Beast TLH

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TLH with simple instrument

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Beast TLH

  1. 1. TOTAL LAPAROSCOPIC HYSTERECTOMY TECHNIQUE TO SIMPLIFIED DR MEHUL V SUKHADIYA DIRECTOR, RADHE ENDOSCOPIC CENTER, GUJARAT
  2. 2. Technique to simplify TLH <ul><li>Hysterectomy is one of the MC performed surgical procedures . </li></ul><ul><li>Despite the advent of these minimally invasive procedures, abdominal hysterectomy remains the most common surgical approach, </li></ul><ul><li>Vaginal and laparoscopic hysterectomies vs TAH </li></ul><ul><li>decreased blood loss , </li></ul><ul><li>shorter hospital stay , </li></ul><ul><li>speedier return to normal activities, and </li></ul><ul><li>fewer abdominal wall infections </li></ul><ul><li>when compared with The vaginal approach is less expensive, </li></ul><ul><li>but </li></ul><ul><li>challenging in pts with a H/O an adnexal mass, endometriosis, pelvic pain, and prior abdominal surgery, or in patients with a narrow pubic arch or poor vaginal descent and big sized uterus. </li></ul>Dr Mehul V. Sukhadiya
  3. 3. Technique to simplify TLH <ul><li>Why not laparoscopic hysterectomy </li></ul><ul><li>The relatively slow adaptation of laparoscopic hysterectomy may in part be attributed to </li></ul><ul><li>-inadequate exposure and </li></ul><ul><li>-training during residency </li></ul><ul><li>LAVH make things more complicate then simple. </li></ul><ul><li>Idea of need of expensive instruments. </li></ul><ul><li>Change society the trends towards the laparoscopic surgery. </li></ul>Dr Mehul V. Sukhadiya
  4. 4. Technique to simplify TLH <ul><li>What </li></ul><ul><li>we need for a </li></ul><ul><li>good </li></ul><ul><li>laparoscopic surgery </li></ul>Dr Mehul V. Sukhadiya
  5. 5. Technique to simplify TLH <ul><li>Basic Knowledge </li></ul><ul><li>Good equipped OT set up. </li></ul><ul><li>Good team. </li></ul><ul><li>And all together help to </li></ul><ul><li>4 . Simplify The Technique </li></ul>Dr Mehul V. Sukhadiya
  6. 6. Dr. Mehul V. Sukhadiya TEAM WORK Skilled Surgeon Expert Anesthetist Trained Assistants Experienced Nursing staff Technique to simplify TLH
  7. 7. Technique to simplify TLH <ul><li>Ten Steps Towards Technique To Simplify The TLH </li></ul><ul><li>Preparation and positioning </li></ul><ul><li>Insertion of uterine manipulator </li></ul><ul><li>Abdominal entry and trocar placement </li></ul><ul><li>Dissection of attachment of uterus </li></ul><ul><li>Mobilization of Bladder and dissection of posterior peritoneum </li></ul><ul><li>Secure the uterine artery </li></ul><ul><li>Separate the cervix from the vagina to form the vault </li></ul><ul><li>Remove the uterus and adenexal tissue </li></ul><ul><li>Suturing of vault and </li></ul><ul><li>Suturing of ports. </li></ul>Dr Mehul V. Sukhadiya
  8. 8. Technique to simplify TLH <ul><li>Preparation of patient </li></ul><ul><ul><li>Proper selection patient </li></ul></ul><ul><ul><li>Pre-cardiac and preanesthetic check-up </li></ul></ul><ul><ul><li>Bowel preparation </li></ul></ul><ul><li>Preparation of OT </li></ul><ul><ul><li>Check the OT trolley </li></ul></ul><ul><ul><li>Light source </li></ul></ul><ul><ul><li>CO 2 source </li></ul></ul><ul><ul><li>Cautery or Harmonic </li></ul></ul><ul><ul><li>Suction and irrigation system </li></ul></ul><ul><ul><li>Recording system: Most important for self evaluation & legal aspect </li></ul></ul><ul><li>Anesthesia: </li></ul><ul><li>Position of patient: </li></ul><ul><ul><li>Dorsal lithotomy position </li></ul></ul><ul><ul><li>Hand underneath buttock to prevent slip out during steep Trendelenburg . </li></ul></ul><ul><ul><li>Keep the table in a low position & </li></ul></ul><ul><ul><li>Monitor directly facing to surgeon to promote an helping working environment </li></ul></ul>Dr Mehul V. Sukhadiya 1.Preparation and positioning
