increasing the risk of
injury to the patient,
seems inadvisable.
The remaining alterna-
tives for large fibroid
uteruses include only
open laparotomy, or
total vaginal hysterecto-
my with manual morcel-
lation or debulking in
vivo. In the hands of all
but a very few surgeons,
this approach carries a
significant risk of bleed-
ing, injury to bladder or
bowel, and particularly,
ureteral damage. For the
smaller uterus, a total
vaginal hysterectomy
(TVH), laparoscopically
assisted vaginal hys-
terectomy (LAVH) or
total laparoscopic hys-
terectomy (TLH) may be
options. But none of
these leaves the vagina
intact and the cervix and
attached ligaments in
place, and all carry a
risk of vaginal dehis-
OSE_1406_part2_Layout 1 6/13/14 11:40 AM Page 56
