Page 49 - WJOLS - Surgery Journal

Hassan
DISCUSSION Poor vaginal accessibility in majority of patients is also the
reason why, despite the use of laparoscopy, some centers use
Hysterectomy is one of the most commonly performed major uterine volume reduction procedures.
operations. Approximately 600,000 hysterectomies are When the use of reduction techniques was essential, several
performed in the United States each year and 20% of women in procedures including morcellation, bivalving, coring, were
the UK undergo hysterectomy before the age of sixty. 2,3 combined. For these patients, laparoscopic surgery should not
Historically the uterus has been removed by either the be considered ‘a waste of time’ but rather as the only solution
abdominal or vaginal route. The vaginal operation is preferable to enable them to avoid laparotomy.
when there are no contraindications because of lower morbidity The indications for abdominal hysterectomy are those that
and quicker recovery. Laparoscopic hysterectomy has gained constitute the contraindication for vaginal hysterectomy.
a lot of attention internationally in the recent passed. The role
of minimally invasive surgery in the management pelvic Laparoscopic vaginal hysterectomy modifies the contrain-
abnormalities continues to expand. However the role of dication since tissue dissection and mobilization is initiated
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laparoscopic assisted vaginal hysterectomy viz a vis that of intra-abdominal as elucidated by Garry and Reich. There is
laparoscopic total hysterectomy remains of great interest and also diversity in the quality of literature on the subject. The
opportunity to expand on the options available to the main variables with regard to the subject mater include the
laparoscopic surgeon to deal pelvic pathology. The most number of patients in the trial, withdrawal of cases, exclusion of
common indications for hysterectomy include fibroids (30%), cases, blinding if the study, local medical care practice, the use
abnormal uterine bleeding (20%), endometriosis (20%) and of prophylactic antibiotic treatment and follow-up failure within
genital prolapsed (15%). 6,7,10 the study period become important factors.
Despite all the advantages of vaginal and laparoscopic A retrospective observational comparing LAVH, TAH and
surgery over laparotomy, the majority of hysterectomies VH was carried out. Many of the laparoscopic vaginal
indicated for benign pathologies are carried out by laparotomy. hysterectomies were converted to abdominal hysterectomy. The
The VALUE study suggested that 67% of surgeons still used evaluate study concluded that although it could be considered
the abdominal approach as the main mode of hysterectomy. that such conversions represented prudent surgery it was felt
Other multicenter studies which provide a good representation that on the balance they represented a failure of planned 7
of the means by which hysterectomies are earned out, show procedure and should be considered as major complications.
that only 30% of the operations use the vaginal route, including Laparoscopic hysterectomies particularly TLH are fast trying
laparoscopic assisted vaginal hysterectomy. 7 to fulfill the goals of every pelvis surgeon of providing safe
For hysterectomies carried out on nonprolapsed uterus the easily performed procedure which provdes significant
results reported demonstrate that on average only 27% are satisfaction to the patient. A great proportion of hysterectomy
carried out by the vaginal route. These results alone justify the are performed totally laparoscopicaly and are much less traumatic
statement that there is a place for laparoscopic surgery for than vaginal, LAVH or open abdominal hysterectomies
hysterectomy in order to reduce the number of laparotomies. according to some studies. The benefits include reduced blood
Nulliparous patients are very representative of the loss, reduced risk of surgical injuries, less pain and early
population of patients for whom vaginal surgery rarely presents mobilization. Studies indicate the potential of TLH to become
under the best conditions for surgeons with average training the method of choice over the currently popular laparoscopically
minimal access surgery. Almost 40% of hysterectomies in assisted vaginal hysterectomy. 3,8
nulliparous patients used laparoscopic surgery. In total laparoscopic abdominal surgery; different levels of
Many studies show that laparoscopic hysterectomy injury have been reported, including bladder, ureter, bowel and
5
increasingly replacing open hysterectomy are in line with this vascular injuries. These results underline the fact that, this is a
evolution. 1,3,30 One reason for this is the laparoscopic surgery difficult operation requiring considerable skill in laparoscopic
technique used for hysterectomy. Whereas certain centers surgery.
perform simple LAVH, others used total laparoscopic Recently the evaluate study concluded that LAVH was
hysterectomy for all the patients. For certain patients, simple associated with a significantly higher rate of major complications
LAVH may be enough to avoid laparotomy, but in others with than abdominal total hysterectomy (TAH). LAVH took longer
very poor vaginal accessibility the only alternative to laparotomy to perform but was associated with less pain, quicker recovery
is to carry out total hysterectomy exclusively via the and better short-term quality of life measures. In contrast to
laparoscopic route. The important role played by vaginal this the study by Lumsden et al did not show any difference in
accessibility when establishing the indication for total postsurgery recovery, satisfaction with the outcome of the
laparoscopic hysterectomy has already been underlined in operation or quality of life four weeks postoperatively between
certain series in which nearly half the patients who underwent TAH and LAVH. The study concluded that although it could
laparoscopic hysterectomy were nulliparous. be considered that such conversions represented prudent

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