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Laparascopic Assisted Vaginal Hysterectomy (Doderlein Approach)
Laparoscopic and Minimally Invasive Procedures
Hysterectomy (removal of the uterus) is one of the most common surgical procedures performed in the United States. Over 700,000 women undergo this procedure each year for the following indications:
Laparoscopic Assisted Vaginal Hysterectomy Indications (LAVH)
- Pelvic Prolapse (Uterine prolapse, enterocele, cystocele)
- Fibroids
- Endometriosis
- Central Chronic Pelvic Pain / Adhesions
- Heavy Vaginal Bleeding
"I feel like I have my life back."
-AB, NCAA Division 1 Women's Basketball Head Coach, Atlanta, GA
There are three major approaches to remove the uterus: through the abdomen (abdominal hysterectomy – AH), through the vagina (vaginal hysterectomy – VH), or through the vagina with the aid of a laparoscope (laparoscopic assisted vaginal hysterectomy – LAVH). The majority of physicians perform the abdominal hysterectomy through a large transverse or vertical incision, despite the fact that the vaginal hysterectomy has fewer complications and has a shorter overall recovery period due to the lack of a large incision. The physicians also add numerous factors to lean toward the abdominal approach to include: uterine size (greater than 12 week size), previous pelvic surgery to include cesarean sections, history of pelvic infections, endometriosis, ovarian cysts, and lack of vaginal deliveries.
As pioneers in advanced laparoscopic surgery, Drs. Miklos and Moore believe the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) is the most beneficial way of removing the uterus if these symptoms are present while addressing any coexisting problems. They agree with a recently published study by Marana et. al., which demonstrated that a laparoscopic hysterectomy may replace abdominal hysterectomy in most patients who require a hysterectomy and have contraindications to Vaginal Hysterectomy, with all the benefits associated with the vaginal route. Secondary to their laparoscopic skills they are able to complete hysterectomy laparoscopically, even in the case of very larger uteri (they recently removed one that was 1.3 Kg in size, ie approx 22 wk size!) secondary to uterine fibroids or other pathology. Dr Moore and Miklos complete most of their reconstructive surgery laparoscopically, therefore completing a laparoscopic hysterectomy at the same time is part of their standard approach for removal of the uterus.
Advantages of Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
- Miniature Abdominal Incisions (<1.2 cm)
- Decreased Post Operative Pain
- Shortened Post Operative Recovery
- Fewer Post Operative Infections
- Fewer Adhesions
- Shortened Hospitalization (<24 Hours)
- Access to Advanced Pelvic Reconstruction Procedures
LAVH Technique
Uterus-Ovarian Ligament Transection
Drs. Miklos and Moore also currently utilize the Gyrus coagulation and cut device to complete this portion of the procedure which eliminates the need for staples. In this patient the ovaries are preserved and not taken out with the uterus.
By utilizing a laparoscopic approach, Drs. Miklos and Moore can either keep or remove the ovaries in a safe and efficient manner. The above picture concludes the laparoscopic portion of the Laparoscopic Doderlein Hysterectomy (LDH). The remaining pictures show the removal of the uterus through the vagina.
Cervical Incision - an incision is made between the junction of the anterior vaginal wall and the anterior portion of the cervix (the portion of the uterus found within the vagina)
Doderlein Approach, clamping a segment of the uterus – the uterus is being delivered through the vagina and the remainder of the hysterectomy completed from below, ie through the vagina. When the uterus is delivered and flipped on itself prior to finishing the hysterectomy, the vessels are clamped and blood loss is typically less versus the standard vaginal approach.
Our doctors incorporate an alternative approach to the Laparoscopic Assisted Vaginal Hysterectomy (LAVH), which allows better operative exposure, decreased blood loss, and decreased operative time which is called the Laparoscopic Doderlein Hysterectomy (LDH). Dr. Miklos published an article in Contemporary OBGYN describing the technique for a laparoscopic hysterectomy in 1997. A recently published article in the Journal of Pelvic Surgery in 2001 supports Dr. Miklos's addition of the laparoscope to the Doderlein procedure. All of the benefits of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) apply to Laparoscopic Doderlein Hysterectomy (LDH) with the added advantages listed below:
Advantages of a Laparoscopic Doderlein Hysterectomy
- Existing Advantages of Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
- Better Surgical Exposure
- Decreased Blood Loss
- Decreased Operative Time
- Access to Apical Cystoceles (Transverse Defects)
Contraindications
Many of the published contraindications to Laparoscopic Assisted Vaginal Hysterectomy (LAVH) and Vaginal Hysterectomy are outdated. They include previous pelvic surgery, history of pelvic infection, endometriosis, benign appearing adnexal (ovarian) masses, and nulliparity (women without a vaginal delivery) without uterine prolapse. We at the Atlanta Urogynecology Center experience successful surgical outcomes with total laparoscopic hysterectomy in patients with these outdated contraindications. The contraindications would be if the uterus is greater than 22-week size or if you have a serious medical condition that would not be safe to undergo anesthesia. In the first situation, the safest approach may be through an abdominal incision or a total vaginal approach. If you have any medical conditions, we would consult an Internal Medical physician to address the severity of your medical condition.
