 minutes compared with 118 +/- 17 minutes, P < .05) but also more blood loss (242 +/- 162 mL compared with 66 +/- 51 mL, P < .05) than LAVH. CONCLUSION: In view of the shorter operative time and less blood loss, LAVH is preferable for uterine weight 350 g or more, whereas transvaginal hysterectomy is better in dealing with uteri weighing less than 350 g.     

Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids

Objective To compare laparoscopically assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH) in patients with uterine fibroids.
Design A prospective randomised study.
Setting The San Paolo Hospital, Milan.
Population Sixty-two patients, who were not suitable for a vaginal hysterectomy, requiring treatment for uterine fibroids.
Methods Randomisation between LAVH and TAH. Comparison of outcomes on the whole series, patients with uteri ≤ 500 g (Group 1) and patients with uteri > 500 g (Group 2).
Main outcome measures To establish operating time, blood loss, complications, febrile morbidity, analgesics administration and hospital stay for both treatment approaches.
Results Median uterine weight was 400 g in both LAVH and TAH group. Median operating time was longer for LAVH (135 min compared with 120 min for TAH;   P = 0.001  ), but patients undergoing LAVH had less analgesics administration (23% compared with 77%,   P < 0.001  ) and a shorter median hospital stay (3.8 compared with 5.8 days;   P < 0.001  ). LAVH, when compared with TAH in the two weight subgroups, required a significantly longer operating time only in Group 2, significantly reduced analgesics administration only in Group 1, and significantly reduced hospital stay in both groups. Conversions of LAVH to laparotomy were significantly more frequent in Group 2 (3/11) than in Group 1 (0/20) (   P = 0.04  ).
Conclusions Compared with TAH, LAVH has advantages in removing uteri weighing ≤ 500 g, with comparable operating time, less post-operative pain and shorter recovery. Among uteri weighing > 500 g LAVH showed a shorter recovery, but longer operating time than TAH and a 27% rate of conversion to laparotomy.     

Laparoscopic-assisted vaginal hysterectomy with in situ morcellation for large uteri

STUDY OBJECTIVE: To estimate whether laparoscopic in situ morcellation (LISM) can facilitate laparoscopic-assisted vaginal hysterectomy (LAVH) for large uteri. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: In all, 147 women with myoma or adenomyosis weighing more than 500 g from January 2004 through December 2007 were enrolled. The patients were divided into 4 subgroups: patients with uteri weighing 500 to 749 g who had traditional LAVH without LISM (group 1A, n = 69) or with LISM (group 1B, n = 16); and patients with uteri weighing 750 g or more who were treated by traditional LAVH without LISM (group 2A, n = 38) or with LISM (group 2B, n = 24). INTERVENTIONS: Laparoscopic-assisted vaginal hysterectomy with or without LISM. MEASUREMENT AND MAIN RESULTS: No significant differences existed in age, body mass index, preoperative diagnoses, complications, or duration of hospital stay among groups. The mean uterine weights were 608 +/- 75, 597 +/- 66, 989 +/- 179, and 935 +/- 226 g for groups 1A, 1B, 2A, and 2B, respectively. The operative time (120 +/- 16 vs 157 +/- 36 minutes, p <.001; 140 +/- 19 vs 224 +/- 57 minutes, p <.001) were significantly shorter in patients with LISM than without in both groups 1 and 2. The estimated blood loss was highest in group 2A. Six (16%) patients lost more than 500 mL of blood and 3 (8%) of them needed blood transfusions. Conversion to laparotomy occurred in 1 (2.6%) of 38 patients in group 2A. No repeated surgery or surgical mortality occurred. CONCLUSION: Laparoscopic-assisted vaginal hysterectomy with LISM was an efficient and safe procedure for removal of large uteri during LAVH.     

