Prof. Dr. R. K. Mishra INTRODUCTION The first laparoscopic hysterectomy (LH) was performed in January 1988 by Harry Reich in Pennsylvania. There has been a great increase in interest following the introduction of LH but most surgeons now perform laparoscopically-assisted vaginal hysterectomy (LAVH) and then total laparoscopic hysterectomy (TLH). This minimal access surgical procedure was designed to be an alternative to abdominal hysterectomy and not vaginal hysterectomy. Benign uterine diseases of uterus are very common and often need hysterectomy and laparotomy. There are several subtypes of LH, including: ■ Total laparoscopic hysterectomy: The uterus and cervix are removed. The entire procedure, including suturing of the vaginal vault, is performed laparoscopically. The uterine specimen is typically removed through the vaginal vault, either intact or after morcellation. ■ Laparoscopic subtotal (supracervical) hysterectomy (LSH): The uterus is removed; the cervix is conserved. The uterine specimen is extracted via the abdominal ports or incisions. ■ Laparoscopic-assisted vaginal hysterectomy: The laparoscopic approach is utilized to perform any needed adnexal surgery and control the adnexal blood supply. The remainder of the procedure is performed vaginally, including entry into the peritoneal cavity and ligation of the uterine vessels from below. LAPAROSCOPIC ANATOMY OF UTERUS The normal nulliparous uterus is approximately 8 cm in length and angled forward so the fundus lies over the posterior surface of the bladder. Uterus is all around covered with peritoneum except where the bladder touches the lower uterine segment at the anterior cul-de-sac and laterally at the broad ligaments (Fig. 1). Two important arteries, uterine and ovarian, are of great significance in uterine surgery. The uterine arteries arise from the internal iliac arteries. They pass medially on the levator ani muscle, cross the ureter and ultimately divide into ascending and descending branch. The uterine artery runs in a tortuous course within the broad ligaments. The uterine Fig. 1: Anatomy of uterus. (1) Umbilical artery; (2) Ureter; (3) Uterine artery; (4) Internal iliac artery; (5) Ovarian artery; (6) Common iliac artery; (7) Uterosacral ligament. arteries ascending branch terminates by anatomizing with the ovarian artery. From anterior to posterior, following important tubular structures are found crossing the brim of true pelvis: the round ligament of the uterus, the infundibulopelvic ligament, which contains the gonadal vessels and the ureter. The ovaries and fallopian tube are found between the round ligament and the infundibulopelvic ligament (Fig. 2). The ovarian ligaments run from the ovaries to the lateral border of the uterus. Ovary is attached to the pelvic side wall with infundibulopelvic ligament, which carries ovarian artery. One of the common mistakes that may happen is injury of the ureter during dissection of the infundibulopelvic ligament. If the uterus is deviated to the contralateral side with the help of uterine manipulator infundibulopelvic ligament is spread out and a pelvic side wall triangle is created. The base of this triangle is the round ligament, the medial side is the infundibulopelvic ligament, and the lateral side is the external iliac artery. The apex of this triangle is the point at which the infundibulopelvic ligament crosses
TABLE 1: Postoperative pain levels. Day LAVH (n = 19) TAH (n = 19) p 1 6.6 6.4 NS 3 4.4 4.3 NS 7 2.8 3.6 S 14 1.6 2.4 S 21 1.46 1.8 S Week 6 1.35 1.4 NS Wilcoxon’s signed-rank test. Ten-point activity scale: 1 = no pain; 10 = unbearable pain. S = significant at p < 0.005; NS = not significant at p < 0.01 TABLE 2: Postoperative activity levels. Day p 3.4 3.3 NS 3 5.4 4.4 NS 7 7.8 5.8 S 14 the external iliac artery. The ureter always enters medial to this triangle into the pelvis. It is visible under the peritoneum overlying the external iliac artery. The ureters enter the pelvis in close proximity to the female pelvic organ and are at risk for injury during laparoscopic surgery of these organs. As the ureters course medially over the bifurcation of the iliac vessels, they pass obliquely under the ovarian vessels and then run in close proximity to the uterine artery. Laparoscopy hysterectomy needs careful identification of ureter with some dissection of retroperitoneum. An incision is made in the peritoneum overlying the pelvic side wall triangle between the fallopian tube and iliac vessel. Pelvic lymph node dissection is also necessary if gynecologist plans to perform radical LH. Node dissection as far distal as Cloquet’s node in the femoral triangle may be included and proximally dissection may be necessary up to para-aortic lymph nodes. If a vaginal