Right up until recently, most gynecologists have shied from carrying out total laparoscopic hysterectomy (TLH) due to the technical challenges and prolonged operating times which are related to it. Instead, they have preferred to do laparoscopically assisted vaginal hysterectomy (LAVH), a comparatively inefficient three-part technique made up of a preliminary laparoscopic phase, then a vaginal phase, and, finally, another laparoscopic phase.
Now it is believed that it has the possibility being the method of choice for any great proportion of hysterectomy cases, specifically in those situations - for example once the pubic angle is narrow, the vagina small, or the uterus high and immobile - in which LAVH includes a reduced chance of success. Simultaneously, however, it is realized that wider adoption of TLH would depend about the growth and development of new tools to facilitate the colpotomy part of the operation, and on the development of a simplified technique that could reduce complications and operative time period.
Operative technique
Posture the individual in a laparoscopic lithotomy position, with aseptic prepping and draping. After dilating the cervix to Hegar 8, Surgeon should sound the uterus to measure its length, and then pick a uterine manipulator less than or add up to the space sounded. If the uterine length falls between tip sizes, choose the smaller-sized tip. A longer tip will hit the uterine fundus, and may perforate.
Colpotomizer selection comes next, and it is a vital the main procedure. A poorly fitting Colpotomizer can undermine the prospects for a successfully completed operation. Gynecologist really should choose the appropriate Colpotomizer by visually comparing the cervix to the Colpotomizer, that can come in small, medium, and large sizes. The Colpotomizer selected must cover the whole cervix. If it's too big, it'll pull the ureters toward the colpotomy incision.
After connecting the uterine manipulator, Fit the pneumo-occluder within the tip and shaft from the Uterine manipulator after which fit the Colpotomizer over the tip. Using lateral or lower and upper vaginal refractors, place a tenaculum on the anterior cervix and pull it down. Next, apply surgical jelly to the tip of uterine manipulator and insert it within the cervical os. The posterior retractor is now removed, along with the interior one. Using the labia spread apart by an assistant, the tip is inserted into the uterus and the cup placed in the vagina. The presence of lower and upper refractors at this point cuts down on the space available for introduction from the Colpotomizer. At this time, while releasing the first tenaculum, introduce a second tenaculum through the fenestration of the cup to trap the cervix and push the uterine manipulator tip further to the uterus to interact the cup around the cervix and from the fornix by pushing the uterine manipulator cephalad, with counter-traction provided by the 2nd tenaculum. Because the cervix was already dilated, this part of the procedure proceeds without problems. In patients having a more enjoyable vagina, it may be possible to depart one retractor in the vagina during this procedure for introduction, vut usually it is better to possess no retractors.
By rotating the grip of the Uterine Manipulator counter clockwise to retroflex the uterus after which pushing the instrument cephalad, the rim from the uterine manipulator becomes easily visible and indicates the region of loose uterovesical peritoneum in which the incision to reflect the bladder will begin. Inflate the uterine balloon with 5 cc of water, after which insert a three-way Foley catheter for bladder drainage. Later on, Gynaecologist can use the catheter to fill the bladder with dilute methylene blue to indicate its position and confirm that it's intact. Finally, inflate the pneumo-occluder with 60 to 100 cc of saline.
Total Laparoscopic Hysterectomy TLH, Step by Step
As well as the 10-mm umbilical port, most of the gynecologists use three secondary 5-mm ports. The instruments includes reusable graspers, bipolar forceps, scissors, a needle holder, and a unipolar hook electrode. To ensure that surgeon have placed the colpotomy system correctly, one should ante flex and retroflex the uterine manipulator tip and palpate the rim from the cup with a grasper, visually identifying the bulge. Gynaecologist then begin operative laparoscopy. One should first desiccate the tubo-ovarian pedicle with bipolar forceps and divide it. Then desiccate and divide the round ligament, and open the parametrium bilaterally. To focus on the anterior fornix, push the cup up firmly. In the level of the fornix, incise the uterovesical peritoneum and dissect the bladder down to expose 1 cm to two cm of the anterior vagina. If done correctly, this will not produce bleeding. Then incise the anterior fornix, using the unipolar hook electrode at 90 watts of unmodulated current. Entry into the vagina is confirmed by visualizing the cup. Next, extend the incision laterally, stopping lacking the uterine vessels, which are desiccated in a later stage of the operation. Bipolar dissection helps to control cuff bleeders. It's of utmost importance to force the uterine manipulator strongly cephalad at this point, stretching the vagina and thus distancing the incision in the ureter. After retroverting the uterus and pushing the colpotomizer against the uterine cervix, an anterior colpotomy is made within the rim of the device in TLH. The strain supplied by the colpotomizer allows a precise incision into the anterior fornix. This incision is extended laterally lacking the vagina on sides.
Next step in total laparoscopic hysterectomy, by revolving the handle of the uterine manipulator clockwise, anteflex the uterus acutely making the posterior colpotomy incision in the rim of the cup, sparing the majority of the uterosacral ligament where it inserts to the posterior fornix. Then move the uterine manipulator handle to reveal the right vaginal fornix and uterine vessels, even while maintaining good pressure on the uterine manipulator. Utilizing an ammeter to monitor tissue desiccation, coapt and desiccate the right uterine vessels above the cup rim. It is good always to check on to make sure that you have completely coapted and desiccated both uterine vein and artery. Then rotate the uterus to the right pelvis and proceed to coapt and desiccate the left uterine vessels. The distance between your section of desiccation and the ureter reaches least 2 cm. To produce even greater distance,
Gynecologist should push the cup up against the fornix, thereby lengthening the vagina and pushing the vessels upward. Using the unipolar hook or vibrating jaw of harmonic, you are able to divide now the already dessicated uterine vessels. You should also divide the lateral vaginal fornix on the right and left sides to complete the colpotomy incision. During this critical stage from the operation, pneumoperitoneum is maintained through the pneumo-occluder. As a result, the anatomy is clearly visible, and hemostasis is unhurried and thorough. Once main operative work is completed, deflate the pneumo-occluder and gently pull the uterine manipulator handle to provide the uterus into the vagina. The uterus may be left within the vagina to maintain pneumoperitoneum, or it may be removed. Subsequently replace and reinflate the pneumo-occluder within the vagina.
It is must to shut the vagina by continuous or interrupted suture of the vault in TLH, using PDS on endoski needle or by three interrupted mattress sutures incorporating the vaginal angles and also the central vagina using 0-Vicryl. Gynecologist should close the vault laparoscopically, avoiding the bladder and ureter. As a substitute if you are not proficient with laparoscopic suturing, the vaginal cuff can be simply closed vaginally with a continuous suture. This can be a rapid, five-minute procedure; the good thing about it is that, because the uterosacral ligaments are not divided as a whole laparoscopic hysterectomy (TLH), you don't have to make a special effort to incorporate them. The large uterus is hard to elevate and maneuver. However, after uterine and ovarian pedicle vessels are desiccated, it is possible to morcellate a fibroid, thus allowing the manipulator to mobilize small uterine mass.
In the great majority of cases, TLH provides operating times during the to 75 to 1 hour 30 minutes. Using the growth and development of the surgical tools and simplified technique described above, the average gynecologist can also add to his / her armamentarium a secure, readily mastered, time-efficient hysterectomy technique that offers the chance of consistently good outcomes.
