This document discusses laparoscopic assisted vaginal hysterectomy (LAVH). It begins with a brief history of laparoscopic hysterectomy and incidence rates of different hysterectomy methods from various studies. It then describes the classification, indications, procedure, complications, and comparison of LAVH, vaginal hysterectomy, and abdominal hysterectomy. While laparoscopic hysterectomy may be preferred for its minimal invasiveness, the document emphasizes that vaginal hysterectomy should be performed when possible to avoid unnecessary procedures. In conclusion, it states that the main goal of LAVH is to reduce abdominal hysterectomy rates by utilizing it where vaginal hysterectomy is contraindicated.

2. “ DR. MANJUSHREE BOOB”
M.B.B.S. M.D. D.N.B. F.I.C.M.C.H.
DIPLOMATE OF NATIONAL BOARDS
FELLOW GUIDE FOR DAWN DGO’S COURSES
“SHUBHAM HOSPITAL”
BADNERA ROAD
AMRAVATI [ M.S. ]
By,…By,…

3. HISTORY :
Harryreich , in 1988 had performed 1st
Laparoscopic hysterectomy at
Kingston.

4. INCIDENCE OF TAH, VH, LAVH
VALUE STUDY 1998 [ U. K. ]
[ Vaginal, Abdominal And Laparoscopic Uterine
Extirpation ]
Abdominal - 74%
Vaginal - 18.4%
Laparoscopic hysterectomy - 7.6% } 1995
U.S.A. STUDY BY KOVACK
Vaginal - 89%
Abdominal - 11%

5. Total Cases - 9095
Abdominal - 93% in 1990
Vaginal - 7%
FINLAND STUDY
While study in 1995 has shown rise in Vaginal hysterectomy
cases.
AUSTRALIAN STUDY
Abdominal route was more preferred up to 90%
DR. SETH’S SIR’S STUDY- INDIA :
Total 5985 cases
Vaginal - 80%
IN THIS NEW MILLENIUM
“ Advent of Laparoscopic surgery has revived and
increased the of incidence of VH tremendously in World

6. SELECT MOST SAEF AND MINIMALLY INVASIVE.
THREE MODES TO REMOVE UTERUS -
UTERINE EXTIRPATION => PLACE OF VARIOUS
ROUTESWHICH ROUTE ??? TO SELECT

7. [ True state of the art Indian
Legacy]
[ Modern Surgery ]
Vaginal
Hysterectomy
L.A.V.H.

8. TLH
[ Ultra Modern Surgery ]
Abdominal Hystectomy
[ AN OLD ART- NEED TO DECREASE THIS MORBID
SURGERY ]

9. CLASSIFICATION _-- laparoscopic hysterectomy.
I – BY HARRY REICH =>
1. LAPAROSCOPIC HYSTERECTOMY- Uterines are secured
L’scopically.
2. LAVH => Uterine secured vaginally.
II – BY ALAN JOHN’S =>
Stage
0 Laparoscopy done- no laparoscopic procedure performed prior to vaginal
hysterectomy.
1 Procedure included laparoscopic adhesiolysis and/or excision of
endometriosis.
2 Either or both adnexae freed laparoscopically
3 Bladder dissected from uterus.
4 Uterine artery transected laparoscopically.
5 Anterior and/or posterior colpotomy or entire uterus freed.

10. INDICATIONS FOR L.A.V.H.
1 Previous pelvic surgery ( fibroids, dysfunctional
uterine bleeding, adenomyosis)
2 Endometriosis
3 Chronic Pelvic pain
4 Significantly large uterus
5 Suspected or confirmed adnexal pathology
6 Associated bowel or appendicular disease.
7 Previous uterine suspension.
8 Previous one or more caesarean section.