hysterectomy can be performed in the first place, there would be no point in adding the costs and complications of laparoscopy. Its greatest benefit is the potential to convert what would have been an abdominal hysterectomy into a vaginal hysterectomy. An abdominal hysterectomy requires both a vaginal incision and a 4–6 inch long incision in the abdomen, which is associated with greater postoperative discomfort and a longer recovery period than for a vaginal procedure. Another advantage of the LH may be the removal of the tubes and ovaries which on occasion may not be easily removed with a vaginal hysterectomy. The most common medical reasons for performing hysterectomies include uterine fibroids (30%), abnormal uterine bleeding (20%), endometriosis (20%), genital TAH (n = 19) 1 Fig. 2: Position of uterus. (1) Uterus; (2) Round ligament; (3) Utero-ovarian ligament (proper ovarian ligament); (4) Uterosacral ligament; (5) Ovary; (6) Suspensory ligament of the ovary; (7) Ureter. LAVH (n = 19) 9.2 6.4 S 21 9.6 7.9 S Week 6 9.95 8.5 S Wilcoxon’s signed-rank test. Ten-point activity scale: 1 = extremely limited activity, 10 = no limits on activity S = significant at p < 0.005; NS = not significant at p < 0.01 prolapse (15%), and chronic pelvic pain (10%). For most of these conditions, other treatments should first be considered, and hysterectomy should be reserved as a last resort. Laparoscopic hysterectomy results in a significantly shorter hospital stay, and a much more rapid return to normal activities than in total abdominal hysterectomy (TAH). The drug requirement to control pain and the level of pain patients experienced were also significantly less. Blood loss was not different for the two procedures (Tables 1 and 2). Postoperative recovery times and pain levels were assessed in 37 patients with a primary complaint of pelvic pain and diagnoses of fibroid uterus, adenomyosis, and severe endometriosis who underwent LH. Women reported an activity level of 8.7 on a scale of 1–10 (10 no limits on activity) by postoperative day 14. In another study, those undergoing abdominal hysterectomy had a mean uterine weight of 418 g compared with 150 g for those undergoing LAVH. The mean hospital stay after abdominal hysterectomy was 4.5 days and after LH 2.5 days. An important public policy issue now confronts us. As it is currently performed, LH is more expensive than TAH. The issue is whether the benefits of shorter convalescence and faster return to the work force, shorter hospitalization, and less need for narcotics for postoperative pain outweigh the disadvantage of the higher cost. If total healthcare system costs are evaluated, the shortterm disability costs of 2 weeks of recovery after LH should 431
SECTION 3: Laparoscopic Gynecological Procedures be compared with disability costs of 6–8 weeks of recovery after abdominal hysterectomy. For LH to be economically viable compared with TAH, savings in disability costs and the increased contribution to the gross domestic product must offset the increased healthcare costs. In the current system, insurance companies and hospitals do not have share in these benefits, only consider the costs. The economic impact of laparoscopic surgery must take into account both the cost to the hospital and insurance payers and these productivity and social issues. Insurance is based on a risk pool whereby the cost of a premium is based on the cost of treatment, not the ability of the subscriber to return to work. An economic and social cost–benefit analysis must be performed before decisions are made to modify or judge a procedure that provides substantial benefits to the patient. Since its introduction in 1989, no one could have imagined that with continued improvement of techniques will progress so rapidly that LH can be performed on daycare basis for many women, and will result in shorter recovery time. Thus, the increased operating room time of approximately 46 minutes is significantly outweighed by the benefits available with widespread application of this procedure. CLASSIFICATION Garry and Reich Classification of Laparoscopic Hysterectomy ■ Type 1: Diagnostic lap + VH ■ Type 2: Lap vault suspension after VH ■ Type 3: LAVH ■ Type 4: LH (lap ligation of uterine artery) ■ Type 5: TLH ■ Type 6: LSH (lap supracervical hysterectomy) ■ Type 7: LHL (lap hysterectomy with lymphadenectomy) ■ Type 8: LHL + O (as above + omentectomy) ■ Type 9: RLH (radical lap hysterectomy) AAGL Classification of Laparoscopic Hysterectomy American Association of Gynecologic Laparoscopists (AAGL) classification of laparoscopic hysterectomy is shown in Table 3. TABLE 3: Laparoscopic hysterectomy classification according to American Association of Gynecologic Laparoscopists. Type 0 