Laparoscopic Assisted Vaginal Hysterectomy(LAVH)

SUMMARY DESCRIPTION OF PROCEDURE:

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 anterioly to free the bladder from the utero-vesical fold is done laparoscopically. A two centimeter posterior colpotomy in between the utero-sacral ligaments at the base of the pouch of douglas is also done laparoscopically. This dissection allows completion of the surgery vaginally with ease.

INDICATIONS:

The indications for laparoscopically assisted vaginal hysterectomy are:

Previous pelvic surgery

PRE-OPERATIVE CARE

Routine check list and physical examination for major surgery to rule out other co-morbidities
Full Blood Count, Urea and Electrolytes
ECG, Chest Xray, Echo and coagulation profile based on clinical assessment
Mandatory pre-anaesthetic review by anaesthiologist
Signed informed consent outlining details of procedure and possible complications
Bowel preparation with luxative on the night before surgery
I.V Ceftriaxone 1 gram stat to be given with induction of anaesthesia

DESCRIPTION OF PROCEDURE
 

SURGICAL TEAM

Lead Surgeon/ Team Leader: Gynaecologist with competency in laparoscopic surgery
Other members: Anaesthiologist, Two Assistant surgeons, Nurse or other doctor as camera man, Scrub nurse.

PATIENT POSITION

Patient is initially supine before introduction of telescope. The abdomen is cleaned, painted with betadined and draped in standard fashion. Thereafter, the patient is re-positioned to steep Trendelenburg's lithotomy position to direct the bowel way from the pelvis.

POSITION OF SURGICAL TEAM

After standard scrubbing and gowning, the Lead surgeon is positioned to the left of the patient, with camera man on the same side but slightly behind and to the right of the lead surgeon.

One assistant surgeon stands to the right side of patient, while the other assistant is positioned between the slightly abducted legs to handle the uterine manipulator. Two video monitors should be provided and coaxially aligned with the surgical team for better vision with less strain of the neck muscles.

PORT POSITION

Telescope is positioned at the umbilicus on the inferior crease through a 10mm incision. After introduction of the telescope with proper definition of the surgical site of interest through diagnostic laparoscopy, the position for two accessory 5mm ports is marked through trans-illumination following the base ball- diamond principle of port position. If the uterus is small, e.g fourteen weeks, with no adnexal pathology, the accessory ports will be in the right and left iliac fossae, about 7.5cms each from the umbilical port so as to give a manipulation angle of 60 degrees.
 
OPERATIVE TECHNIQUE UNDER GENERAL ANAESTHESIA
ABDOMINAL ENTRY

Closed access entry technique with Verres needle is described. The other techniques of open access e.g with Hasson’s trochar system may also be used.

CLOSED ACCESS ENTRY WITH VERRES NEEDLE

A 2mm stab incision is made on the inferior umbilical crease through which the Verresneddle is advanced held like a dart and pushed through the firmly held and lifted anterior abdominal wall at angulation of 90 degrees but with an elevation of 45 degrees till two clicks are felt.  After confirming correct placement, insufflation with medical CO2 is commenced with preset pressure of 15-18mmHg and flow rate of 1l/min. Once the preset pressure is achieved, the Verres needle is withdrawn and the umbilical incision increased to 11mm to facilitate placement of primary port.

The primary port is introduced by the lead surgeon holding the 10mm trochar and canulae like a pistol gun and advancing the instrument through serial screwing motions initially perpendicular to the anterior abdominal wall but later towards the anus at 60-70 degrees when giving way sensation is felt. Confirmation of correct trochar placement is by pressing on valve and feeling the hissing sound of gas escape.

With the 10mm port in the abdominal cavity, the trochar is removed and canulae advanced a little further and medical carbon dioxidegas insufflation connected. The preset pressure is adjusted to 12mmHg andcontinous monitoring of the insufflation through quadrimanometric monitor preferably with microprocessor maintained throughout the surgery.
The 30 degree 10mm telescope with adjusted focus and white balance is introduced for initial assessment.
 
ABDOMINAL INSPECTION

Evaluation starts from the area directly below the primary port where a trickle of blood may be seen. The adjacent bowel is assessed for injury. If no injury is noted, inspection of the whole abdomen is carried out systematically starting from the right paracolicgutter,looking at the appendix without touching and moving up the ascending colon to the right hypochondial area, where the liver and gall bladder are assessed for obvious pathology.

The telescope is moved to the stomach area,omentum and transverse colon and further on to the splenic area and descending colon plus left paracolic gutter. Any pathologies are noted and video recording done. The scope is brought down the pelvis and the sigmoid colon evaluated.

The assessment is completed by a thorough pelvic inspection of the uterus, bladder, ovaries, tubes, round ligament and infundibular pelvic ligament. Key anatomic land marks of the median, medial and lateral umbilical ligaments are noted. The triangles of doom, pain and disaster are appreciated. The external iliac artery and vein are seen. The course of the ureter with visible peristaltic motions tracking down the pelvic wall towards the ureteric tunnel is also noted.  Any endometriotic lesions are documented and mobility of the uterus noted by free manipulation by the second assistant working on the uterine manipulator. Areas of dense adhesions restricting free motion are observed especially cases of previous pelvic surgery, previous CS delivery and PID.

