Laparoskopische suprazervikale Hysterektomie (LASH)

Laparoscopic supracervical hysterectomy (LASH) is a minimally invasive procedure that was developed during the 1990s as a novel treatment option for patients with uterine bleeding disorders. To date, prospective randomized trials comparing LASH with either vaginal or abdominal hysterectomy do not exist. A randomized controlled trial that compared LASH with hysteroscopic endometrial resection found that LASH resulted in better patient satisfaction. A retrospective study compared LASH with laparoscopic assisted vaginal hysterectomy and demonstrated reduced operating time, blood loss, hospitalisation and a quicker return to normal activity for patients who underwent LASH. The potential risk of cervical carcinoma in patients with a cervical stump is often controversially discussed. However, results of follow-up studies do not indicate a higher incidence of cervical cancer after LASH compared to the risk of vaginal cuff carcinoma after total hysterectomy.     

Laparoskopische nervenschonende radikale Hysterektomie

Endoscopic surgical procedures are becoming the standard treatment in gynecological oncological diseases. In the operative treatment of cervical and endometrial cancer, radicality and morbidity are serious problems. The more radical the parametrial structures are dissected and removed, the more often a dysfunction of the bladder and rectum occurs. Laparoscopic nerve-sparing radical hysterectomy combines the advantages of laparoscopy with the advantages of a nerve-sparing radical hysterectomy:, significantly lower postoperative morbidity and faster recovery associated with lower indirect costs.     

Endoskopische Hysterektomie

Laparoscopic hysterectomy is a globally accepted operation procedure but the best option for the patient is still the vaginal approach. In cases in which vaginal hysterectomy is difficult laparoscopy can be used to facilitate a vaginal removal route of the uterus hereby avoiding an abdominal hysterectomy. It has been shown that the laparoscopic and the vaginal approaches are equivalent with respect to morbidity. The different modalities of the laparoscopic hysterectomy are described in this article.     

Die vaginale Hysterektomie

If an indication for hysterectomy exists, the appropriate operative extirpation, abdominal or vaginal, must be chosen. The advantages and disadvantages of both procedures, the uterine size and mobility, the local operation conditions, previous gynaecological operations and laparotomies as well as the surgeon's experience should be considered. Regarding the appropriate indication, the vaginal hysterectomy offers several advantages over the abdominal uterine extirpation. Therefore, a vaginal approach should always be considered and preferred in patients diagnosed with benign diseases. The vaginal uterine extirpation is the first operative choice in patients diagnosed with uterus myomatosus and dysfunctional uterine bleedings. In the case of adenomyosis, vaginal hysterectomy can also be considered. Vaginal hysterectomy is a standard operation in gynaecology and several different techniques exist.     

Laparoskopische Lymphonodektomie

Laparoscopic lymph-node dissection is an attractive technique for the staging of pelvic tumors. Applications in gynaecological oncology include surgical therapy of cancers of the endometrium, cervix and vagina, and early-stage ovarian cancers. Meanwhile studies with large case series have been published and have shown that laparoscopic pelvic and paraaortal lymph-node dissection is at least equivalent to the open procedure in terms of radicality. Advantages over the open technique are reduced intraoperative blood loss, shorter hospital stay, and a reduction in postoperative pain. General dissemination has been hampered by the lack of availability of necessary equipment, the reportedly flat learning curve, and the challenging teaching process for this demanding technique. Modern multimodal and multimedia teaching techniques such as video demonstrations of the pelvic anatomy, phantom and cadaver courses, and visits to centres with the appropriate expertise are promising ways to provide access to the technique in clinical practice and to increase the number of centres offering this procedure to their patients.     

Laparoskopische Follikelpunktion

Normally, transabdominal or laparoscopic follicular puncture is now only necessary in ovarian maldescent, which can be the case in uterine agenesis or ?C rarely ?C uterine malformation. The rate of oocyte retrieval appears to be similar with transabdominal and laparoscopic approaches but is lower than with a transvaginal puncture.     

