Laparascopic Hysterectomy, technical aspect


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This my presentation in Bali, October 2010

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  • Good afternoon ladies & Gentl I know some of you have already met me before but for those who have not my name is Hariyono Winarto, I am a gynecologist oncologist work for University of Indonesia in ciptomangunkusumo Hospital Today my talk is about laparascopic hysterectomy
  • The aim is to review and share the technical aspect of laparascopic hysterectomy So that participants understand basic things of important steps in lap hysterec.
  • My talk will be divided in 4 parts.... My talk will last about 30 minutes incl. 10 minutes video clips in between During my talk it is not necessary to take notes because I will then give you the internet address of my blogger. if you have any question I’d be glad if you could keep it until the end of the session, we will have the discussion then. OK Lets start now
  • The selection just like laparatomy Is big uterine size a matter? The answer is “No” At present it become clear that what limit the selection is the skill and the experiences of the surgeon him or herself. There are some tricks we talk it later in this talk
  • The setting of operating teams: operator is on the left or number 1 the 1st assistant is on the right of the patient helping the operator The 2nd assistant or number 3 is controlling the uterine manipulator to help exposuring the operating field for the operator. Number 6 are monitors for every member of the team, which are put facing operator, 1st and 2nd assistant
  • This 2 pictures describe how we put and manage the patient in op table (1st is the arm, 2nd is the Bladder.....) - Put 2 arms alongside the body - avoid brachial plexus injury - better ergonomics for surgeon and assistant. - bladder catheter is inserted, to expose enough op field;- ideally the buttocks are placed outside the table; tip of patient’s coccyx resting on the table to facilitate uterine manipulation;- both legs are half-bent for manipulation purposes;- patient draped: operative field include the vaginal route (surgeon should be able to manipulate the uterus without any septic risks). ---------------------------------------------- The operating table equipped with leg holders for stretching of legs, should be lowered as much as possible (about 25 cm in comparison with the height used in conventional surgery).The low position of the table is required by the raising of the abdominal wall induced by the pneumoperitoneum and Trendelenburg position, combined with the external length of instruments.1. Monitor to the patient’s right foot2. Monitor to the patient’s left foot3. Monitors: one for the surgeon, a second for the 1st assistant and for the 2nd assistant, each assistant in the vision axis.4. Leg holders A correct positioning of the patient on the operating table will allow easy access to the operative field. Extension of the legs helps to access the anterior pelvic area. 45° flexion of the legs allows better access to the posterior pelvic area and promontorium by changing the angle of the lumbar lordosis. Careful positioning of the coccyx at the edge of the table will prevent the patient from slipping upwards while in Trendelenburg position. It allows satisfactory uterine mobilisation.Now the exposure properly speaking. Firstly the patient is placed in Trendelenburg position with a tilt up to 30°.
  • 1. the right picture describe the trocars position for small / normal size uterus. Camera..., 2 lateral low ports, 1 middle lower ports..the minimal distance between symphysis and umbilicus is 30 cm, and between camera to supra pubic puncture should be at least 8 cm, these are to guaranty the ergonomic movements of the devices and also the trocars 2. On the left picture describe the trocars position for large uterus/ small op. field 3. if the size above the navel/ umbilicus
  • Uterine manipulator: to manipulate uterus position for exposing different faces of uterusColpotomizer: to expose the fornix/ vaginal wall Both uterine manipulator and colpotomizer in laparascopic hysterectomy are very good in exposing the vaginal fornix, to identify the location of the ureter Some surgeons only need vaginal tube, and combine the control of the uterus from above Some do not use at all, 100% controlling the uterus from inside the abdomen cavity
  • Orientation and exposure are really important
  • Cutting of the left round ligament:The 2nd assistant helps positioning the uterus to the right 1st assistant grasps the left round ligament at its corneal origin and does counter-traction rightwards and cranially. The cutting of the left round ligament not to close to uterus, not to medial keeps away from the adnexal vein, limiting the risks of bleeding. ------------------------------------- Occasionally there is a small artery running posterior to the ligament may be noted. (A triangle is formed, bordered by the round ligament cranially, by the iliac vessels laterally, and by the adnexal vein medially. Tension on the left round ligament exposes the central portion of the triangle made of the 2 juxtaposed anterior and posterior peritoneal layers of the broad ligament. This area becomes gray because of CO2 and the presence of an empty space beneath the posterior layer of the broad ligament)
  • After the round ligament has been divided, the vesicouterine space is opened. 1st assistant: tracts the stump of round ligament caudally 2nd assistant: push the uterine manipulator cranially The surgeon uses the tip of the instrument dissected and passed underneath the anterior peritoneal layer to lift it up. Close contact must be kept as it aids in dissecting the vesicouterine space. ---------------------------------------------- The anterior leaflet of the broad ligament is progressively cauterized medially paying attention not to injure the bladder. Peritoneal capillaries are also cauterized. Once the posterior attachments of the anterior leaflet of the broad ligament have been freed, the anterior leaflet is divided using either the cold blade of scissors or monopolar cautery. Such dissection should be discontinued about 1 cm from the midline.