Experience with laparoscopic-assisted vaginal hysterectomy for the enlarged uterus

Objective  The aim of this study is to evaluate the effect of uterine weight on the perioperative and postoperative outcomes of laparoscopically assisted vaginal hysterectomy (LAVH) for benign gynecological conditions. Methods  In a retrospective observational study, 367 patients underwent LAVH (type I laparoscopic hysterectomy) for benign disorders at the Department of Gynecology at the Istanbul Bakirkoy Women and Children Hospital. Patients were divided into two groups with uterine weight <500 g and uterine weight ≥500 g. Outcome measures for both groups were studied comparatively in terms of length of operative time, pain score, amount of blood loss, requirement of blood transfusion, and length of hospital stay. Results  There were no differences in patients’ mean age, parity, gravidity, rate of postmenopausal state, previous pelvic surgery, and body mass index. The most common indications for surgery were myoma and abnormal uterine bleeding. The duration of operation, estimated blood loss and requirement of blood transfusion were significantly less for <500 g group than for ≥500 g group. Three women in the <500 g group sustained a blood loss in excess of 500 ml. By comparison, 18 women in the ≥500 g group sustained a blood loss in excess of 500 ml (P = 0.000). Total complication rate was 8.7%. Postoperative ileus and febrile morbidity were the most common complications. No significant difference was noted in overall complications between groups (P = 0.13). During the vaginal part of the procedure bladder injury occurred in one patient who had uterine weight ≥500 g. Conclusion  LAVH is a safe and efficient way to manage benign uterine disease and despite the increased operating time and blood loss, LAVH can be safely performed for enlarged uterus.     

Laparoscopic-assisted vaginal hysterectomy with uterine artery ligation through retrograde umbilical ligament tracking

STUDY OBJECTIVE: To evaluate the clinical outcomes of uterine artery ligation through retrograde tracking of the umbilical ligament (RUL) in laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: University-affiliated hospital. PATIENTS: Two hundred twenty-five women with myomas or adenomyosis. INTERVENTION: Laparoscopic-assisted vaginal hysterectomy with uterine artery identification and ligation through RUL. MEASUREMENTS AND MAIN RESULTS: The median age of the patients was 46 years, and the median weight of the extirpated uteri was 340 g, with 26.2% of uteri weighing more than 500 g. The median operation time was 135 minutes, and the median blood loss was 50 mL. The median intramuscular meperidine requirements were 1 ampoule (50 mg), and the median hospital stay was 3 days. It took approximately 10 minutes from identification of the umbilical ligament to ligation of the uterine artery. Uterine weight of 500 g or more required a significantly longer operation time compared with uteri weighing less than 500 g (164 min vs 127 min median, p <.001), and there was more blood loss (100 mL vs 50 mL median, p <.001). There were no differences in the median intramuscular meperidine requirements or hospital stay between the two groups. No blood transfusion was needed in either group, even in patients with a uterine weight of more than 1000 g. By regression analysis, uterine weight was significantly related to blood loss and operation time. A linear relationship was found among uterine weight, operation time, and blood loss: Uterine weight = 87.589 + 1.881 x operation time + 0.48 x blood loss (R = 0.531, F = 35.694, degrees of freedom 184, p <.001). No complications related to RUL were observed, although two bladder injuries related to severe pelvic adhesion with endometriosis and previous cesarean section occurred. CONCLUSION: Minimal blood loss and a low complication rate were noted in LAVH by uterine artery ligation through RUL. This technique should be a valid approach, especially in patients in whom minimal blood loss must be achieved.     

Laparoscopically assisted vaginal hysterectomy. A suitable substitute for abdominal hysterectomy?