"I am now referring my friends to the Best Reconstructive Surgeons in the South, i.e. Miklos and Moore!"
– HGI, Suwanee, GA
LAVH Results and Complications
With our approach to the laparoscopic hysterectomy, our patients achieve excellent outcomes with minimal pain and blood loss. The procedure can be completed at the same time as other laparoscopic reconstructive procedures such as laparoscopic sacralcolpopexy (vault prolapse), enterocele repair, or laparoscopic paravaginal repair (cystocele) and/or incontinence procedures. The patients usually go home the next day and often require minimal pain medication. Laparoscopic assisted vaginal hysterectomy, like any surgical procedure, carries a risk of complications. Because of Drs. Miklos and Moore's vast experience in laparoscopic and advanced pelvic surgery, they have a complication rate lower to what is in the published literature of 3.6%. If an injury occurs, it is more important for the physician to recognize the injury at the time of surgery rather than after. The reported complications in the literature include:
Surgical Complications
- Bleeding
- Bladder Injury
- Ureter Injury
- Nerve Injury
- Intestinal Injury
- Post op Infection (abcess)
Table 4 (see below) solidifies our choice for performing a laparoscopic assisted vaginal hysterectomy (Doderlein approach). The "All" column of Table 4 reveals abdominal hysterectomy patients have the highest overall complication rate of 9.3% vs. the lowest complication rate for the laparoscopic assisted vaginal hysterectomy rate of 3.6%. By adding laparoscopy to the vaginal hysterectomy, the complication percentage decreases by 1.7%.
| Complication | Hysterectomy and oophorctomy | Hysterectomy | All | ||||||
|---|---|---|---|---|---|---|---|---|---|
| AH | LAVH | VH | AH | LAVH | VH | AH | LAVH | VH | |
| Hemorrage | 2.2 | 2.9 | 3.3 | 5.7 | 0.0 | 2.3 | 3.4 | 1.8 | 2.4 |
| Acute myocardial infection | 0.3 | 0.0 | 0.0 | 0.0 | 0.0 | 0.3 | 0.2 | 0.0 | 0.2 |
| Postoperative fever or infection | 4.2 | 2.9 | 0.0 | 3.8 | 0.0 | 0.0 | 4.0 | 1.8 | 0.0 |
| Intestinal obstruction | 0.6 | 0.0 | 0.0 | 0.0 | 0.0 | 0.9 | 0.4 | 0.0 | 0.0 |
| Urinary complication | 0.3 | 0.0 | 0.0 | 1.3 | 0.0 | 0.1 | 0.6 | 0.0 | 0.1 |
| Bladder injury | 0.0 | 0.0 | 0.0 | 0.6 | 0.0 | 0.3 | 0.2 | 0.0 | 0.2 |
| Accidental perforation: blood vessel, nerve, or organ | 0.3 | 2.9 | 2.5 | 3.8 | 0.0 | 1.4 | 1.5 | 1.8 | 1.6 |
| Any complication | 7.7 | 5.9 | 5.8 | 12.6 | 0.0 | 5.3 | 9.3 | 3.6 | 5.3 |
Source of Table 4: Obstet Gynecol 2000; 95: 787-793
AH – Abdominal Hysterectomy
LAVH – Laparoscopic Assisted Vaginal Hysterectomy
VH – Vaginal Hysterectomy
Normal Uterine (side view) – The anterior support (vaginal wall (pubocervical fascia) and the posterior wall (rectovaginal fascia)) are very supported. Most importantly, the uterus is perfectly suspended by the uterosacral ligament.
Uterine Prolapse – The uterus begins to prolapse because of the broken uterosacral ligament.
Drs. Miklos and Moore will support the vagina to either the uterosacral ligament or the tailbone. This additional support will help prevent future vaginal vault prolapse once the uterus is out. Please see the difference between normal vaginal support and vaginal vault prolapse in the pictures below.
Normal Support – Vagina apex.
Vaginal Vault Prolapse – Loss of support of the utereosacral ligament. This can occur if the ligaments that supported the uterus are not re-attached to the top of the vagina. Dr Moore and Miklos always re-establish your normal anatomic support and will laparoscopically re-attach the ligaments to the top of the vagina at time of hysterectomy. If more severe prolapse is present, they may utilize mesh to support the top of the vagina up to the tailbone.
Atlanta Urogynecology Associates Experience
Drs. Miklos and Moore have performed the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) procedure over the past 10 years with great success. We believe that the minimally invasive Laparoscopic Assisted Vaginal Hysterectomy (LAVH) is a safe and effective way to the uterus through mini incisions in the abdomen, and it allows us to perform additional pelvic reconstructive procedures that affect your lifestyle. You usually go home the next day and experience minimal pain and discomfort. It is their experience that most patients are pain-free within 2 weeks after the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) procedure.