Ronald L. Levine

The AAGL classification system for laparoscopic hysterectomy

Reich first reported total laparoscopic hysterectomy in 1989.1 Since that time many variations of the procedure have been described, that vary principally by the relative portions of the surgery performed via the vaginal and laparoscopically directed routes. The variations have potential impact on clinical outcomes such as complication rates, and resource utilization outcomes such as the cost of surgical care. In addition, training and credentialing of surgeons may vary depending upon the type of laparoscopic hysterectomy performed. Unfortunately, critical and rigorous evaluation of the technique has been impaired by the varied and inconsistent nomenclature used in the gynecologic literature to describe the spectrum of operations that comprise laparoscopic hysterectomy, including laparoscopically assisted vaginal hysterectomy (LAVH), laparoscopic-directed hysterectomy, laparoscopic hysterectomy and laparoscopicallyassisted hysterectomy. In addition, the rediscovery of subtotal or supracervical hysterectomy and its adaptation to the laparoscopic route has introduced such terms as classic intrafascial Semm hysterectomy (CISH), laparoscopic assisted subtotal hysterectomy (LASH) and others. These procedures, while generally performed under laparoscopic direction, vary both by the amount of dissection performed and by the treatment of the columnar epithelium and the transformation zone of the cervix. These differences may have an impact not only on resource utilization and complications, but also on the long-term incidence of post procedural cervical neoplasia. Such information is important for patients, providers, and health care organizations. A historically useful solution to the problem is the creation of a classification system that is easily reproducible and capable of stratifying cases in a way that allows critical evaluation of procedures performed in different clinical environments by a variety of surgeons. Many attempts have been made to design a classification system for laparoscopic hysterectomy and each has been different in its approach. 2-5 Consequently, the goals of standardized classification have yet to be achieved. The AAGL believes that it is important to develop and support a standard nomenclature for the classification of laparoscopic hysterectomy. The AAGL Classification Committee was charged with designing an acceptable system, or selecting one that has been previously published. The result of the deliberation was the selection of a previously published system 2 accompanied by an abbreviated form of the same system designed for everyday use. The full system, reprinted here with permission, is designed principally for clinical and resource outcomes use by investigators but could be used in whole or in part by practitioners, investigators or provider organizations. It is detailed,

Laparoscopic-assisted vaginal hysterectomy: American Association of Gynecologic Laparoscopists' 2000 membership survey.

A questionnaire was mailed to all members of the AAGL to determine the current performance of laparoscopic-assisted vaginal hysterectomy (LAVH), and to assess the relative frequencies of techniques and complications. Answers of the 1092 members who responded were entered into a database computer program and analyzed. The analysis revealed 14,911 LAVHs performed by 767 members. Complication rates appeared to be in the same range as those reported for vaginal hysterectomy and total abdominal hysterectomy. Inferior epigastric injury was the most common complication. Physicians showed a shift in their practices away from abdominal hysterectomy after they learned LAVH.

Use of laparoscopically mobilized peritoneum in the creation of a neovagina

OBJECTIVE To present an alternative technique for the creation of a neovagina. DESIGN Case study. SETTING Academic university gynecology clinic. PATIENT(S) A patient diagnosed with müllerian agenesis. INTERVENTION(S) Laparoscopically assisted creation of a neovagina by using peritoneum. MAIN OUTCOME MEASURE(S) Patient morbidity and satisfactory intercourse. RESULT(S) The patient underwent the procedure satisfactorily and was discharged within 24 hours. She had no perioperative or postoperative complications, and she became satisfactorily sexually active. CONCLUSION(S) The use of laparoscopically mobilized peritoneum in the creation of a neovagina provided the patient with a functional vagina, allowing satisfactory intercourse.

Laparoscopic suturing and ligation techniques

The laparoscopic literature addressing operative techniques and use of suturing and knot tying is reviewed. Many operations that have traditionally been performed by laparotomy, may now be primarily accomplished by laparoscopy. Increasing improvements in laparoscopic instruments and techniques permit more surgical procedures to be performed on an ambulatory basis, therefore setting a new trend in gynecologic surgery. The evolution of endoscopic procedures will require laparoscopic surgeons to master suturing techniques which will improve their level of comfort and performance. This review of suturing and knot tying procedures may be helpful to both the established surgeons and the beginners as it gives a comprehensive review of laparoscopic suturing and knot tying techniques.

