TOTAL LAPAROSCOPIC HYSTERECTOMY

Vaginal and laparoscopic hysterectomies have been clearly associated with decreased blood loss, shorter hospital stay, speedier return to normal activities, and fewer abdominal wall infections when compared with abdominal hysterectomies. The vaginal approach is less expensive, but may be challenging in patients with a history of an adnexal mass, endometriosis, pelvic pain, and prior abdominal surgery, or in patients with a narrow pubic arch or poor vaginal descent.

STEPS FOR TOTAL LAPAROSCOPIC HYSTERECTOMY

1. Preparation and Positioning

Patients are placed in a dorsal lithotomy position with pneumoboots. The arms are tucked at the sides and a foam mattress is situated directly under the patient to prevent sliding during steep Trendelenburg. The table in kept in a low position and have a monitor directly facing each surgeon to promote an ergonomic working environment.

2. Insertion of a Uterine Manipulator

 First, place a Sims speculum into the vagina, grab the cervix with a tenaculum, and sound the uterus. Then ask for the appropriately sized uterine manipulator tip (6, 8, or 10 cm). The tip can be difficult to attach to the shaft, but dipping the distal end of the shaft in lubricant prior to attaching the tip greatly facilitates this step. The pneumo-occluder then slides over the tip and onto the shaft followed by attachment of the appropriately sized KOH ring (3, 3.5, and 4 cm in width). It is important to choose the correct size because a small ring will not delineate the vaginal fornices and a large ring may increase the risk of a ureteral injury. Next, place a 0 monofilament suture through the anterior lip of the cervix, thread this through the KOH ring, and secure with a haemostat. Insert the tip of the uterine manipulator as far into the cervix as it will go, then release the tenaculum while keeping tension on the cervical stitch. This prevents the uterus from moving cephalad as the tenaculum is removed. After confirming correct placement by palpation or direct visualization, tie the suture to the handle to facilitate specimen removal through the vagina at the end of the case. A Foley catheter is inserted into the bladder and finally the pneumo-occluder is filled with 60 to 100 cc of saline.

3. Abdominal Entry and Trocar Placement

A 5-mm skin incision is made at the deepest part of the umbilicus using a #15 blade.The deepest part of the umbilicus is elevated with a Kocher clamp and a Veres needle is inserted into the peritoneal cavity. The gas tubing is connected to the needle to reduce manipulation following insertion. An easy way to confirm intraperitoneal entry is to look for a negative pressure reading on the insufflator. Once intraperitoneal pressure has reached 15 mm Hg, insert an optical trocar through the umbilicus under direct vision, followed by a complete survey of the abdomen to rule out any visceral injury at the time of entry. The lower quadrant trocar sleeves are placed under direct vision. These trocars are placed lateral to the rectus abdominis muscles, 2 cm above and 2 cm medial to the anterior superior iliac spine. Usually, a 5-mm trocar is placed on the right and a 12-mm trocar on the left. In addition, a 5-mm trocar is placed approximately 8 cm above and parallel to the lower left trocar site. This port will, in most cases, end up being nearly parallel to the umbilical trocar. The 2 ports on the left greatly facilitate suturing and help to maintain an ergonomic position for the surgeon throughout the procedure. The 12-mm port site is ideal for needle passage and specimen retrieval.

4. Hug the Ovaries

The infundibulopelvic (IP) ligament or the utero-ovarian ligament is initially desiccated with a reusable bipolar grasper . It is important to stay close to the ovary (hug the ovary) as this helps to avoid the pelvic sidewall during ovarian removal and the ascending uterine vessel during ovarian conservation. The surgeon should take special care to desiccate the parametrial veins that run between the ovary and the round ligament as these can be quite tortuous and tend to bleed if left unattended. The IP ligament or utero-ovarian ligament is then transected close to the ovary. During this step of the procedure, the uterine manipulator is being pushed upwards and to the contralateral side to provide maximal visualization.

5. Mobilize the Bladder

Transect the round ligament and separate the anterior and posterior leaves of the broad ligament. It is important to find the correct plane; this is where the peritoneum separates easily with gentle manipulation.The vesicouterine peritoneal fold is identified and the dissection is continued anteriorly, thereby mobilizing the bladder off the lower uterine segment. It is important to stay in the loose areolar tissue if at all possible. In patients who have had a prior cesarean delivery, this area may be scarred and it is important to stay relatively high on the uterus during the dissection. A reevaluation of the route of dissection is advised if fat is encountered because the fat belongs to the bladder; this may indicate that the dissection is moving too close to the bladder.

