John O. Schorge and David M. Boruta II
ABDOMINAL HYSTERECTOMY
Procedure Overview
Box 25-1 Master Surgeon’s Corner
Dorsal lithotomy position is preferable when distorted pelvic anatomy or extensive disease is anticipated.
Optimize surgical exposure via an adequate incision and appropriate self-retaining retractor from the very beginning.
“Normalize” anatomy with lysis of adhesions prior to initiating hysterectomy.
Hold vaginal cuff sutures until completely reassured of hemostasis at the cuff and cardinal ligaments.
Approximately 600,000 hysterectomies are performed annually—second only to cesarean delivery as the most frequently performed major surgical procedure for women of reproductive age in the United States. An estimated 20 million US women have had a hysterectomy, more than one-third of them by age 60. Approximately half will undergo concomitant bilateral oophorectomy.1
The 5 classes (or types) of hysterectomy were originally defined by Piver et al2 to more accurately describe the technical features involved when tailoring surgical treatment of women with cervical cancer. Type I hysterectomy, also known as extrafascial or simple hysterectomy, removes the uterus and cervix, but does not require excision of the parametrium or paracolpium. Within gynecologic oncology, a simple hysterectomy is usually performed for benign conditions, preinvasive cervical disease, stage IA1 cervical cancer, and most instances of endometrial or ovarian cancer. Occasionally, a planned simple hysterectomy must be adapted to a type II or III procedure based on intraoperative findings.
Abdominal hysterectomy was the foundation of gynecologic surgery for the latter half of the 20th century. However, several recent developments have resulted in fewer of these procedures being performed each year, a trend that is expected to continue into the future. Nonoperative techniques, such as office endometrial ablation, insertion of levonorgestrel-releasing intrauterine devices, and outpatient uterine artery embolization, have enabled many women to avoid hysterectomy. Additionally, the rapid introduction of minimally invasive surgery over the past decade has decreased the number of abdominal hysterectomies being performed. In many training programs, abdominal cases are now often mainly performed in extreme circumstances, such as a frozen pelvis or massively enlarged uteri. As a result, residents currently graduating may have more experience using a laparoscopic approach. Since trainees in obstetrics and gynecology are increasingly confronted with a wider range of techniques that must be mastered, and fewer hysterectomies are being performed each year, the need for improved surgical education to achieve competency is increasingly recognized.3
Despite the recent paradigm shift to minimally invasive surgery, approximately two-thirds of uteri in the United States are still removed through an abdominal incision. As high-volume surgeons, the majority of gynecologic oncologists have increasingly incorporated laparoscopic and robotic techniques into their practice.4 However, one-quarter of hysterectomies are performed by gynecologic surgeons who perform fewer than 10 per year. Such lower volume surgeons continue to perform the vast majority of their hysterectomies abdominally.5
Abdominal hysterectomy allows the greatest ability to manipulate pelvic organs and thus is often preferred to a minimally invasive approach if large pelvic organs or extensive adhesions are anticipated. Moreover, abdominal hysterectomy typically requires less operating time than laparoscopic or robotic hysterectomy, and no advanced instrumentation or expertise is needed. However, the duration of inpatient hospital stay is longer, and postoperative complications are more prevalent.
Preoperative Preparation
A spectrum of tests may be required to reach the preoperative diagnosis. These tests vary depending on the clinical setting and are discussed within the respective chapters covering those etiologies. Review of all pertinent information and office pelvic examination are crucial to form the best possible surgical plan.
After deciding to perform a hysterectomy, the next decision is to confirm that laparotomy is the best option based on patient circumstances. Abdominal surgery can result in major short- and long-term morbidity, generally exceeding a minimally invasive or vaginal approach. The other major decision in surgical planning is whether a vertical or transverse incision is best. When there is a pre-existing abdominal incision, it may or may not be appropriate for the planned operation. Morbidly obese patients should be examined supine in the office to map out and show where the intended incision will be located. Thereafter, the surgeon can effectively counsel the patient about abdominal hysterectomy via the intended incision. The consent should reflect the thought process behind the approach, as well as all related factors specific to the diagnosis. Concurrent illnesses, prior abdominal surgery, and a poor performance status are potential mitigating circumstances that should be taken into consideration during the consenting process.
Frequently, intra-abdominal findings of gynecologic oncology patients cannot be reliably predicted based on examination or imaging tests. In general, intraoperative bladder injuries are more likely with a history of cesarean section or a large uterus, whereas bowel injuries are more commonly associated with adhesiolysis.6 Patients should be fully informed that such gastrointestinal or genitourinary injuries are possible, as are unexpected bleeding and the need for transfusion. Postoperative wound dehiscence, infection, or other unanticipated sequelae are important to discuss.
When performing a hysterectomy abdominally, or by any other route, a blood sample should be typed and crossed for potential transfusion. Pneumatic compression devices, subcutaneous heparin, or both are particularly important due to the anticipated length of the operation and longer duration of postoperative recovery. Bowel preparation with a polyethylene glycol–electrolyte solution (GoLYTELY) is no longer commonly used. Inadvertent bowel injury should be rare unless extenuating circumstances are identified such as previous bowel surgery, known adhesions, or prior pelvic infections. Similarly, the addition of ureteral stenting varies widely, based on surgeon experience and patient circumstances.
A single dose of perioperative antibiotic prophylaxis with a third-generation cephalosporin such as cefoxitin is ordered to be given prior to incision. This is sufficient to prevent most postoperative surgical site infections, but the dose may need to be repeated if the operation continues beyond 4 hours or excessive bleeding is encountered.
Fortunately, abdominal hysterectomy is largely not dependent on specific instrumentation. In general, a self-retaining retractor, such as the Balfour or Bookwalter, is required. However, the surgeon may have particular requests, such as the Bookwalter extender with deep blades for an obese patient, certain coagulation sealing devices, or other relevant items required for an individual case.
Operative Procedure
Box 25-2 Caution Points
Ensure self-retaining retractor blade tips do not rest on psoas muscles and underlying femoral nerves, especially in thin patients.
Identify the ureter and understand its location during all phases of the procedure.
Dense adhesions between the bladder and cervix require sharp, not blunt dissection.
Stay inside the uterine artery pedicle when clamping the cardinal ligaments to avoid ureteral injury.
Anesthesia and Patient Positioning
Lower extremity compression devices are placed on the patient for venous thrombosis prophylaxis. General endotracheal or regional anesthesia is administered. Many gynecologic oncologists routinely position all abdominal surgery patients in dorsal lithotomy rather than supine position, mainly in the event that access to the perineum for intravaginal manipulation or transrectal placement of stapling devices is required. Frequently, the extent of pelvic disease cannot be anticipated with certainty based on examination findings and preoperative imaging. When positioning in dorsal lithotomy, the patient’s legs are placed in Allen stirrups, the buttocks brought down to the table break, and arms secured laterally. Bimanual rectovaginal examination should always be performed to familiarize oneself with the anatomy and to make a final decision on the type of incision.
The abdomen and vagina are surgically prepared, and a Foley catheter is placed. When there is any perceived possibility of bladder injury, a 3-way Foley provides additional access to easily backfill with methylene blue–colored saline, and the integrity of the bladder should be confirmed before abdominal closure.
Abdominal Entry
Abdominal hysterectomy may be safely performed through a midline vertical, Pfannenstiel, Maylard, or Cherney incision. Many factors go into determining which is most appropriate for the particular patient, but adequate exposure is absolutely critical to prepare for unanticipated findings, excessive adhesive disease, or the unexpected need for cancer staging.
Once the fascia has been incised and the abdominal cavity entered, the undersurface of the abdominal wall is palpated to search for omental or intestinal adhesions. To maximize exposure, the peritoneal incision is sharply dissected as cephalad and caudad as possible within the limits of the skin incision. Peritoneal washings, if appropriate, are collected, and a comprehensive abdominal exploration is performed. Occasionally, the incision will be perceived as inadequate and may need to be further extended before proceeding. Bowel adhesions may need to be dissected away from the pelvic organs.
Next, the surgeon’s preferred self-retaining retractor is assembled. Meticulous care of blade placement and bowel packing is critical to provide excellent visualization, decrease the likelihood of femoral nerve palsy, and allow for surgical efficiency in performing the subsequent surgical steps.
Retroperitoneal Dissection
Curved Kelly clamps are placed bilaterally at the uterine cornua, incorporating the round ligament. An Allis clamp is used to grasp the round ligament, and a single 0-vicryl is tied and held on a clamp laterally. Tagging the round ligament is particularly helpful whenever pelvic lymphadenectomy is to be later performed. The uterus is held medially to put the round ligament on stretch so that it can be divided with cautery. A right angle clamp is used to guide further cautery dissection of the anterior and posterior leaves of the broad ligament. Occasionally, the round ligament cannot be clearly identified due to pelvic disease or anatomical distortion. In this circumstance, the Allis clamp is used to grasp a section of peritoneum laterally on the pelvic sidewall, cautery is used to incise a small opening, the posterior broad ligament is opened, and the round ligament can be identified later in the dissection.
Loose areolar retroperitoneal connective tissue is bluntly dissected until the external iliac artery is palpated just medial to the psoas muscle. The index and middle fingers then are placed on either side of the artery, and the areolar connective tissue is dissected bluntly by a “walking” motion toward the patient’s head (Figure 25-1). The medial peritoneal leaf of the broad ligament is elevated and placed on traction to permit direct identification of the common iliac bifurcation and origins of the external and internal iliac arteries. Blunt dissection with a finger or suction tip is used in a sweeping motion from top to bottom along the medial peritoneal leaf to identify and sufficiently mobilize the ureter crossing at the bifurcation. As a general rule, it is inadequate to just palpate the ureter or assume its location without directly visualizing unequivocal peristalsis. When the peritoneum is held on traction, and the tubular structure presumed to be the ureter is not seen to undergo peristalsis, the surgeon may need to further mobilize it by blunt dissection along its course and relax the peritoneum until its identity is confirmed.
FIGURE 25-1. Finding the ureter. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Consistently performing a comprehensive retroperitoneal dissection has a number of potential advantages, including immediate ability to perform hypogastric artery ligation in case of hemorrhage and defining the anatomy when the pelvis is distorted by endometriosis, malignancy, or adhesions. Small vessel bleeding during this dissection can be quickly controlled with directed cautery, or a small sponge can be firmly placed into the space to tamponade general oozing, while switching to work on the contralateral side of the pelvis.
In the presence of diffuse fibrosis or other extenuating circumstances, it may be advisable to tag the ureter for visualization throughout the abdominal hysterectomy procedure. When the ureter is sufficiently mobilized off the medial peritoneal leaf, a right-angle clamp is used to “pop” through the underlying avascular space. Typically, the clamp is placed in a lateral to medial direction to avoid inadvertent injury to the sidewall vasculature. If the ureteral location does not easily allow this, a Babcock clamp can be used to grasp the ureter gently without crush injury and facilitate clamp placement underneath. Next, a ¼-in-wide Penrose drain is guided by a forceps to the right angle tip and slid back underneath the ureter, and the 2 ends are held on a clamp laterally. It is critical to directly observe unequivocal peristalsis before moving on to the subsequent surgical steps.
Utero-Ovarian Ligament Transection
The next part of the operation depends on whether the adnexa are to be concurrently removed or not. Once the ureter has been identified, the infundibulopelvic (IP) ligament may be divided and peritoneal attachments dissected, as described in Chapter 24. When the adnexa are to be temporarily or permanently left in situ, division of the utero-ovarian ligament is performed.
Development of the retroperitoneal spaces and tran-section of the round ligament should enable the surgeon to wrap a finger around the utero-ovarian ligament and identify an avascular space underneath. Cautery is used to open the space sufficiently to place a curved Heaney clamp laterally. The clamp should be placed with tips pointed toward the uterus in order to best secure the lateral vascular pedicle. Usually, the Kelly clamp originally placed on the uterine cornua can simply be repositioned into the opened space to prevent back-bleeding (Figure 25-2). The intervening tissue is divided, followed by a 0-vicryl free tie to crush the vessels while the Heaney clamp is “flashed” (opened and closed), and then a second 0-vicryl transfixion stitch is placed on the lateral pedicle. A segment of adjacent peritoneum may also be sharply dissected so that the adnexa can be packed away from the operative field. The identical procedures are repeated on the contralateral side.
FIGURE 25-2. Transection of the utero-ovarian ligament. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Bladder Flap
The uterus is pulled upward and cephalad in the mid-line position to best visualize the vesicouterine fold. The peritoneum that connects the superior edge of the bladder to the uterine isthmus should have been cut when the anterior leaf of the broad ligament was opened. Only loose areolar connective tissue joins the posterior surface of the bladder and anterior surface of the uterine isthmus and cervix. Many gynecologists will bluntly dissect the bladder distally, using either a thumb or sponge stick. However, the complicated circumstances wherein a gynecologic oncologist is performing an abdominal hysterectomy frequently dictate the necessity of careful sharp dissection instead. Tumor infiltration, tissue induration, and postsurgical fibrosis all increase the likelihood of bladder injury or deserosalization with blunt dissection.
