View the surgical video: Laparoscopic Hysterectomy
Introduction
Laparoscopic hysterectomy (LH) is an optimum approach to the second most common surgical procedure in the United States.(1) There are close to 600,000 hysterectomies performed annually in the US, with the majority performed via the abdominal route.(2)
Admittance to a hospital for any type of procedure, especially for major surgery, is a foreboding experience for many. One way to alleviate the anxiety associated with such procedures is to ensure them a speedy recovery and less postoperative pain — all at the same cost of a conventional procedure. For women who require a hysterectomy, laparoscopic hysterectomy is an excellent option.
The American Association of Gynecologic Laparoscopy (AAGL) has established five types of laparoscopic hysterectomy.(3) Diagnostic laparoscopy (Type 0) is strictly used to survey the pelvis in preparation for a vaginal hysterectomy in women with a history of chronic pelvic pain, endometriosis, previous abdominal surgery, and those with questionable pelvic anatomy and pathology. Type I involves transection of the infundibulopelvic (IP) or uterovarian pedicles. Type II is the addition of ligating the uterine arteries after the steps of Type I. Type III continues where Type II stopped and includes some portion of the cardinal or uterosacral ligaments. Type IV is the complete ligation of the uterosacral ligaments with colpotomy or laparoscopic entry into the vagina.
Procedure
The basic equipment needed for any laparoscopic hysterectomy includes the following:
- Energy source for coagulation of pedicles,
- Laparoscopic graspers and scissors,
- suction-irrigator,
- uterine manipulator with colpotomizer,
- optional laparoscopic needle driver and knot pusher,
- myoma screw
The term “energy source” refers to instruments used for coagulating and cutting tissue and vessels. Bipolar forceps, Harmonic scalpel ACETM (Ethicon Endosurgery, Inc. Cincinnati, OH), LigasureTM (Valleylab, Boulder, CO), Plasma Kinetic Cutting Forceps (Gyrus ACMI, Maple Grove, MN), and EnSeal TM Laparoscopic Vessel Fusion System (SurgRx, Inc., Palo Alto, CA) are the most commonly used instruments for thermal occlusion in laparoscopy.
Uterine manipulators are vaginally placed instruments which move the uterus to various angles to aid in surgery (Figure 1). Manipulators may be as simple as a sponge stick (i.e. ring forceps holding a gauze) or as complex as a RUMI manipulator with the colpotomizer cup. The latter mentioned instrument involves a plastic or metal cone placed around the cervix. Water filled vaginal occluder balloons are used to create a seal around the cervix to prevent the loss of the pneumoperitoneum. The uterus is rotated in the desired position via the handle of the colpotomizer extending outside the vagina. The RUMI™ (Cooper Surgical, Shelton CT), Valvhev™ (Konkin Surgical Instruments Toronto Canada) and VCare™ (ConMed Corp Utica NY) are some of the highly marketed uterine manipulators.
The preoperative work-up for women undergoing a hysterectomy is similar to that for any major surgery. Pertinent medical history, physical exam, radiographic imaging, and laboratory studies are needed. Documentation of a normal pap smear is important in all women to ensure that further studies and other surgical procedures are not indicated. An endometrial biopsy is required to rule out uterine cancer in women undergoing laparoscopic supracervical hysterectomy and those with abnormal uterine bleeding.
Once the patient is properly positioned, prepped, and all necessary equipment is ready, surgery can begin by inserting the trocars. Proper trocar placement is essential to the fluidity of the case. A 10-mm umbilical incision is used for a 10-or 12-mm trocar that facilitates use of the laparoscope, endocatch bag, or possibly a morcellator. Three to four ancillary trocars are placed in the right and left upper and lower abdominal quadrants, about 8 to 10 cm from the umbilicus or midline, based on the objective of the case (Figure 2). In patients with previous abdominal surgery, or in difficult to insufflate obese patients, a 5-mm trocar can be placed in the left upper quadrant at the border of the rib cage to survey the abdomen to decrease the chance of organ injury during the placement of the umbilical trocar.(4)
Identification of the ureter is important in order to prevent injury. Starting at the pelvic brim is an easy way to locate the ureter crossing over the bifurcation of the common iliac vessels. Whether or not the ovaries are being preserved dictates the next step to occlude and transect the uterovarian or infundibulopelvic ligaments. Ligation can be achieved by using sutures and/or any of the above mentioned coagulating instruments. The tube and ovary are pulled medially with a grasper introduced from the contralateral port, while the coagulating instrument is introduced from the ipsilateral side. After the ovarian pedicles are resolved, ligation of the round ligament and creation of a vesicouterine or bladder flap is performed. The round ligaments are coagulated and transected in the middle portion of the ligament to avoid bleeding from the venous plexus running along the uterus. The bladder flap can be initiated from the transected round ligaments by establishing the vesicouterine tissue plane through the broad ligament. Further dissection of the bladder off the lower uterine segment and cervix is achieved via sharp and blunt dissection, utilizing traction and laparoscopic scissors, after joining the right and left tissue planes.
