Page 50 - WJOLS - Surgery Journal

Laparoscopic Hysterectomy—Beyond Garry and Reich Classification
surgery it was felt that on the balance they represented a failure neoplasm, chronic cervicitis, and the nature of the ovarian
of planned procedure and should be considered as major neoplasm are easily confirmed during TLH/LAVH.
complications. 3 Years after the first case of TLH and laparoscopic assisted
Analysis of studies, show that complications usually arise hysterectomy was published; this operative procedures are
during the learning curve of the new procedure. A publication performed in relatively few centers worldwide. The reasons for
from Finland analyzing prospectively 10110 hysterectomies this restriction can be unavailability of a formal curriculum, lack
performed nationwide revealed that with increasing experience of standardization of procedures and training as well as the
of surgeries performed by the surgeon, the number of cost of infrastructure. Therefore, a proper training program with
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complications was significantly decreased. This can be a standardized procedure is necessary for the education of the
attributed to the performance of the same standardized steps resident and fellow doctors to qualify them for coping with the
every time in the surgeries makes the surgeon well-versed with possible difficulties encountered during this surgery. The cost
the technique and decreases the rate of complications. of equipment and disposables needs to come down as well.
The average intraoperative blood loss for laparoscopic It is important for a gynecological surgeon to add TLH to
assisted vaginal hysterectomy is about 200 m/s. The mean his surgical armamentarium on condition that he is well-familiar
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operative time is two hours. The postoperative complication with the performance of LAVH. In turn, for a surgeon to be
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rate has been quoted to be about 5.9%. Through the use of proficient in LAVH he ought to be a good vaginal surgeon
standardized procedural steps TLH and assisted vaginal capable of performing vaginal hysterectomy for nondescend
hysterectomy can become an easy procedure which can be uterus. So much so, at any stage if difficulty are encountered,
mastered by many. The salient features of the steps include use the surgeon must be able to convert TLH to laparoscopic
of a combination of regional and general anesthesia, ergonomic hysterectomy (LH) or LAVH, and seldom a surgeon may be
port, patient and surgeon positioning, proper retraction of the called upon to complete hysterectomy by the abdominal route
uterus, appropriate sharp dissection and the prudent of (the default operation). 14,17
energized equipment, including bipolar forceps and harmonic. 7 In summary, laparoscopic hysterectomy and laparoscopic
There is compelling need for continuous refining of the assisted vaginal hysterectomy are a safe route provided the
technique of hysterectomy to avoid traumatic, hemorrhagic and surgeons are well-trained, because then the rate of complications
infective morbidity, speedy recovery with minimal hospita- is not higher than that observed with laparotomy or by the
lization, early return to work and therefore providing quality vaginal. It is important to indicate that conversion to any mode
health care. of hysterectomy from another, should be considered as a dictate
The average total LAVH cost is $7,500 to the patients, in of safety and efficacy rather than a surgical complication.
the West, if use of disposable instruments is limited and the The American college of obstetricians and gynecologists
use of bipolar cautery is encouraged instead of sutures or Endo guidelines state that the route of hysterectomy should depend
GIA that are more expensive. 16 on the patient’s anatomy and surgeon’s experience. 12
Minimal access hysterectomy is a recently introduced
technique and even though the complications associated with REFERENCES
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its first description in 1989, its value remained controversial. abdominal hysterectomy. A population based study. Amj
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