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Total Laparoscopic Hysterectomy: Practical Tips and Strategies

Arnold P. Advincula, MD

The next generation of bipolar instrumentation is here, promising improved safety and efficiency for the surgeon who knows how to get the most from the equipment.

Approximately 600,000 hysterectomies are performed annually in the United States, with the majority due to benign conditions.1-3 Before the introduction of laparoscopically assisted vaginal hysterectomy in the late 1980s, hysterectomies were approached via the vaginal or abdominal route.4 Today there is a definite trend toward laparoscopic hysterectomy, with the addition of both laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy.

However, despite the increasing acceptance of laparoscopy, hysterectomy via laparotomy remains the most common route. One explanation for this slow acceptance is the learning curve associated with endoscopic hysterectomy. Another barrier is advanced pathology (eg, extensive pelvic adhesions), which compromises the surgical field and precludes a minimally invasive approach. The approach is also determined by the surgeonÍs skill level and the technical limitations of older laparoscopic instrumentation.5

Critical to overcoming these obstacles is a thorough understanding of pelvic anatomy and of the latest laparoscopic instruments. Possessing this knowledge, in combination with a systematic approach analogous to open surgical technique, will allow the surgeon to undertake complex procedures in a minimally invasive fashion. The practical surgical approach presented here is based on the American Association of Gynecologic Laparoscopists (AAGL) classification system for laparoscopic hysterectomy: an AAGL type IVE (total laparoscopic removal of the uterus and cervix, including vaginal cuff closure).6

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SET-UP


After general endotracheal anesthesia is administered, the patient is placed in the low dorsal lithotomy position with arms padded and tucked at her sides. Antiskid measures should be implemented to avoid patient slippage while in the Trendelenburg position, using either shoulder braces or a foam “egg-crate” mattress behind the patient’s upper back.

Preoperatively, the patient should undergo mechanical bowel preparation to decompress the distal colon and rectosigmoid for improved visualization of the pelvis. On the operating table, the patient’s bladder is drained with a Foley catheter and her stomach evacuated with a nasogastric tube. Based on the surgeon’s preference a variety of uterine manipulators can then be placed to facilitate the procedure. The author utilizes a RUMI uterine manipulator in conjunction with a Koh colpotomy ring and a vaginal pneumo-occluder balloon (Figure 1).

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FIGURE 1. Uterine manipulator with colpotomy ring and vaginal pneumo-occluder balloon. Courtesy of Arnold P. Advincula, MD.

Pneumoperitoneum is established with a Veress needle, followed by the placement of four trocars. A 5-mm port is placed either at or above the umbilicus, depending on uterine size. This port accommodates the laparoscope. There should be at least a handsbreadth (8 to 10 cm) between the laparoscope and top of the elevated uterus during manipulation to allow for sufficient working room between the laparoscope and the uterine fundus. Alternatively, either an open technique or direct trocar entry can be utilized, depending on the surgeonÍs comfort level. A left upper quadrant entry technique can also be performed if there are concerns about adhesions in the umbilical area.

Once the primary trocar is situated the patient is placed in steep Trendelenburg position. Two 5-mm ports are then inserted into the left and right lower quadrants, two fingerbreadths from the anterior-superior iliac spines and diagonally to the umbilicus. For larger uteri, these landmarks are moved more cephalad, along with primary trocar placement. A fourth port is placed two fingerbreadths above the symphysis pubis, along the midline; the author prefers a 10- to 15-mm port, depending on the need for suture or specialized laparoscopic instruments such as a specimen retrieval bag, an Endo Stitch suture-assist device, or a tissue morcellator.

Practical Tips for Total Laparoscopic Hysterectomy

Position the patient for both safe access and “surgeon ergonomics” Know the pelvic anatomy, especially the “danger points” (eg, ureters, ovarian/uterine vasculature, uterosacral ligament) Choose a comfortable and efficient uterine manipulator that can facilitate colpotomy Think through port placement in advance Know the electrosurgical instruments Maintain tension-free coagulation and transaction at all times when using advanced bipolar devices Skeletonize all vascular pedicles (ovarian, utero-ovarian, uterine) Develop an adequate vesicouterine reflection (ñbladder flapî) to minimize the risk of cystotomy and vesicovaginal fistula during colpotomy and vaginal cuff closure Take ñhealthy bitesî from the electrosurgical cut edge during vaginal cuff closure to minimize the risk of dehiscence, bearing in mind the location of the bladder-flap edge Adhere to the principles of open surgical technique ñDonÍt bite off more than you can chewî too early in the learning curve.