Superficial cautery is the most hemostatic method of identifying the right plane between the posterior surface of the bladder and the anterior uterine surface. Bending the cautery tip often facilitates the correct angle of dissection, especially when operating deep in the pelvis (Figure 25-3). Short horizontal bursts of cautery along the cervix, followed by gentle distal mobilization of the fibrous attachments with the cautery tip, should provide a good result. Ideally, the bladder is dissected onto the anterior vaginal fornix before moving to the next steps of the operation. Occasionally, the bladder dome is fused to the anterior uterine corpus with no discernable plane. In this instance, it may be possible to bluntly develop a retroperitoneal space from the left or right lateral location, on top of the anterior cervix distal to the area of dense bladder attachment. Wrapping an index finger around the dense adhesion in this fashion will greatly facilitate sharp dissection and decrease the likelihood of bladder injury. Alternatively, sharp dissection is performed in the imagined plane between the bladder and uterus, with frequent attempts to identify a plane distally. Almost invariably, once the uppermost fibrotic attachments are dissected, the correct plane is encountered at some point thereafter, greatly facilitating distal mobilization of the bladder.
FIGURE 25-3. Dissecting the bladder flap. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Uterine Artery Ligation
The uterus is again held on medial traction to skeletonize the uterine vessels in order to further drop the ureter laterally and allow an isolated vascular pedicle to be secured. Peritoneal attachments and excess connective tissue are gently retracted laterally with fine, smooth forceps and cauterized in a direction perpendicular toward the vessels. The uterine artery and vein are then visualized along the lateral aspect of the uterus at the level of the isthmus. In extenuating circumstances, a uterine vessel may be lacerated in the course of skeletonizing and lead to brisk bleeding. However, because the bladder flap has been taken down in advance, the vessel can be quickly secured by prompt clamp placement.
A curved Heaney clamp is opened, placed across the uterine vessels inferiorly to the planned site of tran-section, and purposefully slides off the lateral cervix as it is closed. The clamp tip must be placed as close to the cervix as possible to secure the entire lumen of both artery and vein. Additionally, the clamp should be placed as perpendicular as possible across the vertical axis of the uterine vessels (Figure 25-4). A Kocher or other straight clamp is placed to control back-bleeding above the planned uterine vessel transection so that its tip abuts the tip of the Heaney clamp and crosses the vessels at an approximate 45-degree angle. The uterine vessels are then sharply transected with curved Mayo scissors with blades pointed up, sliding along the Heaney clamp until reaching the distal tip, when the scissors are turned around to gently divide the last remaining tissue and fully isolate the uterine pedicle. The scalpel may be used in place of scissors but may be an inferior choice in some instances. When visualization is limited by obesity, a bulky uterus, or other mitigating circumstances, the uterine vessels may still be divided safely by the surgeon’s “feel” of the Mayo scissors along the Heaney clamp to reach its tip, whereas the scalpel is a less-controlled approach.
FIGURE 25-4. Clamping the uterine vessels.
A simple stitch of 0-gauge delayed-absorbable suture is placed below the tip of the Heaney clamp, with the needle directed posteriorly away from the bladder. The suture ends are wrapped to the heel of the clamp and tied directly against the back of the Heaney clamp with release upon cinching the knot. Next, the uterus is again pulled upward, and a straight Heaney or Zeppelin clamp is placed medially, inside the uterine pedicle, vertically and directly adjacent to the cervix. Upon closing the clamp onto the paracervical tissue, the handle is gently directed laterally to further press the tip against the cervix and laterally displace the uterine pedicle. The pedicle is similarly cut and ligated, before repeating these steps on the contralateral side.
Supracervical Hysterectomy
The surgeon may choose to amputate the uterus from the midcervix at this point in the operation due to benign disease and patient preference, limited visibility from a bulky uterus, or dense adhesions making cervix removal too risky to proceed. Regardless of the indication, the cautery tip is bent at an angle, its energy source turned up, and suction brought into the field to remove the smoke plume. Often it is advisable to place a hand-held retractor posteriorly to prevent inadvertent cautery injury to the rectum. The uterine fundus is detached and handed off the field.
If the cervix is to remain in situ, the upper endocervix may be further resected or cauterized to prevent cyclic bleeding, which may otherwise be observed postoperatively in premenopausal women. Interrupted 0-gauge delayed-absorbable suture may be placed to achieve hemostasis, but otherwise is not required.
Removal of the Cervix
If the uterus has not been amputated from the cervix, then lateral straight clamp placement and pedicle ligation continue as before. Otherwise, single-toothed Kocher clamps are placed on the anterior and posterior walls of the remaining cervix for upward traction. The bladder flap is further advanced, if needed, by sharp dissection. The cardinal ligaments are successively clamped, cut, and ligated to reach the lateral aspect of the upper vaginal vault. The cervical distance to the vaginal fornix should be checked intermittently by placing a gloved hand into the pelvis, directly grasping the cervix in the palm, and palpating the cervical portio between the thumb and index finger. Otherwise, it is possible to inadvertently perform an upper vaginectomy or prematurely cut into the cervix before reaching the vagina. Further sharp dissection is performed anteriorly to be confident the bladder is sufficiently mobilized distally.
Once the lateral vaginal vault has been reached, upward and lateral traction is again exerted by the Kelly clamps holding the uterine cornua. A curved Heaney clamp is placed in front of the lateral tip of the cervix and swung posteriorly to incorporate the uterosacral ligament. A second Heaney clamp is similarly placed on the contralateral vaginal angle. The lateral vaginal fornices and intervening anterior and posterior vaginal attachments can be divided under direct visualization using a knife (Figure 25-5) or sharply curved scissors. The clamped pedicles are each secured with a transfixing 0-gauge delayed-absorbable stitch. The remainder of the upper vagina can then be closed by either interrupted or continuous running, 0-gauge delayed-absorbable suture.
FIGURE 25-5. Detaching the uterus and cervix from the upper vagina. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
On occasion, a bulky cervix, lateral tissue induration, or a cervix flush with the vaginal apex will dictate the need for a different approach. With the bladder flap dissected distally onto the anterior vaginal fornix, a Kocher clamp is placed anteriorly in the midline beyond the cervical portio. A second, more proximal Kocher clamp is similarly placed and cautery used in between to enter the vaginal vault (Figure 25-6). A right-angle clamp is inserted into the opening (colpotomy) and used to facilitate bilateral cautery dissection. The proximal Kocher is repositioned to grasp the anterior lip of the cervix, reflecting it upward, where cautery or scissors can be used to detach it laterally and posteriorly. The vaginal cuff is grasped with Kocher or Allis clamps and closed, as described earlier.
FIGURE 25-6. Entering the anterior vaginal fornix.
Final Steps
Once the abdominal hysterectomy has been performed, strict hemostasis should be achieved. The course of both ureters and all pedicle sites are re-inspected. Further abdominal exploration may be performed, as needed. Intraoperative drain placement is at the discretion of the surgeon, depending on concurrent ancillary procedures, the amount of blood loss, and other specific concerns. Copious irrigation of warmed saline is advisable, followed by careful attention to closure of the abdominal incision.
Postoperative Care
Box 25-3 Complications and Morbidity
Intraoperative
Hemorrhage
Cystotomy
Ureteral transection, ligation, or “kinking”
Bowel deserosalization or enterotomy
Postoperative
Ileus (more pronounced with vertical incision)
Vaginal or intraperitoneal bleeding
Neurologic deficit (ie, retractor injury)
Wound infection, separation, or fascial dehiscence
Thromboembolic event
Genitourinary fistula (rare)
Incisional hernia (more likely in obese patients)
Abdominal hysterectomy is generally associated with longer patient recovery and hospital stays, increased incisional pain, and a greater risk of postoperative febrile morbidity and wound infection compared to other approaches.7However, sometimes it is the best, or possibly the only, option for effective surgical management of the patient. Only extenuating circumstances, such as intraoperative hemorrhage, multiple concurrent procedures, or severe medical comorbidi-ties, should prompt the surgeon to request specialized services within the intensive care unit for the immediate postoperative recovery.
All patients should be examined by a member of the health care team within several hours, with visualization of the dressing. Most dressings can be safely removed on postoperative day 1. In patients with vertical incisions above the umbilicus, it is often advisable to wait an additional day to remove the dressing as long as it remains dry. Thereafter, the incision site is checked frequently looking for signs of infection.
Typically, Foley catheter drainage may be discontinued on the first postoperative day. However, many gynecologic oncology patients may need to have catheter removal postponed due to difficulty with ambulation, fluid shifts resulting in borderline urine output, or related issues. When an intraoperative bladder injury has been repaired, the catheter should remain in place to keep the bladder decompressed from several days to 2 weeks, depending on the size of the injury. Although meticulous ureteral dissection should reduce the risk, the majority of ureteral injuries will be recognized postoperatively. Thus, symptoms of urinary incontinence or vaginal fluid leakage should alert the surgeon to this possibility.
Abdominal hysterectomy will result in a delay of return to normal bowel function for an unknown duration. In the absence of extensive concurrent surgery, a nasogastric tube is not necessary. The timing of when to advance diet past nothing by mouth (NPO) depends on numerous factors, including the individual surgeon’s experience and specific preferences. Patients with a high vertical incision will be at higher risk of ileus and should be advanced more slowly. In uncomplicated circumstances, sips of clear liquids may be initiated on postoperative day 1 if the patient’s examination is appropriate. Beyond that, advancing the diet is a day-to-day decision until flatus is passed, when a full diet may be allowed. Any signs of abdominal distention, nausea, or emesis should be taken into consideration throughout the hospital stay, with the patient potentially made NPO again if necessary.
Early ambulation is among the most critical interventions to facilitate rapid recovery. Discharge planning should be discussed early, especially when postdischarge rehabilitation is anticipated.
VAGINAL HYSTERECTOMY
Procedure Overview
Box 25-4 Master Surgeon’s Corner
Vaginal hysterectomy avoids the significant morbidity associated with abdominal incisions.
Median episiotomy may facilitate exposure when limited by a small vaginal introitus.
If salpingo-oophorectomy is indicated but difficult due to high location of the adnexa, laparoscopic instruments such as a ligature loop with slip knot may be useful.
Vaginal hysterectomy offers a number of potential advantages over abdominal or laparoscopic surgery, especially when pelvic organs are small, some degree of uterine descensus is present, and access to the upper abdomen is not required.8 Operating time is reduced, regional anesthesia may be an option, inpatient hospitalization is brief, major morbidity is less, and a shorter postoperative recovery may be anticipated, especially when the procedure is performed by high-volume vaginal surgeons.9,10 Moreover, because no abdominal incisions are required, vaginal hysterectomy could rightly be considered more of a minimally invasive operation than laparoscopy or robotic surgery.
In a previous era when the rate of cesarean delivery was very low and the number of births per woman was higher, the prevalence of pelvic organ prolapse made vaginal hysterectomy a popular technique. Currently, less than one-quarter of hysterectomies are performed vaginally in the United States. There are numerous additional reasons why it is not currently used more often, including lack of expertise of the gynecologic surgeon, anticipated pelvic adhesive disease, presence of a contracted pelvis, or other problematic factors. Within gynecologic oncology, even fewer patients are treated by this approach, mainly because the indications for hysterectomy often require intra-abdominal evaluation with or without staging. For the gynecologic oncologist, preinvasive cervical disease is one of the more common indications, as well as the occasional elderly or excessively obese woman with complex atypical hyperplasia or grade 1 endometrial cancer.11 Conceptually, the operational steps are in reverse order compared to abdominal hysterectomy.
Preoperative Preparation
The preoperative evaluation for vaginal hysterectomy largely mirrors that of the abdominal approach. Preoperative pelvic examination is especially important. With careful assessment, the potential for needing laparoscopic assistance or likelihood of converting to a laparotomy should be low. However, intraoperative findings often cannot be reliably predicted based on examination or imaging tests. As when performing other types of hysterectomy, patients should be fully informed that gastrointestinal or genitourinary injuries are possible, as is unexpected bleeding.
Vaginal hysterectomy is not dependent on specific instrumentation. However, sidewall retractors, such as the Breisky, are often helpful. Curved-tip needle drivers may also facilitate suture ligation of pedicles. The individual surgeon may have specific requests, such as certain coagulation sealing devices, to maximize efficiency. Frequently, a dilute saline solution containing vasopressin (20 units diluted in 20 mL of saline) is used to reduce blood loss.12Alternatively, some surgeons prefer using just saline due to concerns that intracervical vasoconstrictor usage may increase the risk of postoperative infection.
Operative Procedure
Box 25-5 Caution Points
Excess bleeding during dissection between the bladder and cervix generally implies that dissection is proceeding in the wrong plane.
Place clamps close to the cervix, inside the uterosacral pedicles, when dividing the cardinal ligament in order to avoid the ureter laterally.
Avoid transfixion sutures on vascular pedicles.