OBJECTIVE: To compare short-term clinical results in a retrospective case-control review of laparoscopically assisted vaginal hysterectomy (LAVH) versus total abdominal hysterectomy (TAH). STUDY DESIGN: One hundred seventeen women undergoing laparoscopically assisted vaginal hysterectomy were compared to 117 women undergoing total abdominal hysterectomy, with or without bilateral salpingo-oophorectomy. The perioperative and postoperative courses of the matched groups were compared. RESULTS: The time intraoperatively was longer in the LAVH group. The mean blood loss was increased in the LAVH group. The need for blood transfusion was higher in the LAVH group. The number of women with intraoperative complications differed significantly between LAVH and TAH. The number of postoperative complications did not. Postoperative time in the hospital was shorter in the LAVH group. The cost of the average case, including operating room time, instruments and hospital stay, did not differ. CONCLUSION: LAVH offers benefits to patients in the form of less time in the hospital and presumably, therefore, faster recovery, though at the expense of potentially longer intraoperative time, increased risk of blood transfusion and increased risk of intraoperative complications.     

Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To compare laparoscopic supracervical hysterectomy (LSH) with laparoscopic-assisted vaginal hysterectomy (LAVH) in terms of indications, pathology, length and weight of removed uteri, operative time, intraoperative blood loss, intra and postoperative complications, and later sexual function. DESIGN: Cohort retrospective analysis of consecutive cases (Canadian Task Force classification II-3). SETTINGS: Hutzel Hospital, Detroit Medical Center,Wayne State University, Detroit, Michigan; Vert-Pre Nouvelle Clinique, Geneva, Switzerland; and Benha University Hospitals, Egypt. PATIENTS: Two hundred and fifty-nine women. INTERVENTIONS: LSH and LAVH. MEASUREMENTS AND MAIN RESULTS: Patients in both groups were matched regarding age, indications, and pathology of the removed uteri. Blood loss with the LSH procedure was significantly lower than it was with the LAVH procedure (mean 125 +/- 5 vs 149 +/- 7 mL, p =.001). Patients that underwent LSH had significantly shorter operating times (mean 120 +/- 3 vs 150 +/- 5 minutes, p =.007). The length of the removed uteri was 14.2 +/- 0.5 cm (range 5.2-18) in the LSH group versus 11.8 +/- 0.4 cm (range, 5.6-14) in the LAVH group. Weight of the removed uteri was 280 +/- 6 g (range, 65-750) in the LSH group compared with 235 +/- 8 g (range, 59-560) in the LAVH group. There was no difference between the groups in hospital length of stay. The number of complications was less in the LSH group (3/123, 2.4%) compared with 5/136 (3.7%) in the LAVH group. Sexual function after surgery was better in the LSH group. CONCLUSION: After exclusion of preoperative cervical disease, LSH can be considered as a safer alternative to LAVH in patients that are candidates for laparoscopic hysterectomy.     

New helical incision for removal of large uteri during laparoscopic-assisted vaginal hysterectomy

The objective of our study was to evaluate the feasibility of a new incision technique for vaginal removal of large uteri during laparoscopic-assisted vaginal hysterectomy (LAVH). The helical uterine incision with uterine arteries preligation was performed during LAVH. The medical records for 522 women with uterine tumors who underwent LAVH from January 2001 through November 2003 were studied retrospectively. The mean uterine weight of all 522 patients was 325 +/- 213 g (range 32-1350 g), and the mean operation duration was 73 +/- 21 minutes. The patients were divided into three subgroups: patients with uteri weighing less than 300 g (group A), patients with uteri weighing between 300 and 500 g (group B), and patients with uteri weighing more than 500 g (group C). The mean uterine weight was 172 +/- 69 g, 374 +/- 56 g, and 678 +/- 181 g for groups A, B, and C, respectively; and the mean operation duration was 67 +/- 17 minutes, 73 +/- 19 minutes, and 90 +/- 24 minutes for groups A, B, and C, respectively. No linear relationship between uterine weight and operation duration was noted in the regression analysis and analysis of variance testing in group B. Uteri weighing between 300 and 500 g were extracted vaginally without difficulty using the new helical uterine incision technique. Use of the helical incision technique reduced operation duration, and restoration of the uterine anatomy for pathologic examination was made easily. The complication rate was 0.8%, which is relatively low compared with our previous report (1.38%) in 580 LAVH procedures. In conclusion, the helical transvaginal uterine incision proved to be an efficient and safe procedure for removal of large uteri during LAVH.     

