Replacement of Abdominal Hysterectomy by the Laparovaginal Technique – Its Success and Limitations

Summary: The objective of this study was to study the effect of replacing of most abdominal hysterectomies with the laparovaginal technique. Three gynaecologists trained in advanced operative laparoscopy performed 160 laparovaginal, open and vaginal hysterectomies in 3 private hospitals in Melbourne. One hundred and twenty seven (79.4%) of hysterectomies were laparovaginal, 16 (10.0%) were open and 17 (10.7%) were vaginal. The distribution of technique was similar for the 3 surgeons. The high incidence of laparovaginal hysterectomy was partly due to the ability to remove uteri up to the size of a 16‐week pregnancy, to divide severe pelvic adhesions and to perform recto‐vaginal excisional surgery in severe endometriosis. Abdominal hysterectomy was preferred for patients with uteri larger than a 16‐week pregnant size, tough intestinal adhesions, multiple pelvic pathology requiring prolonged surgery or with excessive obesity. The infrequent use of vaginal hysterectomy was related to the low occurrence of vaginal prolapse, the routine use of endometrial ablation for the treatment of menorrhagia resistant to drug therapy in uteri less than 10 cm, and the preference for laparoscopic rather than vaginal removal of the ovaries. The considered advantages of laparovaginal hysterectomy compared to abdominal hysterectomy were the reduced time in hospital and reduced convalescence. The cost of laparovaginal hysterectomy in the present study is 600–700 higher than abdominal hysterectomy. The cost may be reduced by decreased use of disposable equipment or by earlier discharge of patients from hospital. Gasless laparoscopy facilitating a combined abdominal and vaginal technique using 2 surgeons may further reduce operating time. Laparovaginal hysterectomy is capable of replacing most open procedures. Its future may depend upon the ability to reduce the operating time to be comparable to that of abdominal hysterectomy and to maintain similar costs. Vaginal hysterectomy is a suitable alternative to laparovaginal hysterectomy for surgeons skilled with this technique.