When is laparoscopic assistance appropriate?
At a fundamental level, its value lies in converting abdominal hysterectomy intovaginal hysterectomy.
KARRAM: In my experience, LAVH is appropriate in the presence of benign adnexal pathology: The adnexa can be evaluated and detached laparoscopically followed by vaginal hysterectomy and vaginal removal of the adnexa. It also is appropriate in any situation that involves excessive pelvic adhesions. The uterus can be mobilized laparoscopically, followed by removal through the vagina.
FALCONE: Any patient who is not a candidate for vaginal hysterectomy should be considered for laparoscopic assistance. The general rationale for the surgery is to convert an abdominal hysterectomy into a vaginal one, so the surgeon should start laparoscopically and then switch to the vaginal approach as soon as possible. Of course, it is impossible to proceed vaginally in some cases. When it is, the entire case can be performed laparoscopically.
LEVY: In my hands, patients with an unidentified adnexal mass who also need or request hysterectomy are appropriate candidates for laparoscopic abdominal exploration followed by vaginal hysterectomy if appropriate. Women with a very contracted pelvis, which precludes transvaginal access to the uterine vasculature, may also be candidates for the laparoscopic approach. However, as surgeons become more skilled at vaginal surgery and learn to use newer instrumentation, the need for laparoscopy to access a tight pelvis will diminish.
Using a laparoscopic approach for patients with fibroids wedged into the pelvis carries serious risk to the pelvic sidewall. It is very difficult to access the sidewall safely laparoscopically in the presence of a large lower segment or cervical myomas.
HERZOG: When LAVH was introduced, many clinicians challenged the utility of combined laparoscopic and vaginal surgery, with some referring to this surgical exercise as a procedure looking for an indication. However, as operative laparoscopy has gained acceptance, some benefits of LAVH have become apparent. The greatest advantage is the potential to convert a procedure that would have been performed abdominally into a vaginal hysterectomy.
The most commonly cited indications for LAVH are to lyse adhesions secondary to prior abdominopelvic surgery, substantial endometriosis, or a pelvic mass.
Is oophorectomy an indication for LAVH?
The need to remove the ovaries does not mean laparoscopic assistance is imperative.
HERZOG: Simple removal of the ovaries can often be performed using the vaginal route, and is not in itself an indication for LAVH.
LEVY: I agree. The ovaries can usually be accessed transvaginally, especially with good fiberoptic lighting and vessel-sealing technology.
FALCONE: Several studies, most notably the one by Ballard and Walters,4 demonstrate that oophorectomy can be carried out vaginally in most cases. In their study, they did not use special instruments.
HERZOG: But LAVH is indicated to facilitate complete removal of the ovaries in riskreduction surgery for documented or suspected BrCa 1 or 2 mutations. The entire ovary and as much of the tube as possible must be removed in these women. Thus, if the patient has other indications for hysterectomy, LAVH may be the preferred route to assure that the blood supply is taken proximally enough to remove absolutely all ovarian tissue. Simply clamping directly along the side of the ovary is not an adequate removal technique for these patients, since an ovarian remnant may become a fatal oversight.
LEVY: Yes, laparoscopy is indicated for riskreducing salpingo-oophorectomy in order to adequately assess the entire peritoneal cavity. Up to 2% of these patients will have occult invasive ovarian or peritoneal carcinoma at the time of their prophylactic surgery, so full surgical abdominal exploration is mandatory and can be nicely accomplished via laparoscopy.5
How endometriosis history affects choice of route
In some women, laparoscopic surgery is preferred over the vaginal route.
FALCONE: Hysterectomy with or without salpingo-oophorectomy can be considered in women whose endometriosis fails to respond to conservative management and who do not desire fertility. Most studies have shown substantial pain relief with definitive surgery.6,7 Although ovarian conservation may be advisable in younger women, in some women it increases the probability of recurrent pain and the need for reoperation. The main concern is whether the endometriosis is completely removed during hysterectomy.
A history of cul-de-sac obliteration or extensive pelvic adhesions from endometriosis is an indication for laparoscopic hysterectomy rather than vaginal hysterectomy. Women with less severe disease will benefit from a diagnostic laparoscopy prior to a vaginal hysterectomy to evaluate the pelvis and excise any endometriosis.
Is there any benefit to leaving the cervix?
There is no evidence of any benefit except in selected cases of heavy bleeding, postpartum hemorrhage, advanced endometriosis, or ovarian cancer surgery.