Due to a wide variety in anatomy and in the course of the uterine vessels, it helpful to initially skeletonize them.The ascending uterine vessel i then dessicated with the bipolar grasper at the level of internal cervical. Note that pushing cephalad with the uterine manipulator helps to move the uterine vessels away from the ureter. Complete desiccation of the vessels can be assessed visually by observing the bubbles coming and going during this process; when the bubbles stop forming the vessel is desiccated and safe to transect. 2 cuts are then usually made in an inverted V-shape anterior and medial and posterior and medial to the vascular pedicle. This enables the vascular pedicle to fall out laterally, thereby providing easy and avascular access to the cervical cup. It is important to take the uterine vessels high and then dissect medially to the uterine vessels down to the cup. This averts ureteral injury and provides a healthy vascular pedicle that can be safely desiccated further in the event of bleeding.

7. Separate the Uterus and Cervix From the Vaginal Apex

Identify the vaginal fornices while pushing cephalad with the uterine manipulator.One can either see the indentation of the KOH colpotomizer or be able to palpate it with a laparoscopic instrument. The Harmonic scalpel is then used to cut circumferentially around the cup. Take care not to direct the Harmonic scalpel directly into the metal because this may result in failure of the device and may even break the active blade

8. Removal of the Uterus

Pull the uterus into the vagina if it fits. The uterus can remain there to maintain pneumoperitoneum during suturing. Alternatively, the uterus is removed and a glove with a pair of 4 × 4 sponges is placed into the vagina to maintain pneumoperitoneum. If the uterus is too large to fit through the vagina, it can be carefully morcellated transvaginally by using a 10-blade scalpel and triple hooks for retraction. In patients with limited vaginal access, the uterus can be morcellated using an electronic morcellator. It is important to keep the tip of the morcellator in clear view at all times.

9. Vaginal Cuff Closure

Closure begins at the distal angle of the vaginal cuff and proceeds in a running fashion, making sure to include the vaginal mucosa and the pubocervical and rectovaginal fascia. Each bite should be approximately 1 cm in thickness—this can be easily underestimated due to the magnification of the laparoscope. A LapraTy is then placed at the end of suture and the needle is cut free and removed through the 12-mm port. The pelvis can now be irrigated and hemostasis at all sites is assured.

10. Port Site Closure

The fascia at the 12-mm incision in the left lower quadrant is closed using 0 vicryl sutures with a fascia closure device. The skin is closed with 4-0 monocryl suture in a continuous subcutaneous fashion. The 5-mm incisions are closed with Dermabond. Cystoscopy is performed after vaginal closure to check ureteral patency and for any signs of bladder injury.

FEW IMPORTANT POINTS

• If the uterus is large and requires manipulation with a tenaculum, consider injecting dilute vasopressin subserosally prior to applying traction to the uterus. This can reduce bleeding associated with pulling and tearing of the uterine serosa.
• In cases with poor exposure, sutures are routinely used to retract organs away from the surgical field. A redundant sigmoid can be retracted by taking a series of bites with a 0 prolene suture through the epiploica and pulling the suture through the lower quadrant port. The port is removed to get the sutures out and then reinserted. The sutures are then secured to the skin with a hemostat. Take care to include a number of epiploica to avoid tearing.
• Alternatively, ovaries or other structures can be tacked away using a 6-inch suture (0 Quill PDO or 0 vicryl) with a LapraTy on the end. The needle is passed through the structure and then a bite is taken through the inside of the anterior abdominal wall. This end of the suture is then secured with another LapraTy and the needle is cut away and removed.
• If access to the uterine vessels is difficult, take the uterine vessels up high initially to secure the blood supply to the upper uterus and then gradually work down, staying medially to the vessels.
• Maintain exposure at all times-do not dig yourself into a hole-always be ready to deal with a sudden onset of bleeding.
• The combination of a prior cesarean delivery and a large uterus is a set up for bladder injury-stay high on the vesicouterine peritoneum, respect any fat that you see, and watch out for air in the Foley balloon.
• In severely distorted anatomy consider entering the retroperitoneum sooner rather than later. The easiest starting point is usually at the round ligament.