Laparoscopic hysterectomy is an alternative to
abdominal hysterectomy. Different techniques are described and
illustrated. Most hysterectomies by laparotomy can be avoided by
using the laparoscopic approach including cases of adhesions,
adnexal masses and endometriosis. According to the status and the
experience of the surgeon the time to perform the laparoscopic
surgery can be reduced. There are many advantages from
laparoscopic hysterectomy for the patient including the length of
hospital stay and convalescence.
HISTORY
The first laparoscopic hysterectomy (LH) was performed in January
1988 by Harry Reich in Pennsylvania (1) and the first LH in
Switzerland was by our team in Lausanne in 1990 (2). There has
been a great increase in interest following the introducation of
LH but most surgeons now perform laparoscopically assisted vaginal
hysterectomy (LAVH). This new procedure was designed to be an
alternative to abdominal hysterectomy and not vaginal
hysterectomy.
INDICATIONS
The indications for laparoscopic hysterectomy are similar to the
generally accepted indications for hysterectomy. In our centre (LEC)
the main indication is abnormal uterine bleeding which we define
as bleeding for over 7 days with clots and the need to wear
additional protection for more than 2 cycles. Abnormal uterine
bleeding includes all the usual causes such as adenomyosis,
fibroids, endometriosis and also patients suffering from bleeding
diastesis.
Prior to surgery the usual investigations must be performed and
medical conditions such as infection, hormonal disease, etc
evaluated. Evidence of anemia should be demonstrated and an
indication for endometrectomy excluded. The conditions when
endometrectomy is a viable alernative to hysterectomy include a
normal sized uterus with a regular cavity which is less than 10 cm
in length in a patient over 40 years old.
The specific indication for LH is when vaginal hysterectomy is not
feasible because of, for instance, a history of previous surgery,
adhésions, endometriosis, adnexal masses, a narrow vaginal space
in a nulliparous woman, narrow subpubic arch and difficult vaginal
exposure.
If the surgeon has limited experience in vaginal surgery that,
too, may be an indication for laparoscopically assisted surgery.
Reich considers that LH is also suitable for Stage I cervical and
ovarian cancer (6,7,8) and laparoscopy may also be used following
reconstructive surgery involving the vaginal cuff and repair of
rectocele after vaginal hysterectomy. Other indications include
endometrial carcinoma with pelvic lymphadenectomy and severe
endometriosis with extensive involvement of the cul-de-sac. Great
surgical skill is required to remove all the endometriotic nodules
before hysterectomy otherwise remnants of endometriosis can
persist and make subsequent surgery difficult.
CONTRAINDICATIONS
Contraindications include postpartum hysterectomy and adnexal
masses which cannot be removed with an endobag. The size of the
uterus and access to it also limit the scope of the procedure
depending on the experience of the surgeon.
PREOPERATIVE MANAGEMENT
When the uterus is over 12 weeks in size or when there are
multiple large fibroids gonadotrophin releasing hormone (GnRH)
analogues may be given. The administration of analogues for 2-3
months reduces the size of the uterus and myoma thus making
surgery easier(9,10). During treatment anaemia can be corrected
and if necessary autologous transfusion given.
Pubic hair need not be shaved and perineo-vulval hair only cut if
excessive. Bowel preparation should be considered if difficult
surgery is anticipated.
POSITIONING OF THE PATIENT
All laparoscopic surgery is performed under general anaesthesia
with endotracheal intubation. The use of a naso-gastric tube
avoids trocar injury to the stomach and reduces bowel distension.
The patient is placed in the dorso-lithotomy position, with the
legs supported by stirrups and adjusted to permit mobilization of
the uterus by the nurse or the assistant surgeon. The vaginal
surgical box including wall retractors is prepared.
POSITIONING OF THE OPERATING STAFF
The position of the medical staff is demonstrated in figure 1
where the surgeon is on the left side of the patient, the first
assistant stands on the right side and holds the camera. There
should be two monitors to allow staff on either side of the table
to follow the operation. The surgeon has both hands free for
surgery. The nurse is between the patient's legs and has the
double role of scrub nurse and uterine manipulator.