Laparoscopic-directed preparation for vaginal hysterectomy Type I* Dissection up to but not including uterine arteries Type IΑ IΑ + anterior structures Type IC IΑ + posterior culdotomy Type ID¶ Type II* Ovarian artery pedicle(s) only Type IΒ¶ IΑ + anterior structures and posterior culdotomy Type I + uterine artery occlusion and division, unilateral or bilateral Type IIΑ Ovarian artery(ies) and uterine artery(ies) occlusion and division only ¶ Type IIΒ IIΑ + posterior culdotomy Type IID¶ Type III* IIΑ + anterior structures Type IIC IIΑ + anterior structures and posterior culdotomy Type II + portion of cardinal-uterosacral ligament complex only, unilateral or bilateral Type IIIΑ Type IIIΒ¶ IIIΑ + anterior structures Type IIIC IIIΑ + posterior culdotomy Type IIID¶ Type IV* Uterine and ovarian artery pedicles with portion of the cardinal-uterosacral complex only, unilateral or bilateral IIIΑ + anterior structures and posterior culdotomy Type II + total cardinal-uterosacral ligament complex, unilateral or bilateral Type IVΑ Uterine and ovarian artery pedicles with complete detachment of the total cardinal-uterosacral ligament complex only, unilateral or bilateral Type IVΒ¶ IVΑ + anterior structures Type IVC IVΑ + posterior culdotomy ¶ Type IVD IVΑ + anterior structures and posterior culdotomy Type IVE Laparoscopically directed removal of entire uterus (AAGL: American Association of Gynecologic Laparoscopists) The system describes the portion of the procedure completed laparoscopically. *A suffix "o" may be added if unilateral or bilateral oophorectomy is performed concomitantly (e.g., type IoA). ¶ The B and D subgroups may be further subclassified according to the degree of dissection involving the bladder and whether an anterior culdotomy is created: (1) incision of vesicouterine peritoneum only, (2) dissection of any portion of bladder from cervix, and (3) creation of an anterior culdotomy.
LAPAROSCOPIC-ASSISTED VAGINAL HYSTERECTOMY Laparoscopically-assisted vaginal hysterectomy is one of the most frequently performed gynecologic operations, and numerous authors have demonstrated its safety and feasibility. A laparoscopic-assisted vaginal hysterectomy is a type 3 Garry and Reich hysterectomy in which the adnexal pedicles of the round ligament, fallopian tube, and ovarian ligament are released abdominally through laparoscopic approach while the uterine artery and vein are secured through the vaginal approach. Further dissection of the broad ligament anteriorly to free the bladder from the uterovesical fold is done laparoscopically. A 2 cm posterior colpotomy in between the uterosacral ligaments at the base of the pouch of Douglas is also done laparoscopically. This dissection allows completion of the surgery vaginally with ease. side of the body of patient. One more assistant is required between the legs to handle uterine manipulator. The patient should ideally get general anesthesia with endotracheal intubation. A Foley catheter should be inserted to provide bladder drainage throughout the operation. Port Position A 10-mm umbilical port for camera should be along the inferior crease. Two 5-mm ports should be placed at 5 cm away from umbilicus on either side. Sometime, accessory port at right or left iliac region may be required according to need. Port position should be in accordance with baseball diamond concept. If the left side of tube has to be operated, one port should be in right iliac fossa and another below left iliac fossa (Fig. 5). Operative Technique Preoperative Measures Patients are evaluated same way as that of any major surgery. Routine preoperative tests include a complete blood count with differential, serum electrolyte, bleeding time, and urinalysis. More comprehensive blood studies include thrombin time, partial thrombin time, ECG, chest X-ray, and endometrial biopsy. Mechanical and antibiotic bowel preparation is advised. Peglec powder 1 sachet with water a night prior to surgery is advised. It is important throughout the procedure to be able to manipulate the uterus for optimal observation. Patient Position Patient should be in steep Trendelenburg and lithotomy position. One assistant should remain between the legs of patient to do uterine manipulation whenever required (Figs. 3A and B). Position of Surgical Team (Fig. 4) Surgeon stand left to the patient, camera assistant should be left to the surgeon. Second assistant should be the opposite A Fig. 4: Surgical team position in laparoscopically-assisted vaginal hysterectomy. B Figs. 3A and B: Pervaginal examination should be routine. Fig. 5: Port position for laparoscopically-assisted vaginal hysterectomy. 433
