Video Clips on DVD
Conventional Total Laparoscopic Hysterectomy
Sealing and Transection of Left Infundibulopelvic Ligament
Development of Bladder Flap
Uterine Vessel Ligation
Robotic-Assisted Laparoscopic Supracervical Hysterectomy
Development of Bladder Flap and Sealing of Right Uterine Vessels
Transection of the Upper Pedicles on the Left Uterine Corpus
Transection of the Uterine Corpus from the Cervix
Closure of the Cervical Os
Approximately 40% of hysterectomies in the United States are performed by minimally invasive routes, including laparoscopic hysterectomy with or without vaginal or robotic assistance and vaginal hysterectomy (see Chapter 7 ). Since laparoscopic-assisted vaginal hysterectomy was introduced by , laparoscopic surgery for hysterectomy has gained popularity but has not resulted in widespread conversion of abdominal hysterectomies to minimally invasive procedures as initially predicted. Reasons for this include the steep learning curves associated with advanced laparoscopic techniques (laparoscopic suturing and knot-tying, difficult bladder dissection, ureterolysis, and difficult retroperitoneal dissection) and insufficient advanced laparoscopic training and experience in many residency programs. After Food and Drug Administration (FDA) approval of robotic-assisted laparoscopy for gynecologic surgery in 2005, increased adoption of minimally invasive surgery has ensued, especially in gynecologic oncology. Laparoscopic suturing and precise dissection for pelvic and para-aortic lymph node excision and radical hysterectomy have been revolutionized with robotic assistance, partly because of three-dimensional magnified views and endowrist instrumentation with seven degrees of freedom.
Types of laparoscopic hysterectomy include total laparoscopic hysterectomy (TLH; extirpation of the uterus and cervix) and laparoscopic supracervical or subtotal hysterectomy (LSH; removal of the uterine corpus with preservation of the cervix). All steps of TLH are performed by the laparoscopic route whereas laparoscopic-assisted vaginal hysterectomy (LAVH) encompasses the laparoscopic portions of the procedure (ligation and transection of the utero-ovarian or infundibulopelvic ligaments, broad ligament, and possibly the uterine vessels) with the remaining steps completed by vaginal route (colpotomy, bladder dissection, ligation and transection of the uterosacral and cardinal ligaments). Staging of the various types of laparoscopic hysterectomy is shown in Table 10-1 . According to the Cochrane review, the term “laparoscopic hysterectomy” should be applied to any hysterectomy in which all vessels are occluded laparoscopically. When no portion of the procedure is performed vaginally, the term “total laparoscopic hysterectomy” should be employed. This chapter will discuss total and supracervical laparoscopic hysterectomies, LAVH, and robotic-assisted laparoscopic hysterectomy, and will briefly summarize single-port laparoscopic hysterectomy.
|Laparoscopy performed without additional laparoscopic procedures prior to vaginal hysterectomy
|Laparoscopy including both laparoscopic adhesiolysis and/or excision of endometriosis prior to vaginal hysterectomy
|Laparoscopic mobilization of either or both adnexa prior to vaginal hysterectomy
|Laparoscopic dissection of bladder from uterus in addition to transection of all upper pedicles prior to vaginal hysterectomy
|Uterine artery and all upper pedicles transected and bladder flap dissected laparoscopically
|Anterior and/or posterior colpotomy or entire uterus freed laparoscopically
|One ovary excised laparoscopically
|Both ovaries excised laparoscopically
Case 1: Abnormal Uterine Bleeding and Endometrial Hyperplasia
A 48-year-old gravida 3, para 3 woman presents with complaints of heavy, prolonged, frequent uterine bleeding for the last 9 months. Her menses are not associated with cramping or pelvic pain. Gynecologic history includes regular Papanicolaou (Pap) smears, which are all normal, and no history of sexually transmitted diseases. Past medical history is significant only for hypertension. She is taking a beta-blocker, multivitamin, and calcium; does not exercise regularly; and has no other medical problems. Family history is significant only for a maternal grandmother with history of breast cancer. She does not smoke, drink, or take drugs. On examination her vital signs are within normal limits, and her body mass index is 25 kg/m 2 . On speculum examination there is some blood at the vaginal vault, no lesions on the bladder base or vaginal walls, and cervix is appears normal. Her uterus is 6 to 8 weeks in size and nontender; rectovaginal examination reveals no parametrial thickening or cul-de-sac nodularity. Ultrasound evaluation revealed a thickened endometrial lining and normal uterus and ovaries. An endometrial biopsy and endocervical sampling demonstrated endometrial glands (back-to-back architecture) with luminal outpouching, and minimal intervening stroma lined by atypical cells. A diagnosis of complex hyperplasia with atypia was made.
