Total Laparoscopic Hysterectomy- Tips, Tricks & Techniques

TOTAL LAPAROSCOPIC

HYSTERECTOMY Tips & Techniques

Dr. K. Sendhilkumar, MS,FACS,FICS,DNB (Surg Gastro)

Dr. Piyush Patwa, DNB, FMAS, FIAGESConsultant Laparoscopic Surgeon

“THE PAPER”

 Reich H, De Caprio J, McGlynn F. Laparoscopic hysterectomy. J Gynaecol Surg. 1989;5:213–6.

WHY LAPAROSCOPY

Laparoscopic hysterectomies have been clearly associated with

Relatively lesser blood loss, Shorter hospital stay, Speedier return to normal activities – Concept of

Day Care surgery Better cosmesis & patient acceptance 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

1) An adnexal mass, 2) Endometriosis, 3) Pelvic pain, & prior abdominal surgery, 4) In patients with a narrow pubic arch or poor

vaginal descent.

POSITIONING OF THE PATIENT

The patient is placed in Trendelenburg position - for better access to the pelvic organs

The patient’s arms are tucked in. The patient’s legs are flexed at hip & knoee joints &

placed in stirrups using caution to prevent compression on the lateral calf and thus peroneal nerve damage.

THE OT SETUP

ANATOMY IN BRIEF

THE UTERINE ARTERY USUALLY ARISES FROM THE ANTERIOR DIVISION OF THE INTERNAL ILIAC ARTERY. IT CROSSES THE URETER ANTERIORLY, REACHING THE UTERUS BY TRAVELING IN THE CARDINAL LIGAMENT. IT TRAVELS THROUGH THE PARAMETRIUM OF THE INFERIOR BROAD LIGAMENT OF THE UTERUS.

URETER

Ureter enters into the pelvis at the bifurcation of the common iliac artery in front of the sacroiliac joint.

To be remembered !! - In the female, the ureter passes above the lateral fornix of the vagina lateral to the supravaginal portion of the cervix and lies below the broad ligament and uterine vessels

LETS DO TLH TOGETHER“STEP BY STEP”

INSERT A VEREES NEEDLE INTO THE PERITONEAL CAVITY.

TIP : - An easy way to confirm intraperitoneal entry is to look for a negative or low pressure reading on the insufflator

TIP :- Use Palmer’s Point ( Left subcostal midclavicular line/perpendicular to skin/stomach should be emptied/?Hepato-Splenomegaly) for Obese patients / patients with previous abdominal surgeries including C-sections.

PORTS PLACEMENT

ONCE INTRAPERITONEAL PRESSURE HAS REACHED TO SET 14 MMHG, INSERT 10MM UMBILICAL /SUPRAUMBILICAL TROCAR

MUST : complete survey of the abdomen to rule out any visceral injury at the time of Verees/trochar entry

MYOMA SCREW

At Gateway Clinics, we routinely use the myoma screw for uterine manipulation during total laparoscopic hysterectomy.

Others- uterine manipulator/Elevator/Uterine Hitch

REMEMBER its use is avoided in two situations. 1) in endometrial cancer, where peritoneal

spread of tumor cells is feared. 2) in patients with pyometra in cervical cancer,

where insertion of the screw would lead to spillage of pus into the abdominal cavity.

Inspect the 1) Ureter at the pelvic brim, 2) the infundibulopelvic ligament, 3) Utero-ovarian ligament Tip :- Ligaments Coagulated & incised with

combination of Vessel Sealing an Ultrasonic scalpel ( As perfect Haemostasis would be the key to Day care surgery )*

DESSICATION OF THE UTERO-OVARIAN LIGAMENT (TIP: - HUG THE OVARY)

DISSECTION OF THE ROUND LIGAMENT 

TRANSECT THE ROUND LIGAMENT AND SEPARATE THE ANTERIOR & POSTERIOR LEAVES OF THE BROAD LIGAMENT WITH THE HARMONIC SCALPEL

FIND THE CORRECT PLANE- THIS IS WHERE THE PERITONEUM SEPARATES EASILY WITH GENTLE MANIPULATION

Immediately after the round ligament is incised ↓ The uterus, on the myoma screw / uterine

manipulator, is pulled cephalad to recreate the “traction-counter-traction” concept of open surgical dissection of the lower uterine segment.