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KEY INSTRUMENTATION

A variety of conventional laparoscopic instruments can be used to perform a hysterectomy. These include atraumatic and toothed graspers, monopolar scissors and hooks, and knot pushers. Energized bipolar dissection systems can greatly facilitate laparoscopic surgery, particularly with regard to hemostasis. However, traditional bipolar instruments (eg, Kleppinger forceps) can cause thermal collateral damage to adjacent structures, mainly by heat conduction. Additionally, overdesiccation due to a lack of tissue impedance feedback can result in partially ligated vascular pedicles.

Advanced bipolar devices can reduce the incidence of such problems by permitting active feedback control over the power output. Devices that incorporate tissue impedance feedback include the LigaSure, the Gyrus PK, and the EnSeal. These improve the seal on the vascular pedicles with minimal thermal spread, tissue sticking, instrument heating, and surgical plume. Typically these devices have a 2- to 3-mm thermal spread profile, and can seal pedicles up to 7 mm in diameter while maintaining a burst pressure exceeding 300 mm Hg.

When using these instruments, it is essential to maintain tension-free application to the tissue being treated. Exerting excessive traction or force on the tissue can result in poor application of the radiofrequency current and possible bleeding as a consequence.7 Once mastered these advanced bipolar devices allow for safe, efficient completion of hysterectomy with minimal instrument exchanges. Depending on the surgeonÍs preference, ultrasonic devices can be used in a similar fashion. Finally, it is advisable to develop facility with a tissue morcellator when dealing with large uteri.

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TECHNIQUE

The authorÍs technique is similar to an open surgical approach, and still consistent with an AAGL type IVE laparoscopic hysterectomy. Safe, successful completion of a total laparoscopic hysterectomy requires adherence to the basic principles of open surgery, which include proper development of avascular planes and skeletonization of vascular pedicles prior to ligation either by suture or radiofrequency current. The approach presented here uses an advanced bipolar device (Gyrus PK cutting forceps).

The surgeon begins with the cutting forceps in the right hand and atraumatic graspers in the left hand. Monopolar scissors can be substituted for the atraumatic graspers. When using monopolar current the power settings on the radiofrequency generator should be kept to a minimum to avoid excessive energy delivery. The factory default settings on the Gyrus ACMI generator can be used for the cutting forceps.

Regardless of whether the adnexae are to be removed, they should be detached initially from the uterus to avoid obstruction of the view of the broad ligament and unnecessary retraction by the first assistant. This is accomplished by first skeletonizing the fallopian tube and utero-ovarian ligament on each side. The cutting forceps is then used to coagulate, seal, and transect the pedicles (Figure 2). The surgeon must take care to identify the ureters bilaterally and keep them out of the field. The cutting forceps is then used to transect the round ligaments bilaterally, followed by incision of the anterior and posterior leaves of the broad ligament.

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FIGURE 2. Cutting forceps applied to the skeletonized fallopian tube and utero-ovarian ligament (on the right). Courtesy of Arnold P. Advincula, MD.

The next step is to create a vesicouterine reflection and skeletonize the uterine vasculature bilaterally (Figure 3). The first assistant facilitates this dissection by moving the uterus cephalad with the uterine manipulator. Alternatively, a heavy grasper or laparoscopic tenaculum can provide upward uterine traction. This clearly delineates the colpotomy ring as a landmark while allowing the ureters to fall laterally out of the field. Proper bilateral skeletonization of the uterine vascular pedicle will ensure a much better tissue effect from any advanced bipolar device and minimize the risk of lateral thermal spread to adjacent structures such as the ureter or bladder (Figure 4). The use of vascular pedicle skeletonization prior to ligation is consistent with the technique for open hysterectomy. Tension-free application of the advanced bipolar device should be maintained during coagulation and desiccation of the uterine vasculature. Should the surgeon find it necessary to perform multiple applications, this must be balanced against the risk of excessive instrument and tissue heating with possible lateral thermal damage.

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FIGURE 3. Development of the vesicouterine reflection Courtesy of Arnold P. Advincula, MD.

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FIGURE 4. Cutting forceps applied to skeletonized uterine vasculature on the right during upward movement of the uterine manipulator. Courtesy of Arnold P. Advincula, MD.