11. PROCEDURE PER SE :
ABDOMINAL INCISION AND PORT
SITE
Patient Position

12. LAPAROSCOPIC INCISION LINE OF UTERUS

13. LAPAROSCOPIC COMPONENT OF LAVH
1. Division of major pedicles viz- Infundibulo pelvic ligaments or
uterovarian ligaments and round ligaments.
2. Dissection of the urinary bladder by opening UV fold by
monopolar spatula
3. Anterior colpotomy by inserting a wet sponge on holder in
anterior vagina and opening by monopolar spatula.
Vaginal Component:
1. Posterior colpotomy by direct cut with scissors
2. Clamping, cutting and Transfixing uterosacrals and cardinals
on either side.
3. Clamp, cut and ligate uterine artery on eitherside
4. Remove the uterus
5. Close the vaginal vault.

14. Right Round Ligament Coagulation
Right Tubo-ovarian Ligament Coagulation
Steps Of L.A.V.H.

15. Left Tubo-ovarian Ligament Coagulation
Dissection of the utero-vescical

16. Mobilization of the urinary
Dissection of the utero-
vescical peritoneum

17. Vaginal steps of LAVH
Opening Anterior
Pouch

18. Opening Posterior Pouch.
Delivering Uterus
Vaginaly
Clamping
Cutting &
Ligating
Uterosacral
Cardinal &
Uterine
Pedical.

19. Clippings

22. Opening Posterior Pouch.
Delivering Uterus
Vaginaly

23. -Surgical procedure involving dissection of tubovarian pedicle and
bladder dissection is done through Laparoscope - while vaginally
uterines are ligated under vision by delevering uterus through
colpotomy incision.
[ L A D H ]
Laparoscopic assisted Doderlein’s
Hysterectomy
Cutting the right infundibulopelvic
ligament
Dividing the peritoneum in the
uterovesicular pouch

24. L A D H
Anterior colpotomy performed with an
incision from the nine o’clock to the three
Uterus delivered out through the
anterior colpotomy
Clamp on the right uterine pedicle Clamp on the right uterosacral/cardinal
pedicle

25. COMPLICATIONS :
Morbidity
1. Interaoperative—
a. Urinary Bladder injury
b. Bowel injury
c. Collateral vessal injury ( near the Cloquet’s
lymph node)
2. Immediate Postoperative--
i) Surgical a. Haemoperitoneum
b. Vesicovaginal fistula
c. Ureteral injury
d. Postoperative vault induration ( small
haematoma)
ii) Medical a. Postoperative pyrexia of unknown origin
b. Urinary tract infection
c. ARDS
d. Deep vein thrombosis
Mortality 1. Medical or Unexplained ( Chronic anemia with

26. COMPARISION OF VAGINAL VERSUS LAPROSCOPIC VERSUS
ABDOMINAL HYSTERECTOMY
Vaginal Hysterectomy Laparoscopic
Hysterectomy
Abdominal
Hysterectomy
Regional Anesthesia General Anesthesia General Anesthesia
4 Week Convalescence 4 Week Convalescence 8 Week Convalescence
1 Night in the Hospital 1-2 Nights in the Hospital 2-3 Nights in the
Hospital
Internal Incisions Only Internal & External
Incisions
External & Internal
Incisions
No Abdominal Scars 4 Small Abdominal Scars Large Abdominal Scar
Lowest Complication
Rate
Highest Complication Rate Average Complication
Rate
Less Expensive More Expensive More Expensive
Highest Surgical Skill
Required
Moderate Surgical Skill
Required
Least Surgical Skill
Required

27. At last commenting on place of LAVH Today,
any procedure should have following A’s to be
popular amongst patient and doctors
1. Available
2. Affordable
3. Acceptable
4. Accessible
5. Adaptable
6. Artifice Ease
7. Aquantible
8. Acquisible
9. Admirable

28. “ Look on this procedure with WONDER, Love
this procedure and Enhance the learning skill
for LAVH And I assure,
“ALL THE NOVICE GYNAECOLOGIST CAN DO
IT IF ALL A’S PUT TOGETHER”

29. CONCLUSION:
LAPAROSCOPIC HYSTERECTOMY is glamorized more
than its actual scientific value. Laparoscopic
Hysterectomy should not be taken only for glitter or
glamour specially in cases were vaginal hysterectomy
is possible, So LAVH should be done where VH is
contraindicated and main aim is to the decrease the
incidence of morbid AH World wide.

30. INDEBTED TO ONE AND ALL
FOR
PATIENT LISTENING