INSTRUMENTS
There should be an electronic high flow CO2 insufflation apparatus
which gives a minimum flow of 9 l/minute. This is necessary to
compensate for the loss of CO2 and to maintain a constant pressure
which should be just below 15 mmHg during the whole operation
despite colpotomy and suction.
We try to avoid disposable cannulae and instruments. However a 5
mm cannula with a retention screw grid (Apple Medical, Bolton MA)
is used to facilitate extra-corporeal suturing with a knot pusher.
The Kleppinger bipolar forceps is used for haemostasis of large
vessels including the uterine artery. The knot pusher is used for
suturing pedicles. The other instruments are those for standard
laparoscopy.
A single prophylactic dose of antibiotics is given intravenously.
In patients with previous caesarean section, the bladder is
emptied and 50 ml of Methylene blue instilled to better recognise
any bladder injury during the surgery. The patient is laid flat
during umbilical trocar insertion and then placed in a 30 degree
Trendelenburg tilt.
It is important to cannulate the uterus. Several devices are now
available which mobilize the uterus in every direction. Some also
act as vaginal plugs to prevent gas deflation. If a mobilizer is
not available, a 15 cm Simm's curette may be used instead. A
sponge may be used to demarcate the cul-de-sac and assist the
anterior and posterior vaginal incisions. In cases of severe
endometriosis, a rectal probe is also used to identify and
mobillize the rectum.
LAVH may be performed through 3 incisions: one 10-12 mm umbilical
incision and two 5 mm lateral incisions. If there has been
previous lower abdominal surgery either open laparoscopy is
performed or the Veress needle insertion is in the left ninth
intercostal space because adhesions are very rare in that area.
The lower trocar sleeves are inserted under laparoscopic vision
lateral to the rectus abdominis muscles to avoid deep epigastric
vessels and 2cm medial to the anterior superior iliac spine.
In cases with no additional lesion such as adhesions,
endometriosis or ovarian cysts, the hysterectomy is started with
bipolar coagulation (Fig. 1) of the round ligament and section
with monopolar scissors. The anterior leaf of the broad ligament
is then opened while the nurse pushes the uterus into
retro-version (Fig.2). Next the posterior leaf of broad ligament
is opened (Fig. 3) to permit the utero-ovarian ligament and tubes
to be defined. This is also performed with bipolar coagulation and
monopolar scissors (Fig 4 - 5) and is followed by dissection of
the broad ligament. The uterus is pushed towards the opposite side
by the nurse using the uterine cannula or by traction with the
toothed forceps by the assistant. The uterine vessels are
isolated, the peritoneum of the utero-vesical pouch is opened with
monopolar scissors and the bladder is pushed downwards (Fig. 6).
The surgeon completes the procedure with a standard vaginal
hysterectomy.
2. Total Laparoscopic Hysterectomy (TLH)
The early stages of total laparoscopic hysterectomy are performed
in the same way as LAVH. When the broad ligament has been
dissected the surgeon ties the uterine pedicle with a 0 Vicryl
using a knot pusher. The procedure is shown in figure 7 where the
needle is being inserted round the uterine vessels. Figure 8 shows
the absorbable suture being brought outside the abdomen through
the 5 mm cannula after cutting and parking the needle in the
peritoneum. The knot is tied using the knot pusher. Figure 9 shows
the internal view and figure 10 the external view. The uterine
vessels should be ligated in two places and the vessels incised
with scissors between the knots.
Haemostasis of the uterine vessels may also be achieved with
bipolar forceps (Fig. 11) using intermittent small applications of
electric energy to the end-point of cessation of flow thus
avoiding excessive heating of the ureters. It is essential at all
times to be aware of the position of the ureters and to ensure
that all haemostatic procedures are carried out at a distance from
them. Elevation of the uterus allows the ureters to separate
further from the uterus.