Anesthesia and Patient Positioning
One of the important advantages of vaginal hysterectomy is that it can be comfortably performed under regional anesthesia in patients who have a heightened surgical risk. Once regional or general anesthesia has been administered, positioning is particularly important. Access to the perineum is limited, and visualization is critically important. The patient is placed in dorsal lithotomy position with her feet comfortably positioned in stirrups. Candy-cane stirrups are preferred in order to provide maximal exposure to the operative field and allow room for 1 or 2 assistants. Extra care, including alternative stirrups (such as Allen), is sometimes necessary but may result in imperfect exposure. Next, the patient’s hips are brought over the edge of the operating room table, and leg positioning is reassessed to confirm appropriate padding. Improper positioning can lead to sciatic, peroneal, and/or femoral nerve palsies.
Bimanual rectovaginal examination is performed before prepping to familiarize oneself with the anatomy. The vagina is surgically prepared, and a Foley catheter is placed. When there is any perceived possibility of bladder injury, a 3-way Foley may be indicated. It is often good practice to prep the abdomen as well, in case circumstances dictate the need to look laparoscopically or convert to an abdominal approach.
Vaginal Wall Incision
The operating table is raised to the appropriate height for the surgical team. A weighted vaginal speculum is placed posteriorly, and a right-angle or other suitable retractor is placed along the anterior vaginal wall to be held by the surgical assistant. A Lahey thyroid clamp is used to grasp both the anterior and posterior cervical lips, and the cervix is placed on downward and outward traction. The margin of the bladder can be identified as a crease in the overlying vaginal epithelium and accentuated by in-and-out movement of the cervix. Between 10 and 15 mL of diluted vasopressin solution is injected circumferentially beneath the mucosa at a level above the cervicovaginal junction, but below the inferior margin of the bladder to aid in defining tissue planes.
The location of the vaginal wall incision is crucial to facilitate the subsequent steps of the operation. If the incision is made too close to the cervical os, it results in unnecessary difficulty in entering the peritoneal cavity. Alternatively, an incision too far away from the os can lead to inadvertent bladder or rectal injury. Bending the cautery tip 45 degrees and using it on “cut” mode will facilitate dissection into the appropriate tissue planes. With the cervix pulled forward, the incision is started at the point of the posterior fornix attachment to the cervix. The anterior retractor is rotated to provide exposure so that the circular (or diamond-shaped) incision can be performed circumferentially.
Entering Posteriorly
Frequently, the peritoneal cavity is first entered posteriorly because it is easiest. Although it is tempting to bluntly dissect posteriorly after the vaginal incision has been made, that maneuver pushes the peritoneum farther away, making it much harder to enter the cul-de-sac. Instead, the cervix is pulled anteriorly to expose the posterior vaginal vault, and an Allis clamp is placed on the incised edge of the posterior vaginal wall. The Allis clamp is pulled downward to create tension across the exposed posterior peritoneum, and the posterior vaginal vault is boldly cut with curved Mayo scissors, with tips pointed up (Figure 25-7). If the peritoneal cavity is not entered with a single stroke, then the Allis clamp can be used to regrasp the posterior vaginal wall and the process repeated. If there is any concern for proximity to the rectum, a rectal examination can be performed to help guide the dissection. Inordinate difficulty in entering the peritoneal cavity posteriorly is unusual and may indicate an unanticipated obliteration of the cul-de-sac.
FIGURE 25-7. Entering the posterior cul-de-sac.
Upon entering the peritoneal cavity, the opening is expanded laterally by placing the Mayo scissors within the defect and opening widely. An index finger should be inserted to confirm position within the peritoneal cavity and gently palpate for adhesive disease or other pathology. The midportion of the posterior peritoneum is sutured to the posterior vaginal wall incision with a single 0-gauge delayed-absorbable suture and held on a straight snap. The weighted speculum is removed and ideally replaced by one with a longer blade (such as the “duckbill”), which is inserted through the opening into the cul-de-sac. The tie is maneuvered underneath the speculum to be used later during closure of the peritoneum at the procedure’s end.
Entering Anteriorly
The cervix is again held downward, and the bladder is mobilized anteriorly with the right-angle retractor. Brief horizontally directed strokes of cautery with intermittent upward mobilization using the tip should allow the tissue to fall away and facilitates identification of the correct plane of dissection. When the cautery dissection is too vigorous, the cervical stroma may be entered. To re-establish the correct plane, meticulous fine dissection is required above and distal to the inadvertent stromal entry. The anterior vaginal wall is next grasped and elevated with an Allis clamp. This traction will reveal fibrous bands still connecting the bladder and cervix. Typically, the cautery is exchanged for Metzenbaum scissors at this point to allow more precise dissection of these fibers (Figure 25-8). Blunt dissection with a finger or surgical gauze should be limited, if performed at all, to avoid pushing the anterior peritoneum farther away and making it harder to reach. Additionally, when the fibrous bands are thick and the fascial plane is hard to visualize, it is possible to create a cystotomy with blunt dissection that is more difficult to repair than when a small entry is made with sharp scissor dissection.
FIGURE 25-8. Sharp dissection between bladder and cervix. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
If a cystotomy is made, it will often allow the correct tissue plane to be more easily identified inferiorly. Once the hysterectomy is completed, cystoscopy can be performed to assess the injury’s proximity to the trigone, and then typically it can be easily repaired vaginally. Injuries near the trigone may require ureteral stent placement.
The bladder dissection is continued until the vesicouterine fold is reached. Usually, it can be identified as a transverse white line across the anterior cervix. Palpation reveals 2 thin smooth layers of peritoneum slipping against one another. The vesicouterine fold is grasped and elevated to place this peritoneal layer on tension. If there is any concern for the tissue fold representing bladder mucosa, the bladder can be backfilled and the presumed vesicouterine fold re-examined. The peritoneum then is incised (Figure 25-9).
The surgeon’s index finger next explores the opening to confirm peritoneal entry and to palpate for any unanticipated pathology. The anterior retractor is then repositioned with its distal blade entering the peritoneal cavity, thereby elevating the bladder.
FIGURE 25-9. Vesicouterine fold incision. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Dividing the Lateral Ligaments and Vessels
Once the peritoneum has been safely entered anteriorly and posteriorly, the hardest part of the operation is over. Firm lateral traction on the Lahey thyroid clamp both pulls the supporting uterine ligaments into view and prevents ureteral injury. Especially in obese patients, the Breisky sidewall retractor is often helpful at this point in the operation to facilitate visualization of the lateral pedicles. The uterosacral ligament is identified, clamped using a curved Heaney with tips pressed against the cervix, transected, and suture ligated with a transfixing stitch. The suture is tagged with a curved Kelly clamp, and the procedure is repeated on the contralateral side. Tissue sealing and cutting devices may be used instead of clamping and suturing to perform the steps more quickly, but the ligaments cannot be tied together later to provide vault support.
Next, the cardinal ligaments are similarly clamped, cut, and suture ligated (Figure 25-10). When feasible, the anterior jaw of the Heaney clamp should be positioned around the cardinal ligaments, incorporating the anterior peritoneal edge into the pedicle. The cardinal ligaments are held with curved hemostats to distinguish them later from the uterosacral pedicles. Frequently, the supportive ligaments are not easy to distinguish individually, and more than 2 clamp placements are required bilaterally to divide all of the connective tissue.
FIGURE 25-10. Cardinal ligament transaction. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
The uterine vessel pedicle, which contains the uterine artery and vein and the broad ligament peritoneum anterior and posterior to these vessels, is clamped with a single curved Heaney clamp, cut, and ligated with a single ligature. A transfixion suture should not be used on this vascular pedicle because of the possibility of injuring a vessel and causing a broad ligament hematoma. When the uterus is larger, it may be beneficial after securing the uterine vessels to deliver the uterine corpus posteriorly in order to expose the round and utero-ovarian ligaments (Figure 25-11). To accomplish this, tenaculum clamps can be used in tandem to pull the fundus into the vagina.
FIGURE 25-11. Delivery of the uterine corpus posteriorly. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
If the uterus is small and descensus adequate, 2 curved Heaney clamps are placed in tandem across the utero-ovarian and round ligaments, as close to the uterine fundus as possible. Often the surgeon’s index finger can be looped around the pedicle to help guide the final clamps safely in place, avoiding omentum or loops of bowel. When visibility is limited, clamps may be placed bilaterally with removal of the uterus and cervix before securing the pedicles. A free tie is used first to ligate the lateral pedicle and occlude all vessels. Next, a transfixion suture ligature is placed with removal of the medial clamp (the one closest to the uterus). The ties are again held laterally with matching clamps to help identify them later.
Oophorectomy
If removal of the ovaries is desired, the adnexa is grasped with a Babcock clamp and gently pulled toward the incision. An index finger is wrapped around the IP ligament to isolate it from surrounding structures. The IP ligament is clamped and ligated similarly to the utero-ovarian pedicle (Figure 25-12). The ends of the transfixing suture may be held by matching hemostats.
FIGURE 25-12. Salpingo-oophorectomy. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Vaginal Cuff Closure
The surgical pedicles should be inspected for bleeding and resecured if necessary with additional free ties or suture ligature. If hemostasis is adequate, then the utero-ovarian (or IP) ligament ties are cut. The peritoneum may be closed in a purse-string manner using 2-0 delayed-absorbable suture in order to extraperitonealize the pedicles. However, this is not a required step, and it can certainly be skipped when visualization is limited.
The easiest and quickest way to provide apical support is to tie both cardinal ligaments together in the midline, and then to do the same for the uterosacral ligaments. Finally, the cardinal ligament suture is tied to the uterosacral suture. Alternatively, a suspensory suture may be included in which the cardinal or uterosacral or both ligaments are sutured to the lateral vaginal cuff on each side. More complex variations of preventing future vault prolapse are at the discretion of the surgeon. Strict hemostasis should be observed prior to cuff closure. The vaginal mucosa is closed from anterior to posterior with running suture, ultimately securing it to the posterior peritoneal stitch placed at the beginning of the operation.
Final Steps
Vaginal packs are not required at the completion of vaginal hysterectomy, but some surgeons will use them on occasion to tamponade surface oozing in the immediate postoperative period. When the abdominal entry is particularly challenging anteriorly or there is any other concern for injury to the genitourinary tract, diagnostic cystoscopy should be performed prior to extubation.
Postoperative Care
Box 25-6 Complications and Morbidity
Intraoperative
Rectal injury during posterior dissection
Cystotomy during anterior dissection
Enterotomy due to unanticipated obliteration of the cul-de-sac or incorrect clamp placement
Ureteral transection, ligation, or “kinking”
Hemorrhage
Postoperative
Vaginal or intraperitoneal bleeding
Neurologic deficit from hyperflexion of the hips
Vaginal cuff complications (ie, cellulitis, abscess, or dehiscence)
Genitourinary fistula
Vaginal vault prolapse
Vaginal hysterectomy patients typically have faster return of normal bowel function, easier ambulation, decreased analgesia requirements, shorter duration of hospital stay, and speedier return to normal activities compared to abdominal hysterectomy patients.10 Rarely, signs of excessive vaginal bleeding and/or hemo-dynamic instability may necessitate a return to the operating room to achieve hemostasis. The Foley catheter is removed on the first postoperative day, the diet quickly advanced, and the patient discharged
LAPAROSCOPIC HYSTERECTOMY
Procedure Overview
Box 25-7 Master Surgeon’s Corner
Abdominal hysterectomy principles of retroperitoneal dissection should be maintained (eg, identification of the ureters).
A carefully placed, well-functioning uterine manipulator facilitates appropriate angles of approach for laparoscopic instruments.
Use of a colpotomy cup to define the cervicovaginal junction pushes the ureters laterally and provides a consistent landmark.
Skeletonization of vascular pedicles allows the tissue to be sealed/cauterized more effectively and protects nearby structures such as the ureter.
Several laparoscopic techniques have been developed for hysterectomy and vary depending on the degree of laparoscopic dissection versus vaginal surgery required to remove the uterus and the instrumentation used, including the robotic platform. Laparoscopically assisted vaginal hysterectomy (LAVH) was the most popular method for several years, until being recently largely supplanted by total laparoscopic hysterectomy (TLH). Numerous surgeons routinely perform these operations with robotic assistance rather than using “straight-stick” instrumentation. Relatively few gynecologic oncologists have mastered the technology involved to offer single-incision laparoscopic surgery (SILS) to their patients, but that method may be more common in the future.13
Appropriate patient selection is critical to successfully perform any variation of laparoscopic hysterectomy and concurrent surgery, including lymphadenectomy or other cancer staging. Limiting factors include morbid obesity, previous pelvic infection, and extensive or bulky disease. In addition, laparoscopy creates unique physiologic cardiopulmonary changes that stem mainly from hypercarbia and pulmonary compliance changes. Patients with significant cardiac or pulmonary disease may not tolerate a laparoscopic approach, especially for long durations. Extensive prior abdominal surgeries with subsequent dense adhesions limiting exposure may significantly lengthen operative times and ultimately require conversion to laparotomy. Uterine size can also affect the surgical approach. Specifically, a large bulky uterus may be difficult to manipulate, may block visualization, and may be too large for vaginal removal. Importantly, morcellation should be avoided when dealing with uterine or adnexal malignancy. Just as important, determining the extent of disease and potential spread of cancer to other organs is essential before proceeding with laparoscopic hysterectomy.
