Sarah L. Cohen1 and Jon I. Einarsson1
Division of Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
Sarah L. Cohen (Corresponding author)
Jon I. Einarsson
9.2 Choice of Equipment
9.3 Operative Technique
9.4 Special Considerations
9.5 Postoperative Care
Since the first successful performance of hysterectomy in the nineteenth century (Langenbeck 1817; Burnham 1854), the procedure has been transformed by advances in surgical technique and technological innovations. Laparoscopic approach to hysterectomy was introduced in the late 1980s by Kurt Semm and Harry Reich (Semm 1991; Reich et al. 1989). As of 2005, national surveillance data from the United States shows that 14 % of hysterectomies were performed laparoscopically, 22 % vaginally, and 64 % abdominally (Jacoby et al. 2009). The laparoscopic approach has demonstrated benefits of decreased morbidity, shorter hospital stay, and quicker return to normal activities when compared to abdominal hysterectomy (Nieboer et al. 2009), with decreased postoperative pain and shorter length of hospitalization when compared to vaginal hysterectomy (Gendy et al. 2011).
As with all surgical procedures, the first steps to a successful operation involve careful preoperative planning, medical clearance, and informed consent. Specifically with regard to laparoscopic hysterectomy, the patient must be informed of the option to retain versus remove the cervix; issues surrounding concomitant removal of adnexal structures should also be discussed. Finally, appropriate preoperative antibiotic and venous thromboembolism prophylaxis should be administered. The routine use of mechanical bowel preparations is not recommended, though antibiotic bowel preparation may be appropriate in select cases (Cohen and Einarsson 2011).
9.2 Choice of Equipment
A uterine manipulator system can be useful for mobilization of the uterus at the time of hysterectomy, though some surgeons prefer to achieve this with abdominal instrumentation such as a tenaculum or myoma screw. Additional advantages of a uterine manipulator include: excellent cephalad displacement at the time of colpotomy, enhanced delineation of the vaginal cuff, provision of a channel through which chromopertubation can be performed, and maintenance of pneumoperitoneum. Although many options for uterine manipulators exist, including disposable, partially reusable, and reusable devices, two of the more commonly utilized devices for laparoscopic hysterectomy are the RUMI® Uterine Manipulator (Cooper-Surgical, Trumbull, CT) and the VCare® Uterine Manipulator/Elevator (ConMed Endosurgery, Utica, NY). The VCare® device is a streamlined option which is relatively easy to insert. The RUMI® manipulator cervical cup provides excellent visualization of the vaginal fornices, particularly in cases of a long cervix, however is more cumbersome to employ (Einarsson and Suzuki 2009). Other versatile options include the MANGESHIKAR and CLERMONT-FERRAND Uterine Manipulators (both from Storz, Tuttlingen, Germany), along with reusable simpler designs that are commonly used for general laparoscopy.
Standard laparoscopic tools which are useful for laparoscopic hysterectomy include: blunt graspers, scissors, a suction/irrigation device, and one or more electrosurgical devices. Regarding electrosurgical devices, options exist for monopolar or bipolar tools, ultrasonic dissectors, and advanced bipolar vessel sealing/ligation devices. Monopolar devices, available in blade, hook, or scissor form, create cutting, fulgurating, and desiccating effects. Care must be taken when employing monopolar energy to avoid complications such as direct or capacitive coupling and insulation failure (Brill et al. 1998). Conventional bipolar devices, available in grasper form, are less prone to visceral injury but can cause char formation and lateral thermal spread on the target tissue (Brill 2008). Advanced vessel sealing/ligation devices include: LigaSureTM sealing device (Covidien, Boulder, CO), PlaskmaKineticsTM (PK) Sealer (Gyrus ACMI Medical, Maple Grove, MN), Harmonic® Scalpel (Ethicon Endo-Surgery, Somerville, NJ), EnSealTM Vessel Fusion System (SurgRx, Inc., Palo Alto, CA), and the Thunderbeat integrated bipolar/ultrasonic device (Olympus, Center Valley, PA), among others. Surgeon preference dictates the selection of a particular electrosurgical device and should include consideration of cost related to using multiple disposable instruments.
9.3 Operative Technique
After induction of anesthesia, the patient is carefully positioned in a neurologically neutral fashion in dorsal lithotomy position with arms tucked at her sides. Antislip devices, such as egg crate foam or a vacuum-beanbag mattress, are helpful to limit cephalad movement of the patient when in Trendelenburg position. Abdominal access is obtained by surgeon’s preferred technique and trocars are placed. For conventional multiport laparoscopy, an umbilical trocar and bilateral lower quadrant trocars are utilized. A fourth trocar may be placed to aid with laparoscopic suturing or advanced dissection; common locations for an additional trocar site include midline suprapubic or left upper quadrant.
