TASK ANALYSIS FOR TOTAL LAPARASCOPIC HYSTERECTOMY
DR MOKOMBA ALFRED
The first hysterectomy was done in 1843 by Charles clay in Manchester England. The first laparoscopic hysterectomy was done in 1988 by Reich. Hysterectomy is among the most common surgeries done in women outside pregnancy in the United States.
Among the indications for TLH are:
1. Abnormal uterine bleeding especially menorrhagia
2. Uterine fibroids
3. Endometriosis
4. Uterine size greater than 12 weeks
5. Endometrial malignancy.
TASK ANALYSIS
1.PREOPERATIVE PREPARATION
2.SURGICAL STEPS
3.INTRAOPERATIVE
4.PNEUMOPERITONEUM
5.PORTS PLACEMENT
6.SURGICAL STEPS
PRE-OPRATIVE PREPARATION
1) Patient clerkship and physical examination.
2) Review all investigations, ultrasound, MRI, pap smear, complete blood count, urea creatinine and electrolytes
3) Informed consent from patient.
4)Laxatives two days preoperatively
5) Surgical safety checklist
INTRAOPERATIVELY
• Prophylactic antibiotics on induction
• General anaesthesia
• Patient in Trendelenburg position
• Abdominal shaving
• Speculum exam
• Tenaculum application to cervix
• Monitors in position 15 to surgeon’s eye axis surgeon on left assistant on the right
• Second assistant between the legs,
• Ensure all cables in order
6.pneumoperitoneum
Introduce Verres needle and carbon dioxide gas to pressures of 15 mmhg, flow of 25 l /min
7. Ports placement
Depends on size of uterus.
The laparoscope is placed at umbilicus or palmers point. For a large uterus midpoint between xiphisternum and umbilicus.11mm trochar
Accessory ports are placed at least 7.5 cm from central trocar lateral to umbilicus. Trocar size 7.5mm
Eye instrument axis must be maintained. the target is the uterine vessels
8.The uterine manipulator
Allows mobilization of uterus (lateral, retroversion anteversion, on axis rotation).
Visualization of vaginal cuff and sealing.
9. division of round ligament and broad ligament
Coagulation and division of round ligament, open vesicouterine space and dissection of bladder. Coagulate round ligament at centre between two posterior and anterior broad ligaments.
Dissection of bladder by blunt dissection.
The broad ligaments are fenestrated on the right and left.
10.division of adnexa
The opening is extended towards uterosacral ligament, and suspensory ligament of ovary. The adnexa are coagulated and divided where it merges with the uterus by bipolar coagulations followed by division.
11.Uterine vessels.
Posterior dissection, uterus is pushed upwards and to the right
The posterior peritoneum is and base of parametrium, then toward cardinal and uterosacral ligaments. The peritoneum is divided, the cardinal ligament is coagulated and cut, releasing arch of the artery, the uterosacral is sectioned in turn, the ureter is now visible .the uterine artery is coagulated taking care not to injure bladder. The uterine can be tied with surgeons extracorporeal Mishra knot ligatures
12.opening and division of vagina
The uterine manipulator can be turned 360 degrees, the cylinder is advanced to the into vagina, the vagina is opened all round with monopolar hook starting from anterior vaginal wall.
13.extraction of uterus and closure
Extraction via colpotomy, assistant draws uterus into vagina.
If it is large it can be morcellated.
Closure is carried out with vicryl0 or 1 the vagina is transfixed completely to produce complete haemostasis.
14. A final lavage completes the surgery, followed by closure of the ports
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