In gynecologic oncology, the use of and perceived indications for minimally invasive surgery, particularly with robotic assistance, continue to increase. The most common indication for laparoscopic hysterectomy among gynecologic oncologists is for the treatment and staging of endometrial cancer.4 Despite longer operative time when compared to laparotomy, laparoscopic hysterectomy offers less postoperative pain, a shorter hospital stay, shorter recovery time, fewer complications, and vastly lower surgical site infection rates.14,15 Laparoscopic hysterectomy is otherwise appropriate for a wide range of other gynecologic diagnoses.
Preoperative Preparation
The basic preoperative evaluation for laparoscopic hysterectomy is similar to that of either the abdominal or vaginal approach. Preoperative pelvic examination is important to determine uterine size and mobility. Although there are no specific upper limits, a wide bulky uterus (width > 8 cm) with minimal mobility may be difficult to remove vaginally. Fortunately, findings such as a narrow introitus, a cervix flush with the vaginal apex, or a contracted pelvis are less problematic than when considering vaginal hysterectomy. Once a patient has been deemed eligible for a laparoscopic approach, the same preoperative evaluation as for an open procedure applies.
Laparoscopic hysterectomy is very dependent on specific instrumentation. The setups for LAVH, TLH, robotic-assisted hysterectomy, or SILS hysterectomy are quite different. Basic laparoscopic instruments include trocars, a video laparoscope, and laparoscopic devices for suturing, suction/irrigation, and coagulation, cutting, and sealing of tissue. Bariatric trocars may be needed for excessively obese patients. A number of suitable electrosurgical and ultrasonic energy-based devices are available and used according to surgeon preference and local availability. The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) is the only currently available robotic-assisted laparoscopy platform. It provides 3-dimensional imaging for the surgeon as well as a wide selection of “wristed” instruments that provide additional degrees of freedom of movement compared to traditional “straight-stick” instruments. To perform SILS, a port system allowing passage of 3 to 4 instruments, a deflecting tip laparo-scope, articulating instruments, and other individualized equipment must be available. Regardless of the laparoscopic technique, access to a suitable uterine manipulator, such as the RUMI (CooperSurgical, Inc., Trumbull, CT) or V-Care (ConMed Corp., Utica, NY), as well as a colpotomy cup, such as the KOH Colpotomizer ring (CooperSurgical), is also important.
Operative Procedure
Box 25-8 Caution Points
Consider alternate trocar entry points (ie, left upper quadrant) in patients with scars at the umbilicus.
Directly observe all subsequent trocar placements with the laparoscope.
Frequently ensure that the colpotomy cup is being pressed firmly into the vagina by the assistant.
Insist upon good visualization and tissue retraction by regular communication with your assistant throughout the procedure.
Anesthesia and Patient Positioning
The introductory steps for laparoscopy are described in Chapter 31. Lower extremity compression devices are placed, and general endotracheal anesthesia is administered. To avoid stomach puncture by a trocar during primary abdominal entry, an orogastric tube should be placed to decompress the stomach. The patient is placed in dorsal lithotomy position using Allen stirrups, and the buttocks are brought to the edge of table. If very steep Trendelenburg position is anticipated, placement of the patient on beanbags or foam pads specially designed to prevent patient movement should be considered. The use of shoulder blocks or tape across the chest may be considered as well, but should be done with caution given the risk of brachial plexus injury and limitation on ventilation, respectively.
After sufficient vascular access is confirmed, the patient’s arms are gently tucked and padded alongside her body. The use of toboggans designed to support the patient’s arms may be necessary in morbidly obese women. Special attention is given to securing the patient’s hands because they often are in the vicinity of where the Allen stirrup is positioned. Bimanual rectovaginal examination is performed before prepping to familiarize oneself with the anatomy. The abdomen and vagina are surgically prepped and draped.
Placement of the Uterine Manipulator
An open-sided speculum is inserted into the vagina to visualize the cervix. The anterior lip is firmly grasped with a single-toothed tenaculum. With outward traction provided by the tenaculum, the cervical canal is progressively and generously dilated, followed by uterine sounding. The measured distance from the external os to the fundus will determine the length of the uterine manipulator. When a RUMI is used for manipulation, the appropriate-size tip is selected (usually 8 or 10 cm in length) and attached to the manipulator. If there is a question between 2 sizes, it is preferable to request the larger size when also using a colpotomy cup. Next, the vaginal occluder balloon is placed over the uterine manipulator tip. An appropriately sized colpotomy cup (usually the medium) is placed over the end of the manipulator tip and occluder balloon (Figure 25-13). Metal colpotomy cups are appropriate when colpotomy is to be performed using ultrasonic energy, whereas blue plastic cups should be used when electrocautery is planned. The speculum is removed with the tenaculum remaining on the anterior lip of the cervix. The manipulator is grasped in the right hand with the index finger at the tip, and by providing downward traction of the tenaculum using the left hand, the manipulator tip is guided into the dilated cervix. The uterine manipulator tip is advanced toward the pelvis as the colpotomy cup is slid into the vagina. While maintaining pressure toward the pelvis on the manipulator, the tenaculum is removed, allowing the colpotomy cup to advance flush to the cervicovaginal junction. The manipulator tip balloon and vaginal occluder balloon are filled. The manipulator handle is adjusted to test placement and moved upward to provide extreme anteversion of the uterus, thereby helping to prevent the manipulator from inadvertently being displaced or falling out.
FIGURE 25-13. Uterine manipulator with attached colpotomy cup.
Mitigating patient factors can make an otherwise straightforward manipulator placement very challenging. An introitus too narrow to allow insertion of a colpotomy cup may be expanded by performing an episiotomy. Cervical stenosis prohibiting dilation may prompt the surgeon to postpone further attempts until the camera has been placed and intraperitoneal visualization is possible. If the vagina is too contracted to permit placement of any colpotomy cup, the uterine manipulator can be placed without it. Occasionally no manipulator placement is possible, in which case a rectal probe can be placed vaginally to assist with upward uterine movement and demarcation of the cervicovaginal junction.
The Foley catheter is inserted after placement of the uterine manipulator so that it does not get in the way during placement. When there is any perceived possibility of bladder injury, a 3-way Foley may be indicated.
Port Placement
The primary surgeon stands on his or her preferred side of the patient, and the first assistant stands across the operative table. A second assistant, if available, sits or stands between the patient’s legs. Ideally, the surgeon and first assistant should have a video screen directly in front of them, usually adjacent to the leg contralateral to their position.
The scope of the anticipated operation is very important when selecting where to begin the primary trocar entry and subsequently other port sites. The primary trocar can be placed using one of several methods, including the open technique, direct trocar insertion, or transumbilical insertion of a Veress needle. An umbilical or supraumbilical site is usually preferred for primary entry, unless planning for a robotic-assisted para-aortic node dissection, when the port is typically placed a few centimeters cephalad to the umbilicus. In the presence of known or anticipated adhesive disease near the umbilicus, initial access may be most appropriate by left upper quadrant Veress needle insertion in the midclavicular line.
In the open technique, a 1- to 2-cm skin incision is made just below (or within) the umbilicus. A combination of Mayo scissor dissection and retraction using S-shaped retractors is used to reach the fascia. A Kocher clamp is placed, and the fascia is further dissected free of subcutaneous tissue until a second clamp is placed. The fascia is elevated and entered sharply between the 2 clamps. Once the fascia is entered, the peritoneum is grasped with hemostats and incised sharply. The fascial edges are tagged with 0-gauge delayed-absorbable sutures. An index finger should be inserted to confirm intraperitoneal location and sweep along the anterior wall for adhesions or omental attachments. The tip of the S-shaped retractor is inserted into the peritoneal opening and used to guide a 10- or 12-mm Hasson trocar into the abdominal cavity. The trocar is twisted in place and secured laterally with the fascial-anchoring sutures, and the obturator is removed. When performing SILS, a similar technique is performed, although a slightly larger periumbilical incision is required for insertion of the specialized multiport device. Insufflation of the abdomen can begin through this umbilical port by connecting the carbon dioxide (CO2) tubing to the side port of the trocar. High flow is appropriate for insufflation, and the intra-abdominal pressure should be maintained at 15 mm Hg. The laparoscope is then placed through the trocar. The abdomen and pelvis are thoroughly inspected to assess the extent of disease and adhesions. At this point, discovery of unanticipated metastatic disease or pelvic tumor extension may prompt the surgeon to convert to laparotomy. Trendelenburg position is used to facilitate pelvic exposure by movement of bowel into the upper abdomen. Additional ports are placed under direct laparoscopic visualization.
Four port sites are preferred for complex laparoscopic gynecologic procedures performed with traditional instruments (ie, not robotic-assisted or SILS). The umbilical port most often holds the laparoscope. Often, the remaining ports consist only of 5-mm trocars, thus decreasing the risk of postoperative port-site hernia. If specimens need to be removed or a needle inserted, a 5-mm laparoscope can be inserted through a lateral port. Usually the primary surgeon will use 2 ports to allow for work with both hands simultaneously. This is best facilitated with 2 laterally placed ports, but may also be accomplished with use of a suprapubic port and 1 lateral port. However, the ports must be spaced far enough apart to prevent instrument collision outside the patient. The assistant will typically hold the camera and have an additional lateral port. The second assistant provides uterine manipulation and should ensure that the uterus is pushed up into the pelvis during the entire procedure. The current setup for robotic-assisted procedures involves placement of 2 or 3 8.5-mm robotic ports, in addition to a 10- to 12-mm right upper quadrant “first assistant” trocar.
Retroperitoneal Access and Lateral Dissection
Either the da Vinci Surgical System is docked with the surgeon operating via the console, or the procedure continues laparoscopically. The following operative steps will describe traditional, “straight-stick” technique, but are generally applicable to robotic surgery. The uterus is mobilized to 1 side by movement of the uterine manipulator and/or by an intraperitoneal blunt grasper holding 1 cornu. In doing so, the contralateral round ligament should be stretched. The first assistant holds the contralateral fallopian tube medially to provide further exposure and stretch of the broad ligament. The surgeon tents up either the round ligament or the pelvic peritoneum above the psoas muscle. The tissue is sealed and cut with the surgeon’s instrument of choice in order to obtain initial access to the retroperitoneum. The peritoneal incision is extended cephalad in parallel to the IP ligament (Figure 25-14). The ureter is conclusively identified retroperitoneally along the medial leaf of the broad ligament, usually most easily at the pelvic brim.
FIGURE 25-14. Opening the posterior broad ligament. (Reproduced, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
An avascular space within the medial leaf of the broad ligament is identified above the ureter and below the adnexal structures. An opening within this space is made using either blunt, sharp, or energy-based dissection. The surgeon expands the opening by placing 2 instruments within it and gently stretching the peritoneum by moving the instruments in opposite directions parallel to the IP ligament. Development of this opening ensures separation between the ureter and the adnexa. The IP or utero-ovarian ligament is then transected depending on whether the adnexa are to be removed or retained. While cauterizing or sealing the vascular pedicle, tension on the pedicle should be minimized to ensure a hemostatic transection. The uterus is then deflected in the opposite direction, and a similar dissection is performed on the other side.
Anterior Dissection and Bladder Mobilization
The uterine manipulator is adjusted to provide retroflexion, as pressure is maintained by firmly pushing the uterus cephalad from below. A peritoneal incision is made bilaterally within the anterior leaf of the broad ligament and extended across the anterior cul-de-sac at the vesicouterine fold. The surgeon elevates the peritoneum over the bladder centrally, placing the underlying fibrous attachments on stretch. A combination of blunt and sharp or energy-based dissection is used to develop the plane between the cervix and bladder (Figure 25-15). Although the bladder flap is most often initially developed centrally, the presence of scar, usually as a result of prior cesarean section, may necessitate approaching the plane of dissection laterally. It is crucial to adequately mobilize the bladder beyond the colpotomy cup to facilitate safe colpotomy and cuff closure.
FIGURE 25-15. Mobilization of the bladder distally.
Posterior Dissection
The uterine manipulator is adjusted to provide mild anteflexion and is slightly directed to 1 side, exposing the uterosacral ligament and uterine isthmus and cervix laterally. The peritoneum of the medial leaf of the broad ligament is incised toward the uterosacral ligament with care to remain above the ureter. The incision should be directed toward the underlying colpotomy cup, which should be identified posteriorly. Gentle traction by the surgeon on the peritoneum medially and posteriorly will allow for its separation from the uterine isthmus. The uterine vasculature may be visible lateral to the uterine isthmus above the level of the colpotomy cup. After adjustment of the uterine position, the identical procedure is repeated on the contralateral side. Although a peritoneal incision extending across the posterior cul-de-sac is not necessary, it may facilitate development of the rectovaginal space in cases where the rectum is adherent to the cervix posteriorly. When performing an LAVH, the operation can be converted to the vaginal portion at this point or after dividing the uterine vessels.
Division of the Uterine Vessels
After ensuring adequate development of the bladder flap and following posterior dissection, the location of the uterine vessels will be in between, along the lateral uterine isthmus. When used, the colpotomy cup serves as a landmark at which the uterine vasculature should be transected. The uterus and cup should be directed firmly cephalad into the pelvis during the upcoming steps in order to ensure proper position and to minimize risk of injury to the ureters or bladder.