  • Windows of the right and left broad ligaments is created by blunt or sharp or electric dissection. The window is made on the posterior leaf of broad ligament, by holding and pulling the adnexa cephalic, then pushing the thin layer, but be careful of the big vein laterally, that looks like free posteriorly, especially in adhesive case
  • The adnexal cutting are easy after windows are made. Just hold the ovary or tube or the tissue surround these structure and push medio-cephalic, and cut in between the ovary and uterus if to be preserved or in IP ligaments. For an ideal cauterization, it is preferable to set the power to 35 Watts and increase exposure times. The linear graspers are highly indicated. A blue cartridge of stapler closed equal to 1.5 mm could be used. The grasper is ideally introduced through a 12 mm trocar situated centrally and upwards.
  • 2nd assistant push the uterus cephalic. Surgeon grasp the bladder forming fold and showing the inferior edge of the bladder (about 1 cm from the junction bladder-uterine isthmus). Then it is grasped by the first assistant, with an atraumatic forceps; and tented upwards, showing the dissection plane. Cutting is performed in a plane perpendicular to the uterus while the uterus is pushed upwards by the 2nd assistant to avoid any bladder injury. The 2 internal bladder pillars (vesicouterine ligaments) are cauterized and divided. This maneuver contributes to place the ureters distally. They run laterally to the internal bladder pillars.
  • After cutting adnexa, uterine pedicles is more exposed. The operator dissect posterior part of uterine pedicle, with the help of 1st assistant grasps the stump of the left round ligament and lifts it medially. 2nd assistant push uterus cephalad and to the right. Posterior dissection is continued towards the uterosacral ligament The uterosacral ligament is then cut According to Wattiez the uterine artery is visualized, after vaginal fornix freed from the cardinal ligament posteriorly. After that surgeon progresses towards the uterine pedicle anteriorly, 1st assistant still pull anterior medially, 2nd assistant control the uterine manipulator so that the uterus anteflexed ===================================principles in avoiding ureteral injuries:- uterine vessels dissected anteriorly, laterally, and posteriorly;- cauterization on the ascending uterine artery;- cauterization time as limited as possible. Short and repeated cauterization should be preferred to lengthy cauterizations;- cauterization induces tissue resistance to electric currents, and division should be performed to remove such tissue; cauterization should be carried out on non-cauterized tissue.
  • At the level of its ascending branch the uterine pedicle is fully grasped by the surgeon’s bipolar forceps Left uterine pedicle grasp by bipolar which is put through the left lateral port and the other way around The pedicle is progressively divided. Veins of the periarterial uterine plexus are perfectly cauterized, and the artery is cauterized and divided. Dissect further anteriorly and posteriorly in order to lower the pedicle just beneath the margin of the vaginal fornix. The remaining elements of the cardinal ligament are cauterized and divided at this stage. The same technique is performed for the right pedicle. Other technique ligature-division:ligatures or clip application. Clip application requires dissection of the artery on all its aspects. -------------------------------------------------------- For the safety of the ureter, the uterine pedicle should be clearly identified. The pedicle should be divided with a right angle at the level of its ascending portion, hence reducing any ureteral damage. The surgeon keep a control on the activation pedal.
  • - The principle is to cut right above the internal OS, it’s should be precisely determined anatomically - The cutting it self could be with or without colpotomizer, the colpotomizer will exposure the area where we should cut (Koh colp, Donnez colp, Clemont Ferrant valve or McCartney vag. tube) - The vagina should be opened over 360° by the surgeon. The more the vagina is opened, the more the 2nd assistant loses control of the uterus with the cannula. Theoretically it is easier to start at the posterior surface of the uterus. The 2nd assistant performs anteversion combined with anteflexion of the uterus. The posterior fornix forms a bulge, which is easy to open using monopolar cautery via the left trocar. Monopolar cautery is used to safely divide the anterior, left lateral, and posterior portions of the fornix.
  • There are two routes: vaginal route or laparoscopically. a glove filled up with packs or water is placed in the vagina to maintain the pneumoperitoneum. This picture describe the laparascopy route of suturingIt is critical to completely transfix the vagina for complete hemostasis. There are several way in suturing, Wattiez and Koh make it in 2 layer, first the inner layer without taking the fascia and 2 the outer layer, including transfixing the stump of sacrouterine ligaments vaginal closure, a polyglactin suture 0 or 1.0 mounted on a curved 30 mm needle is used.
