Total Laparoscopic Hysterectomy

Andrew Doering

Minimally Invasive Surgery Lab

University of Kentucky

Patient Presentation• A patient in need of a Total Laparoscopic

Hysterectomy may present with symptoms such as abdominal pain and abnormal uterine bleeding

• Possible causes of these symptoms include Fibroid Uterus, Adenomyosis, Endometrial Polyps, Endometrial Hyperplasia, Endometrial Cancer, and Endometriosis

Alternative Treatments• Non-surgical management includes hormonal

therapy and NSAIDs• A Dilatation & Curettage and Endometrial

ablation can be performed if the patient does not want a hysterectomy

Advantages of the Laparoscopic Technique• A hysterectomy can be completed through

open, vaginal, and laparoscopic approaches• Total laparoscopic hysterectomies and vaginal

hysterectomies have been found to result in decreased blood loss, shorter hospital and recovery periods, and fewer abdominal wall infections than open hysterectomies

• The contraindications for a vaginal hysterectomy include prior abdominal surgery, long and narrow vagina, and endometriosis.

Female Pelvic Anatomy• The uterus is located posterior and rostral to

the bladder, typically in an anteverted position• The broad ligament of the uterus is composed

of an anterior and posterior leaf and connects the sides of the uterus to the pelvic cavity

• The ureters enter the pelvic cavity by crossing anterior to the iliac vessels

• Within the pelvic cavity, the ureters travel within the cardinal ligament beneath the uterine arteries to reach the bladder

Female Pelvic Anatomy

Female Pelvic Anatomy

Patient Positioning• The patient is placed in Trendelenburg position

in order to give the surgeon better access to the pelvic organs

• The patient’s arms are secured against their body

• The patient’s legs are bent and placed in stirrups using caution to prevent compression on the lateral calf and thus peroneal nerve damage

Operating Room Set Up• The anesthesiologist is located at the patient’s

head• The surgeon stands on the left side of the

patient.• There are assistants to the right of the patient

and between the patient’s legs.• The scrub nurse is located to the left of the

patient near the surgeon• Monitors are placed around the room so that

each member of the operating team has a direct view of the video feed

Operating Room Set Up

Trocar Placement• A Total Laparoscopic Hysterectomy typically uses

three 11 mm trocars and an optional fourth 11 mm trocar.

1) The optical trocar is placed at the umbilicus.

2) Two operating trocars are placed lateral and inferior to the optical trocar within the oblique muscles.

3) A fourth operating trocar may be placed in the midline, inferior to optical trocar. This trocar allows for the placement of a bowel retractor which may be needed in obese patients who can not tolerate steep Trendelenburg positioning.

Trocar Placement

Instruments• 0° laparoscope• Uterine manipulator with colpotomy ring• 3-4 11 mm trocars• Insufflator• Harmonic Scalpel• Grasping Forceps• Endostitch Suturing Device• Lapra Ty’s

Pelvic Cavity Prior to Surgery

Procedure Outline1) Dissection of the Utero-Ovarian Ligaments

and Fallopian Tubes (left 9:00, right 15:00)

2) Dissection of the Round Ligament (left 10:00, right 16:50)

3) Dissection of the Anterior Leaf of the Broad Ligament and the Endopelvic Fascia (17:30)

4) Dissection of Cardinal Ligaments (left 29:30, right 37:00)

5) Separation of the Uterus from the Vagina (46:15)

6) Removal of the Uterus and closure of the Vaginal Cuff (1:03:30)

Utero-Ovarian Ligament and Fallopian Tube Dissection• The Utero-Ovarian Ligament and Fallopian

Tube are bilaterally dissected with the Harmonic Scalpel during the same step

• The dissection is carried out along the medial border of the ovary in order to prevent damage to the uterine veins

• The uterine manipulator is used to push the uterus upward and to the contralateral side

Fallopian Tube Dissection

Round Ligament Dissection• The Round Ligament of the Uterus is

bilaterally transected with the Harmonic Scalpel

• The uterine manipulator is used to push the uterus upward and to the contralateral side

Round Ligament Dissection

Broad Ligament Dissection• The Broad Ligament is dissected with the

Harmonic Scalpel in order to mobilize the bladder off of the anterior wall of the uterus

• This dissection is carried out in the plane between the Anterior and Posterior Leaves of the Broad Ligament

• Care must be taken to avoid damage to the bladder during this step

• Adipose tissue indicates the location of the bladder and should not be dissected

Broad Ligament Dissection

Cardinal Ligament Dissection• The Cardinal Ligament is initially coagulated

medially in order to control back bleeding from the Uterine Artery

• The Cardinal Ligament is dissected with the Harmonic Scalpel along the border of the uterus with each cut being more medial than the next. This is done to prevent damage to the ureters

• The uterine manipulator is used to push the uterus to the contralateral side

Cardinal Ligament Dissection

Separation of the Uterus and Vagina• At this point in the procedure, the uterus

should have a whitish appearance due to lack of blood supply

• The Uterus is separated from the Vagina by cutting along the colpotomy ring with the Harmonic Scalpel

• The Harmonic Scalpel is used as a blade in this step

• After complete separation, the uterus is removed through the vagina

Separation of the Uterus and Vagina

Closure of the Vaginal Cuff• The Vaginal Cuff is closed with the Endostitch

Suturing Device and Lapra Ty’s• Irrigation is performed after closure of the

Vaginal Cuff to check for bleeding

Closure of Vaginal Cuff

Pelvic Cavity After Surgery

Complications• Injuries may occur during a Total Laparoscopic

Hysterectomy at two points:

1) During trocar placement

2) During dissection of the ligaments attaching the Uterus to the Pelvic Cavity

Complications (continued)• During placement of the optical trocar, the

surgeon must be aware of and avoid the Aorta and Vena Cava which are deep to the umbilicus. This is more of a concern with thin patients.

• During placement of the operating trocars, the surgeon must be aware of and avoid the Inferior Epigastric Arteries.

Complications (continued)• Within the Pelvic cavity, the surgeon must be

aware of three structures:

1) Colon – is located posterior to the uterus and may be perforated by the surgical instruments

2) Bladder – is located anterior to the uterus and may be damaged during mobilization. A fistula may form between the bladder and vagina if it is not completely mobilized off of the uterus

3) Ureters – most often damaged during dissection of the cardinal ligaments and at the pelvic brim

Post Operative Care• Patients typically go home the day of the

surgery or the following morning• Patients are told to rest and relax• Patients normally resume their normal

activities 2 – 3 weeks after the surgery