Peritoneal and fibrous attachments are dissected away to skeletonize the uterine vasculature. The isolated vessels are then coagulated or sealed (Figure 25-16). Performing this step bilaterally prior to transection of the vessels minimizes back-bleeding. The vessels are divided perpendicular to their course at the level of the underlying colpotomy cup. The uterine vessels are dissected so that they fall laterally away from the cervix and underlying colpotomy cup.
FIGURE 25-16. Sealing and dividing the uterine vessels.
Laparoscopic Supracervical Hysterectomy
If desired, the corpus can be amputated from the cervix following division of the uterine vasculature. The corpus is incised at a point just below the internal os and superior to the uterosacral ligaments once the uterine vessels have been divided. A conical incision is extended down into the cervix to limit the possibility of residual endometrium (Figure 25-17). Adjunctive coring or ablation of the endocervical canal also may be performed to decrease the risk of long-term postoperative bleeding. Although a uterine manipulator is used during performance of a laparoscopic supracervical hysterectomy, a colpotomy cup is not usually necessary. The uterine manipulator tip will be identified during the amputation of the corpus and is removed vaginally. The uterine corpus is removed either through an enlarged skin incision or via laparoscopic morcellation. The procedure is performed in limited fashion within gynecologic oncology given concerns regarding morcellation in the setting of known or suspected malignancy.
FIGURE 25-17. Uterine amputation. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Detachment of the Cervix From the Vagina
The uterine manipulator is adjusted to provide maximum anteflexion and is directed centrally, pushing the colpotomy cup up firmly against the cervicovaginal junction below. The vaginal occluder balloon should be inflated to prevent loss of pneumoperitoneum during colpotomy incision. The upper vagina is incised anteriorly immediately over the underlying colpotomy cup.
The incision is extended circumferentially by adjustment of the uterine manipulator and intra-abdominal retraction of the uterus. The uterus and cervix, with or without adnexa, are completely detached and removed vaginally.
Occasionally, the manipulator will come out without removal of the uterus due to a small vaginal incision, a bulky uterus, or other circumstances. In this instance, the specimen can usually be grasped with a tenaculum and removed through the vagina. The tenaculum should be placed while visualizing the cervix either vaginally or laparoscopically to avoid injury to the rectum or bladder. If the indication for hysterectomy is benign, a large uterus can be laparoscopically bivalved or divided into pieces to facilitate removal vaginally. Very rarely, an abdominal incision will be required for removal of the uterus.
Closure of the Vaginal Cuff
Closure of the vaginal cuff following laparoscopic hysterectomy may be performed either vaginally or laparoscopically. If a laparoscopic approach is planned, pneumoperitoneum must be reinstituted by occlusion of the vagina using the uterus, the vaginal occluder balloon, a bulb syringe, or a glove stuffed with sponges. Irrigation and suction should be performed to clear the vaginal cuff of blood or small clots.
Laparoscopic closure of the vaginal cuff can be performed by multiple methods. For the method described below, the surgeon stands on the patient’s right side. Two lateral ports are used, allowing the surgeon to work naturally with both hands. A 0- or 2-0–gauge delayed-absorbable suture is trimmed to about the length of a laparoscopic instrument. The suture on a CT-1 needle is introduced through the umbilical 10-to 12-mm port. Pistol grip, curved-tip needle drivers, with the curves directed inward at each other, facilitate efficient suturing and intracorporeal knot tying in the deep pelvis. The lateral vaginal angle on the right side is grasped, and the suture is passed through the full-thickness vagina anteriorly and then posteriorly. The stitch is pulled through until a 3- to 4-cm tail is present. The suture is tied using intracorporeal technique, and the tail is left for later use. The surgeon holds the trailing strand of suture to assist in positioning the vaginal cuff and creating resistance for passage of suture. The needle is passed through the full-thickness vagina from anterior to posterior in a running fashion progressing from right to left. Upon closure of the left vaginal cuff angle, a second running layer is accomplished from left to right. The assistant holds the trailing strand to follow the surgeon while the surgeon holds the initial suture tail, both working to elevate the cuff. Upon reaching the right-side angle, the suture is tied to the initial tail using intracorporeal knot tying. To confirm integrity of the cuff closure, a gloved hand is placed vaginally and the apex probed for defects.
Final Steps
Once the laparoscopic hysterectomy and any other operative procedures have been completed, a final inspection for hemostasis is performed. When robotic assistance has been used, it is undocked and backed away from the operating field. Ports are then removed under direct visualization, and the patient is taken out of Trendelenburg position. All fascial defects 10 mm or greater should be closed with delayed-absorbable suture to avoid a port-site hernia. Various methods of skin closure are available and include subcuticular suturing, skin adhesive (Dermabond; Ethicon, Cornelia, GA), or surgical tape strips (Steri-Strips; 3M, St. Paul, MN) plus tincture of benzoin. If difficulty in delivering the uterus was encountered, the vagina should be inspected prior to reversal of anesthesia and any vaginal lacerations repaired. Diagnostic cystoscopy is at the discretion of the surgeon.
Postoperative Care
Box 25-9 Complications and Morbidity
Intraoperative
Trocar injury to bowel or blood vessels
Hemorrhage
Ureteral transection
Vaginal or periurethral laceration from initial colpotomy cup placement or later attempts at removing uterus
Postoperative
Vaginal or intraperitoneal bleeding
Vaginal cuff complications (ie, cellulitis, abscess, or dehiscence)
Port-site bowel herniation or infection)
Delayed thermal injury to bowel or genitourinary tract
Genitourinary fistula
Laparoscopic hysterectomy patients typically have the same fast return of normal bowel function, easier ambulation, and decreased analgesia requirements as those undergoing vaginal hysterectomy.7 Postoperatively, the care is also very comparable. Intravenous narcotics are often unnecessary, and oral narcotic medication may be required for only 1 or 2 days.
Within a few hours after surgery, the abdominal bandages should be checked for excessive bleeding or serous fluid. Longer cases may result in facial swelling, periorbital edema, subcutaneous edema, and shoulder pain from extended Trendelenburg positioning, all of which usually resolve without complication over the first 24 hours postoperatively.
Although select patients may be discharged on the same day as surgery, typically patients leave the hospital within 24 hours. The Foley catheter is removed early in the morning on the first postoperative day, the diet quickly advanced, and ambulation encouraged.
Patients should be counseled to report heavy vaginal bleeding, fever, increased abdominal pain, or nausea and vomiting. A low threshold of suspicion for the presence of a bowel injury should exist in women who underwent extensive adhesiolysis should they present with fever and increasing abdominal pain. Rarely, women will present semi-emergently with vomiting and abdominal pain and be diagnosed with a trocar-site hernia.
Upon discharge, strict precautions should be reinforced not to resume sexual activity or place anything within the vagina until complete healing has taken place, approximately 6 to 8 weeks later. Laparoscopic hysterectomy is associated with a higher risk of vaginal cuff dehiscence compared to the abdominal or vaginal approach. This may be due to cautery effect near the suture line or technical limitations during surgery that prevent including sufficient tissue within the closure. Regardless of etiology, surgical repair can be performed either vaginally or laparoscopically.16
MODIFIED RADICAL ABDOMINAL HYSTERECTOMY (TYPE II)
Procedure Overview
Box 25-10 Master Surgeon’s Corner
Type II hysterectomy principles may be necessary in some benign conditions, such as a large cervical fibroid or a distended lower uterine segment.
Development of the pararectal and paravesical spaces allows for assessment of the parametria and pelvic lymph nodes.
With limited resection of the cardinal and uterosacral ligaments compared to type III procedures, less bladder and bowel dysfunction is anticipated.
Modified radical hysterectomy represents the second of 5 types of extended hysterectomy originally defined by Piver et al.2 The anatomic landmarks distinguishing a type II hysterectomy are somewhat vague and thus allow a surgeon to tailor the procedure to a patient’s specific situation.17 Type II modified radical hysterectomy is increasingly being performed using a minimally invasive approach.
The purpose of the type II hysterectomy is to remove more paracervical tissue, while still preserving the blood supply to the distal ureters and bladder. Four main procedural differences distinguish a type II hysterectomy. First, the uterine artery is transected just medial to the ureter to ensure preservation of the distal ureteral blood supply. Second, the medial half of the cardinal ligament is resected. Third, the uterosacral ligament is divided halfway between the uterus and sacrum. Lastly, the upper one-third of the vagina is removed. When performed abdominally, these modifications serve to reduce surgical time and associated morbidity compared to a type III hysterectomy, while still enabling complete resection of smaller cervical tumors.
Absolute indications for performing a modified radical hysterectomy are relatively few and often controversial. Frequently, stage IA2 cervical cancer is the presenting diagnosis. Type II hysterectomy is also performed on occasion for (1) preinvasive or microinvasive cervical disease when a more invasive lesion cannot be excluded, (2) selected stage IB1 cervical cancers with lesions smaller than 2 cm, and (3) small central postirradiation recurrences.18Occasionally, extensive uterine cancer will also require a variation of this procedure. In addition, adaptation of the type II hysterectomy may be required if more extensive dissection is required to remove benign disease in the presence of tissue induration or other complicated circumstances.
Preoperative Preparation
Preoperative preparation is similar to that for abdominal hysterectomy. If the patient has had a diagnostic loop or cold knife conization, then it is prudent to wait 6 weeks for tissue healing before attempting radical surgery.
After deciding to perform a modified radical abdominal hysterectomy, the next decision in surgical planning is whether a vertical or transverse incision is best. When there is a pre-existing abdominal incision, it may or may not be appropriate for the planned operation. Whereas a Pfannenstiel incision may be appropriate in some situations, a bulky uterus or morbidly obese patient may suggest the necessity of a Maylard, Cherney, or vertical incision to obtain adequate exposure.
Significant morbidity and potentially unforeseen short- and long-term complications are more likely compared to a simple type I hysterectomy. These complications are more likely in women with obesity, prior pelvic infections, previous radiation therapy, and prior abdominal surgery. Of potential intraoperative complications, the most common is acute hemorrhage. Due to a more limited dissection, subacute postoperative complications, including ureterovaginal or vesicovaginal fistula and significant postoperative bladder or bowel dysfunction, are less likely than with the more radical type III hysterectomy.18 Additionally, potential long-term effects on sexual function, loss of fertility, and other body functions should be candidly reviewed.
Modified radical abdominal hysterectomy is not dependent on specific instrumentation. In general, a self-retaining retractor, such as the Balfour or Bookwalter, is needed. However, the surgeon may have specific requests, such as cervical tunneling clamps, certain coagulation sealing devices, or other relevant items required for an individual case.
Operative Procedure
Box 25-11 Caution Points
Ensure development of the pararectal space is performed medially, following the sacral curve. Dissecting too laterally below the internal iliac vasculature may cause inadvertent hemorrhage from the adjacent venous plexus.
Identify and tag the ureter early, and regularly verify its location, especially while transecting cardinal and uterosacral ligaments.
Direct pressure toward the posterior vagina when developing the rectovaginal space to avoid injuring the rectum.
Anesthesia and Patient Positioning
General endotracheal anesthesia is administered, and the patient is positioned similarly, whether the planned operation is a type I, II, or III abdominal hysterectomy. Bimanual rectovaginal examination should always be performed in the operating room before scrubbing to familiarize oneself with the anatomy and to make a final decision on the type of incision. The abdomen and vagina are surgically prepared, and a Foley catheter is placed.
Abdominal Entry
Modified radical hysterectomy may be safely performed through a midline vertical or transverse incision. Following entry to the peritoneal cavity and abdominal exploration, the self-retaining retractor is assembled.
Retroperitoneal Dissection
The initial steps of modified radical abdominal type II hysterectomy mirror those of the type I or III procedure. However, the round ligament is sutured and divided more laterally than in a type I hysterectomy. The anterior and posterior leaves of the broad ligament are incised, exposing the retroperitoneum. The ureter is identified, mobilized, and tagged with a ¼-in Penrose drain. The pararectal space is developed by placing an index finger between the internal iliac artery and ureter. Pressure is directed medially and along the sacral curve toward the coccyx using a gentle swirling motion (Figure 25-18). As a result, the ureter, medial leaf of the broad ligament, and ultimately pararectal tissues are separated from the lateral pelvis.
FIGURE 25-18. Making the pararectal space. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Next, the paravesical space is developed by elevating the lateral tie on the round ligament and dissecting bluntly following the external iliac artery to the pelvic bone. The index, middle, and ring fingers of the right hand then are swept horizontally toward the midline, but remaining lateral to the umbilical vessels. By placing the index finger in the paravesical space and the surgeon’s middle finger in the pararectal space, the parametria can be assessed for tumor extension before proceeding with this less radical operation. Otherwise, a type III hysterectomy might be more appropriate.
Utero-Ovarian Ligament Transection
The next operative step depends on whether the adnexa are to be concurrently removed or not. Once the ureter has been identified, the IP or utero-ovarian ligament may be divided and peritoneal attachments dissected, as described in the Abdominal Hysterectomy section.