  9. 9. Technique to simplify TLH <ul><li>Manipulators </li></ul><ul><ul><li>RUMI Uterine Manipulator </li></ul></ul><ul><ul><li>VCare Uterine Manipulator </li></ul></ul><ul><ul><li>Elevator (ConMed Endosurgery, Utica, NY) </li></ul></ul><ul><ul><li>SUKHADIYA MANIPULATOR </li></ul></ul><ul><ul><ul><li>Cheap </li></ul></ul></ul><ul><ul><ul><li>Easily available </li></ul></ul></ul><ul><ul><ul><li>Very easy to use </li></ul></ul></ul><ul><ul><ul><li>Additional rotational movement </li></ul></ul></ul><ul><ul><ul><li>Helpful in minimising use of instruments during Dissection </li></ul></ul></ul><ul><ul><ul><li>Helpful in bladder dissection </li></ul></ul></ul><ul><ul><ul><li>Helpful during separation cervix from vagina </li></ul></ul></ul><ul><li>Procedure of insertion of manipulator: </li></ul><ul><li>---Important step for the further step </li></ul>Dr Mehul V. Sukhadiya 2. Insertion of uterine manipulator .
  10. 10. Technique to simplify TLH <ul><li>Entry the abdomen </li></ul><ul><li>Primary port only blind procedure during laparoscopy </li></ul><ul><li>closed method vs open method </li></ul><ul><li>negative pressure in insufflators – intra-peritoneal </li></ul><ul><li>intra peritoneal pressure of 12mmHg </li></ul><ul><li>First inspection should done underneath structures of entry side. </li></ul><ul><li>Secondary ports site ( depend on size of uterus ) </li></ul><ul><li>Under vision </li></ul>Dr Mehul V. Sukhadiya 3. Abdominal entry and trocar placement .
  11. 11. Technique to simplify TLH <ul><li>The infundibulopelvic ligament(IP) or the ovarian ligament is initially desiccated with a reusable bipolar cautery. </li></ul><ul><li>to stay close to the ovary as this helps to avoid the pelvic sidewall during ovarian removal & ascending uterine vessel during ovarian dissection. </li></ul><ul><li>take special care to dissect 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 . </li></ul><ul><li>The IP ligament or utero-ovarian ligament is then transected close to the ovary using the scissor or Harmonic Scalpel </li></ul><ul><li>Position of manipulator helpful in maximum visualization and proper traction of IP ligament that helpful in dissection of fallopian tube, round ligament, IP ligament & broad ligament by the help of only bipolar and scissor or bipolar and harmonic scissor. </li></ul>Dr Mehul V. Sukhadiya 4. Dissection of attachments of uterus
  12. 12. Technique to simplify TLH <ul><li>separate the anterior and posterior leaves of the broad ligament . </li></ul><ul><li>Posterior leave separate up to medial to Utero-sacral ligament. </li></ul><ul><li>It is important to find the correct plane ; this is where the peritoneum separates easily with gentle manipulation </li></ul><ul><li>identify the vesico-uterine peritoneal fold and continue the dissection anteriorly, thereby mobilizing the bladder off the lower uterine segment. </li></ul><ul><li>prior cesarean delivery, this area may be scarred and it is important to stay relatively high on the uterus during the dissection. </li></ul><ul><li>if fat is encountered a reevaluation of the route of dissection is advised because the fat belongs to the bladder; this may indicate that the dissection is moving too close to the bladder </li></ul>Dr Mehul V. Sukhadiya 5.Mobilization of Bladder & dissection of posterior peritoneum.
