Laparoscopic Assisted Vaginal Hysterectomy (LAVH)

Anesthesia Implications

Position: Trendelenburg, arms tucked
Time: 2-4 hours (long)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Trendelenburg position – most surgeons like very steep trendelenburg for this case, so make sure patient is secured to the bed. May be a good practice to do a “test” tilt as far as possible before draping.

PONV – These patients are at a much higher risk for PONV, so it’s common to give a full run of antiemetics for prevention/prophylaxis.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Laparoscopic cases (general considerations): The patient’s peritoneum is insufflated (which is called a pneumoperitoneum), and instrumentation will be inserted into the abdomen. General anesthesia, ETT tube, and paralytics are necessary. Some of the procedures are rather short, so make sure the timing is right to reverse the paralytic. The pressure in peritoneum affects the organs of that space. Anything more than 10 mmHg will begin to alter hemodynamics. Cardiac output is decreased and SVR is increased. Peak inspiratory pressures rise. Renal vessels will be compressed, which reduces flow to the kidneys, and activates the renin angiotensin aldosterone system (RAAS). Reduced blood to the kidney means reduced urine output. Peak inspiratory and plateau pressures will also increase. The gas used to insufflate the peritoneum is CO2 – so, as you might guess, hypercarbia can develop – and with it, acidosis. You’ll see this sometimes reflected in the end-tidal CO2. This is all adding to the stress response we try to avoid in anesthesia.

Trendelenburg Position (general considerations): Take precautions for upper airway obstruction or stridor. Avoid excessive fluid administration. OG tube is a good consideration to empty the contents of the stomach. Regurgitation of stomach contents can ulcerate the airway and/or damage the eyes. Consider throat packs and/or eye lubrication to further protect the patient. Brachial nerve injury is also a strong possibility. Be very careful with head and shoulder brace positioning. Peroneal nerve injury is a strong possibility if the patient is also in the lithotomy position. Make sure pressure points are padded. If there’s peroneal nerve damage, it will manifest as foot drop. Increased IOP. Take precaution with patients that have glaucoma. Conjunctival swelling will sometimes be irritating to the patient post-operatively. Keep reminding the patient not to rub their eyes. Increased ICP. Cerebral perfusion pressure = MAP-ICP. Make sure you keep the MAP up.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

This surgery is a combination of a vaginal and a laparoscopic hysterectomy. This surgery is completed by removing the uterus through the vagina after the laparoscopic surgical excision of the uterus.

This technique causes less bleeding and blood loss than the standard/open approach.