SECTION 3: Laparoscopic Gynecological Procedures A B Figs. 6A and B: Laparoscopically-assisted vaginal hysterectomy using bipolar. A B Figs. 7A and B: Successive desiccation and dissection. Different types of uterine manipulators are available. Depending on the laparoscopic procedure, digital examination, probes, and sponge stick applicators are used in the cul-de-sac for identification of structures during laparoscopy. The direction and location of both ureters should be identified as much as possible (Figs. 6A and B). With the patient in lithotomy position, after the pneumoperitoneum insufflated to a pressure of 12–14 mm Hg, three ports should be introduced. The 10 mm optical umbilical trocar, 5 mm in lateral border of the right rectus abdominis in right iliac fossa, 5 mm in the same position on the left side for the Ligasure forceps. The ureters were visualized transperitoneally. If adnexectomy is planned, following electrodesiccation and cutting of the round ligaments 2–3 cm from the uterus, then infundibulopelvic ligament is desiccated and cut, taking progressive bites of tissue starting at pelvic brim and moving towards the round ligament. It is important to avoid the coagulation of the round ligament near the uterus because of higher bleeding (Figs. 6A and B). In order to preserve the adnexa, the coagulation and section is performed proximal to the fallopian tubes and the utero-ovarian ligament. The dissection continues posteriorly on the broad ligament, taking care not to cut the uterine pedicle’s vessels (Figs. 7A and B). The anterior leaf of the broad ligament is opened towards the vesicouterine fold and bladder flap is developed. The anterior leaf of the broad ligament is grasped with forceps, elevated and dissected from the anterior lower uterine segment. The utero-ovarian ligament, proximal tube, and mesosalpinx are progressively dissected and cut and posterior leaf of the broad ligament is opened. Similarly, the round ligament, fallopian tube, and utero-ovarian ligament are grasped closed to their insertion into the uterus then secured with the bipolar, Ligasure, or harmonic scalpel and cut. The distal end of the energized instruments must be kept free of the bladder and ureter (Fig. 8). The uterovesical junction is identified, grasped, and elevated with forceps while being cut with scissors. The bladder pillars are identified desiccated and cut. The bladder can be completely freed from the uterus by pushing downward with the tip of a blunt probe along the vesicocervical plane until the anterior cul-de-sac is exposed completely. In patients with severe anterior cul-de-sac
coagulated and dissected. Further descent of the uterus is gained, and the uterine pedicles are clamped, secured, cut and tied. The uterus is then delivered vaginally. Once the uterus is removed, the vaginal vault is closed to ensure support of the vault; the vaginal angles are attached to the uterosacral and cardinal ligaments with 2-0 vicryl. Any coexisting cystocele or rectocele is repaired. A very large fibroid uterus should be debulked by morcellation for removal vaginally. It can be combined with laparoscopic adnexal surgery, e.g., ovariectomy or adhesiolysis. Once the vaginal surgery is completed again laparoscopic inspection of the pelvis is done. Fig. 8: Dissection of bladder peritoneum. Total Laparoscopic Hysterectomy endometriosis, previous CS or adhesions, sharp dissection can be performed. Injecting 5 mL of indigo carmine in the patient’s bladder helps to detect bladder trauma (Figs. 9 and 10). Colpotomy A folded gauze in sponge forceps is used to mark the fornix. The vaginal wall is tented and transacted horizontally with hook electrode (Figs. 11A to C). Once the dissection is extended to the lower uterine segment or to the level of cardinal ligament, laparoscopic procedure is temporarily terminated and vaginal part of LAVH started. VAGINAL PART OF LAPAROSCOPICASSISTED VAGINAL HYSTERECTOMY The sponge forceps occluding the colpotomy is withdrawn together with the uterine manipulator. Three vaginal specula are used to get proper access for vaginal part of LAVH (Figs. 12A to D). With aid of appropriate-sized speculum and adequate lateral and anterior retraction by the assistant, the anterior and posterior lips of the cervix are held by tenaculum. Using monopolar energy in circumcision of the skin at 2.5 cm above the external os towards the vaginal vault is done. Further dissection with gloved finger or dissecting scissors creates a flap in which the superior Sims speculum or narrow angled retractor is placed to lift the bladder away. Gradual release of the tissues results in entry to the abdominal cavity (Figs. 13A to H). Using appropriate-sized caucus clamp, the uterosacral pedicles are identified bilaterally clamped, secured, cut, and tied with the tail of the thread left as mark or coagulated