Vaginal Approach Faces Uphill Battle.

ORLANDO, FLA. -- Most laparoscopic hysterectomies done in the United States today could be performed exclusively by the vaginal route, and few hysterectomies, if any, should be performed using a total abdominal approach, Dr. Harry Reich said at a meeting of the One Kilo Club.

Dr. Reich, who is credited as being the first surgeon to ever perform laparoscopic hysterectomy, is disappointed with how the surgery has been put into practice in the ensuing 15 years.

"Laparoscopic hysterectomy has done the opposite of what I intended it to do. So far, there has been almost no impact, in fact, almost a negative impact" on surgical care of women with the introduction of laparoscopic hysterectomy, he said at the meeting held in conjunction with the 37th International College of Surgeons' North American Federation Congress.

The concept behind laparoscopic hysterectomy was that it would replace abdominal hysterectomies for difficult cases: women with large, fibroid uteri, for example. Instead, laparoscopic hysterectomy and Laparoscopically assisted vaginal hysterectomy (LAVH) now are both used for simple cases that should be performed as vaginal hysterectomies, ironically exposing patients to more invasive surgery than they require, Dr. Reich contended.

Seventy percent of U.S. hysterectomies are done with an open incision, even though this approach requires longer hospital stays and involves more patient discomfort. Critics of the laparoscopic approach maintain that it is technically difficult and time consuming.

Dr. Reich, who currently practices in New York City and Kingston, Pa., maintains that minimally invasive hysterectomies are safe.

In 68 consecutive LAVH procedures performed at Columbia, 21 were in nulliparous women, and the uteri weighed a mean 550 g, with a range of 105-2,783 g. One surgery was converted to a laparotomy in a case where the uterus weighed more than 2,000g. Complications consisted of one low-grade sarcoma, one postoperative abscess, and several situations that could have been very serious had they not been immediately detected: a lacerated bladder and bowel perforation due to morcellation of a large uterus. Both were repaired at the time of laparoscopy, as were three instances of ureteral ligation discovered during a cystoscopy at the time of surgery. In those three cases, the suture was removed from the ureter, and there were no major sequelae.