Laparoscopic Hysterectomy

Laparoscopic Hysterectomy (includes "robotic" assisted)

Key Points

Hysterectomy, by any route, is an option for patients with fibroid-associated symptoms with no interest in future fertility or who have failed or are unsuitable for medical therapy or minimally invasive uterine sparing procedures.
Laparoscopic hysterectomy for women with uterine leiomyomas is a minimally invasive approach that is considered to be a preferred alternative to hysterectomy via laparotomy approach as it can decrease hospital length of stay, with reduced recovery time, and, when properly performed, a lower rate risk of intra- and postoperative complications.
Vaginal hysterectomy remains the preferred approach to total hysterectomy as it avoids any complications associated with either laparoscopic or laparotomic techniques.
When the uterine corpus cannot be removed intact vaginally because of size or supracervical technique, morcellation is required. Concerns about dissemination of benign or, rarely, malignant tissue have caused many surgeons or healthcare systems to require that morcellation be "contained" within the confines of a bag placed within the peritoneal cavity.
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Unlike vaginal hysterectomy, laparoscopic techniques can be performed in a fashion that allow for contained morcellation.
As with all hysterectomy procedures, there should be consideration of steps to prevent delayed vaginal vault prolapse and entrocele.

ToolBox

Generic

Operating room table with padded stirrups for low-lithotomy positioning
Vaginal speculum, tenaculum, cervical dilators
Foley catheter and drainage bag

IMImaging Components

Laparoscopes: 0º and 12º - optical or digital construct
Endoscopic camera unit; detachable camera "head" for optical systems
Video monitors attached to movable supporting systems. At least two are preferable, one each aligning with each of the patient's legs.
Light source and light cable (for optical); digital systems are built into the laparoscope; video signal processor (unit) connected to the monitor and recording system

Peritoneal Access

Insufflation needle (if preinsufflation technique)
"Hasson" cannula and obturator (if "open" technique)
Oral gastric or nasogastric tube if needed for left upper quadrant access
Ultrasound with abdominal transducer if needed for identification of "safe" sites when previous surgery
Cannulas and trocar-cannula systems; 5 and 10 mm outside diameter or as appropriate for instrumentation

Exposure and Tissue Manipulation

Uterine manipulator with colpotomy ring (alternate: Vaginal probe to delineate vaginal fornices)
Vaginal occluder system to allow maintenance of pneumoperitoneum when total hysterectomy performed
CO2 source
Electronic CO2 insufflator with appropriate connecting tubing

Energy Based Cutting and Vessel Sealing

Radiofrequency (RF) Electricity: Monopolar systems; Generic Bipolar Systems; Proprietary Tissue Monitored Systems
Ultrasound
Hybrid Systems

Other Hand Instruments

Laparoscopic scissors
Laparoscopic graspers
Laparoscopic tenaculum
Suction cannulas and appropriate tubing for connection to suction systems
Laparoscopic needle drivers and appropriate suture for technique
"Open" needle drivers if vaginal cuff closure planned
Lapar

Tissue Removal (morcellation)

Electromechanical instrument and appropriate blades
Tissue containment bags (abdominal or vaginal)
Manual (minilaparotomic) morcellation equipment: Wound protectors, tenaculi, ring forceps, scalpels, Mayo scissors or equivalent

Specific Technique 1

Specific Technique 2

Specific Technique 3

Tool Box

Patient Preparation

Imaging (US, MRI) and surgical planning (i.e ureteric catheters/ stents) including potential for complications and need for other surgical specialties (ie. Urology or bowel surgeons)
Optimization of patient health/conditions- I.e anaemia
Possible use of GnRH analogues or other myoma suppressing medications for decreasing uterine size pre operatively.

Procedure Descriptions

Elements from May 8 2023

List / summary of steps of laparoscopic hysterectomy (total and supracervical) with supporting images and videos of salient steps particular to hysterectomy of a uterus with multiple leiomyomas (I.e. possible ligation of uterine arteries at the origin, bagging the uterus, morcellation/ delivery of uterus)

Elements Added by Munro July 16 2023

Operating Room Setup

Bedside Laparoscopy
Remote, Microprocessor-assisted Laparoscopy - eg da Vinci

Uterine Manipulator and Vaginal Occlusion

Manipulator
Cervical "cup"
Vaginal occlusion device

Peritoneal Access

Preinsufflation
Minilaparotomy/Hasson
High Risk Situations

Port Placement Options

Port type
Port location

Insufflation/Visualization

Pressure
Smoke management
Light

Continued procedure descriptions

Identification of Anatomy

Bladder
Ureters
Uterine Vessels
Rectosigmoid

Dissection Technique

Using Ultrasound for dissection and hemostasis
Using RF for dissection and hemostasis
Retroperitoneal ureteric identification
Ovaries

Oophorectomy - ID and transection of IP ligamnt
Ovarian conservation - ID and transection of "triple pedicles"

Uterine Cervix

Total Hysterectomy - Culdotomies including cuff closure
Supracervical Hysterectomy - Transection of uterine isthmus

Removal of the Uterus or Uterine corpus

Vaginally, no Morcellation
Vaginally, "in -bag" morcellation
Abdominally, Electromechanical Morcellation (in /out of bag)
Abdominally, minilaparotomy
Supracervcial

Vault suspension

Final Check

Wound Management and Closure

Vaginal Extraction, No Morcellation (FPO)

Electromechanical Contained Morcellation (FPO)

Minilaparotomic Contained Morcellation (FPO)

Postoperative Management

Post operative surgical review
Histopathology of specimen sent,
Need for ongoing cervical screening if supracervical .

Adverse Events

Brief description/list of complications that can arise particular to hysterectomy with enlarged/irregular uterus including short and long term complications and their management.