Uterine Artery Ligation
Ligation of the uterine artery in a type II hysterectomy is performed medial to the ureter, necessitating less radical dissection of sidewall tissues than in a radical type III procedure. The superior vesical artery does not have to be identified, nor does the entire extent of the internal iliac artery need to be dissected free of adventitial tissue. The ureter should be followed along the broad ligament, and the ureteral tunnel opening through the cardinal ligament should be palpated. The uterine vessels are divided at that location using clamps and delayed-absorbable ties (Figure 25-19) or a coagulation sealing device. Ligation of the uterine artery as it crosses the ureter allows preservation of distal ureteral blood supply.
FIGURE 25-19. Uterine artery ligation. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Cardinal Ligament Resection
The bladder is mobilized distally off the cervix and onto the upper vagina as described for a type I abdominal hysterectomy. The ureteral tunnel through the cardinal ligament is unroofed with division of the medial half of the cardinal ligaments and anterior leaf of the vesicouterine ligament. The tissues are clamped, cut, and suture ligated with care to avoid the ureter (Figure 25-20). In contrast to the type III hysterectomy, the ureter is not dissected out of the tunnel bed, but is rolled laterally to expose the medial cardinal ligament. Maintenance of the posterior attachments between the ureter and the cardinal ligament further preserves its blood supply.
FIGURE 25-20. Cardinal ligament resection. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw- Hill; 2008.)
Uterosacral Resection
Posterior radical dissection often is best performed near the end of the procedure because exposed retroperitoneal tissues typically bleed until the vaginal cuff is closed. The cervical external os is palpated, and cautery is used to superficially incise the peritoneum between the uterosacral ligaments.
A plane is developed by gently pressing a finger toward the vaginal wall without poking through into the vault. This rectovaginal plane should be developed by gentle pressure toward the sacrum and enlarged laterally until 3 fingers can be inserted comfortably. This maneuver frees the rectosigmoid away from the uterosacral ligaments and prevents inadvertent bowel injury. Remaining peritoneal attachments are dissected sharply to fully expose the rectovaginal space. The uterosacral ligaments are clamped halfway to the pelvic sidewall (instead of at the pelvic sidewall for a type III hysterectomy), transected, and ligated with 0-gauge delayed-absorbable suture, or sealed and divided with a coagulating sealing device. The uterus and adjacent parametrium can then be lifted well out of the pelvis, and any additional tissues can also be clamped, cut, and ligated.
Vaginal Resection
At this point in surgery, the modified radical hysterectomy specimen should be held in place only by the paracolpium and vagina. The bladder and ureters are further bluntly and sharply dissected free until at least 2 cm of upper vagina are included in the specimen (instead of 3 to 4 cm as is the case for a type III hysterectomy). Curved clamps are placed on the lateral paracolpium, which is then cut and suture ligated (Figure 25-21). The upper vagina can then be closed with a continuous running method using 0-gauge delayed-absorbable suture. The specimen should be carefully examined to ensure an adequate upper vaginal segment and grossly negative margins.
FIGURE 25-21. Upper vaginal resection. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Final Steps
Once the modified radical abdominal hysterectomy has been performed, a final review of the operative field should be performed, as for any type of abdominal surgery. Intraoperative drain placement is not required, unless the blood loss has been excessive or other extenuating circumstances warrant it.
Postoperative Care
Box 25-12 Complications and Morbidity
Intraoperative
Hemorrhage
Bladder or rectal injury
Ureteral transection, ligation, or “kinking”
Postoperative
Ileus (more pronounced with vertical incision
Vaginal or intraperitoneal bleeding
Neurologic deficit (ie, retractor injury)
Wound infection, separation, or fascial dehiscence
Thromboembolic event
Genitourinary fistula (infrequent)
Incisional hernia (more likely in obese patients)
Long-term bladder or rectal dysfunction (limited)
Sexual dysfunction (limited)
Modified radical abdominal hysterectomy is associated with longer patient recovery and hospital stays, increased incisional pain, and a greater risk of postoperative febrile morbidity compared to laparoscopic or robotic approaches. In general, postoperative care should not be much different than that for simple type I abdominal hysterectomy. Overall, the incidence of complications is lower than compared to the more extensive type III radical operation.18Partial sympathetic and parasympathetic denervation should be much less extensive. Thus, bladder dysfunction is much less likely, and successful voiding occurs much earlier. Foley catheter drainage may be discontinued on the second postoperative day and is followed by a voiding trial.
RADICAL ABDOMINAL HYSTERECTOMY (TYPE III)
Procedure Overview
Box 25-13 Master Surgeon’s Corner
Type III hysterectomy principles may be necessary in a variety of surgical situations not involving malignancy.
If suspicion of metastatic disease is present in the parametria or lymph nodes, intraoperative pathologic assessment should be considered if confirmation will change the operative plan.
Obesity and extreme depth to the pelvis hinder the exposure essential to safe performance of a type III procedure; ensure availability of adequate retractors and longer instrumentation.
Radical hysterectomy refers to the third of 5 types of extended hysterectomy originally defined by Piver et al.2 Type I and II hysterectomies were reviewed in the Abdominal Hysterectomy and Modified Radical Abdominal Hysterectomy (Type II) sections, respectively. Type IV hysterectomy involves excision of the superior vesicle artery and three-fourths of the upper vagina. Type V hysterectomy includes portions of the distal ureter or bladder. The aim of the type III operation involves wide radical excision of the parametrial and paravaginal tissues in addition to removal of intervening pelvic lymphatics. Type III radical hysterectomy is increasingly being performed by a minimally invasive approach (see Laparoscopic Radical Hysterectomy section).
Four main procedural differences distinguish a “true” radical hysterectomy. First, the uterine artery is ligated as it originates from the internal iliac artery (rather than where it crosses the ureter, as in a type II procedure). Second, dissection of the ureter from the pubovesicle ligament (ie, the “tunnel”) is completed until its entry into the bladder, except for a small lateral portion between the lower end of the ureter and the superior vesicle artery, thereby maintaining some distal ureteral blood supply. Third, the uterosacral ligaments are resected at their sacral attachments (instead of directly adjacent to the uterus as in a type I procedure, or halfway between the uterus and sacrum as in the type II procedure; Figure 25-22). Lastly, the upper one-third, about 3 to 4 cm, of the vagina is removed. This operation is chiefly indicated for stage IB1 to IIA cervical cancer, small central recurrences following radiation therapy, or clinical stage II endometrial cancer when tumor has extended to the cervix.
FIGURE 25-22. Extent of uterosacral ligament resection by hysterectomy type. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Radical hysterectomy is a dynamic operation that always requires significant intraoperative decision making. Every step requires a focused, consistent surgical approach. In many ways, radical abdominal hysterectomy initially defined the field of gynecologic oncology. Familiarity with its concepts continues to be critically important in developing expertise in complex pelvic surgery.
Preoperative Preparation
A spectrum of tests may be required to reach an accurate preoperative diagnosis, but typically, radical abdominal hysterectomy is performed for early-stage cervical cancer. Pelvic examination under anesthesia with cystoscopy and proctoscopy is not mandatory for smaller lesions, but accurate clinical staging of cervical cancer with appropriate imaging is critical prior to surgery. Other tests vary depending on the clinical setting and are discussed in Chapter 5. Unfortunately, there are limitations in what can be reliably detected preoperatively, and occasionally, unanticipated metastases will be discovered intraoperatively. If the patient has had a diagnostic loop or cold knife conization, it is often prudent to wait 6 weeks for tissue healing.
Radical abdominal hysterectomy can result in major short- and long-term morbidity, generally exceeding the minimally invasive approach.19,20 Thus, the reasoning for laparotomy should be clearly communicated to the patient. The other major decision in surgical planning is whether a vertical or transverse incision is best. When there is a pre-existing abdominal incision, it may or may not be appropriate for the planned operation. Whereas a Pfannenstiel incision may be appropriate for type I or II hysterectomy, most gynecologic oncologists find it provides inadequate exposure to the lateral pelvis when performing a type III procedure.
Significant morbidity and potentially unforeseen short- and long-term complications are certainly more likely compared to a type I or II hysterectomy. These complications may develop more frequently in obese women and those with prior pelvic infections or prior abdominal surgery. Of potential intraoperative complications, the most common is acute hemorrhage. Blood loss averages 500 to 1000 mL, and transfusion rates are variable but relatively high.21Subacute postoperative complications may include ureterovaginal or vesicovaginal fistula (1%-2%) and significant postoperative bladder or bowel dysfunction (20%).22 Additionally, long-term effects on sexual function, loss of fertility, and other body functions should be candidly reviewed.23 The tone of the consenting process should reflect the extent of the operation required to hopefully cure or at least begin treatment of the malignancy. In addition, the patient must be advised that the procedure may be aborted if unexpected metastatic disease or pelvic tumor extension is found.
Other preoperative preparations follow as described for any type of abdominal hysterectomy. However, due to the potential for intraoperative hemorrhage, it may be prudent to have 2 units of packed cells typed and crossed in case they are urgently needed. Fortunately, radical abdominal hysterectomy is not dependent on specific instrumentation. In general, the equipment is similar to that used for a type II hysterectomy. Two doses of perioperative antibiotic prophylaxis with a third-generation cephalosporin such as cefoxitin may need to be given at spaced intervals if excessive bleeding occurs, due to the rapid clearance of antibiotics from the operative site.
Operative Procedure
Box 25-14 Caution Points
Type III hysterectomies can be associated with large intraoperative blood loss, much of which occurs at a few select steps in the procedure.
Ligation and transaction of uterine vasculature, especially venous structures deep to the arter.
Ligation and transection of the vesicouterine ligaments while unroofing the urete.
Ligation and transaction of the uterosacral ligaments posteriorl.
Identify and tag the ureter early, especially while transecting the cardinal and uterosacral ligaments.
Anesthesia and Patient Positioning
General endotracheal anesthesia is administered, and the patient is positioned similarly, whether the planned operation is a type I, II, or III hysterectomy. Bimanual rectovaginal examination should always be performed in the operating room before scrubbing to familiarize oneself with the anatomy and to make a final decision on the type of incision. The abdomen and vagina are surgically prepared, and a transurethral Foley catheter is placed.
Abdominal Entry
A midline vertical abdominal incision provides excellent exposure but typically prolongs hospital stays and increases postoperative pain. Alternatively, Cherney or Maylard incisions offer postoperative advantages found with transverse incisions and allow increased access to the lateral pelvis. However, upper para-aortic nodes are not readily accessible through these transverse incisions. Following entry into the peritoneal cavity, the surgeon thoroughly explores the abdomen for obvious metastatic disease. Suspicious lymph nodes and any other lesions should either be removed or biopsied. Confirmation of metastatic disease or pelvic tumor extension should prompt an early decision about whether to proceed or abort an operation based on the overall intraoperative findings and clinical situation.
Entering the Retroperitoneal Space
The initial steps of a type III hysterectomy mirror those of the type I or II procedure except that, in this case, the round ligament is sutured with 0-gauge delayed-absorbable suture as far laterally as possible to facilitate the excision of parametrial tissue out to the pelvic sidewall. The anterior and posterior leaves of the broad ligament are sharply dissected, the ureter is placed on a ¼-in Penrose drain, and the paravesical and pararectal spaces are opened, as described earlier for type II hysterectomy.
Utero-Ovarian Ligament Transection
The next operative step depends on whether the adnexa are to be concurrently removed or not. Cervical cancer spread to the adnexa is much less common than via the lymphatics. Thus, removal of the adnexa should depend on a woman’s age and potential for metastases. In candidates for ovarian preservation, transposition of ovaries out of the pelvis may be considered in premenopausal women if postoperative radiation is anticipated. However, symptomatic periadnexal cysts are common in transposed ovaries, and sustained ovarian function may not result. Regardless, once the ureter has been identified, the uteroovarian or IP ligament may be divided and peritoneal attachments dissected, as described in the Abdominal Hysterectomy section.
Uterine Artery Ligation
The superior vesical artery serves as the medial boundary for the paravesical space, which has been thoroughly developed. A narrow curved Deaver retractor is placed into the space and used to elevate and retract the artery medially. The vessel is both bluntly and sharply dissected on its lateral aspect down to its bifurcation off of the internal iliac artery. Placement of the surgeon’s hand into the pelvis with the middle finger in the paravesical space and the index finger in the pararectal space allows for assessment of the parametria. Medial traction of the parametrial tissue and uterus places the uterine vasculature on stretch and exposes the medial surface of the internal iliac artery. From its bifurcation with the external iliac artery, parametrial attachments and areolar tissue are dissected along the internal iliac artery and reflected medially. During this dissection, the uterine artery will become apparent at its origin.
The uterine artery is one of several branches from the anterior division of the internal iliac artery; in the course of a radical hysterectomy, the posterior division should not be visible. The tissues immediately proximal and distal to the uterine artery are bluntly dissected, and a right-angle clamp is placed beneath this artery to retrieve a 2-0 silk suture (Figure 25-23). The uterine artery tie is placed as close as possible to its origin from the internal iliac artery. The process is repeated to place a separate silk suture far enough medial to enable vessel transaction. Silk ties help identify the proximal and distal portions of the uterine artery throughout the remainder of the operation. A small vascular clip can also be placed lateral to the silk tie on the proximal uterine artery for additional security of hemostasis. The uterine artery is then cut. The underlying uterine vein may also then be isolated, clipped or tied, and cut.