Comparison of total laparoscopic hysterectomy and laparoscopically assisted vaginal hysterectomy

We compare the surgical results of 60 women undergoing laparoscopically assisted vaginal hysterectomy (LAVH) and 41 having total laparoscopic hysterectomy (TLH) under the indications of uterine fibroids or adenomyosis. With similar specimen weight, TLH required longer surgery duration (140.4 vs. 115.1 min; p < 0.05) than LAVH. Among women with uteri weighing 0.05) although the TLH group had a significantly higher rate of previous abdominal surgery (57.7 vs. 20%; p < 0.05). There were no significant differences between the two groups with respect to the mean cost, length of hospital stay and rate of various complications (p > 0.05). As for sexual symptoms, dyspareunia decreased significantly post-operatively in the LAVH group (p < 0.05), but not in the TLH group. A significant reduction in the frequency of orgasms after surgery was detected in both groups (p < 0.05). In conclusion, LAVH has advantages over TLH with reduced operating time. Although it is a technical challenge, TLH can be effectively performed within reasonable time limits in selected cases. The effects on sexual function, following either LAVH or TLH, are found to be similar.     

A simplified method to decrease operative blood loss in laparoscopic-assisted vaginal hysterectomy for the large uterus

STUDY OBJECTIVE. To evaluate the role of oxytocin in decreasing operative blood loss in laparoscopic-assisted vaginal hysterectomy (LAVH) for the large uterus (weight > or = 500 g). DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: Tertiary care university hospital. PATIENTS: Eighty-eight women scheduled for a hysterectomy for large benign uterine tumors. INTERVENTION: Two ampules of oxytocin (10 u/mL/amp) were added to 1000 mL of saline solution running at the rate of 40 mU/min during the course of LAVH. MEASUREMENTS AND MAIN RESULTS: Blood loss and blood transfusion rate were significantly greater in the group without oxytocin infusion (group B) than in the group with oxytocin infusion (group A), with 485.7 +/- 321.6 mL versus 364.1 +/- 173.2 mL (p <.05) and 26.7% versus 6. 1% (p <.05), respectively. There was no significant difference in average age, body weight, and number of vaginal deliveries and cesarean sections between the two groups. There also was no significant difference in mean uterine weight, postoperative stay, and complications between the two groups. CONCLUSION: Oxytocin infusion can cause uterine contractions that decrease uterine perfusion. It is a safe and inexpensive method to help decrease operative blood loss during LAVH for the large uterus.     

Single-port laparoscopic hysterectomy for uteri greater than 500 grams

ObjectivesTo study the operative outcomes of single-port laparoscopic hysterectomy in uteri greater than 500 g, using either laparoscopic assisted vaginal hysterectomy (LAVH) or laparoscopic supracervical hysterectomy (LSH).Materials and methods78 patients were included in a single institute by a single surgeon from March, 2013 to January, 2018.ResultsThe median uterine weight was 686.5 g. Larger uterine weight was correlated with longer operative time and greater estimated blood loss. Two types of operations were performed: LAVH (n = 55) or LSH (n = 23). There were no differences in operative time (150.2 ± 45.1 vs. 158.6 ± 82.1, P = 0.66) and estimated blood loss (365.8 ± 298.5 vs. 356.5 ± 46.6, ml, P = 0.94) between LAVH and LSH. However, patients in LAVH had more excess blood loss (>500 mL) compared with LSH (32.7% vs. 21.7%, P = 0.42). In the later study period, the operative time was shorter and complication rates were lower. Such differences were especially significant in the LAVH group. By multiple regression analysis, operative time was independently correlated with age, body mass index, estimated blood loss and uterine weight in LAVH. The correlation between operative time and uterine weight in LSH was attenuated by estimated blood loss. Estimated blood loss was the dominant factor correlated with longer operative time in LSH.ConclusionsBoth LAVH and LSH could be feasible in uteri greater than 500 g. LSH appeared to have less complication and less blood loss than LAVH. Operative time was correlated significantly with bleeding amount. Therefore, better bleeding control and surgical experience were warrants for single-port laparoscopic hysterectomy in uteri greater than 500 g.     

