Tommaso Falcone Mark D. Walters

Laparoscopic-assisted vaginal hysterectomy (LAVH) was introduced in the past 20 years as an alternative to abdominal hysterectomy. LAVH is a safe alternative to abdominal hysterectomy when a vaginal hysterectomy is contraindicated. In a prospective randomized clinical trial of LAVH versus abdominal hysterectomy at the Cleveland Clinic Foundation, LAVH was shown to be associated with less postoperative pain, shorter hospital stays, and a more rapid return to normal activities and work than 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 a laparoscopic-assisted one. 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. Ligation of the uterine artery by laparoscopy does not necessarily imply a more difficult case or one requiring more skill. Often the term is meant to convey to the operating room staff whether a vaginal table should be ready for the case.

We do not give oral antibiotics or preoperative bowel preparation. The patient is given a single dose of intravenous antibiotic, usually a cephalosporin, before the procedure. Pneumatic compression stockings are placed on the calves. An orogastric tube is used if stomach distention is suspected. Examination under anesthesia is carried out, and a Foley catheter is inserted.

A standard three-port technique is used: one umbilical and one in each lower quadrant. One of the lower ports is a 10-mm site for introduction of an electrocoagulating/cutting device such as a Seitzinger tripolar cutting forceps (Cabot Medical, Langhorne, Pennsylvania). We use the electrosurgical device set at 50W pure cut current.

We use a Hulka tenaculum as our uterine manipulator. A useful instrument for a total laparoscopic hysterectomy is a Koh colpotomizer (CooperSurgical Inc, Trumbull, Connecticut). This rigid cone fits on the RUMI uterine manipulator (CooperSurgical) and fits snugly on the cervix. It serves to delineate the fornices of the vagina that will be incised laparoscopically. This apparatus also has a balloon that will prevent escape of carbon dioxide through the vagina. The vaginal table should include vaginal wall retractors and long instruments. At the end of the case a cystoscopy is performed. The bladder should be distended to check for injury. Intravenous indigo carmine also can be used to verify the integrity of the ureters.