Discussion of Case: Total Laparoscopic Hysterectomy
Abnormal uterine bleeding (AUB) can be caused by many different conditions. The specific diagnostic approach will depend on whether the patient is premenopausal, perimenopausal, or postmenopausal. In the perimenopausal female normal hormonal cycling begins to change, a decrease in progesterone secretion coupled with continued estrogen secretion can cause the endometrium to grow and produce excess tissue. This histologic change in the endometrium (endometrial hyperplasia) can potentially cause abnormal bleeding. Also, the obese woman has high levels of endogenous estrogen due to the conversion of androstenedione to estrone and the aromatization of androgens to estradiol, both of which occur in peripheral adipose tissue ( ). The presence of nuclear atypia is a worrisome finding in this case and puts the patient at risk to develop carcinoma. More important, the rate of endometrial carcinoma found at hysterectomy in women with a biopsy diagnosis of atypical endometrial hyperplasia is 42.6% according to a study by The Gynecologic Oncology Group ( ) . A similar rate, 45.6%, was reported at John Radcliffe Hospital, Oxford, UK, by Pennant and associates ( ). When considering management strategies for women who have a biopsy diagnosis of atypical endometrial hyperplasia, clinicians and patients should take into account the considerable rate of concurrent carcinoma. This patient was amenable to minimally invasive surgery, had a normal-sized uterus and thus required no morcellation of the uterus. Cancer staging with prehysterectomy, pelvic washings, and para-aortic and pelvic lymph node dissection can be performed by conventional or robotic-assisted laparoscopy.
Surgical Technique: Total Laparoscopic Hysterectomy (See Video 10-1 )
The patient is positioned directly on an egg crate mattress or beanbag cushion, which has been taped to the surgical bed ( Fig. 10-1A ). In cases in which a steep angle of Trendelenburg positioning is required, we work with our anesthesia colleagues to tape the patient’s chest to the bed without restricting ventilation (see Fig. 10-1B ). These maneuvers prevent slippage of the patient toward the head of the bed while in steep Trendelenburg position. The legs are placed into Allen or Yellofin stirrups (Allen Medical Systems, Acton, MA) with the heel resting easily into the back of the boot, ascertaining that no lateral pressure on the calves, internal rotation of the knees, nor hyperflexion of the hips is present. Arms are tucked bilaterally with hands protected by pieces of egg crate or similar material. The hands must be checked intermittently to make sure that changing positions of the stirrups or foot of the bed do not result in inadvertent injury to the tucked hand. If the patient with tucked arms is wider than the bed, padded sleds are used to keep the arms in place. A three-way catheter facilitates retrograde filling of the bladder during difficult bladder dissection.
Uterine manipulators include the RUMI or ZUMI with Koh colpotomizer and balloon occluder (CooperSurgical Inc., Trumbull, CT), VCare (Conmed Corporation, Utica NY), the reusable Valtchev uterine manipulator (Conkin Surgical Intruments, Toronto, Canada), and the Pelosi uterine manipulator (Apple Medical, Bolton, MA). Placement of the uterine manipulator is performed concomitant with setup of laparoscopic equipment. More recently, the Koh uterine manipulator has been adapted with an independently standing bedside attachment, specifically for, but not limited to, robotic-assisted surgery ( Fig. 10-2A and B ). This minimizes the need for a vaginal assistant. One or two held stitches placed in the cervical parenchyma at 3 and 9 o’clock via vaginal route are threaded through the grooves of the snugly fitting Koh colpotomizer cup, easing placement of the RUMI manipulator. The VCare ( Fig. 10-3 ) and Valchev manipulators do not require stay sutures. Choice of uterine manipulator is a matter of surgeon preference. The RUMI arm and associated colpotomizer cups and Valtchev and Pelosi uterine manipulators are reusable alternatives.
Our technique employs a 5-mm laparoscope inserted into a 5-mm optical trocar introduced through an intraumbilical incision for most laparoscopic hysterectomies whether conventional or robotic-assisted. Alternatively, a left upper quadrant port placement (two fingerbreadths below the subcostal margin in the midclavicular line) is performed to gain peritoneal access if infraumbilical adhesions are anticipated. For enlarged uteri, the laparoscope port is placed cephalad of the umbilicus. Distance away from the umbilicus depends on uterine size and whether concomitant para-aortic lymph node dissection is performed. Accessory ports are placed in the bilateral lower quadrants and lateral of the umbilicus as desired ( Fig. 10-4 ). Size of the accessory ports depends on instrumentation. One or two 5 to 12 mm trocars with conical valves are used for introduction of CT-1 or CT-2 needles. The conical valve minimizes escape of pneumoperitoneum during extracorporeal knot tying. The 5 to 12 mm port is easily enlarged to 15 mm for introduction of a uterine morcellator. Insufflation of CO 2 through an upper-quadrant port and plume evacuation through one of the lower quadrant ports optimizes visual clarity and allows movement of gas upward when the patient is in steep Trendelenburg position.
