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Laparoscopic Assisted Vaginal Hysterectomy (Doderlein Approach)

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:

LAVH Indications

	Pelvic Prolapse
	Fibroids
	Endometriosis
	Central Chronic Pelvic Pain/Adhesions
	Heavy Vaginal Bleeding (Periods)

"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.

Advantages of 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

Technique

Laparoscopy Figure: 1	Laparoscopy Figure: 2
Initial Incision	Open Laparoscopy Technique
Laparoscopy Figure: 3	Laparoscopy Figure: 4
Uterus-Ovarian Ligament Transection with the Laparoscopic Stapling Device Scissors	Bladder Flap Incision with Laparoscopic Scissors By utilizing laparoscopic staples, Drs. Miklos and Moore can either keep or remove the ovaries in a safe and efficient manner. This picture concludes the laparoscopic portion of the Laparoscopic Doderlein Hysterectomy(LDH). The remaining pictures show the removal of the uterus through the vagina.
Laparoscopy Figure: 5
Laparoscopy Figure: 6	Laparoscopy Figure: 7
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

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 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 16-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 would be through an abdominal incision. 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 Surgeon."
-HGI, Suwanee, GA

Results and Complications

Surgical Complications

	Bleeding
	Bladder Injury
	Ureter Injury
	Nerve Injury
	Intestinal Injury

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%.

Source of Table 4: Obstet Gynecol 2000; 95: 787-793

AH - Abdominal Hysterectomy
LAVH - Laparoscopic Assisted Vaginal Hysterectomy
VH - Vaginal Hysterectomy

Laparoscopy Figure: 8 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.	Laparoscopy Figure: 9 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.

Laparoscopy Figure: 10 Normal Support - vagina apex	Laparoscopy Figure: 11 Vaginal Vault Prolapse - Loss of support of the uterosacral ligament

Atlanta Urogynecology Associates Experience