Uterus didelphys with microscopic communication between horns

The case of a 14-year-old female adolescent, gravida 1, para 0, abortions 1, with a didelphic uterus and a blind vaginal pouch with microscopic communication between horns is reported. Reproductive performance in such cases is usually poor. The challenge of detection and evaluation as well as the genetic-embryologic origin is discussed.

A teaching model for endoscopic surgery: hysteroscopy and pelviscopic surgery.

The tissue model described is readily available and can be manipulated in many ways to stimulate intraoperative conditions that may be approached by gynecologic endoscopic surgery. The value in using the sow uterus and bladder is that details of tissue management can be induced in the instructional course. The student can learn where and how to make incisions, to remove tissue from the cavity (abdomen or uterus), and to perform endoscopic suturing when indicated. The student can observed what happens to tissue under the influence of various energy forms such as bipolar or monopolar electrosurgery and lasers. The range of actual simulations is limited only by the imagination of the instructors and can probably be adapted to many other procedures not described in this report.

A new technique for the creation of a neovagina

Background: There are many described reconstructive techniques for vaginal agenesis including vaginal dilators, skin covered molds, sigmoid grafts, vulval and large muscle flaps all of which aim to produce a vagina of normal axis, secretory capacity and length. We report the laparoscopic approach to Davydovs operation which utilizes peritoneum to line the newly dissected vesicorectal space. Methods: A case report detailing preoperative evaluation, surgical technique and outcome.Results: There were no intraoperative or immediate postoperative complications. The patient was discharged from hospital within 23 hours of surgery. Six month follow up revealed a vagina 7-8 cm in length, lined with squamous epithelium. The patient reports satisfactory sexual intercourse.Conclusion: This technique provides a satisfactory option for the surgical management of vaginal agenesis.

Jaypee Gold Standard Mini Atlas Series: Laparoscopic Surgery in Infertility and Gynecology

This mini-book by Dr. Jain is a well organized text that, despite its small size,covers much of the field of gynecologic laparoscopy. It is well written in an easy-to-understand style. Its 14 chapters progress from simple operating room setup to relatively complex surgery. The chapters contain important information on energy sources, and proceed to the more difficult procedures such as treatment of rectovaginal endometriosis and myomectomy. The ending chapter on Prevention and Management of Complications contains some excellent tips that may be helpful to all readers. The book can be read swiftly, and could be used as a refresher before surgery by residents and also by practicing gynecologists who do not frequently perform laparoscopy. The chapter on Ovarian Drilling probably should not have been included because it is a technique, at least in the United States, that has been abandoned by most reproductive surgeons.

The Pebble Effect

The young person stands on the bank of a lake, looking out over the calm blue waters. He/she bends down and picks up a pebble. It is a random choice among the many pebbles on the shore, however, he/she selects only one that feels right in the hand. With a cocking of the wrist the pebble is thrown high in the air over the still water and when the pebble lands it produces a small, circular ripple that moves rapidly out expanding in an ever-larger circle, and depending upon its size and weight, the pebble has produced a wave that will touch many areas of the lake. If the person throws several pebbles, they produce an effect such that even he or she cannot realize the possibilities of his/her actions. I think that this is a metaphor of my life with the American Association of Gynecologic Laparoscopists (AAGL). At the recent meeting in Las Vegas I was extremely touched by the president mentioning me as his mentor. He stated that I brought him into AAGL and thus to his present status as president and gave him the opportunity to interact with many international friends. That would have been more than enough for me, but several others came up to me and thanked me for being a large part of their life insofar as they have become so active with AAGL and that has been an important part of their professional activity. AAGL has been the hand that picked me to grab the pebbles that I helped throw into the lake of minimally invasive gynecology. The fact that these individuals made many