FIGURE 25-23. Ligating the uterine artery. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Uniting Paravesical and Pararectal Spaces
Once the uterine artery has been divided, it must be mobilized medially over the ureter along with surrounding parametrial tissue. Placement of a finger in both the paravesical and pararectal spaces results in the parame-trial tissues being pressed together. Medial mobilization of the parametrial tissue unites these spaces and can be performed by several methods: (1) clamping, cutting, and suturing (Figure 25-24); (2) stapling with the gastrointestinal anastomosis stapler; (3) electro-surgical blade dissection to the pelvic sidewall using a right-angle clamp to elevate and isolate parametrial tissue; or (4) use of an electrothermal bipolar coagulator. Dissection is continued until the parametrial tissue is able to be fully mobilized medially over the ureter.
FIGURE 25-24. Uniting the spaces, division of parametrial tissue. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Ureter Mobilization
To detach the ureter from the medial leaf of the peritoneum, the tips of a right-angle clamp are positioned perpendicular to and just above the ureter. By opening the tips parallel to the ureter, a plane is created that permits it to be further bluntly dissected away from the peritoneum. The ureter is placed on gentle traction using the previously placed Penrose drain. An index finger placed medial to the ureter carefully sweeps it downward and laterally until the opening of the “tunnel” into the paracervical tissue is palpated ventromedially (Figure 25-25). Additional parametrial dissection is often required to ensure that the uterine artery and surrounding soft tissue have been entirely lifted medially over the ureter.
FIGURE 25-25. Mobilizing the ureter. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Unroofing the Ureteral Tunnel
The bladder is mobilized distally off of the anterior cervix as described for a type I or II hysterectomy, but will need to be additionally dissected several centimeters onto the upper vagina to allow for the more radical margin associated with a type III procedure. The uterus is placed on medial traction, and the proximal ureter is held laterally on traction by gently pulling on the Penrose drain. The tunnel opening should be palpated. Concurrently, a right-angle clamp is inserted above the ureter on its medial side with tips directed upward. Direct visualization of the underlying ureter is confirmed. The tips are directed medially toward the cervix, parallel to the course of the tunnel, and “popped” through the paracervical tissue ventrally. A second clamp is placed through the opening. The ureter can be bluntly dissected and pushed posteriorly toward the tunnel floor. It should be visible below before cutting the overlying paracervical tissue (Figure 25-26). Delayed-absorbable 3-0 suture ties are placed to secure the paracervical tissue pedicles. Significant bleeding is commonly encountered during these steps. The same procedure may need to be repeated several times to completely unroof the tunnel and fully expose the course of the ureter. The dissection should proceed in a proximal to distal fashion with direct visualization of the ureter at all times, because this is the part of the operation where the ureter is most at risk for transection or other types of injury. Increasingly, the use of new technologies, such as an ultrasonic shear, can be used to secure and divide the pedicles, thereby decreasing operating time and blood loss. After unroofing the ureter, it is retracted upward and laterally. Filmy attachments between the ureter and tunnel bed are sharply divided.
FIGURE 25-26. Unroofing the ureteral tunnel. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Uterosacral Resection
Posterior radical dissection is generally performed as described for a type II hysterectomy, but the uterosacral ligaments are clamped at the pelvic sidewall (Figure 25-27). The tissue is transected and ligated with 0-gauge delayed-absorbable suture or sealed and divided with a coagulating sealing device. This procedure may need to be repeated to complete transection of the entire uterosacral ligament and adjacent supportive tissues. The uterus and adjacent parametrium can then be lifted well out of the pelvis and any additional tissue attachments divided.
FIGURE 25-27. Uterosacral resection. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Vaginal Resection
At this point in the operation, the radical hysterectomy specimen should be attached only by the paracolpium and vagina. The bladder and ureters are further bluntly and sharply dissected free until at least 3 to 4 cm of upper vagina can be included with the resected specimen. Curved clamps are placed on the lateral paracolpium. The ureter should be lateral and directly visible. Tissue is then cut and suture ligated with 0-gauge delayed-absorbable suture. The upper vagina can then be incised circumferentially at the point of desired margin and closed with either continuous or interrupted 0-gauge delayed-absorbable suture. The specimen should be carefully examined to ensure an adequate upper vaginal segment and grossly negative margins.
Suprapubic Catheter Placement
The radical resection of the parametrial tissues in a type III procedure commonly results in early postoperative difficulty with voiding, necessitating bladder drainage for an extended period. In general, the transurethral Foley catheter will be satisfactory for postoperative management. However, placement of a suprapubic catheter may aid postoperative voiding trials in carefully selected, motivated patients. The tip of a second Foley catheter is brought through a stab incision in the lateral abdominal wall. The Foley catheter already within the bladder is held firmly and anteriorly in a distal extraperitoneal location. A 5-mm transverse incision is made through the bladder wall using an electrosurgical blade set to cutting mode. The Foley bulb should be directly visible to confirm entry through the mucosa. After being incised, the bladder mucosal edges are held with 2 Allis clamps. The second Foley catheter tip is inserted, and the balloon is inflated. A snug, but not overly tight, purse-string 3-0 chromic suture is used to close the bladder defect around the catheter. If the knot is placed too tightly, it may result in difficulty when removing the catheter postoperatively.
Delayed-absorbable suture in a running fashion is used to “bury” the visible intra-abdominal portion of the Foley catheter tubing in a tunnel of overlying peritoneum until its exit at the lateral anterior abdominal wall. The Foley catheter should be secured at the skin with a permanent suture that does not occlude the tubing. The urethral Foley catheter can be discontinued postoperatively when urine is seen to be draining from the suprapubic catheter.
Final Steps
Active bleeding should be controlled by cautery or ligature when the radical hysterectomy specimen has been removed. With bleeding controlled, ovarian transposition (Chapter 24) and/or lymphadenectomy (Chapter 28) may be performed next.
Once all planned surgical procedures have been completed, the surgeon should assess the vascular support to the ureter and other sidewall structures. If any structures appear particularly devascularized, an omental J-flap may be mobilized to provide additional blood supply. If ovarian transposition has been performed, the ovaries should be carefully inspected before abdominal closure to exclude vascular compromise. Routine pelvic suction drainage and closure of the peritoneum are not necessary in the absence of extenuating circumstances.24
Postoperative Care
Box 25-15 Complications and Morbidity
Intraoperative
Hemorrhage
Bladder or rectal injury
Ureteral transection, ligation, or “kinking”
Postoperative
Ileus (especially with vertical incision or excess blood loss)
Vaginal or intraperitoneal bleeding
Neurologic deficit (ie, retractor injury)
Wound infection, separation, or fascial dehiscence
Thromboembolic event
Genitourinary fistula (significantly more likely than for type II hysterectomy, especially when postoperative radiation is used)
Incisional hernia (more likely in obese patients)
Long-term bladder or rectal dysfunction (common)
Sexual dysfunction (common, particularly following postoperative radiation)
Radical abdominal hysterectomy is associated with longer patient recovery and hospital stays, increased incisional pain, and a greater risk of postoperative febrile morbidity compared to laparoscopic or robotic approaches.19-21Admission to the intensive care unit is uncommon but may be indicated for intraoperative hemorrhage, hemodynamic instability, or other medical comorbidities that might prompt the need for increased surveillance. In general, postoperative care is not dramatically different than for type I or II hysterectomy, or any type of abdominal surgery with a few exceptions.
Bladder tone typically returns slowly and is thought to be related to the degree of sympathetic and para-sympathetic denervation during radical dissection. Foley catheter drainage is commonly continued until the patient is at least passing flatus, because improving bowel function typically accompanies resolving bladder hypotonia. Removal of the catheter or clamping of the suprapubic tube should be followed by a voiding trial, either prior to hospital discharge or at the first postoperative visit. A successful trial involves voiding more than 100 mL with a postvoid residual volume measuring less than 100 mL. When the trial is unsuccessful, it can be reattempted in several days. To remove the suprapubic tube, the skin stitch is cut, and the catheter should gently slide out. The small bladder opening will heal spontaneously.
Patients should be counseled that successful voiding may take several weeks to achieve. Unfortunately, in some cases, postoperative bladder dysfunction is permanent. Frequently, these patients had pre-existing abnormal urodynamic findings that were simply exacerbated by radical hysterectomy. For the less than 5% of women who develop long-term bladder hypotonia or atony, the preferred management is intermittent self-catheterization rather than indwelling urinary catheterization. Although most instances of long-term bladder dysfunction are unavoidable and simply represent a known risk of radical hysterectomy, some surgeons advocate a nerve-sparing technique as a way to reduce the likelihood.25
Tenesmus, constipation, and episodes of fecal incontinence are common immediate symptoms that should improve significantly months or years later. More than half of surgical patients report a worse sex life, at least in the short-term. Fortunately, patients treated by surgery alone can eventually expect a quality of life and overall sexual function similar to peers without a history of cancer.26
Although development of a fistula should be rare, the incidence increases 2- or 3-fold when patients require postoperative pelvic radiation. In addition, cervical cancer survivors treated with radiotherapy have much worse sexual functioning. Severe orgasmic problems, uncomfortable intercourse due to a reduced vaginal capacity, and severe dyspareunia may develop, sometimes resolving to some degree within 6 to 12 months. However, a persistent lack of sexual interest and lubrication often persist long-term.
LAPAROSCOPIC RADICAL HYSTERECTOMY (TYPES II AND III)
Procedure Overview
Box 25-16 Master Surgeon’s Corner
The position of the laparoscope within the pelvis provides excellent views of deep pelvic anatomy often not achievable by laparotomy.
The wristed instrumentation available with the robotic platform permits an ease of angulation to approach challenging anatomy. More effort is required to achieve similar results with traditional laparoscopic instruments.
The current robotic platform lacks haptic feedback, which many gynecologic oncologists find useful during open abdominal and traditional laparoscopic procedures.
Laparoscopic type II or III radical hysterectomy encompasses the identical anatomic boundaries as described for the corresponding abdominal procedures [see Modified Radical Abdominal Hysterectomy (Type II) and Radical Abdominal Hysterectomy (Type III) sections]. A minimally invasive laparoscopic approach, whether performed with traditional “straight-stick” instrumentation or with robotic assistance, is advantageous due to shorter recovery time, less postoperative pain, and decreased length of hospital stay.19,20 Although initial series suggest similar oncologic outcomes compared to procedures performed abdominally, more long-term survival data are needed.27Laparoscopic radical hysterectomy, especially the type III procedure, is associated with initial long operative times and a flat learning curve. Utilization of a robotic platform in performance of the procedure is associated with accelerated skill acquisition. The currently available platform offers 3-dimensional imaging and wristed instrumentation, both of which are greatly beneficial given the meticulous dissection required. As a result, the majority of gynecologic oncologists use robotic assistance when performing laparoscopic radical hysterectomies.21
Selecting appropriate candidates is critical to successful minimally invasive surgery. In general, potentially problematic factors and other limitations are similar to those described earlier for laparoscopic type I hysterectomy. However, prior pelvic infections or other causes of retroperitoneal fibrosis may be particularly challenging to overcome when performing laparoscopic type II or III procedures due to the need for extensive dissection and development of tissue planes. Large cervical tumor size may limit the ability to place and use a uterine manipulator. A bulky uterus may be difficult to manipulate, block visualization within the pelvis, and be too large for vaginal removal. Patients with these findings may require an open, abdominal approach.
Preoperative Preparation
The basic preoperative evaluation for laparoscopic type II and III radical hysterectomy is similar to that of the abdominal approach. Preoperative pelvic examination is important to determine cervical appearance, uterine size, and mobility. Once a patient has been deemed appropriate for minimally invasive surgery, the same preoperative evaluation as for an open procedure applies. The consent should reflect the potential for needing to convert to laparotomy if exposure and organ manipulation are limited, the risks of gastrointestinal or genitourinary injuries, and other possible complications. Complications specific to laparoscopy include entry injury to the major vessels, bladder, ureters, and bowel.
Even more so than with performing a simple laparoscopic type I hysterectomy, the type II and III procedures are very dependent on specific instrumentation. Currently, the only commercially available robotic system is the da Vinci Surgical System (Intuitive Surgical). The specifics of this system and fundamentals of robotically assisted surgery are described in detail in Chapter 31. Important robotic instruments for radical hysterectomy include the EndoWrist monopolar scissors and the EndoWrist bipolar Maryland grasper. A PK Dissecting forceps is available as an alternative bipolar cautery source. The Harmonic Scalpel is also available but lacks the benefit of wristed movements. Various additional graspers and retractors can be used in the fourth robotic arm as desired for the procedure. The surgical assistant uses traditional laparoscopic instruments through a 12-mm assistant port. Some gynecologic oncologists prefer not to use a uterine manipulator in the setting of a cervical tumor, relying instead on the fourth arm of the robot to hold the uterus with a grasper. Others find use of a suitable uterine manipulator, as well as a modified colpotomy cup, to be indispensible.
