Laparoscopy Assisted Vaginal Hysterectomy

Laparoscopically Assisted Vaginal Hysterectomy (LAVH) is a procedure using laparoscopic surgical techniques and instruments to perform a hysterectomy.  A hysterectomy is a surgical procedure to remove a woman's uterus or womb.  The uterus cradles and nourishes a fetus from conception to birth, and aids in the delivery of the baby. It also produces the monthly menstrual flow, or period.The ovaries have two major functions. The first is the production of eggs, which if fertilized may result in pregnancy.  If the egg that is released during a woman's normal monthly cycle is not fertilized, the lining of the uterus is shed by bleeding or menstruation. The second is the production of hormones or chemicals which regulate menstruation and other aspects of a woman’s health.   After a hysterectomy, a woman can no longer have children and menstruation stops. The ovaries generally continue to produce hormones, although in some cases they may have reduced activity.There are two ways to remove the uterus:  through the abdomen, called an abdominal hysterectomy, and through the vagina, called a vaginal hysterectomy.  The LAVH procedure can convert what would have been an abdominal hysterectomy into a vaginal hysterectomy. An abdominal hysterectomy requires both a vaginal incision and a four to six inch long incision in the abdomen, which can result in greater discomfort after the procedure as well as a longer recovery period than for a vaginal hysterectomy. 

The Laparoscope

A laparoscope is a long, slender, viewing tube which is attached to a camera and a light. The laparoscope is inserted through an incision, and sends images to a video screen nearby, which gives the surgeon a clear view of the organs.  The images can also be photographed to be examined later by the surgeon or others.  Often, other instruments are placed in additional small incisions; some allow the surgeon to gently manipulate the uterus in order to get different views throughout the procedure.

When LAVH is Recommended

If a woman no longer plans to have children, a hysterectomy is sometimes recommended as a treatment for certain serious problems with the uterus.  Those include:

• Fibroids - Common non-cancerous (benign) tumors of the uterus which are the most frequent reason for recommending a hysterectomy.  They are made up of muscle and fibrous tissue, and grow from the muscular wall of the uterus.   Many women have fibroids and are unaware of it because they have no symptoms.
  In some women, however, the fibroids may cause heavy bleeding, pelvic discomfort and pain and sometimes pressure on other organs. 
• Endometriosis - Another common reason for undergoing a hysterectomy.  It is a noncancerous medical problem in which cells from the uterine lining grow in the body but outside of the uterus. These growths can occur on the ovaries, fallopian tubes, bladder, bowel and other pelvic structures, including the uterine wall.  These cells may cause pain and discomfort by bleeding at the time of menstruation. Endometriosis may also cause scarring, adhesions and infertility.
• Prolapse – Sometimes, as a woman ages, the vaginal supports begin to lose their muscle tone and she may feel her uterus or cervix bulge from her vagina. This is called uterine prolapse.  When this happens, the bladder or rectum may also be pulled downward.  If the prolapse worsens, some women experience problems in controlling bladder or bowel functions, and other difficult symptoms.  
• Pelvic adhesions - Scarring that can result from endometriosis, infections or injury.  Symptoms may include severe pain, infertility, and bladder or bowel problems. 

The LAVH Procedure

For the procedure, the woman is given a general anesthesia and will sleep through the surgery.  An intravenous (IV) line will be attached, and the pelvic area and abdomen may be shaved.  The procedure is usually performed on an operating or examination table with the legs and feet supported by stirrups.  After the anesthesia has taken effect, one or more small (one-quarter- to one-half-inch) incisions are made near the navel or the pubic hairline. A harmless gas is usually used to inflate the abdomen, giving the surgeon more room to see and work.The laparoscope is inserted through an incision in the navel, and sends images to a video screen nearby, which gives the surgeon a clear view of the organs.  The images can also be photographed to be examined later by the surgeon or others. Other instruments are placed in other small incisions; these devices will help to remove the uterus and may include forceps, clamps, or scissors.  Sometimes an electrosurgical tool is used to cut tissue or stop bleeding.  The uterus is then detached from the ligaments that attach it to other pelvic structures.   If there are adhesions, they are removed.  If the fallopian tubes and ovaries are to be removed, they are detached from their ligaments and blood supply. They then can be removed along with the uterus. Since the incisions are small, the scarring and pain from LAVH is often less than that associated with abdominal hysterectomy.Risks with LAVH are similar to risks for any other major surgery.  This includes the possibility of bleeding, infection, blood clots in the lungs or veins, and problems with the anesthesia.

Recovery

Recovery after any type of hysterectomy takes time. Immediately after a hysterectomy, the patient often stays in the hospital for one or two days for postsurgery care.   

Once home, the woman should strictly follow her physician’s recommendations, which will always include resting, avoiding any kind of exertion, and refraining from sexual intercourse for at least a few weeks.  The physician will also determine when it is advisable for the patient to drive, exercise, and go back to work.   However, most women are able to immediately resume their normal diet, when desired; take a bath or shower and use lotion on the skin around the incision to relieve itching.The patient should also be aware of the warning signs that may indicate a serious problem. 

They include:

• Severe abdominal pain
• Fever or chilling
• Heavy vaginal bleeding or discharge
• Redness, swelling or discharge from the incisions
• Problems with urination or bowel movements

Remember

If a hysterectomy is needed, LAVH can often allow the surgeon to perform a vaginal hysterectomy instead of an abdominal hysterectomy.  This can result in less discomfort with the surgery, less scarring and a faster recovery time.