腹腔镜下不同子宫切除术2272例临床分析

目的　评价腹腔镜鞘膜内子宫切除术 (LISH)、腹腔镜子宫次全切除术 (LSH)、腹腔镜全子宫切除术(LTH)和腹腔镜辅助阴式子宫切除术 (LAVH)4种术式的临床效果。方法　回顾性分析各种腹腔镜子宫切除术 2272例的手术时间、出血量、并发症及术后恢复情况等。结果　保留子宫颈的两种术式中,LISH1323例(LISH组),手术时间为(91±21)min,出血量为 (93±23)ml,并发症发生率为 4 1%;LSH229例(LSH组),手术时间为(70±18)min,出血量为 (69±17)ml,无一例并发症发生;LISH组的手术时间、出血量及并发症发生率均高于LSH组,差异有统计学意义 (P<0.01)。去除子宫颈的两种术式中,LAVH588例(LAVH组),手术时间为(119±28)min,出血量为 (156±23)ml,并发症发生率为 1 0%;LTH132例(LTH组),手术时间为 (121±30)min,出血量为 (193±38)ml,并发症发生率 1 5%;LAVH组的手术时间、并发症发生率与LTH组比较,差异无统计学意义(P>0.05),而术中出血量LTH组明显多于LAVH组,差异有统计学意义(P<0.01)。结论　4种术式均为腹腔镜下子宫切除的有效术式,且各有利弊;应根据患者的具体情况选择适宜术式。     

Laparoscopically-assisted vaginal hysterectomy for fibroid uteri weighing at least 500 grammes

We retrospectively reviewed the medical records of 13 women who underwent laparoscopically-assisted vaginal hysterectomy (LAVH) where the uterus weighed 500 g or more. LAVH was successfully performed in 10 of these 13 women for whom the mean uterine weight was 619 g, mean operating time 99 minutes, and mean postoperative hospital stay 3.7 days. One of the 3 women who underwent abdominal hysterectomy required blood transfusion for intraoperative bleeding. There was no febrile or other operative morbidity associated with any patient. As up to 75% of hysterectomies are performed abdominally, LAVH may replace many abdominal hysterectomies for large fibroid uteri when vaginal hysterectomy is not feasible.     

Vaginal hysterectomy versus laparoscopically assisted vaginal hysterectomy for large uteri between 280 and 700 g: a randomized controlled trial

Objective

To compare surgical outcomes, postoperative complications and costs between vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy in cases of large uteri.

Methods

Prospective randomized controlled trial done at Ain Shams University Maternity Hospital, where 50 patients were recruited and divided into two equal groups (each 25 patients). First group underwent vaginal hysterectomy, and the second underwent laparoscopically assisted vaginal hysterectomy.

Results

Patient characteristics were similar in both groups. As for surgical outcomes, estimated intraoperative blood loss (P = 0.90), operative time (P = 0.48), preoperative hemoglobin (P = 0.09), postoperative hemoglobin (P = 0.42), and operative complications (P = 1.0) did not differ between the two groups. The hospital costs (converted from Egyptian pound to U.S. dollars) were significantly higher in case of LAVH group [VH: $1060.86 ($180.09) versus LAVH: $1560.5 ($220.57), P value <0.001]. No significant difference exists in the duration of postoperative hospital stay between the two groups [VH: 49.92 h (28.50) versus LAVH: 58.56 (27.78), P = 0.28] or the actual uterine weight measured postoperatively [VH: 350.72 g (71.78) versus LAVH: 385.96 g (172.52), P = 0.35].

Conclusion

Both vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy are safe procedures in cases of large uteri with no significant difference between them except in terms of costs as VH appears to be more cost effective.

