Re: Gyn: Hysterectomy; Is there more than
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Fri Sep 21 16:07:15 2007
I sure like your reply and thinking--and glad this has generated
comments.
An easy fast for you and yours, I hope. . .
Garry
At Fri, 21 Sep 2007, l.glazerman@rcn.com wrote:
>
>Garry:
>
>All great questions. My humble opinions, FWIW:
>
>1. I'd always suggest a TVH if it's within the skill and confidence level of the surgeon. If you need to do a diagnostic laparoscopy for some reaon (suspected endometriosis, suspected adhesions, etc), then, as you suggested, do a laparoscopy followed by a TVH, if you can do a TVH.
>
>2. I personally think there's no indication EVER (almost) for an LAVH. The way most of us do an LAVH, the laparoscopic dissection doesn't really help with the vaginal part. If you can do an LAVH, IMHO, you could probably to a TVH.
>
>3. I'm a big fan of LSH. My rationale is if it (the cervix) ain't broke, why fix (or remove) it? The data is split on benefits of leaving the cervix (support defects, sexual function, etc), vs the benefits of removing (cervical cancer). I do believe that LSH is simpler than TLH (no suturing) and patients recover more quickly.
>
>4. IF we're going to be doing TLH's, it's incumbent on us to do the same support procedures that we'd do at the time of TAH. If we can't do that, don't do the laparoscopic procedure, or learn how to!!!!
>
>5. Regarding suspected adenomyosis, one of the situations in which I don't personally prefer LSH over TLH is endometriosis/suspected adenomyosis. I've had to do a few trachelectomies on patients after LSH for endometriosis for residual pain, all of whom have been cured with the trachelectomy. Having said that, I'll discuss that issue with the patient, let them know that in general, I'm a big fan of LSH, but that I don't think it's the ideal option for her. If she requests it, I'll still do the LSH.
>
>I'm very interested in others' comments as well.
>
>LArry
>
>>>---- Original message ----
>>Date: Fri, 21 Sep 2007 14:45:39 -0500
>>From: garrys@mindspring.com (Garry E. Siegel,M.D.)
>>Subject: Gyn: Hysterectomy; Is there more than one way to skin a cat?
>>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>>
>>Over the past few months, "how" to perform a hysterectomy has been on my
>>mind, with several diverging options and opinions. This all may be
>>based on personal preference, skill, equipment availablity, etc. We all
>>agree that if you do an operation well, and if several operations meet
>>the patient's needs, it is better to do the operation you do best. . .
>>
>>Anyway, for discussion, I would like to focus on the surgical options
>>and techniques, and rationale, if any, behind what one does. This may
>>bleed over into cervical retention versus removal, which, to a degree,
>>may influence what is done and how it is done.
>>
>>35 YO P3003, all vaginal deliveries, who has completed her family, with
>>disabiling menorrhagia (normal CBC) and dysmenorrhea, who cannot/will
>>not use hormonal contraception (hemiplegic migraines per her), and has a
>>strong family history of endometriosis. Her exam, ultrasound, and CBC
>>are normal. She requests a hysterectomy with ovarian retention.
>>
>>FWIW, she underwent a LAVH yesterday unremarkably, with a normal pelvis
>>and pathology pending.
>>
>>So. . .
>>
>>What about Total Laparoscopic Hysterectomy (TLH)? Laparoscopic
>>Supracervical Hysterectomy (LSH)? Old-fashioned TVH? Did she need a
>>laparoscopy? (I think so). If so, why not a diagnostic laparoscopy and
>>then TVH?
>>
>>If you do a TLH, might you be "missing" the chance to support the
>>vaginal to the uterosacrals as one might do vaginally? Is it needed?
>>McCalls?
>>
>>Might you avoid this with an LSH? But, if you do an LSH, might the stump
>>contain suspected adenomyosis?
>>
>>All food for thought--discussion welcome.
>>
>>--
>>Garry E. Siegel, M.D.
>>Private Practice
>>Roswell, GA
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