PLACEMENT OF ACCESSORY PORTS

Once the all the pathologies are clearly defined and surgical sites identified, accessory ports are placed to ease dissection following base ball-diamond principle for optimum ergonomics.

We describe port accessory port placement for a 14 week sized uterus in a patient with adenomyosis diagnosed on ultrasound.

No endometriotic or other adnexal pathology was found on inspection. Base-ball diamond principle is used
Two additional ports are made, one ipsilateral 5mm port in the left iliac fossa and 7.5cms from the primary port with a contralateral port at a similar distance. Both are introduced through 5mm stab incisions with trans-illumination of the anterior abdominal wall to visualize the inferior epigastric vessels and prevent vascular injury. The 5mm trochar and canulae are held like a pistol gun and advanced through the stab incisions at 90 degrees through screwing motions. When tenting of the peritoneum is noted on the video monitor, the angulation is adjusted with the trochar directed towards the hollow pelvis. Once the ports are safely in, dissection commences with appropriate instruments. Both monopolar and bipolar can be used. Other energy sources may be used based on availability and knowledge of handling.
We describe electrosurgical dissection with ligasureand harmonic scapel.

ELECTROSURGICAL DISSECTION WITH LIGASURE AND HARMONIC SCAPEL

The ipsilateral side

The atraumatic grasper is introduced through the contralateral 5mm port and advanced under direct vision towards the fundus of the uterus. Ligasure is introduced through the ipsilateral port.

The round ligament is held with atraumatic grasper near the uterus. With the assistant below providing traction through the uterine manipulator, the ligasure clamp is placed 3-4cms from uterine end of the round ligament. Under traction, the pedicle is ‘cooked’ and cut. The same is repeated for the fallopian tube and ovarian ligament. The ovarian ligament is clamped close to the ovary because its small size.

Contralateral side

Once all the adnexal pedicles arereleased, the instruments are changed with the ligasure moved to contralateral
The atraumatic grasper is also used to hold the pedicles one at a time and provide traction. Working together with manipulation of the uterus from below the task is repeated.

 After release of the pedicles, the ligasure is withdrawn and harmonic introduced under direct vision.
The dissection proceeds with opening of the broad ligament and freeing of bladder from the uterovesicalfold. To facilitate the uterus is pushed by assistant below using the manipulator to a retroverted position. The anterior lower uterine segment becomes clearly visible. The peritoneum is held up by the atraumatic grasper and the open jaw of the harmonicscapel completes the dissection until the bladder is adequately advanced.
Posterior colpotomy

With the uterus anterverted, a sponge holding forceps is pushed up the pouch of douglas by the assistant from below. Using the active blade of the harmonic or a monopolar hook, a small colpotomy of 2 cms is made in midline in between and 3 cms below the visible uterosacral ligaments. The sponge forceps wrapped in gauze is maintained in position to prevent gas leakage.

All the instruments are withdrawn under vision but ports left in place. The gas is released and insufflator tubingdisconnected from the primary port.

The laparoscopy surgery is halted temporarily and vaginal approach commenced.

VAGINAL PART

The sponge forceps occluding the colpotomy is withdrawn together with the uterine manipulator. With aid of appropriate size speculum and adequate lateral and anterior retraction by the assistant, the anterior and posterior lips of the cervix are held by tenuculum. Using monopolar energy in BLEND 1 circumcision of the skin at 2.5 cms 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 angledretractor is placed to lift the bladder away. Gradual release of the tissues results in entry to the abdominal cavity.

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. With release of the uterosacrals, the uterus descends into the vaginal cavity. Similarly the cardinal ligaments are bilaterally clamped, secured, cut and tied with a mark. Further descent of the uterus is gained and the uterine pedicles are clamped, secured, cut and tied with no mark.

The uterus is then delivered vaginally. Vault closure is carried out with vicyrl no1 incorporating the marked ends of the uterosacral and cardinal pedicles.  With no active bleeding noted, the vaginal part is now completed.

COMPLETION OF LAPAROSCOPY

The telescope is re-introduced into the abdomen through the primary port. Gas is reconnected and insufflation restarted.
Inspection of the vault is done any area of bleeding noted. If haemostasis is satisfactory warm saline lavage is done. The ureter is inspected for peristalsis and if present, the surgery is completed by removal of accessory ports under direct vision.

The gas is switched off and the pneumoperitoneum decompressed by opening of valves on the primary canulae port and mild pressure of the abdomen. When satisfactory decompression is achieved the telescope and primary port are removed safely under vision.

PORT CLOSURE

All ports more than 10mm should be closed in layers beginning with rectus to avoid risk of hernia formation.
In this case the primary port with introduced through the Scandinavian approach going through the obliterated vitello-intestinal duct.Skin closure withvicryl suture 3.0 was done and sterri strip skin dressing applied.

POST OP CARE

Patient is observed in recovery room for two hours before transfer back to the ward
Analgesics and anti-emetic given
Observation for 24 hours in the ward before discharge