with Ligasure, harmonic scalpel, or bipolar instrument specially made for vaginal hysterectomy (Figs. 12A to D). With release of the uterosacral, the uterus descends into the vaginal cavity. Similarly, the cardinal ligaments are bilaterally clamped, secured, cut, and tied with a mark or Preparation and Positioning of Patient Preoperative check of consent form and patient past medical history should be taken followed by proper preanesthetic checkup (PAC). Patients is placed in a dorsal lithotomy position. The arms are tucked at the sides and a foam mattress is situated directly under the patient to prevent sliding during steep Trendelenburg. Gynecologist should keep the table in a low position and have a monitor directly facing each surgeon to promote an ergonomic working environment (Fig. 14). Abdominal Entry and Trocar Placement A 10-mm supraumbilical skin incision is made using a #15 blade and insert a Veress needle is introduced into the peritoneal cavity. Once intraperitoneal pressure has reached 15 mm Hg, insert trocar through the supraumbilical incision, 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. These secondary trocar position varies according to the size of uterus. Usually, a 5-mm trocar is placed on the right and a 5-mm trocar on the left. For TLH port position can be ipsilateral or contralateral. Two ports on the left greatly facilitate suturing and help to maintain an ergonomic position for the surgeon throughout the procedure (Figs. 15A and B). Insertion of a Uterine Manipulator Different types of uterine manipulators are available. Generally, most of the gynecologists use the RUMI® or Mangeshkar Uterine Manipulator; however, in patients with a very narrow introitus the VCare® Uterine Manipulator is useful because this is easier to insert (Fig. 16). 435
SECTION 3: Laparoscopic Gynecological Procedures Fig. 9: Opening of anterior and posterior leaf broad ligament. A Fig. 10: Separation of bladder. B C Figs. 11A to C: Steps of colpotomy. A B C D Figs. 12A to D: Anterior and posterior colpotomy.
A B C D E F G H Figs. 13A to H: Successive clamping and desiccation of uterine pedicle through the vaginal route using bipolar. 437
SECTION 3: Laparoscopic Gynecological Procedures Dissection of Infundibulopelvic Ligament The infundibulopelvic (IP) ligament or the utero-ovarian ligament is initially desiccated with a reusable bipolar grasper, Ligasure, or harmonic scalpel. It is important to stay close to the ovary as this helps to avoid the pelvic sidewall during ovarian removal and the ascending uterine vessel during ovarian conservation. The gynecologists 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 transacted close to the ovary. During this step of the procedure, the uterine manipulator is being pushed upward and to the contralateral side to provide maximal visualization (Fig. 17). Mobilization of the Bladder Transect the round ligament and separate the anterior and posterior leaves of the broad ligament with the harmonic scalpel or monopolar scissors. It is important to find the correct plane; this is where the peritoneum separates easily with gentle manipulation. After peritoneal separation, identify the vesicouterine peritoneal fold and continue the dissection 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 section, this area may be scarred and it is important to stay relatively high on the uterus during the dissection. In case of adhesion a pledget dissection combined with sharp dissection with cold scissors is helpful. 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 (Fig. 18). Securing the Uterine Vessels Uterine artery course is diverse and due to a wide variety in anatomy and in the course of the uterine vessels, it is helpful to initially skeletonize them with the harmonic scalpel. Then desiccate the ascending uterine vessels with the bipolar grasper or Ligasure at the level of internal cervical os. 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 and tissue color turns brown the vessel is desiccated and safe to transect with the harmonic scalpel or Ligasure. It is important to take the uterine vessels high and then dissect medially to the uterine vessels down to the cup of colpotomizer. This averts ureteral injury and provides a healthy vascular pedicle that can be safely desiccated further in the event of bleeding (Figs. 19A and B). Colpotomy Fig. 14: Position of the patient for total laparoscopic hysterectomy. A After dissection of uterine pedicle the next step is to identify the vaginal fornices while pushing cephalad with the uterine manipulator. Gynecologist will 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 B Figs. 15A and B: Abdominal entry and trocar placement.
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