腹腔镜辅助阴式子宫切除术（图文演示）

LAPAROSCOPICALLY   ASSISTED   VAGINAL   HYSTERECTOMY
Authors
T Falcone
Abstract
The description of the laparoscopically assisted vaginal hysterectomy (LAVH) covers all aspects of the surgical procedure used for the management of uterine pathology.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure/Incision, ovarian vessels, bladder dissection, uterine vessels, uterus removal, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.

中文版：腹腔镜辅助阴式子宫切除术（中文图文演示）

1. Introduction
Laparoscopically assisted vaginal hysterectomy (LAVH) was introduced in the early 1990s as an alternative to abdominal hysterectomy. In a recent large hospital survey in Ohio, USA, only 8% of all hysterectomies were performed with laparoscopic assistance (Weber and Lee, 1996). LAVH is a safe alternative to abdominal hysterectomy when a vaginal hysterectomy is contraindicated. A randomized clinical trial showed that vaginal hysterectomy and LAVH were associated with similar hospital stays, and similar intraoperative and postoperative morbidity. Operative times and costs were higher in the LAVH group (Summitt et al., 1992).

In several prospective randomized clinical trials of LAVH versus total abdominal hysterectomy, the former was associated with less postoperative pain, shorter hospital stays and a more rapid return to normal activities (Summit et al., 1998; Marana et al., 1999; Falcone et al., 1999; Ferrari et al., 2000). Several studies have shown that the costs of LAVH were similar to (Summitt et al., 1998; Falcone et al., 1999) or less than (Ellstrom et al., 1998) the costs of total abdominal hysterectomy.

There are several classifications of laparoscopic hysterectomy. The laparoscopic ligation of the uterine artery appears to be the critical step that differentiates a laparoscopic procedure from LAVH. In fact this division is arbitrary. In practice, the procedure is continued laparoscopically until the surgeon is confident that the procedure can be completed vaginally. However in some cases, the anatomy does not permit any portion to be performed vaginally and the whole procedure is carried out laparoscopically.

2. Anatomy
• Topographic anatomy

1. Uterus
2. Round ligament
3. Utero-ovarian ligament (proper ovarian ligament)
4. Uterosacral ligament
5. Ovary
6. Suspensory ligament of the ovary
7. Ureter

• Vasculature

1. Umbilical artery
2. Ureter
3. Uterine artery
4. Internal iliac artery
5. Ovarian artery
6. Common iliac artery
7. Utero-sacral ligament

3. Indications
Indications for laparoscopic access for hysterectomy:
- same indications as hysterectomy by laparotomy;
- a vaginal hysterectomy is not feasible;
- need to evaluate other intraperitoneal tissue or organs.

Contraindications to hysterectomy:
- desire to maintain future fertility,
- known medical or psychological risks that exceed the benefits.

Contraindications to laparoscopic access:
- inexperienced surgeon;
- bowel obstruction;
- ileus;
- peritonitis, unless it is to assess pelvic inflammatory disease or a tubo-ovarian abscess;
- hemorrhage in an unstable patient;
- diaphragmatic hernia;
- severe cardiorespiratory disease.

4. Preop period
The patient takes a preparation to cleanse the bowel the day before the procedure. We do not use oral antibiotics. We do not routinely order any preoperative testing unless there is a specific history, such as excessive vaginal bleeding, in which case a complete blood count is required. Potential complications, possible conversion to a laparotomy and the need for autologous blood transfusion are discussed with the patient.

5. Operating room set-up
• Patient

- general anesthesia;
- dorsal lithotomy;
- Trendelenburg is not used until after the introduction of the primary cannula;
- the legs are placed in foam-padded leg stirrups where the calves and heels are supported and can be elevated for the vaginal portion. They are fixed with adhesive tape.
- pneumatic compression stockings are placed on the calves;
- both arms are tucked alongside the body;
- an orogastric tube is placed if there is a left upper quadrant trocar inserted or if stomach distension is suspected;
- examination under anesthesia is performed;
- a urinary catheter is inserted;
- an intrauterine manipulator is inserted.

• Team

1. The surgeon's position is on the left side of the patient if he or she is right-handed. The reverse is true for left-handed surgeons.
2. The assistant is on the opposite side of the surgeon.
3. The scrub nurse stands between the patient's legs so that the uterus can be mobilized appropriately.

• Equipment

1. Monitor
2. High-flow insufflator
- camera control unit and camera (3-chip camera);
- electrosurgical unit (unipolar and bipolar systems: the unipolar system should generate both non-modulated and modulated currents);
- image-recording device;
- light source (xenon light source).

6. Trocar placement

The trocars are placed as follows:
A: A 10 mm trocar is placed in the umbilicus.
B and C: Two other trocars are placed in the lower abdomen, at the level of the anterior superior iliac spine, lateral to the rectus abdominis muscle. These may be reusable 10 mm trocars if no laparoscopic suturing is anticipated. If the vaginal cuff is closed by laparoscopy, one of the trocars will be a 10 mm disposable trocar.
D: Finally, in particularly difficult cases, a 5 mm reusable trocar may be placed at the level of the umbilicus, lateral to the rectus abdominis muscle.

7. Instrumentation
• Instrument table

1. Laparoscopes: 3 sizes (2-3 mm, 5 mm and 10 mm); 0° lens
Graspers and dissectors:
2. Atraumatic graspers
3. Soft bowel clamps
4. Maryland dissectors
5. Scissors
6. Needle holders
7. Bipolar forceps and cord
8. Endoloop
9. Aspiration-suction device
Tissue morcellator for large uterus

• Vaginal instrument table

1. Single tooth tenaculum
2. Allis graspers
3. Dilators
4. Uterine manipulator
5. Cohen cannula (alternative uterine manipulator)
Speculum
Urinary catheter (Foley catheter)

8. Major principles

▶
Trocars are introduced, and a view of the peritoneal cavity is systematically obtained.
The round ligament is electrocoagulated and transected.
The incision from the round ligament is continued cephalad to open the retroperitoneal space lateral to the ovarian vessels and caudad to incise the bladder peritoneum.
The ureter is identified and kept in view.
The ovarian vessels are grasped and electrocoagulated.
The uterine artery is identified and electrocoagulated.
The process is repeated on the opposite side.
The bladder peritoneum is dissected downwards until the vagina is identified.
A sponge forceps is placed in the vagina in the anterior fornix and the vagina is tented upwards.
An incision is made circumferentially around the vagina.
The vault is sutured with 0 polyglactin.

9. Exposure/Incision
• Retroperitoneal space

1. Uterus
2. Lateral retroperitoneal space
If the ovaries are to be removed, the round ligament is grasped mid-segment and, using a bipolar electrocoagulating/cutting device that is set at 50 W pure cut, electrocoagulated and cut. The retroperitoneal space lateral to the ovarian vessels and medial to the external iliac artery is dissected.

• Round ligament incision

1. Electrocautery of the round ligament
2. Left side: ureter identified on the peritoneum
The incision from the round ligament is continued cephalad lateral to the ovarian vessels. The ureter is then identified on the medial leaf of the broad ligament.
If the ovaries are to be retained, the round ligament, utero-ovarian ligament and tube are grasped near the uterus and electrocoagulated and cut. A stapling device can also be used.