Page 16 - World Journal of Laparoscopic Surgery

Sheriff Z Kotb et al
Laparoscopic-assisted vaginal hysterectomy is now patient is placed in 20° to 30° Trendelenburg position for
regarded as a safe and feasible technique for managing visualization of the pelvic structures. Additional sheaths
uterine diseases, because it offers minimal postoperative are placed under laparoscopic guidance. Two 5-mm
discomfort, less blood loss, shorter hospital stay, rapid sheaths are placed approximately 3 to 4 cm medial to
convalescence, and an early return to activities of daily and slightly above the level of the anterior superior iliac
living. 7 spines. The inferior epigastric vessels should be avoided
Hand-assisted laparoscopic surgery was first des- when these sheaths are being placed. Additional 10-mm
cribed in the early 1990s to facilitate the performance of sheath is placed in the suprapubic location.
challenging laparoscopic procedures while maintaining The bowel is manipulated out of the pelvis with
the advantages of a minimally invasive approach. 8 atraumatic forceps. The course of every pelvic ureter is
In this technique, the surgeon’s nondominant hand is visualized through the medial leaf of the broad ligament,
introduced into the abdominal cavity by means of a hand- and its position is verified during each portion of the
port device while maintaining pneumoperitoneum. The procedure.
dominant hand is then used to manipulate instruments The uterus was placed on lateral traction (with the
in concert with a surgical assistant. Hand-assisted help of uterine manipulator), and the round ligament
laparoscopy combines the benefits of laparoscopy with on each side was elevated and divided with the endo-
advantages of a conventional laparotomy, allowing for scopic scissors using monopolar electrocautery or
improved exposure, manual exploration, blunt dissection, with clip applier (Fig. 1). The peritoneum was opened
and immediate control of hemostasis. 9
lateral to the fallopian tube and infundibulopelvic liga-
ment, and ovarian vessels were controlled with endo-
MATERIALS AND METHODS
scopic scissors with monopolar cautery or with ligature
This cross-sectional study included 41 sequential (Fig. 2). In majority of cases salpingo-oophorectomy was
patients scheduled for hysterectomy at the Oncology performed.
Center, Mansoura University (OCMU) who were divided
randomly (patient by patient) into two groups: Group 1
included 21 patients who underwent LAVH and group 2
included 20 patients who underwent HALH from August
2010 to March 2013.
Patients were excluded from this study if they had
contraindications to either vaginal hysterectomy, such
as several prior abdominal surgeries, vaginal stenosis,
or severe endometriosis, or to laparoscopy, as underlying
medical conditions that could be worsened by pneumo-
peritoneum or the Trendelenburg position. Body mass
index (BMI) was not a limiting factor for patient inclusion
in the study.
Full history and general, abdominal, and vaginal
examinations were conducted for every patient. Complete
blood count, liver and renal functions, and electrocardi-
ography were ordered too. An informed consent for every Fig. 1: Using uterine manipulator, the left round ligament is exposed
patient was obtained. All patients underwent the same and divided with clip applier or endoscopic scissors with monopolar
standard preparation prior to surgery, including antibi- cautery
otic prophylaxis and administration of low molecular
weight heparin.

Group 1: Laparoscopic-assisted
vaginal hysterectomy

A peritoneal access is performed with a 10-mm sheath
placed infraumbilically using closed (Veress needle)
or open (Hasson trocar) technique. Carbon dioxide is
insufflated with a high-flow (>3 l/min) insufflator at
pressures of <15 mm Hg. The laparoscope is inserted
and upper abdominal contents are visualized. The Fig. 2: Control of the infundibulopelvic ligament with the ligature
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