  • 1. Cutting the Round Lig. 2. Developing the vesico-uterine space 3. Making window on posterior leaf of broad lig 4. Adnexal cutting 5. Bladder dissection 6. Uterine art. preparation 7. Cutting the uterine art. 8. Dividing the vagina 9. Closing the vagina
  • This is an intracorporeal suturing, it needs your time at least 1-2 hour a day to accelerate your learning curve
  • In supracervical hysterectomy The cervix is amputated approximately on the level or slightly below the internal cervical ostium. It is still at some point of the superior part of sacro-uterine ligaments.
  • This is the amputation in supracervical laparascopic hysterectomy, you could see it is not to low and need accuracy
  • The process of taking out the uterus in supracervical laparascopic hysterectomy with morcellator takes time
  • Laparascopic Hysterectomy, technical aspect

    1. 1. Laparascopic hysterectomy <ul><li>Hariyono Winarto </li></ul><ul><li>Faculty of Medicine University of Indonesia Gynecologic Oncology Division </li></ul>
    2. 2. Aim of this talk <ul><li>REVIEWING the technical aspects of laparascopic hysterectomy </li></ul>Participants understand basic things of: “ Important Steps in laparascopic hysterectomy”
    3. 3. 4 parts <ul><li>Preparation </li></ul><ul><li>Technique </li></ul><ul><li>Video clips of some steps </li></ul><ul><li>supracervical hysterectomy </li></ul>
    4. 4. Patient selection <ul><li>Basically the same as laparatomy </li></ul><ul><li>Size? </li></ul>Depend on the surgeon/operator
    5. 5. <ul><li>Surgeon </li></ul><ul><li>First assistant </li></ul><ul><li>second assistant </li></ul><ul><li>Scrub nurse </li></ul><ul><li>Op Table </li></ul><ul><li>Video screen </li></ul>Preparation : position of team & monitor 5 6 6 6 I control the uterine manipulator
    6. 6. Preparation : positioning patient <ul><li>Arms </li></ul><ul><li>Bladder </li></ul><ul><li>Coccyx’s tip </li></ul><ul><li>Draped incl. the vagina </li></ul>Head
    7. 7. Trocars placement 5/10 5/10 C C Small/normal size Large uterus/small op. field Larger Uterus and/or scar C
    8. 8. uterine manipulator? colpotomizer? Uterine artery Ureter
    9. 9. 4 parts <ul><li>Preparation </li></ul><ul><li>Technique </li></ul><ul><li>Video clips of some steps </li></ul><ul><li>Supravaginal hysterectomy </li></ul>
    10. 10. Orientation and exposure
    11. 11. Division of round lig’s
    12. 12. Opening vesico-uterine space
    13. 13. Windows making
    14. 14. Adnexal cutting
    15. 15. Bladder dissection
    16. 16. Uterine artery preparation
    17. 17. Uterine artery cutting
    18. 18. Opening and division of vagina
    19. 19. Closure of the vagina
    20. 20. Summary of the steps in TLH
    21. 21. 4 parts <ul><li>Preparation </li></ul><ul><li>Technique </li></ul><ul><li>Video clips of some steps </li></ul><ul><li>Supravaginal hysterectomy </li></ul>
    22. 22. Video Clip of some important steps (Source: Hariyono Winarto)
    23. 23. The suturing in TLH <ul><li>Source: </li></ul><ul><li>OBGYNnet | April 17, 2008 </li></ul><ul><li>This Surgery is performed by Dr. Koh of the Milwaukee Institute of Minimally Invasive Surgery </li></ul>
    24. 24. 4 parts <ul><li>Preparation </li></ul><ul><li>Technique </li></ul><ul><li>Video clips of some steps </li></ul><ul><li>supracervical hysterectomy </li></ul>
    25. 25. Laparascopic supracervical hysterectomy
    26. 26. Supracervical amputation in laparascopy
    27. 27. Removal of the uterus by morcelator takes time...
    28. 28. Summary <ul><li>patient selection is not different from laparatomy </li></ul><ul><li>Size is depend on the operator </li></ul><ul><li>Ports should be based on the size of uterus </li></ul><ul><li>The steps of TLH basically is not different from TAH (laparascopy is one of the technical approach) </li></ul><ul><li>Supracervical technique does not need a meticulous uterine a. preparation as TLH but need the accuracy of cutting supracervically, and morcelating takes time.... </li></ul>