Clinical Trials.Gov

NCT02826304.

     

Comparative study of vaginal,laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study

BACKGROUND: The purpose of this study was to compare peri-operative morbidity, preoperative sonographic estimation of uterine weight and postoperative outcomes of women with uterine fibroids larger than 6 cm in diameter or uteri estimated to weigh at least 450 g, undergoing either vaginal, laparoscopically assisted vaginal or abdominal hysterectomies. METHOD: Ninety patients who met the criteria of uterine fibroids larger than 6 cm by ultrasonographic examination were included in our prospective study. Patients were randomized into laparoscopic-assisted vaginal hysterectomy (30 patients), vaginal hysterectomy (30 patients) and abdominal hysterectomy (30 patients) groups. RESULTS: The laparoscopically assisted vaginal hysterectomy group had significantly longer operative times than the abdominal and vaginal hysterectomy groups (109 +/- 22 min, 98 +/- 16 min, and 74 +/- 22 min, respectively, p < 0.001). Blood loss for vaginal hysterectomy was significantly lower than for either abdominal or laparoscopically assisted vaginal hysterectomies (215 +/- 134 ml, 293 +/- 182 ml, and 343 +/- 218 ml, respectively, p = 0.04). Vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy groups had shorter hospital stays, lower postoperative pain scores, more rapid bowel recovery and lower postoperative antibiotic use than the abdominal hysterectomy group. Uterine weight in the abdominal hysterectomy group was significantly heavier than in the vaginal and laparoscopically assisted vaginal hysterectomy groups (1020 +/- 383 g, 835 +/- 330 g, and 748 +/- 255 g, respectively, p = 0.02). We estimated that when a myoma measured between 8 and 10 cm, the uterus weighed approximately 450 g, and the sensitivity of this prediction was 57.5%. For a myoma larger than 13 cm, the estimated uterine weight was more than 900 g and the sensitivity of this prediction was 71%. CONCLUSION: The study shows vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy can be performed in women with uterine weight of at least 450 g. Preoperative ultrasonographic examination can provide the surgeon with valuable information on the size of the fibroid and the estimated weight of the enlarged uterus before implementing a suitable surgical method.     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

Vaginal hysterectomy for the enlarged uterus

OBJECTIVE: To evaluate the effect of uterine weight on the perioperative outcomes of vaginal hysterectomy for benign gynecological conditions. MATERIALS AND METHODS: The medical records of 312 consecutive women who underwent vaginal hysterectomies for benign gynecological conditions without major pelvic reconstruction at Temple University Hospital between March 1994 and August 1999 were reviewed. 88 women with uterine weights > or =250 g were compared with 224 women with uterine weights <250 g. The risk of perioperative complications, operative time, perioperative hemoglobin change, length of postoperative hospital stay, and readmission were evaluated between the groups. RESULTS: Groups were similar with respect to age, parity, history of previous pelvic surgery and concurrent adnexal removal. Operative time was significantly increased for women with uteri weighing > or =250 g. Women with uterine weight > or =250 g had a higher risk for postoperative febrile morbidity. The risks of all other major complications, perioperative change in hemoglobin concentration, length of stay, and readmission risk were not statistically different between the groups (p < 0.05). CONCLUSIONS: Despite the increased postoperative febrile morbidity and prolonged operative time, women with uteri weighing > or =250 g who underwent vaginal hysterectomy were discharged from the hospital without any increase in other complications when compared to women with a smaller uterus.     

