Laparoscopic Hysterectomy-With and Without Salpingo-Oophorectomy

 

Revolutionary advancements in endoscopy have dramatically changed the practice of gynecology. With the introduction of the newest generation of endoscopic instruments, we have become more proficient in laparoscopically assisted hysterectomies with bilateral salpingo-oophorectomies.

There is still controversy as to whether traditional vaginal hysterectomy is the better procedure compared with its laparoscopic counterpart. Our experience with laparoscopic hysterectomy demonstrated that the laparoscopic approach is superior in most patients with myomas, previous cesarean sections, undiagnosed endometriosis, chronic pelvic inflammatory disease and unexpected intestinal pathology.

The greatest advantage of a laparoscopic hysterectomy is the significant reduction in postoperative pain, discomfort and the shorter recovery period. Compared to traditional open surgical procedures, laparoscopic hysterectomy has reduced the hospital stay and cost by 50%. The patient can return to work after 3 weeks versus 6 weeks. For these reasons, it is anticipated that laparoscopic hysterectomy will become the standard rather than the exception within 5 years.

INSTRUMENTS

1 VERSAPORT* 11-5 mm Trocar

2 VERSAPORT* 12-5 mm Trocars

1 Kronner Manipujector Uterine Manipulator-Injector

1 ENDO SHEARS* 5mm Instrument with Unipolar Cautery

1 ENDO BABCOCK* 10mm Clamp

1 ENDO DISSECT* 5mm Instrument with Unipolar Cautery or Roticulator Endo Dissect 5 mm Instrument with Unipolar Cautery

1 Multifire ENDO GIA* 30 Stapler 12 mm with 3.5 regular and 2.5 vascular Disposable Loading Units or Multifire ENDO GIA* II 12 with equivalent cartridges.

1 Multifire ENDO HERNIA* Stapler

1 ENDO CLIP* ML 10 mm Applier with Medium-Large TITANIUM Clips

1 Valleylab Electrocautery Hock with hand switch and suction irrigation 5 mm

1 Storz 45cm Grasper

Note: The telescope used in these cases is a Storz straightforward telescope 0 with parallel eyepiece and 5mm instrument channel. A Storz Video system is used. All patients are given Toradol (Roche Pharmaceuticals) 30mg IM and Cefizox (Fujisawa USA) 2 Gm IV during the induction phase.

THE PROCEDURE

Operating Room Setup

Trocar Placement

The Technique

The patient is placed in lithotomy position with Allen universal stirrups. A Kronner Manipujector is inserted. The abdomen and perineum are prepped in the usual manner.

The pneumoperitoneum is created. The trocars are inserted. The intraabdominal cavity is visualized. Using the uterine manipulator, the uterus and adnexa are moved, and all aspects of the internal genitalia are exposed and examined.

If intraabdominal adhesions are present, an enterolysis will be performed using the ENDO SHEARS* and ENDO DISSECT* instruments connected to the electrocautery.

The ovary is grasped at its ligament and elevated with an ENDO DISSECT* instrument. The infundibulopelvic ligament is identified and spread. A Multifire ENDO GIA* 30 instrument is inserted via the ipsilateral 12mm trocar site and closed on the triple pedicle, which includes the round ligament, the fallopian tube and the ovarian ligament. The Multifire ENDO GIA* 30 stapler is fired and the triple pedicle transected. The tubo-ovarian complex will be separated from the uterus. If this maneuver is not done, the tubo-ovarian complex will constantly drop into the operating field. Another application of the Multifire ENDO GIA* 30 instrument will be needed to continue this dissection on the parametria.

The same procedure is repeated on the other side.

The operative site is brought into telescopic view by moving the Kronner Manipujector. The anterolateral aspect of the uterovesical junction is placed under tension. Using the ENDO SHEARS* instrument connected to an electrocautery source, the peritoneal bladder flap is developed in traditional fashion.

The dissection is started laterally and continued anteriorly around the cervix. The bladder flap is gently peeled away with the ENDO SHEARS* instrument. The hemostasis is controlled with electrocautery. The posterior sheath of the broad ligament is dissected down to the uterosacral ligament. The uterosacral ligaments are transected using an ENDO SHEARS* instrument.

The uterine vessels (artery and vein) are identified. At this level, they usually run parallel to the uterus. The ureter will also be lateral to the vessels and also parallel to the uterus. Stay as close as possible to the uterus while clipping, almost clipping the vessels into the cervix.

The assistant places a curved sponge stick into the posterior vagina.

A posterior colpotomy is made with the ENDO SHEARS* instrument. This vaginal incision is not made by cutting but merely by using the electrocautery power with the ENDO SHEARS* instrument to transect. It is performed slowly so that the pneumoperitoneum will not be rapidly lost (CO2 leak).

The vaginal will be packed and sealed with wet Kerlix gauze. The pneumoperitoneum is recreated. The colpotomy is completed anteriorly and laterally. The colpotomy is extended around the base of the cervix on the vagina until the uterus is detached from the vagina.

If a bilateral oophorectomy is to be performed, a Multifire ENDO GIA 30 instrument is inserted and used to staple and transect the infundibulopelvic ligament. The tubo-ovarian complex is then freed on each side.

The vaginal pack is removed. A large Kocher clamp is passed transvaginally into the intraabdominal cavity under direct vision. The uterus and both tubo-ovarian complexes are removed via the colpotomy.

The colpotomy is then closed transvaginally with interrupted size 2-0 Polysorb absorbable sutures. The pneumoperitoneum is again created. The peritoneal edges are approximated with an ENDO DISSECT* instrument and with the extended grasper passed via the working channel of the telescope. A Multifire ENDO HERNIA* stapler is inserted via a lateral VERSAPORT* 12mm trocar and peritoneum is closed with Multifire Endo Hernia staples.

The abdomen is irrigated with Ringer’s lactate solution; desufflated and all the cannulas are removed. The 12mm insertion sites should be closed in a two-layer fashion.

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