Task Analysis of Total Laparoscopic Hysterectomy

DR VELPULA SRI LAKSHMI [ MS OBGY, F.MAS, D.MAS]

DEFINITION :

It is a minimal surgical procedure were nonprolapsed uterus is removed through vaginal route.it is a type 5 in GARRY AND REICH classification 

INDICATIONS :

AUB
Adenomyosis
Fibroid uterus
Endometriosis
Endometrial malignancy
Uterine size more than 12 wks

CONTRAINDICATIONS:

Severe COPD or cardiac disease
Generalized peritonitis
Previous extensive abdominal surgery
Hypercoagulable states 
Huge cervical or broad ligament myoma

PREOP PREPARATION:

1. Informed consent from the patient.
2. Laxative Dulcolax 2 tabs night before surgery and clear liquids one day before surgery.
3. The patient should be given general anesthesia and bladder catheterization done.
4.Patient in lithotomy positions
5.The surgeon on the left side, one assistant on the right side to hold the camera and second assistant in between legs for uterine manipulator
6. Monitor on the opposite side of the surgeon so that the center of the monitor, target of dissection, the eye of the surgeon should be in the same line ie, coaxial alignment.
7. The height of the table should be 0.49 cm× height of surgeon in cms, so that handle of instrument is at the level of the elbow.
8. The distance of the monitor from the eye should be five times the diagonal length of the screen as an image will come on to macula.

PROCEDURE:

 9. Check the veress needle for its spring action and patency.
10. Take 2allis forceps to evert and hold on either side of the umbilicus.
11. Use the number 11 blade to place a small horizontal stab wound on the inferior crease of umbilicus.
12. Mosquito artery to dissect subcutaneous adipose tissue and expose rectus sheath.
13. Measure abdominal wall thickness and add 4cm for distance to hold veress needle.
14. Veress needle should be held like a dart.
15. Lift suprapubic part of the abdominal wall with the left hand.                 
16. Insert veress needle in stab incision with 45-degree elevation angle, and distal end pointed towards anus and perpendicular to the abdominal wall.
17. The surgeon can hear two click sounds and maintain the 45-degree angle.
18.Confirm correct veress needle placement by irrigation test, aspiration test, and hanging drop test.
19.Connect the carbon dioxide gas tube to the veress needle.
20.Check quadromanometry for intraperitoneal placement of veress needle.
21.Check uniform distension of the abdomen and obliteration of liver dullness.
22.Pneumoperitoneum is created with veress needle with preset pressure of 12-15mmhg and a set flow rate of 1- 2.5lit/min at the inferior crease of umbilicus.
23.After the actual flow rate becomes 0, actual pressure equals preset pressure then removes the veress needle. 
24.Take a cannula of 10mm and mark its impression on the skin.
25.Extend incision to the size of the cannula impression.
26.Introduce a 10mm port by holding it like a piston, perpendicular to the abdomen.
27.Confirm intraabdominal placement of port by escaping air sound and audible click.
28.Put the main optical 10mm port in the inferior crease of the umbilicus, and after entering into the abdominal cavity, set the flow rate between 6-10 lit/min.
29.Patient in Trendelenburg position.
30.Put two ipsilateral accessory ports, 1st ipsilateral 10mm port is 7.5cm below and lateral to the optical port.
31.Second ipsilateral 5mm port is 7.5cm below and lateral to the first accessory port
32.If the uterus is greater than 8wks follow the baseball diamond concept of port placement using the supraumbilical port and one extra accessory contralateral port placement.
33.Put Mangeshkar uterine manipulator, so that mobilization of the uterus is easy
34Can use infrared ureteric stenting so that the entire ureter will glow to avoid injury.
35.Use ligasure or bipolar cautery with scissors for pedicles.
36.First, keeping the uterine manipulator at 9*clock position coagulate and cut right round ligament 4cm lateral to the uterus, coagulate and cut right fallopian tube mesosalpinx 3cm lateral to the uterus, coagulate cut right ovarian ligament mesovarium 2cm lateral to the uterus.
37.Keeping uterine manipulator at 3*clock position coagulate cut the left round ligament 4cm lateral to the uterus, coagulate and cut left fallopian tube, mesosalpinx 3cm lateral to the uterus, coagulate cut left ovarian ligament mesovarium 2cm lateral to the uterus.
38.Do bilateral symmetrical to have more flexibility, so that first do upper bilateral adnexa.
39.Keep uterine manipulator at 5*clock position and stretch anterior left peritoneum with a left-hand atraumatic grasper and cut with scissors, hook or harmonic with a right hand and open an anterior leaf of the broad ligament, and push peritoneum as lateral as possible.
40.Uterine manipulator at 6*clock position and separate anterior UV fold.
41.Uterine manipulator at 7*clock position and stretch anterior right peritoneum with a left-hand atraumatic grasper and cut with scissors, hook or harmonic with the right hand and open an anterior leaf of the broad ligament, and push peritoneum as lateral as possible.
42.Again come back to 6*clock position with the uterine manipulator, with the help of pledget or 3×4cms gauge four folded hide in reducer to separate bladder from anterior vaginal wall till you see pearl white cervical fascia with longitudinal blood vessels.
43.The bladder can be pushed down with the help of suction irrigation cannula by blunt dissection. 
44.Keeping a light cable at 6*clock position and uterine manipulator 1,12,11* clock and again to 12*clock position separate posterior peritoneum and reach up to cervical part of uterosacral ligaments.
45.Keeping uterine manipulator at 3,9*clock position coagulate cut left and right uterine artery with mackendrots.
46.With active tip end of harmonic or with hook do colpotomy and cut vagina with in-ring of full circle colpotomiser, coagulate and cut as near to cervix, one half of colpotomy is done from one side and another half from another side.
47. Coagulate and cut 2cm above uterosacral ligaments.
48.Never touch the vaginal part of the uterosacral.
49.Uterus with the cervix is free of all its supports.
50.Pull uterus with cervix by tenaculum of the manipulator by making up down right and left movements.
51.Glove packed with a cotton pad is used to pack the vagina to prevent a gas leak.
52.Bilateral salpingo-oophorectomy was done by giving anteromedial traction and take a specimen out from vault.
53.Vault closed in full-thickness, including vaginal epithelium with a square knot or Dundee jamming knot with Aberdeen termination.
54.Take 5mm accessory ports under vision.
55.Close 10mm ports with veress needle or port closure needle after desufflation.