A technique to deal with severe adhesions between the uterus and bladder or rectum in laparoscopic-assisted vaginal hysterectomy

Severe adhesions between uterus and bladder or rectum, especially caused by endometriosis and multiple cesarean sections, remain a great challenge to surgeons in laparoscopic-assisted vaginal hysterectomy. Dense adhesions and anatomic variations cause difficulty in dissecting tissue planes, significant bleeding, lengthy operative time, and visceral injuries, especially an unrecognized thermal injury leading to late-onset fistulae or abscess. A modified technique, the combination of vaginal and laparoscopic approach with assistance of a Deaver retractor, is introduced in this article, which can achieve several advantages, including easily and safely dissecting tissue planes as close to the edge of adhesions as possible, avoidance of bladder or rectum injuries, less bleeding, shortened operative time, and minimized possibility of conversion to exploratory laparotomy if the surgeon is experienced in this technique.