Once all ports are placed, the entire perintoneal cavity is inspected. The same principles of countertraction and exposure in open and vaginal surgery apply to laparoscopy except when utilizing electrosurgical instruments. The instrumentation is longer; the incisions are smaller; and the field is magnified in two dimensions on the screen for conventional laparoscopy. We apply the same surgical techniques for laparoscopic hysterectomy as for abdominal hysterectomy with the exception of suture ligation of pedicles (vessel-sealing devices instead of suture ligation, although many surgeons use vessel-sealing devices via laparotomy). Adhesions, which obscure the operative field or port-site areas, are lysed. Excision of superficial cul-de-sac or pelvic sidewall endometriosis is easiest when all organs and sidewall attachments are intact. We emphasize that most “smart” bipolar and ultrasonic devices must be utilized with little or no tension on the tissues to ensure vessel sealing (see the discussion of electrosurgical intruments later in the chapter). This “no-tension” principle is counterintuitive to maximizing countertraction to gain exposure but results in less blood loss.
We commence the hysterectomy by manipulating the uterine fundus away from the operative site to enhance exposure. The ipsilateral round ligament is electrosurgically or ultrasonically ligated and cut. This allows easy access for dissection of the retroperitoneal space and exposure of the ureter. The anterior broad ligament peritoneum is incised inferiorly to the bladder flap and superiorly toward the infundibulopelvic ligaments (see Video 10-1B ). The bladder flap is dissected with simultaneous upward traction of the cervix and retroflexion or midplane uterine placement. The areolar tissue is incised to a level 1 cm below the colpotomizer cup. The ureter is visualized transperitoneally or through retroperitoneal dissection, where it courses in the medial leaf of the broad ligament toward its path beneath the uterine vessels.
When we perform concomitant salpingo-oophorectomy, we dissect a window in the medial leaf of the broad ligament above the ureters and ligate and cut the ovarian vessels (see Video 10-1A ). Alternatively, the utero-ovarian ligament is sealed and cut prior to dissecting and incising the broad ligament and skeletonizing the ipsilateral uterine vessel (see Video 10-1C ). Once the uterine vessel is sealed, the same pedicles are ligated on the contralateral side. Division of the uterine vessels after they are sealed bilaterally minimizes uterine back-bleeding. The cardinal ligaments are sealed and incised bilaterally prior to or after colpotomy depending on surgeon preference (see Video 10-1D ). The uterosacral ligaments are incised as part of the colpotomy incision but can be tagged with suture for concomitant uterosacral ligament vaginal vault suspension or culdoplasty.
Colpotomy is performed with either a monopolar, bipolar, or ultrasonic hook. Another option is the monopolar tip of a recently introduced dual purpose instrument (Ligasure Advance, Covidien Inc., Boulder, CO). Alternatively, the ultrasonic energy scissors (Harmonic Ace, Ethicon Inc., Cincinnati, OH) or monopolar scissors may be utilized. The superior border of the colpotomizer or cervical rim of the VCare manipulator cup delineates the incision line for the colpotomy. A tight-fitting colpotomizer or cup around the cervix provides the greatest amount of upward countertraction to ensure that the bladder is thoroughly dissected away for safe colpotomy and results in optimal vaginal length. Once the cervix is incised from the vagina, the uterus is pulled through the vagina and sent for pathologic examination. A balloon occluder or tied-off glove is introduced into the vagina to maintain pneumoperitoneum. Alternatively, the uterus may be placed into the vagina to maintain pneumoperintoneum. Large myomatous uteri are morcellated in total or to a size suitable for delivery through the vagina.
Closure of the vaginal cuff can be done with simple or figure-of-eight interrupted No. 0 delayed absorbable sutures or a running suture using a Lapra-Ty (Ethicon, Inc., Cincinnati, OH) at each end. When closing the vaginal cuff we utilize laparoscopic needle holders and tie our knots with a open- or closed-ended knot pusher. A cautionary note is that increasing rates of dehiscence of the vaginal apex have been reported ( ) and that interrupted delayed absorbable sutures for closure and use of ultrasonic or bipolar energy cutting devices, which minimize lateral thermal damage of tissue (as opposed to monopolar energy cutting devices) for colpotomy may help to circumvent vaginal cuff dehiscence.
We recommend reattachment of the uterosacral ligaments to the vaginal cuff in all cases to decrease risk of postoperative vaginal apex prolapse. In cases of mild uterine prolapse, the uterosacral ligaments are attached to the vaginal cuff with No. 0 absorbable or delayed absorbable sutures with or without reefing the cul-de-sac peritoneum. For greater amounts of uterine prolapse, multiple stitches are placed, bilaterally suspending the vagina high on the uterosacral ligaments. We recommend a peritoneal incision to release the ureters lateral of the uterosacral ligaments if necessary ( Fig. 10-5 ). We also recommend routine use of cystoscopy to evaluate upper and lower urinary tract injury.