Laparoskopische Kolposuspension

Zusammenfassung Die Kolposuspension hat sich in den beiden letzten Jahrzehnten als erfolgreichste Operation zur Behandlung der Stre?harninkontinenz erwiesen. Der laparoskopische Zugang zum Cavum Retzii vermeidet die Nachteile einer Laparotomie, die im Vergleich zu den rein vaginalen Operationsverfahren eine erh?hte Frühmorbidit?t aufweist. Der folgende Beitrag beschreibt die Ergebnisse der in Manchester üblichen Technik der laparoskopischen Kolposuspension. Der Zugang zum retropubischen Raum erfolgt transperitoneal. Die Fixation der endopelvinen Faszie am Cooperschen Ligament wird durch jeweils zwei paraurethrale N?hte mit der geraden Nadel sichergestellt. Die Hauptgefahren bestehen in der Verletzung der Arteria epigastrica inferior, der Blase, des Darmes und die Ausbildung von Hernien durch die Trokartkan?le. In 10 % kam es postoperativ zu einer de novo Detrusorinstabilit?t. Die postoperative Inzidenz von Deszensus- oder Prolapszust?nden betrug 15 %. Mindestens sechs Monate postoperativ waren 86 % geheilt. Die Heilungsrate bei Rezidivinkontinenz betrug 60 %. Diese Resultate veranlassen zu vorsichtigem Optimismus. Allerdings k?nnen erst die Langzeitresultate über den Wert dieser neuen Methode entscheiden.     

Hysterektomie: interventionelle Alternativen

If hysterectomy is medically indicated or there is a patient wish for guaranteed freedom from suffering, nowadays in order to avoid an abdominal hysterectomy, the preferred approaches are vaginal hysterectomy as well as laparoscopically-assisted procedures, such as total laparoscopic hysterectomy (TLH), laparoscopically-assisted supracervical hysterectomy (LASH) and laparoscopically-assisted vaginal hysterectomy (LAVH). The type of procedure used depends on the diagnosis, the wishes of the patient and the technical competence. Hysterectomy is not indicated in some cases and can often be replaced by organ preserving procedures especially for myomas and bleeding disorders. Enucleation of myomas and new procedures of myoembolization and magnetic resonance imaging-guided focused sonography are of great importance. An atrophy of the cervical mucosa in bleeding disorders by endometrial ablation can lead to an improvement and reduction of symptoms after exclusion of a malignancy and where there is no desire to have children. Robot-assisted surgery is being used increasingly more for hysterectomy and myoma enucleation.     

Vaginale und abdominale Hysterektomie

Hysterectomy is one of the most common major gynecological operations. There are several different techniques for performing it, and if it is indicated, the appropriate operative approach, vaginal or abdominal, must be chosen. The advantages and disadvantages of the two approaches, the uterine size and mobility, previous operations, the surgeon’s experience, and the local operating conditions should all be considered. Vaginal hysterectomy has advantages compared with abdominal hysterectomy: The operating time is shorter, it is safer, and the hospital stay and recovery time are shorter as well. Therefore, a vaginal approach should be preferred in patients with benign diseases. Vaginal uterine extirpation is the first operative choice in patients with uterus myomatosus and dysfunctional uterine bleeding. The integration of new technical possibilities, such as bipolar coagulation forceps, has improved haemostasis and produces less blood loss and less postoperative pain.     

Laparoskopische Therapie von Andextumoren

Zusammenfassung Von 6/89 bis 7/92 wurden nach Ausschlu? der Extrauteringravidit?t 171 P. mit oder ohne akute Symptomatik wegen Adnextumoren laparoskopiert, davon 103 P. laparoskopisch operiert. Dank striktem Einhalten der Kontraindikationen (Vaginalsonographie und intraoperative Inspektion) wurde kein Malignom laparoskopisch anbehandelt. Perioperative Komplikationen traten keine auf, die postoperative Komplikationsrate lag bei 1%, wobei 75% der P. organerhaltend operiert worden waren.     

Laparoskopische Therapie der Endometriose

In endometriosis, surgical removal of manifestations of the disease is considered the state-of-the-art treatment for both symptom control and infertility. While whenever possible, laparoscopic surgery should be employed, both persistence and recurrence are unsolved problems of the disease.