Laparoscopically assisted vaginal hysterectomy

OBJECTIVE: To report our experience with laparoscopically assisted vaginal hysterectomy (LAVH) and evaluate the advantages of LAVH. STUDY DESIGN: From January 1991 to August 1992, 176 LAVHs were performed at the Department of Obstetrics and Gynecology, College of Medicine, Chung-Ang University, Seoul, Korea. The indications for LAVH, based on the preoperative diagnosis, were uterine myomas, dysmenorrhea, chronic pelvic inflammatory disease or pelvic pain, dysfunctional uterine bleeding and cervical intraepithelial neoplasia (in order of frequency). RESULTS: Patients had concomitant procedures, including incidental appendectomy, posterior wall repair, pelvic adhesiolysis and salpingo-oophorectomy. Bipolar forceps were used to compress and desiccate vessels. The Nd-YAG laser, scissors and/or unipolar electrode were used for tissue division, excision of adhesions and cutting. The intraoperative complications were bladder perforation, massive hemorrhage and inferior epigastric vessel injury (one case each). The postoperative complications were infection, voiding difficulty, febrile morbidity, pelvic abscess, incisional hernia, vaginal vault bleeding and peroneal nerve palsy (one case each). CONCLUSION: Hysterectomy can be safely performed vaginally assisted by operative laparoscopy by well-trained laparoscopists, resulting in reduced surgical morbidity, blood loss, postoperative discomfort, recovery time and hospitalization.     

Laparoscopically assisted vaginal hysterectomy. A review of current issues

A review of 39 articles found no consensus on indication for laparoscopic assisted vaginal hysterectomy (LAVH) compared with traditional approaches. Since only three randomized trials comparing LAVH with traditional methods exist, the scientific basis for surgical choice is lacking. Uncontrolled studies indicated that outcomes following LAVH were not superior to vaginal hysterectomy and costs were significantly higher.     

腹腔镜辅助阴式全子宫切除术与腹式全子宫切除术的对比分析

目的 比较腹腔镜辅助阴式全子宫切除术(LAVH)及经腹全子宫切除术(TAH)的效果及安全性.方法 回顾性分析31例LAVH及30例TAH手术病例,比较两种术式的手术时间、术中出血量、术后住院天数及术后排气时间.结果 LAVH组的术中出血量、术后排气时间及术后住院天数均明显少于TAH组[(80.4±30.9)mLvs(200.2±45.6)mL、(10.3±4.5)hvs(20.2±7.6)h、(5.6±1.8)dvs(9.7±3.1)d],但手术时间明显长于TAH组[(105.1±30.5)minvs(40.5±21.7)min],差异均有统计学意义(P＜0.01),结论 LAVH为微创手术,具有损伤小、术中出血少、恢复快等优点,是有效的子宫切除方式.     

Supracervical uterus amputation via the vaginal route

A new method of supracervical amputation of the uterus (with or without extirpation of the adnexae) is presented. The operation is performed using a, the through vaginal route, opening the Douglas cavity through posterior coeliotomy. The advantages of the method, compared with Semm's laparoscopy operation, are discussed.     

Complications following vaginal hysterectomy

Model experiments with two structurally different proteins (alcohol dehydrogenase and salmine) show that glycine, alanine, and tyrosine are by far more frequently involved in photochemically induced cross-link formations with DNA than is cysteine. The yields for cross-link formation of thymidine with salmine (cysteine-free) are about as high as those with alcohol dehydrogenase (athiol protein).     

A technique of minilaparotomy-assisted vaginal hysterectomy

PURPOSE: To report a patient with acute retinal pigment epitheliitis examined less than 24 hours after onset of symptoms. METHOD: One day after the onset of blurred vision in her left eye, a 33-year-old woman had a best-corrected visual acuity of LE, 20/60 -2. The left eye had classic uniform golden-colored nodules in a honeycomb pattern in the foveal retinal pigment epithelium. Intravenous fundus fluorescein angiography disclosed staining of the foveal pigment epithelium. RESULTS: One month after initial examination, visual acuity was LE, 20/20, and fine subfoveal pigmentary clumping was present. CONCLUSION: The pigmentary maculopathy of acute retinal pigment epitheliitis may be nonspecific, resulting from more than one type of primary foveal inflammation.     

Bilateral femoral neuropathy after vaginal hysterectomy

A case of bilateral femoral neuropathy as a complication of vaginal hysterectomy is presented. A 45-year-old woman developed weakness of both quadriceps, absence of bilateral knee jerks, and numbness over bilateral anteromedial thighs and medial lower legs after a vaginal hysterectomy. Electromyographic examination revealed evidence of denervation in the bilateral quadriceps. A nerve conduction study showed prolonged distal latencies and markedly reduced amplitude of the compound muscle action potentials in bilateral femoral nerves. It is suggested that this complication is caused by a microvascular and/or local mechanical injury of the femoral nerve, which is compressed beneath the tough inguinal ligament in a sustained posture with the hip joint in an extreme abduction and external rotation position. The prognosis was excellent with almost complete recovery within 10 weeks. The complication may be preventable by minimizing operating time, changing the patient's posture, and limiting the degree of flexion, abduction, and external rotation of the hip.     

Supracervical and total abdominal hysterectomy trends in New York State: 1990-1996

To describe practice trends for total abdominal hysterectomy (TAH) and supracervical abdominal hysterectomy (SCH) in New York State and to identify fiscal features associated with these two operations, all inpatient discharges for TAH and SCH performed for benign indications from 1990 to 1996 were reviewed using the Statewide Planning and Resource Cooperative System, a centralized data reporting system. For each year examined, the number of TAHs and SCHs performed, the procedure rates adjusted for the total New York State female population, and the per diem charge (calculated from mean institutional charge as a function of average length of stay) were evaluated. While the TAH rate declined in New York State, from 34.0 in 1990 to 28.4 in 1996 (P = .01), the SCH rate increased nearly five-fold during the same period, from 0.62 to 3.07 (P = .0003). Patients tended to be discharged later following SCH than for TAH, although by 1996, the LOS for both operations was equivalent. The per diem institutional charge for SCH was consistently higher than for TAH in each year studied. The changes in charge and relative frequency of TAH and SCH in New York State invite further study to describe these trends more fully.     