Intra-fascial hysterectomy is continued by the same bipolar
forceps and monopolar scissors, coagulating the cervico-vaginal
vessels and opening the vagina. The anterior and posterior vaginal
walls are incised with monopolar scissors (Fig. 12) and
haemostatis is completed by bipolar coagulation (Fig. 13). After
uterine extraction (Fig. 14) laparoscopic or vaginal suturing may
be performed (Fig. 15).
At the completion of the hysterectomy, the intraperitoneal CO2
pressure should be reduced to allow bleeding points to be
recognised. The pelvis is not reperitonized nor is drainage
necessary.
Alternative methods of achieving haemostasis have been used. These
include haemostatic clips (Fig 16) but they have the disadvantage
of springing open when the uterus is displaced. Automatic stapling
is popular with some surgeons. These devices consist of two jaws
each containing a triple row of micro-titanium staples which
produce haemostatis and peritonisation and a knife which passes
between the jaws to incise the tissues (11). This is faster than
other procedures but is also very expensive. However, in cases of
large varicosities in the broad ligament, we still use staples to
divide the round and the broad ligaments.
ALTERNATIVE TECHNIQUES Subtotal hysterectomy
Subtotal hysterectomy is being performed more frequently when the
cervix is healthy and the vault well supported. The uterus is
cannulated with a Simm's curette covered by a Foley catheter. This
allows the cervix to be cut electrically with no transmission of
energy along the curette.
The upper part of the broad ligament is opened as in LAVH (Fig 23)
and after opening the peritoneum of the utero-vesical pouch the
ascending branches of the uterine artery are coagulated with
bipolar forceps. The peritoneum over the uterosacral ligaments is
opened (Fig 24) and the cervix cut with monopolar scissors (Fig.
25). The final cut of the cervix is around the curette covered by
the Foley catheter (Fig. 26). A posterior colpotomy is then
performed with monopolar scissors after pushing up the posterior
fornix with the the vaginal extractor which includes a 10 cm
forceps to remove the uterus (Fig. 27-28). Alternatively the
uterus may be removed through a 10 mm abdominal cannula after
morcellation. The cervix is then closed and the peritoneum sutured
with O suture (Figure 29-30).
ADDITIONAL SURGERY
1. Adhesiolysis
The commonest indication for laparoscopic assistance to
hysterectomy is the presence of adhesions due to previous surgery
or pelvic inflammatory disease. Adhesiolysis must be performed
before starting the hysterectomy. In cases of adnexal masses,
adnexectomy must be performed with bipolar or automatic stapling
(while identifying the ureter) and stretching the adnexa
sufficiently far away from the ureter to ensure its safety.
2. Excision of Endometriosis
Complete removal of endometriosis must be performed before
hysterectomy because the presence of the uterus facilitates the
dissection between rectum and bladder.
3. Ovariectomy
Ovariectomy can be performed routinely during hysterectomy in
women over 45 years old, or for benign ovarian lesions before that
age. Ovariectomy may also be indicated when there is ovarian
pathology or when there is little residual ovarian tissue
remaining after ovarian cystectomy for endometriosis or teratoma.
The main problems faced in ovariectomy are avoidance of spillage
and extraction of the specimen. The 5 mm abdominal incisions are
the same as for hysterectomy. The contralateral cannula is used
for forceps which apply traction on the ovary pulling it away from
the pelvic side wall and the ureter. The ipsilateral cannula
carries bipolar forceps to coagulate the infundibulo-pelvic
ligament. Coagulation and scissor dissection are used alternately
to divide the ligament. The incision should be as close as
possible to the ovary to avoid injury to the identified ureter.
The utero-ovarian ligament is then coagulated and divided in the
same manner or the procedure may be accomplished with an automatic
stapling device. An Endobag is then passed through a 12 mm cannula
on the contra-lateral side. The ovarian cyst is then placed in the
bag and deflated by syringe and needle or, alternatively, the
incision may be enlarged with scissors to allow extraction of the
endobag without spillage of the cyst contents. Closure of the 12
mm fascia incision is performed in layers to prevent herniation
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