  13. 13. Technique to simplify TLH <ul><li>Due to a wide variety in anatomy & in the course of the uterine vessels, we find it helpful to initially skeletonized them. </li></ul><ul><li>Note that pushing cephalad with the uterine manipulator helps to move the uterine vessels away from the ureter. </li></ul><ul><li>then desiccate the ascending uterine vessels with the bipolar cautery at the level of internal cervical os. </li></ul><ul><li>Complete desiccation of the vessels can be assessed visually by observing the bubbles coming and going during this process; when the bubbles stop forming its indicate that vessel is desiccated. </li></ul><ul><li>safe to transect with the scissor or Harmonic scalpel. </li></ul><ul><li>uterine artery should not be desiccate before separation of bladder. </li></ul><ul><li>It is important to take the uterine vessels high and then dissect medially to the uterine vessels down to the cup. </li></ul><ul><li>This averts ureteral injury and provides a healthy vascular pedicle that can be safely desiccated further in the event of bleeding. </li></ul>Dr Mehul V. Sukhadiya 6. Secure the uterine artery.
  14. 14. Technique to simplify TLH <ul><li>Identify the vaginal fornices while pushing Plunger of the uterine manipulator. </li></ul><ul><li>Identified the Plunger of the manipulator around vaginal cuff. </li></ul><ul><li>Superficial bipolar cauterization over the vault </li></ul><ul><li>Make incision over the vault by use of mono-polar energy or harmonic scalpel up to visualization of plunger. </li></ul><ul><li>Then make full dissection on the edge of plunger by help of bipolar and mono polar or bipolar and scissor or harmonic scaple. </li></ul>Dr Mehul V. Sukhadiya 7.Separate the cervix from the vagina .
  15. 15. Technique to simplify TLH <ul><li>Pull the uterus into the vagina & same time pushing the vault inward with fingers so that to avoid the vault injury. </li></ul><ul><li>The uterus can remain there to maintain pneumo-peritoneum during suturing. </li></ul><ul><li>If the uterus is too large to removed through the vagina, it can be removed carefully by morcellator. </li></ul><ul><li>It is important to keep the tip of the morcellator in clear view at all times. </li></ul>Dr Mehul V. Sukhadiya 8.Remove the uterus and adenexal tissue
  16. 16. Technique to simplify TLH Dr Mehul V. Sukhadiya 9.Suturing of vault
  17. 17. Technique to simplify TLH Dr Mehul V. Sukhadiya 10.Suturing of Ports
  18. 18. Technique to simplify TLH <ul><li>10 steps </li></ul><ul><li>illustrated above are not inevitable to be an absolute truth, </li></ul><ul><li>but </li></ul><ul><li>somewhat a true and tested method </li></ul><ul><li>that has served us well to </li></ul><ul><li>safely accomplish this procedure. </li></ul>Dr Mehul V. Sukhadiya
  19. 19. <ul><li>Are great things ever done smoothly? </li></ul><ul><li>Time, </li></ul><ul><li>patience, and </li></ul><ul><li>determined will must show </li></ul>
  20. 20. Technique to simplify TLH <ul><li>Take Home Message </li></ul><ul><li>Slow but steady start attitude towards laparoscopic surgery </li></ul><ul><li>Initially consider simple cases </li></ul><ul><li>Make the team competent as is a team work </li></ul><ul><li>Clam and quite during surgery </li></ul><ul><li>Follow the every steps systematically to simplify TLH </li></ul><ul><li>Take lesson from every surgery by reviewing recorded system repeatedly. </li></ul>Dr Mehul V. Sukhadiya
  21. 21. Technique to simplified TLH Dr Mehul V. Sukhadiya Thank you jai Swaminarayan
  22. 22. Technique to simplified TLH Dr Mehul V. Sukhadiya

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