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Wednesday, April 30, 2008

Laparosocpic Assisted Vaginal Hysterectomy

I have been practicing LAVH at my hospital ( Khetarpal Hospital, New Delhi, India) since last 11 years, and till date I have performed little more than 6,500 procedures. Most commonly the indication for LAVH remains uterine fibroids, symptomatic leiomyoma, endocervical retention cyst, pelvic inflammatory disease, ovarian cyst, cervical erosion, refractile cervical dysplasia, endometriosis, adenomyosis. Initially clips were used to clamp the vessels and ligaments, but as they tend to slip over from bigger structures eg round ligament. Later on with the advancement of technology, monopolar cautery was used which uses the high frequency electrical current passed from a single electrode and patient’s body serves as a ground. Since it contained low costs, higher coagulating properties and ease of use, it was skillfully used at a higher rate and it eased the technique of LAVH to an extent. However it had its share of setbacks, primarily it was associated with more number of iatrogenic thermal injuries and it was used with endostaplers, which in itself proved to be a cost-escalating measure, which was not an enthusiastic factor in the context of a developing country like India. With the passage of time, harmonic scalpel were used in place of monopolar cautery with the advantages of minimal lateral tissue damage and reduced charring and dessication. Gradually bipolar cautery was introduced in LAVH ( along with scissors from the same port) which imparted simultaneous cutting and coagulating, less thermal injuries, less production of smoke and almost equal coagulating properties in comparison to monopolar cautery. For last 2 and half years, ligasure is being used for LAVH as it offers versatile tissue grasping with its superiority in regards with fine dissection with its adaptability for permanently fusion of tissue and vessels upto 8 mm in diameter.

It is important for a laparoscopic surgeon to adapt to newer and more developed instruments being developed to ease the minimal access surgery. As laparosocpic surgery is relatively a nascent speciality, a lot of work is being carried out to make it easier for surgeons and safer for patients. A lot of focus is being given to Total Laparoscopic Hysterectomy ( which does not uses the vaginal route for any intervention ), however I feel there is no significant advantage of the procedure with LAVH. Primary experiences have revealed TLH to be causing increased operating time, increased morbidity, increased cost of surgery and requiring enhanced skills on the part of the operating surgeon.

The procedure for LAVH remains largely the same everywhere, its just the skills and sound anatomical knowledge of the surgeon which make a difference in the outcomes.As laparoscopy is the evolving science, it is yet to see what does the future holds for LAVH, which has proved to be a boon for underdeveloped countries in a major way, by reducing loss of work days and softening the health care burden from government hospitals by reducing the hospital stay.

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