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. 
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  • 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. 
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  • 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.
  • W
  • 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
  1. Oophorectomy - ID and transection of IP ligamnt
  2. Ovarian conservation - ID and transection of "triple pedicles"
  • Uterine Cervix
  1. Total Hysterectomy - Culdotomies including cuff closure
  2. 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.

References

Citation 1

Citation 2

Contributors


Contributors: Swetha Kumar, Megan Wasson, Philippe Descamps, Malcolm Munro.


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