After normalizing pelvic anatomy as necessary, the hysterectomy is begun by dividing the infundibulopelvic ligaments (if removing the ovaries) or utero-ovarian ligaments (if preserving the ovaries). By remaining close to the ovary when controlling these ligaments, one can avoid ascending uterine vasculature or retroperitoneal structures, respectively (Fig. 9.1). After transecting the round ligament, the broad ligament is opened to reveal anterior and posterior leaves (Fig. 9.2). The dissection continues along the peritoneal reflection of the vesicouterine peritoneum in order to mobilize the bladder caudally (Fig. 9.3). The uterine vessels are then skeletonized, sealed, and incised at the level of the internal cervical os; the uterus should be mobilized cephalad during this step to increase distance from the ureter (Fig. 9.4).
Coagulation of ligament ovari proprium
Opening of ligamentar latum
Incision of bladder flap
Coagulation of uterine artery
When performing a supracervical hysterectomy, the uterus is separated from the cervix at the level of the internal cervical os with either a monopolar device (such as a spatula, scissor, hook, or loop) or harmonic scalpel. After transection of the uterine corpus, the endocervical canal may be desiccated in an attempt to decrease the occurrence of postoperative cyclic spotting. Specimen removal is then achieved with a mechanical tissue morcellation device or via minilaparotomy. Care should be taken whenever performing morcellation to do so in a contained fashion to avoid inadvertent spread of tissue within the abdomen.
In the case of total laparoscopic hysterectomy, the uterine vascular pedicle is further lateralized below the level of the cervix (Fig. 9.5) and care is taken to ensure the bladder has been mobilized below the level of intended colpotomy incision. Cephalad deflection of the uterus aids with identification of the vaginal fornices, and the colpotomy is made in a circumferential fashion with monopolar or harmonic device of choice (Fig. 9.6). In cases of a narrow introitus where it is not feasible to employ a uterine manipulator, laparoscopic upward traction is essential in order to distance the ascending uterine vessels from the ureters and allow for safe colpotomy performance. The specimen is then removed through the vagina or morcellated as necessary, either laparoscopically or vaginally. Following specimen retrieval, pneumoperitoneum is maintained by occlusion of the vaginal canal; one useful option for this purpose is a sponge-filled surgical glove. Vaginal cuff closure is performed with laparoscopic suturing techniques, with care to take bites of sufficient distance from the thermal margin and incorporate both the vaginal mucosa as well as rectovaginal and pubocervical fascia.
Opening to vagina
Incision on the vaginal cup
9.4 Special Considerations
Of particular concern during advanced laparoscopic surgery, and specifically hysterectomy, is the avoidance of injury to ureter or bladder. It is imperative that the surgeon keeps the anatomic course of the ureter in consideration throughout the procedure, with retroperitoneal dissection and ureterolysis as necessary. The transection of the infundibulopelvic ligament and creation of uterine vascular pedicles are steps where the ureter is under particular risk of damage; suggestions for limiting potential ureteral injury are provided in the Operative Technique section earlier (Janssen et al. 2011). Cystoscopy should be employed liberally if there are any concerns about injury to bladder or ureter. However, a normal cystoscopy does not guarantee lack of injury, particularly in cases of thermal damage or partial transection (Dandolu et al. 2003).
In cases of large uteri extending to or above the level of the umbilicus, it may be helpful to place the accessory trocars at a more cephalad position and/or utilize left upper quadrant entry at Palmer’s point. The technique of “port hopping” (whereby the laparoscope is moved between umbilical and lateral ports) can also be useful in cases where visualization is limited by a bulky uterus. Another consideration with larger uteri is the limited mobility provided by traditional uterine manipulators. In these cases, injection of dilute vasopressin solution subserosally into the uterus, followed by application of a laparoscopic tenaculum, may provide additional visualization. If there is an obstructed view caused by one or more dominant myomas, it may be beneficial to perform myomectomy first in order to generate more space in the pelvis. Similarly, in cases of planned total hysterectomy of a large uterus, it may be necessary to perform a supracervical transection first, mobilize the uterine specimen out of the pelvis, and then complete the procedure with a trachelectomy.
9.5 Postoperative Care
Laparoscopic hysterectomy patients may be offered the option of same-day discharge after an uncomplicated procedure if appropriate based on patient preferences, comorbid medical conditions, and home support system (Taylor 1994; Thiel and Gamelin 2003; Morrison and Jacobs 2004; Lieng et al. 2005). A randomized trial of day-case versus inpatient laparoscopic supracervical hysterectomy found similar satisfaction rates with lower self-reported short-term quality of life in the day surgery group (Kisic-Trope et al. 2011). Recommendations for patient activity following hysterectomy include 4–6 weeks of pelvic rest (longer for total hysterectomies) and avoidance of heavy lifting or vigorous activity in the immediate recovery period. Patients may be counseled that the majority of activities can be resumed by 2–4 weeks postoperatively (Claerhout and Deprest 2005).
Laparoscopic hysterectomy has demonstrated benefits to patients in terms of decreased morbidity and faster return to normal activities. With the techniques described earlier and sufficient surgical experience, laparoscopic hysterectomy can be implemented in a range of clinical scenarios, including complicated cases with distorted pelvic anatomy or large uteri. Continued emphasis on surgical training and awareness of laparoscopic techniques will allow for increased patient access to minimally invasive hysterectomy.
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