Laparoscopic-assisted vaginal hysterectomy for patients with extensive pelvic adhesions: a strategy to minimise conversion to laparotomy.

AIM: To evaluate a strategy for successful laparoscopic-assisted vaginal hysterectomy (LAVH) in patients with extensive pelvic adhesion.

METHODS

Two hundred and thirty-six patients who underwent LAVH at National Taiwan University Hospital were retrospectively enrolled. Twenty-three patients (9.7%) had unexpected extensive pelvic adhesions. A special procedure of uterine artery preligation through retroperitoneal downstream ureter tracking was applied to overcome this problem. The clinical characteristics of the study group were analysed. The operative parameters and the outcome were compared between those with and without extensive pelvic adhesions.

RESULTS

Having extensive adhesions, 17 patients were associated with endometriosis and the other six were secondary to previous Caesarean delivery or pelvic inflammation. The cul-de-sac was partially and totally obliterated in 10 and 13 patients, respectively. These 23 patients had longer operation time (184 vs 146 min, P < 0.05), more blood loss (146 vs 89 mL, P < 0.05), but smaller extirpated uteri (278 vs 372 g, P = 0.063), compared with the other 213 patients. The average hospital stay was comparable (3.2 vs 3.4 days) and there were no ureteral injuries or excessive bleeding. Most importantly, not a single case was converted to laparotomy.

CONCLUSION

Pelvic adhesions of various underlying diseases are associated with increased complication and conversion rates during LAVH. Although this technique is not new, we believe that the special procedure of uterine artery preligation through retroperitoneal downstream ureter tracking may provide a safe approach for general gynecologists to complete successful LAVH in patients with unexpected extensive pelvic adhesions.