Robert E. Richardson

Is laparoscopic hysterectomy a waste of time

Laparoscopic hysterectomy (LH) is a way to avoid laparotomy. However, there is evidence that most women treated by abdominal hysterectomy are suitable for vaginal surgery. To test this hypothesis, and to determine the relative merits of laparoscopic and vaginal hysterectomy (VH) and the best technique for LH, we prospectively studied 98 women who had relative contraindications for vaginal surgery by traditional criteria. 75 underwent LH and 23 VH. The LH group included 22 women who had been assigned to this route of surgery as part of a prospective randomised controlled comparison with VH (23 women). Surgery was completed with the intended technique in 93.9% of cases. 5 women in the LH group (6.7%) and 2 in the VH group required laparotomy or additional procedures. In the prospective randomised study LH took longer than VH (mean duration 131 vs 77 min). VH was the faster procedure, irrespective of uterine size and need for oophorectomy. With LH, the operative time increased as more of the hysterectomy was carried out with laparoscopic rather than vaginal dissection. Complication rates, blood loss, analgesia requirements, and recovery were similar for the two techniques. Our study confirms that most hysterectomies could be performed vaginally, and that LH is a much slower procedure. If LH is done, it should be converted to a vaginal procedure as early as possible to reduce the overall operating time. LH does seem to be a waste of time for most patients.

Vaginal hysterectomy for the large uterus

Objective To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size.

Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial

OBJECTIVE To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure. DESIGN A randomized double-blind, placebo-controlled trial. SETTING An undergraduate university teaching hospital in London. PATIENT(S) One hundred twenty patients undergoing outpatient hysteroscopy. INTERVENTION(S) Application of lignocaine spray to the cervix, cervical canal, and uterine cavity during outpatient hysteroscopy. MAIN OUTCOME MEASURE(S) The need to use additional anesthesia and the pain experienced at various steps of the procedure. RESULT(S) Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy. There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups, although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls. CONCLUSION(S) Lignocaine spray has beneficial effects on cervical but not uterine sensation. Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy.

Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy

OBJECTIVE To evaluate patient acceptance and the clinical feasibility of carbon dioxide compared with normal saline for uterine distension in outpatient hysteroscopy. DESIGN Prospective, randomized clinical trial. SETTING Outpatient hysteroscopy clinic in a university hospital. PATIENTS One hundred fifty-seven patients undergoing outpatient hysteroscopy. INTERVENTIONS Outpatient hysteroscopy was performed with carbon dioxide or normal saline with endometrial biopsy when indicated. MAIN OUTCOME MEASURES Need for local anesthesia, cervical dilatation, view of uterine cavity, need to change from carbon dioxide to normal saline distension, procedure time, patient discomfort (lower abdominal pain, shoulder tip pain, nausea) and complications. RESULTS Carbon dioxide was used for uterine distension in 79 women and normal saline was used in 78. Cervical dilatation was required more often with carbon dioxide hysteroscopy, although there was no increased requirement for local anesthesia. Hysteroscopic vision was similar between the two media, but eight carbon dioxide cases had to be converted to liquid distension. Procedure times were significantly longer for carbon dioxide hysteroscopy as was the occurrence of bubbles during the procedure. Lower abdominal pain and shoulder tip pain were significantly worse with carbon dioxide distension. Although the incidence of nausea and vomiting was higher with the use of carbon dioxide, the differences did not achieve statistical significance. CONCLUSION The use of normal saline for uterine distension had no adverse affects on the hysteroscopic view. It provided a shorter operating time and was well accepted by patients. Because of its easy availability and low cost, normal saline is an excellent alternative to carbon dioxide in women undergoing outpatient hysteroscopy.

Transvaginal endoscopic oophorectomy

Four women underwent transvaginal endoscopic oophorectomy during vaginal hysterectomy. The adnexa were visualized with a laparoscope inserted into the upper vagina. Bilateral salpingo-oophorectomy or oophorectomy was carried out with standard laparoscopic instruments introduced through the vagina without a pneumoperitoneum; Endoloop sutures and bipolar electrocoagulation were used for hemostasis.

Subtotal vaginal hysterectomy

SummaryFive women requiring hysterectomy for benign indications and with normal cervical cytology, underwent the new procedure of subtotal (supracervical) vaginal hysterectomy combined with salpingo-oophorectomy in two cases. Using the Doderlein-Kronig approach, an anterior colpotomy was made and the uterine fundus delivered into the vagina. The ovarian and uterine pedicles were ligated in turn before amputating the uterine body from the cervix. The cervical incision was then repaired and the vaginal incision closed. Operative times ranged from 35 to 150 min, one procedure being prolonged by difficulty with bladder dissection following two previous Caesarean sections. Subtotal vaginal hysterectomy is an alternative to abdominal and laparoscopic subtotal hysterectomy, which avoids two of the disadvantages of these techniques, the need for abdominal incisions and the need for laparoscopic expertise.