↓ This elevates the uterine arteries along the lower

cervix away from the ureters. 

TIP:- THE PARAMETRIAL VENOUS PLEXUS BETWEEN THE OVARY & THE ROUND LIGAMENT COAGULATED WITH VESSEL SEALER & DIVIDED USING HARMONIC SCALPEL

THE VESICOUTERINE PERITONEAL FOLD

(UV FOLD)TIP:- LIFT THE BLADDER NICELY

BLADDER MOBILIZATIONTIP:- STAY IN THE LOOSE AREOLAR TISSUE

PLANE

THE DISSECTION OF THE ANTERIOR LEAF OF THE BROAD LIGAMENT CONTINUES ANTERIORLY, THEREBY ENABLING DISSECTION OF THE BLADDER FROM THE LOWER UTERINE

SEGMENT.TIP :- HUG THE CERVIX

WATCH FOR AIR / BLOOD IN UROBAG !!

PANAROMIC VIEW

SECURE THE UTERINE VESSELSTIPS :- PULLING UTERUS CEPHALAD WITH THE MYOMA SCREW HELPS TO MOVE THE UTERINE

VESSELS AWAY FROM THE URETER

IT IS IMPORTANT TO TAKE THE UTERINE VESSELS HIGH AND THEN DISSECT MEDIALLY TO THE UTERINE VESSELS DOWN TO THE CUP. IT AVOIDS URETERAL INJURY AND PROVIDES A HEALTHY UTERINE

PEDICLE THAT CAN BE SAFELY DESICCATED FURTHER IN THE EVENT OF BLEEDING WHEN RETRACTED LATERALLY

VESSEL SEALER & HARMONIC JODI

(LAPAROSCOPIC VIEW)

VESSEL SEALER & HARMONIC JODI(EXTERNAL VIEW)

TIP :- KEEP SETTING - MIN AT 1 WHILE TACKLING UTERINES

SEPARATE THE UTERUS AND CERVIX FROM THE VAGINAL APEX

TIP : DONT TOUCH THE HARMONIC SCALPEL DIRECTLY INTO THE METAL OR CCL BECAUSE THIS MAY RESULT IN FAILURE OF

THE DEVICE AND MAY EVEN BREAK THE ACTIVE BLADE

CCL VAGINAL BALL EXTRACTOR

NEARING COMPLETION OF THE COLPOTOMY

PULL THE UTERUS INTO THE VAGINA

TAKE CARE OF BLADDER & RECTUM

VIEW THROUGH VAGINA

DELIVERING THE DELIVERY ORGAN

LOCK THE ESCAPE OF PNEUMO

*TAKE OUT ALL THE SPECIMENS*BRING IN THE SUTURE THROUGH THE

VAGINA

VAGINAL VAULT (CUFF) CLOSURE*REMEMBER UTEROSACRALS

 MCCALL CULDOPLASTYTHE SUTURES WHEN TIED, THE UTEROSACRAL-CARDINAL LIGAMENTS ARE DRAWN TOWARD THE MIDLINE, THEREBY

HELPING TO CLOSE OFF THE CUL-DE-SAC

1-0 VICRYL SUTURE PROCEEDS IN A RUNNING FASHION, MAKING SURE TO INCLUDE THE VAGINAL

MUCOSA

COMPLETION OF VAGINAL VAULT CLOSURE

THE PELVIS IS IRRIGATED & HEMOSTASIS AT ALL SITES

SECURED

THE FINAL APPEARANCE