Total Laparoscopic

Hysterectomy
Andrew Doering
Minimally Invasive Surgery Lab
University of Kentucky
Patient Presentation
• A patient in need of a Total Laparoscopic
Hysterectomy may present with symptoms
such as abdominal pain and abnormal uterine
bleeding
• Possible causes of these symptoms include
Fibroid Uterus, Adenomyosis, Endometrial
Polyps, Endometrial Hyperplasia, Endometrial
Cancer, and Endometriosis
Alternative Treatments
• Non-surgical management includes hormonal
therapy and NSAIDs
• A Dilatation & Curettage and Endometrial
ablation can be performed if the patient does
not want a hysterectomy
Advantages of the
Laparoscopic Technique
• A hysterectomy can be completed through
open, vaginal, and laparoscopic approaches
• Total laparoscopic hysterectomies and vaginal
hysterectomies have been found to result in
decreased blood loss, shorter hospital and
recovery periods, and fewer abdominal wall
infections than open hysterectomies
• The contraindications for a vaginal
hysterectomy include prior abdominal surgery,
long and narrow vagina, and endometriosis.
Female Pelvic Anatomy
• The uterus is located posterior and rostral to
the bladder, typically in an anteverted position
• The broad ligament of the uterus is composed
of an anterior and posterior leaf and connects
the sides of the uterus to the pelvic cavity
• The ureters enter the pelvic cavity by crossing
anterior to the iliac vessels
• Within the pelvic cavity, the ureters travel
within the cardinal ligament beneath the
uterine arteries to reach the bladder
Female Pelvic Anatomy
Female Pelvic Anatomy
Patient Positioning
• The patient is placed in Trendelenburg position
in order to give the surgeon better access to the
pelvic organs
• The patient’s arms are secured against their
body
• The patient’s legs are bent and placed in
stirrups using caution to prevent compression
on the lateral calf and thus peroneal nerve
damage
Operating Room Set Up
• The anesthesiologist is located at the patient’s
head
• The surgeon stands on the left side of the
patient.
• There are assistants to the right of the patient
and between the patient’s legs.
• The scrub nurse is located to the left of the
patient near the surgeon
• Monitors are placed around the room so that
each member of the operating team has a direct
view of the video feed
Operating Room Set Up
Trocar Placement
• A Total Laparoscopic Hysterectomy typically uses
three 11 mm trocars and an optional fourth 11 mm
trocar.
1) The optical trocar is placed at the umbilicus.
2) Two operating trocars are placed lateral and
inferior to the optical trocar within the oblique
muscles.
3) A fourth operating trocar may be placed in the
midline, inferior to optical trocar. This trocar
allows for the placement of a bowel retractor
which may be needed in obese patients who
can not tolerate steep Trendelenburg
positioning.
Trocar Placement
Instruments
• 0° laparoscope
• Uterine manipulator with colpotomy ring
• 3-4 11 mm trocars
• Insufflator
• Harmonic Scalpel
• Grasping Forceps
• Endostitch Suturing Device
• Lapra Ty’s
Pelvic Cavity Prior to
Surgery
Procedure Outline
1) Dissection of the Utero-Ovarian Ligaments
and Fallopian Tubes (left 9:00, right 15:00)
2) Dissection of the Round Ligament (left 10:00,
right 16:50)
3) Dissection of the Anterior Leaf of the Broad
Ligament and the Endopelvic Fascia (17:30)
4) Dissection of Cardinal Ligaments (left 29:30,
right 37:00)
5) Separation of the Uterus from the Vagina
(46:15)
6) Removal of the Uterus and closure of the
Vaginal Cuff (1:03:30)
Utero-Ovarian Ligament and
Fallopian Tube Dissection
• The Utero-Ovarian Ligament and Fallopian
Tube are bilaterally dissected with the
Harmonic Scalpel during the same step
• The dissection is carried out along the medial
border of the ovary in order to prevent damage
to the uterine veins
• The uterine manipulator is used to push the
uterus upward and to the contralateral side
Fallopian Tube Dissection
Round Ligament Dissection
• The Round Ligament of the Uterus is
bilaterally transected with the Harmonic
Scalpel
• The uterine manipulator is used to push the
uterus upward and to the contralateral side
Round Ligament Dissection
Broad Ligament Dissection
• The Broad Ligament is dissected with the
Harmonic Scalpel in order to mobilize the
bladder off of the anterior wall of the uterus
• This dissection is carried out in the plane
between the Anterior and Posterior Leaves of
the Broad Ligament
• Care must be taken to avoid damage to the
bladder during this step
• Adipose tissue indicates the location of the
bladder and should not be dissected
Broad Ligament Dissection
Cardinal Ligament Dissection
• The Cardinal Ligament is initially coagulated
medially in order to control back bleeding from
the Uterine Artery
• The Cardinal Ligament is dissected with the
Harmonic Scalpel along the border of the
uterus with each cut being more medial than
the next. This is done to prevent damage to the
ureters
• The uterine manipulator is used to push the
uterus to the contralateral side
Cardinal Ligament Dissection
Separation of the Uterus and
Vagina
• At this point in the procedure, the uterus
should have a whitish appearance due to lack
of blood supply
• The Uterus is separated from the Vagina by
cutting along the colpotomy ring with the
Harmonic Scalpel
• The Harmonic Scalpel is used as a blade in this
step
• After complete separation, the uterus is
removed through the vagina
Separation of the Uterus and
Vagina
Closure of the Vaginal Cuff
• The Vaginal Cuff is closed with the Endostitch
Suturing Device and Lapra Ty’s
• Irrigation is performed after closure of the
Vaginal Cuff to check for bleeding
Closure of Vaginal Cuff
Pelvic Cavity After Surgery
Complications
• Injuries may occur during a Total Laparoscopic
Hysterectomy at two points:
1) During trocar placement
2) During dissection of the ligaments
attaching the Uterus to the Pelvic Cavity
Complications (continued)
• During placement of the optical trocar, the
surgeon must be aware of and avoid the Aorta
and Vena Cava which are deep to the
umbilicus. This is more of a concern with thin
patients.
• During placement of the operating trocars, the
surgeon must be aware of and avoid the
Inferior Epigastric Arteries.
Complications (continued)
• Within the Pelvic cavity, the surgeon must be
aware of three structures:
1) Colon – is located posterior to the uterus
and may be perforated by the surgical
instruments
2) Bladder – is located anterior to the uterus
and may be damaged during mobilization.
A fistula may form between the bladder
and vagina if it is not completely
mobilized off of the uterus
3) Ureters – most often damaged during
dissection of the cardinal ligaments and at
the pelvic brim
Post Operative Care
• Patients typically go home the day of the
surgery or the following morning
• Patients are told to rest and relax
• Patients normally resume their normal
activities 2 – 3 weeks after the surgery