Once the bladder is sufficiently dissected, the uterine arteries are identified, skeletonized, occluded and transected. Prior to occlusion, the location of the ureter is once again checked to prevent injury. Adequate exposure of the uterine arteries is achieved by applying traction on the uterus from the contralateral grasper placed on the round ligament. The uterus is also pushed cephalad and tilted to the contralateral side by the uterine manipulator. Using any of the above mentioned vessel coagulating devices on the uterine arteries is efficient and reliable. Laparoscopic suturing can be used as well.
Once the uterine arteries have been transected, the opening of the vaginal cuff is executed via elevation of the vaginal cuff with a uterine manipulator or a more rudimentary device, such as a bulb suction controlled with ring forceps. Once the bladder is sufficiently down, the cervix is identified. The vaginal cuff incision can be made using monopolar electricity, bipolar spatula, or ultrasonic scalpel. At this point, reassurance of the location of the ablated uterine arteries and of the ureter is important to maintain hemostasis and prevent ureteral injury, respectively. To help maintain vaginal cuff support, the uterosacral ligaments are mostly kept intact. This is another advantage of total laparoscopic hysterectomy over the abdominal hysterectomy or vaginal hysterectomy, in which the uterosacral ligaments are transected lower on the cervix jeopardizing vaginal cuff support.
Once the uterus is completely detached, it can be removed by grasping it and pulling it through the vaginal cuff. Closure of the vaginal cuff can be done in a variety of ways. Intracorporeal and extracorporeal suturing can be used to complete a total laparoscopic hysterectomy (TLH) without entering the vagina. The cuff can be closed vaginally as well.
In a laparoscopic assisted vaginal hysterectomy (LAVH), the round ligaments and IP ligaments are taken laparoscopically, and the rest of the case is finished vaginally. In our practice, when performing an LAVH, we occlude and transect the uterine arteries laparoscopically, because of the advantage of visually ligating the vessels with a lesser chance of ureteral injury. We also perform extensive laparoscopic dissection of the bladder flap that will facilitate easier vaginal entry into the abdominal cavity. Once the laparoscopic dissection is completed, the rest of the hysterectomy is done vaginally. Attention is initially focused on entering the abdominal cavity through anterior or posterior incisions on the cervix. Careful dissection anteriorly and posteriorly along the correct tissue planes prevents injury to the bladder and rectum, respectively. The uterosacral ligaments are palpated and ligated. The rest of the case involves simply resecting the uterus until the vaginal dissection meets the laparoscopic dissection, which releases the uterus.
Laparoscopic supracervical hysterectomy (LSH) is executed in the same manner as a LAVH; however, the uterus is amputated at the level of the internal os. The cervix and uterosacral ligaments are left intact. There are two crucial steps in performing a LSH. The first step involves transecting the uterine corpus from the cervix via monopolar scissors, bipolar spatula, or harmonic scalpel. Special attention is given to elevating the uterus away from the rectum, bladder, and pelvic sidewall to prevent injury. The second crucial step involves morcellating the uterine corpus and/or adnexal structures. This is performed by using a laparoscopic morcellator. The tip of the morcellator blade must be kept in the center of your visual field at all times. The tissue is grasped and pulled into the morcellator blade, until the entire uterus is removed. This type of hysterectomy is best suited for uteri with large fibroids or difficulty with dissection due to adhesions. Women undergoing a LSH still require annual pap smears. According to research, it is controversial whether sexual activity is affected by removal of the cervix; nevertheless, some women opt to retain their cervix.(5) In general, patients undergoing a LSH typically recover faster. These patients have less chance of infection since no vaginal entry or cuff closure is required.(1)
Discussion
The lack of use of laparoscopic hysterectomy may be due to operator skills.(6) Laparoscopy requires training, and surgeons can only offer patients surgical procedures within their capabilities.(7) In a study by Hawe and Garry, complication rates were assessed for women undergoing laparoscopic, vaginal, and abdominal hysterectomies. Overall, laparoscopic hysterectomies had the lowest complication rate at 15.6 for every 100 women. Vaginal and abdominal hysterectomies were 24.5 and 42.8, respectively.(8) The cost of laparoscopic hysterectomy is somewhat inversely proportional to the surgeon’s laparoscopic skills. However, reusable instruments can help abate the equipment cost.
The advantages of laparoscopy far outweigh the disadvantages. The length of hospital stay has been observed to be significantly decreased with laparoscopic hysterectomy versus vaginal and abdominal hysterectomy. Many patients are discharged within 12 to 24 hours of surgery, while requiring only minimal amounts of postoperative pain medication.(9,10) Laparoscopic surgery provides an alternative to laparotomy for obese patients to avoid the likelihood of a wound breakdown. Some large pelvic masses may be attempted laparoscopically as well.(11) Laparoscopy is also an alternative to vaginal surgery for cases involving fixed or immobile uteri and adnexa, as well as patients with poor vaginal access.(12,13)
On average, only 10% of hysterectomies in the U.S. are done laparoscopically.2 With more patient education concerning surgical alternatives and the exposure of more surgeons to laparoscopy, this gap in usage of minimally invasive procedures will be reduced.
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