Total laparoscopic hysterectomy in cases of very large uteri: a retrospective comparative study

In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighting more than 500 grams. We compared surgical outcomes and short term follow-up in 149 patients with the uterus weighing less than 350 g (group A: 40-350 g) and 100 patients with the uterus weighing more than 500 g (group B: 500-1550 g). We discovered no statistical difference between the 2 groups in terms of intraoperative complications (group A: 0%; group B: 2%) and postoperative stay (group A: 3.05 +/- 1.89 days; group B: 3.2 +/- 1.28 days). There were statistically significant differences between the 2 groups in terms of operative time (group A: 101.3 +/- 34.3 min; group B: 149.1 +/- 57.2 min.; p <.0001) and postoperative hospital stay length (group A: 2.8 +/- 0.7 days; group B: 3.5 +/- 1.7 days; p <.0001). No major complications occurred in either group. Postoperative minor complications were more frequent in group B (group A: 8.7%; group B: 18%; p = .03). Median time to well-being was comparable in both groups. In conclusion, TLH is a feasible surgical technique also in cases of very large uteri. An increase in operative time, intraoperative blood loss, hospital stay length, and postoperative minor complications can be expected as the uterine weight increases.     

Assessing the impact of introducing laparoscopically assisted vaginal hysterectomy into a community-based gynecology practice

This study was undertaken to determine the effects of introducing laparoscopically assisted vaginal hysterectomy (LAVH) into a community-based gynecology practice on the route of hysterectomy, operating time, patient costs, length of hospitalization, and morbidity, including complications and blood loss. All patients in the author's practice who had hysterectomies during the 10 months before completion of an advanced operative laparoscopy course were compared with the patients having a hysterectomy in the 10 months after the course. The route of hysterectomy, surgery time, length of hospital stay, preoperative and postoperative hemoglobin, uterine weight, diagnoses, and historical clinical data were compared between the two groups using a level of significance (alpha = 0.01) to assess statistical relevance. The rate of vaginal hysterectomy was remarkably higher in the AFTER group (53.2%, n = 62) vs the BEFORE group (27.7%, n = 65). The AFTER group had a significantly shorter hospital stay (3.4 days +/- 1.22 vs 4 days +/- 1.26, p < or = 0.01) but a much longer surgery time (115.9 min +/- 38.98 vs 80.1 min +/- 27.95, p < or = 0.01). There was no real difference in complication rates or fall in hemoglobin between the two groups. When LAVH was compared with TAH, the LAVH patients tended to be younger (37.4 +/- 8.66 vs 46.2 +/- 16.5 years) and to have a shorter hospital stay (3.1 +/- 0.99 vs 4.1 +/- 1.27 days), a longer surgery time (114.9 +/- 37.45 vs 85.3 +/- 33.74 min), and a bigger hospital bill ($6245 +/- 380 vs $5140 +/- 410) than patients with TAH.(ABSTRACT TRUNCATED AT 250 WORDS)     

Benefits of intracervical injection of sterile saline solution in laparoscopically assisted vaginal hysterectomy with vaginal colpotomy and bladder mobilization

OBJECTIVE: To evaluate the influence of intracervical saline injection on inexperienced operators and on laparoscopically assisted vaginal hysterectomy (LAVH). STUDY DESIGN: This retrospective study included 273 women undergoing LAVH. From July 1997 to June 2002, 138 LAVHs were performed with laparoscopically approached colpotomies and bladder mobilization. Among 135 LAVHs with a vaginal approach, colpotomies/bladder mobilization was done directly in 62 and in the other 73 after a circumferential intracervical saline injection. All operations were performed by inexperienced operators under the supervision of senior surgeons. Blood loss, operative time and complications were analyzed. RESULTS: The average follow-up period was 41.2 +/- 17.4 months (range, 12-72). No statistically significant differences were observed in age, hemoglobin levels or length of postoperative hospital stay. The incidence of postoperative infection, hematoma and bowel injury was not significantly different. LAVH with vaginal colpotomies/bladder mobilization and intracervical saline injection was associated with the smallest estimated blood loss (p = 0.002) and operative time (p < 0.001). LAVH with laparoscopic colpotomies and bladder mobilization had the longest operative time (p<0.001) and the highest bladder injury rate (p= 0.004). CONCLUSION: A circumferential injection of normal saline at the cervicovaginal junction is a good option for inexperienced operators.