Laparoscopic assisted spine surgery

A neonate presented with atrial flutter complicating acute Coxsackie B2 myocarditis. The tachyarrhythmia was successfully terminated with electrocardioversion followed by digoxin administration. The infant survived with no long-term cardiac sequelae. Atrial flutter is an unusual complication of Coxsackie myocarditis that has not previously been reported.     

Outpatient vaginal hysterectomy in a community hospital

From Sept 1, 1992 to Dec 31, 1993, 38 outpatient vaginal hysterectomy patients were evaluated for identification of complications after discharge, adequacy of pain relief at home, return to baseline lifestyle, and costs. No complications that would have necessitated an overnight or longer stay were identified. All patients reported adequate pain relief and a more rapid return to activity than they had expected. The hospital cost of outpatient vaginal hysterectomy was about half that of inpatient, and additional significant savings were realized in the cost of postoperative medication. Patients were positive about returning home the day of surgery and would recommend the protocol to others who qualified.     

Ovarian abscess 15 months after vaginal hysterectomy. A case report

BACKGROUND: Ovarian abscess is a primary infection of ovarian parenchyma. Since 1869, only 44 cases after vaginal hysterectomy have been reported in the medical literature. The pathophysiology of bacterial infection in these cases is different from the traditional ascending mechanism. CASE: A 28-year-old woman presented with complaints of lower abdominal pain and fever 15 months after transvaginal hysterectomy. Her white blood cell count was 22,700/mm3, with 90% neutrophils. Bimanual examination revealed a tender mass in the cul-de-sac, and computed tomography showed a large, multiloculated pelvic mass. Laparotomy, pathologic examination and microbiologic study confirmed the diagnosis of ovarian abscess. CONCLUSION: Our case represents another rare posthysterectomy ovarian abscess. Most of these cases were managed by surgery and antibiotic treatment.     

Ectopic pregnancy after a laparoscopically-assisted vaginal hysterectomy

PURPOSE/METHODS: Rubinstein-Taybi syndrome is a constellation of clinical findings characterized by mental and motor retardation, broad thumbs and broad first toes, marked growth retardation, microcrania, typical facies, high-arched palate, and cryptorchidism in males. Ocular and adnexal abnormalities are quite common and include antimongoloid slant of the palpebral fissures, epicanthal folds, congenital obstruction of the lacrimal excretory system, ptosis, strabismus, and severe ametropia. Macrocornea, microophthalmos, colobomas of the iris and of the optic nerve head, congenital cataract, and optic nerve atrophy have also been described. Congenital glaucoma is a rare complication. We examined a patient with Rubinstein-Taybi syndrome with bilateral congenital glaucoma. RESULTS/CONCLUSIONS: Examination of this patient revealed bilateral antimongoloid slants of the palpebral fissures, and bilateral congenital glaucoma. Gonioscopic examination revealed the iris to be inserted flatly into the trabecular meshwork. This case emphasizes the importance of detailed, complete ocular examinations in patients with Rubinstein-Taybi syndrome, and also highlights the occurrence of ocular abnormalities rarely associated with this disease.     

The value of prophylactic antibiotics after vaginal hysterectomy

Prophylactic antibiotics were given postoperatively to a consecutive series of 74 patients who underwent vaginal hysterectomy. Antibiotics were administered in the immediate postoperative period. There was a highly significant decrease in febrile morbidity in the treated group compared to 190 control subjects having similar surgery but treated with antibiotics only on the appearance of fever and/or other signs of infection. There was a failure to relate the increased febrile morbidity in the control group to patient's age, menopausal state, type of catheterization, or to the type of operative procedure. The increased morbidity in the control group related only to the failure to use prophylactic antibiotics. The antibiotic-treated portion (58 per cent) of the control group had a longer period of hospitalization.     

Laparoscopy-assisted radical vaginal hysterectomy modified according to Schauta-Stoeckel

In laparoscopy-assisted radical vaginal hysterectomy, laparoscopy is used to develop the paravesical and pararectal spaces. The cardinal ligament is isolated and cut after bipolar coagulation to the level of the deep uterine vein. By the vaginal approach, the ureters are identified before their entry into the bladder pillar. The uterine vessels are pulled down until their laparoscopically coagulated ends become visible. After incision of the vesicocervical reflection, the uterine fundus is grasped and developed (D?derlein maneuver). The lower cardinal and uterosacral ligaments are exposed by pulling the cervix and fundus uteri to the contralateral side. The cardinal and uterosacral ligaments are dissected and ligated, and the specimen is removed. We combined laparoscopic lymphadenectomy with radical vaginal hysterectomy in 33 women with cervical cancer. The mean operating time was 80 minutes for the vaginal phase and 215 minutes for the laparoscopic phase, including paraaortic and pelvic lymphadenectomy and preparation of the cardinal ligaments. Blood transfusions were necessary in four women. Three patients sustained injury to the bladder, one patient to the left ureter, and another patient to the left internal iliac vein. Repair was achieved at primary surgery for all intraoperative complications. No fistula was observed. The patients had fully recuperated after a mean of 28 days. The laparoscopy-assisted Schauta-Stoeckel approach may prove to be a safe alternative to conventional radical abdominal hysterectomy.