Once the uterine vasculature is coagulated bilaterally, the uterus should become ischemic in appearance. The pedicles are not transected until colpotomy is performed. The ascending branches of the uterine vasculature are also coagulated bilaterally to minimize any ñback-bleedingî during colpotomy.

Either a monopolar hook or advanced bipolar hook is utilized to divide the cardinal and uterosacral ligament complexes bilaterally, as for an intrafascial hysterectomy. Anterior and posterior culdotomy is facilitated by the colpotomy ring while the first assistant provides upward uterine traction (Figure 5). Pneumoperitoneum is maintained by inflating the vaginal pneumo-occluder balloon placed at the onset of surgery.

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FIGURE 5. Colpotomy with incision of the cardinal and uterosacral ligament complexes using a monopolar hook; the blue colpotomy ring is visible. Courtesy of Arnold P. Advincula, MD.

If the adnexae are to be removed, this should be accomplished prior to colpotomy, with specimens placed in the posterior cul-de-sac for retrieval after delivery of the uterus into the vagina. After skeletonization of the infundibulopelvic ligaments (ovarian vasculature) and identification of the ureters in the retroperitoneum bilaterally, the cutting forceps are used to coagulate, seal, and transect the pedicles. Again, a tension-free technique is critical to successful ligation. Additional applications may be utilized if necessary, again taking care to avoid excessive instrument and tissue heating. If the surgeon is uncomfortable coagulating large vascular pedicles with advanced bipolar technology, then traditional suture ligation can be performed with conventional laparoscopic needle drivers and either intracorporeal or extracorporeal knot-tying.

Once the uterus and cervix are completely detached, the specimen (with or without the adnexae) is delivered into the vagina. If the uterus is too large to pass through the colpotomy, a tissue morcellator can be used for debulking. The uterine fundus can be used to maintain pneumoperitoneum during closure of the vaginal cuff, or the vaginal pneumo-occluder balloon can be replaced. A sterile glove stuffed with a Ray-Tec can be tied and placed in the vagina during this portion of the procedure. Either interrupted 0-polyglactin sutures on CT-2 needles cut to 6 inches or a running suture of 0-polyglactin on a CT-2 needle cut to 11 inches is used to close the vaginal cuff with standard laparoscopic needle drivers. Depending on suture length, either intracorporeal or extracorporeal knot-tying is appropriate. Adequate ñbitesî must be taken far enough back from the cut edge of the vaginal cuff where the radiofrequency current was applied to avoid a pull-through of suture and potential vaginal cuff dehiscence. Once the vaginal cuff is closed, the specimen is removed from the vagina along with any pneumo-occlusive device. If difficulty is encountered utilizing conventional laparoscopic needle drivers, a suture-assist device can be employed (Figure 6).

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FIGURE 6. Vaginal cuff closure with the aide of an Endo Stitch device. Courtesy of Arnold P. Advincula, MD.

Prior to concluding the procedure, all operative sites should be irrigated and a low insufflation pressure check performed to ensure hemostasis. All instruments are then removed from the patientÍs abdomen and the pneumoperitoneum released. Port sites are closed and the vaginal cuff is inspected from below to confirm hemostasis.

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CONCLUSION

The latest improvements in energized instrumentation allow for almost sutureless total laparoscopic hysterectomy, with the exception of the vaginal cuff closure. Like a skilled chess player, the surgeon can address or avoid any potential obstacles by employing a systematic game plan and thinking several moves ahead during each step of the hysterectomy. This is by no means the only way to perform total laparoscopic hysterectomy, but it represents a safe, efficient, and minimally invasive approach to gynecologic pathology.

Arnold P. Advincula, MD, is associate professor and director of minimally invasive surgery, Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor.

References

1. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002; 99(2):229-234..
2. Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988-1990. Obstet Gynecol. 1994; 83(4):549-555.
3. Lepine LA, Hillis SD, Marchbanks PA, et al. Hysterectomy surveillance—United States, 1980-1993. MMWR CDC Surveill Summ. 1997;46(4):1-15.
4. Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg. 1989;5:213-216.
5. Wattiez A, Cohen SB, Selvaggi L. Laparoscopic hysterectomy. Cur Opin Obstet Gynecol. 2002;14(4): 417-422.
6. Olive DL, Parker WH, Cooper JM, Levine RL. The AAGL classification system for laparoscopic hysterectomy. Classification committee of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc. 2000;7(1):9-15.
7. Wang K, Advincula AP. ñCurrent thoughtsî in electrosurgery. Int J Gynaecol Obstet. 2007;97(3):245-250.

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