Operative Procedure
Box 25-17 Caution Points
The ureter must be consciously, consistently held laterally during critical laparoscopic steps because it cannot be tagged as it is during abdominal surgery.
Dissect the ureter out of the cardinal ligament tunnel with surgical effort directed just over and medial to the ureter. Dissecting under a ureter that is off tension can lead to accidental laceration just ahead of the leading edge of dissection.
Although essential in maintaining a hemostatic operative field during laparoscopy, energy should be used in careful moderation in close proximity to the ureter and other fragile tissues.
Anesthesia and Patient Positioning
Administration of anesthesia and positioning are as previously described. After positioning the patient in dorsal lithotomy and before she is prepped and draped, a test of steep Trendelenburg should be performed to confirm secure positioning on the table. Bimanual rectovaginal examination is performed before prepping to familiarize oneself with the anatomy. Finally, the abdomen and vagina are surgically prepped and draped.
Placement of the Uterine Manipulator
When a bulky cervical cancer prevents insertion of a uterine manipulator, a blunt rectal probe may be inserted vaginally to facilitate the operation. Otherwise, whenever feasible, placement of an effective uterine manipulator is helpful. The technique is further described in the Laparoscopic Hysterectomy section. A modification of colpotomy cup placement has been described that facilitates incision of the vagina with a margin sufficient for radical hysterectomy.28 Briefly, the smallest of 3 commonly available colpotomy cups is placed within the largest, and both are then placed on the uterine manipulator. The smaller cup exerts force directly on the cervix, while the ring of the larger demarcates the vagina at about 2 cm distal to the cervicovaginal junction. Because manipulator placement can often be difficult, the Foley catheter is inserted afterward so that it does not get in the way during placement. When there is any perceived possibility of bladder injury, a 3-way Foley provides additional access to easily backfill with methylene blue–colored saline, and the integrity of the bladder should be confirmed at the end of the procedure.
Port Placement
The surgeon and assistant(s) are positioned around the patient, and abdominal entry is performed as described earlier in the Laparoscopic Hysterectomy section. The abdomen and pelvis are thoroughly inspected to assess the extent of disease and adhesions. At this point, discovery of unanticipated metastatic disease or pelvic tumor extension may prompt the surgeon to convert to laparotomy. Otherwise, additional ports are placed under direct intra-abdominal visualization. The patient is placed in steep Trendelenburg. Either the da Vinci Surgical System is docked with the surgeon operating via the console, or the procedure continues laparoscopically. The following technique is applicable regardless of whether or not robotic assistance is used. Instrumentation will differ according to approach and availability, but the general principles and steps should replicate an open, abdominal procedure.
Opening the Paravesical and Pararectal Spaces
Entering the retroperitoneum to identify the underlying structures is the initial step. As described for laparoscopic type I hysterectomy, the uterus is mobilized to 1 side by movement of the uterine manipulator and/or by an intraperitoneal blunt grasper holding 1 cornu. In doing so, the contralateral round ligament should be stretched. The surgeon tents up the round ligament, which is sealed and cut far laterally with the surgeon’s instrument of choice, and initial access to the retroperitoneum is achieved. When performing robotic surgery, the Maryland bipolar forceps and monopolar scissors are used, whereas with traditional laparoscopy, ultrasonic shears are favored. The peritoneal incision is extended cephalad in parallel to the IP ligament.
While the first assistant holds and retracts the medial peritoneal edge medially, the surgeon uses 2 instruments in tandem to bluntly develop the retroperitoneum. Areolar tissue is separated easily, while small fibrous and vascular strands are sealed and cut. The lateral portion of the round ligament is elevated, and areolar tissue underneath is bluntly dissected. The external iliac vasculature is identified and exposed with extension of the peritoneal incision along the pelvic sidewall to above the bifurcation of the common iliac artery. The ureter is identified at the pelvic brim and exposed with retraction of the medial leaf of the broad ligament under the IP medially (Figure 25-28). The internal iliac artery is thus exposed down to the origin of the superior vesical artery. Development of the pararectal space between the ureter and internal iliac vasculature is performed by the surgeon with 2 instruments working in tandem, bluntly retracting tissue in opposite directions. The dissection proceeds cautiously and is directed medially along the sacral curve. The uterine artery is usually identified in doing so.
FIGURE 25-28. Identifying the retroperitoneal structures.
Development of the paravesical space is facilitated by retraction of the medial umbilical ligament in the anterior pelvis medially by the first assistant. This places traction on the superior vesical artery to enable the surgeon to identify the correct plane of dissection. Blunt dissection beginning under the lateral portion of the cut round ligament directed medially toward the retracted medial umbilical ligament will initiate opening of the space. Tissue is then bluntly mobilized laterally away from the superior vesical artery all the way to its origin. Lastly, the obturator nerve is identified within the obturator fossa. Once the paravesical and pararectal spaces are opened, the parametria are now isolated between these 2 spaces. The uterus is then deflected in the opposite direction, and similar dissection is performed on the other side.
Adnexectomy or Ovarian Preservation
The utero-ovarian or IP ligament will be transected as previously described following identification of the ureter and development of an avascular space within the medial leaf of the broad ligament, depending on whether the adnexa are to be removed or retained. The procedure is repeated on the contralateral side.
Ureteral Isolation
The first assistant holds and retracts the medial edge of the cut medial leaf of the broad ligament medially, exposing the ureter. The surgeon bluntly develops the plane between the ureter and peritoneum. The act of opening a closed fine grasper placed immediately medial to the ureter is a useful technique to safely begin development of this plane, which is then extended all the way until the uterine vasculature is to be encountered. Occasional cautious use of energy (ie, short bursts of monopolar cautery or use of ultrasonic shears) will be necessary to separate the ureter from more dense fibrovascular attachments. Later, the ureter will be further dissected in stages from surrounding attachments, depending on whether a type II or III hysterectomy is performed.
Bladder Mobilization
The bladder is mobilized laparoscopically as previously described, but to a greater degree compared to in a type I procedure. Fibrous attachments are divided with an energy source from proximal to distal between the posterior bladder and the uterus/anterior vagina. As the bladder is pushed inferiorly, the colpotomy cup, if present, will be palpable. Alternatively, a rectal probe can be used within the vagina both to provide vaginal landmarks and a firm surface on which to dissect. It is crucial to adequately mobilize the bladder onto the upper vagina to provide a satisfactory distal margin of the resection. Although the technique for performing laparoscopic type II and III hysterectomy has been identical to this point, the operative steps begin to diverge.
Uterine Artery Ligation and Ureteral Dissection
Type II Modified Radical Hysterectomy
The ureter has been dissected to a level near the uterine artery. Although the intent of a type II procedure is to transect the uterine artery where it crosses the ureter, it is often easiest to first identify the artery at its origin. Blunt dissection along the internal iliac and superior vesical arteries along with medial tension on the uterus will assist in its identification. In the case of a type II procedure, the uterine artery path is traced back to its intersection with the ureter. The ureter is then dissected so that it falls a short distance from the vessel, which can then be safely cauterized or sealed, and cut (Figure 25-29). The medial cut end of the uterine vessels along with the associated parametrial tissue are then elevated and held medially by the first assistant. The ureter is held on gentle lateral traction while the surgeon works to separate it from any medial attachments to the parametria. The tunnel of the ureter is encountered, comprised of cardinal and vesicouterine ligaments. The medial half of these ligaments is incised by successive sealing and dividing the paracervical tissue medially, until reaching the upper vaginal margin. It is essential that the ureter be held laterally on slight tension while the tunnel is dissected to avoid cutting into a curve of ureteral tissue off tension. This is the most demanding step in a laparoscopic radical hysterectomy and where the wristed instrumentation of the robotic platform is most helpful. The ureter is unroofed and rolled medially, but not completely removed of its lateral attachments.
FIGURE 25-29. Dividing the uterine artery as it crosses the ureter (type II procedure).
Type III Radical Hysterectomy
The ureter has been dissected to a level near the uterine artery. At this point, the artery is identified at its origin. Blunt dissection along the internal iliac and superior vesical arteries along with medial tension on the uterus will assist in its identification. With blunt dissection, the uterine artery is isolated, slightly skeletonized, and then ligated as close to its origin from the internal iliac artery as possible using clips, cautery, or ultrasonic shears, followed by transection (Figure 25-30). Once the uterine artery has been ligated, it is mobilized medially over the ureter along with its associated parametrial tissue. The medial cut end of the uterine vessels along with the associated parametrial tissue are then elevated and held medially by the first assistant. The ureter is held on gentle lateral traction while the surgeon works to separate it from any medial parametrial attachments. The tunnel of the ureter is encountered, comprised of the cardinal and vesicouterine ligaments. The medial half of these ligaments is incised by creating a space ventrally (Figure 25-31), then successive sealing and dividing of the paracervical tissue medially, until reaching the upper vaginal margin. It is essential that the ureter be held laterally on slight tension while the tunnel is dissected to avoid cutting into a curve of ureteral tissue off tension. This is the most demanding step in a laparoscopic radical hysterectomy and where the wristed instrumentation of the robotic platform is most helpful. The ureter is unroofed and completely detached of all lateral and dorsal attachments to the cardinal ligament. It is then mobilized along with the bladder well off the vagina in preparation for later vaginotomy.
FIGURE 25-30. Dividing the uterine artery at its origin (type III procedure). Instrument used should be harmonic scalpel. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
FIGURE 25-31. Unroofing the ureter (type III procedure). (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Uterosacral Transection
The pararectal space has been previously well developed, and the ureter has been dissected off of the broad ligament and pararectal tissues. The uterosacral ligaments can now be isolated and transected. First, the uterus is severely anteverted and the peritoneum within the posterior cul-de-sac incised from side to side. The rectovaginal space is developed with a combination of blunt dissection and focused use of cautery or the ultrasonic shears. The appropriate plane is best achieved beginning on the left side, further away from the rectal mesentery. In developing this space, the uterosacral ligaments will become evident bilaterally. The uterosacral ligaments, now isolated, can then be ligated halfway (type II procedure) or close to the sacrum (type III) using ultrasonic shears (Figure 25-32) or bipolar coagulation and scissors. The ureters should be retracted laterally before transecting the uterosacral ligament.
FIGURE 25-32. Dividing the uterosacral ligament. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
Vaginal Resection
With complete mobilization of the bladder and rectum, the anterior and posterior vagina should be easily identified. The radical hysterectomy specimen is now held in place only by the paracolpium and vagina, and manipulation of the specimen should be facile. If a modified colpotomy cup is present, it serves as a 2-cm marker within the vagina. Alternatively, a rectal probe can be used to direct the incision. The upper vagina is incised distally on the vaginal wall to allow resection of a portion of proximal vagina (1-2 cm for a type II; 3-4 cm for a type III; Figure 25-33). This incision is extended circumferentially, and the specimen is removed vaginally. The specimen should be inspected for adequate margins (Figure 25-34), and an additional vaginal margin should be removed if necessary.
FIGURE 25-33. Upper vaginal resection. (Redrawn, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008.)
FIGURE 25-34. Laparoscopic radical hysterectomy specimen.
Final Steps
Laparoscopic closure of the vaginal cuff can be performed by multiple methods as previously described. Other procedures, such as lymphadenectomy or ovarian transposition, may be performed, depending on patient circumstances. Once procedures have been completed, an inspection for hemostasis is performed. If used, the robotic platform is undocked. Ports are next removed under direct visualization. All fascial defects 10 mm or greater should be closed with delayed-absorbable suture to avoid hernia development at the site. Skin incisions are closed by the surgeon’s preferred method. Diagnostic cystoscopy is at the discretion of the surgeon.
Postoperative Care
Box 25-18 Complications and Morbidity
Intraoperative
Trocar injury to the bowel or vessels
Hemorrhage
Bladder or rectal perforation
Ureteral transection, ligation, or “kinking”
Postoperative
Vaginal or intraperitoneal bleeding
Neurologic deficit (eg, brachial plexus or peroneal nerve injury)
Port-site bowel herniation or infection)
Delayed thermal injury to bowel or genitourinary tract
Genitourinary fistula (comparable to abdominal types II and III)
Long-term bladder or rectal dysfunction (comparable to abdominal types II and III)
Sexual dysfunction (comparable to abdominal types II and III)
Laparoscopic and robotic-assisted type II and III hysterectomy patients typically have the same fast return of normal bowel function, easier ambulation, and decreased analgesia requirements as those undergoing a type I procedure. Often pain is adequately controlled with oral medications, and intravenous narcotics are not needed.
Postoperatively, the care is also very comparable. The diet may be advanced quickly, and early ambulation is encouraged. The same principles for retaining a Foley catheter apply as described for the comparable abdominal procedures [see Modified Radical Abdominal Hysterectomy (Type II) and Radical Abdominal Hysterectomy (Type III) sections]. Patients undergoing type II hysterectomy may have the Foley catheter removed on day 2 with a voiding trial. Type III patients are typically sent home with the Foley catheter and return to clinic for a voiding trial in about 1 week. Overall, laparoscopic and robotic-assisted radical hysterectomy techniques appear to be equally adequate and feasible.29
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