The first laparoscopic hysterectomy was performed by Dr Harry Reich in 1988.¹ Since then, 12% to 14% of hysterectomies for benign disease in the United States are now performed through a laparoscopic approach.^2,3 Professional societies encourage the use of minimally invasive techniques for hysterectomy when appropriate due to decreased morbidity compared with an abdominal approach.^4,5 The American Congress of Obstetricians and Gynecologists state that “vaginal hysterectomy is the approach of choice whenever feasible,” and “laparoscopic hysterectomy is an alternative to abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible.”⁵

The advantages of laparoscopic surgery over an abdominal approach include improved visualization of anatomy, shorter hospital stays, decreased postoperative pain, faster recovery times, and better cosmetic appearance of smaller incisions. Disadvantages include a steep learning curve in acquiring laparoscopic suturing skills and mastery of the techniques of retroperitoneal dissection, as well as the cost associated with disposable surgical instruments. There are few contraindications to performing a laparoscopic hysterectomy. These absolute contraindications include medical comorbidities precluding the use of appropriate anesthesia or positioning of the patient and a known or likely uterine malignancy where morcellation would be required. A relative contraindication would be insufficient training and experience in laparoscopy.

The decision to perform a laparoscopic hysterectomy may be influenced by the need for adhesiolysis, evaluation of chronic pelvic pain with treatment of endometriosis, management of large uteri, adnexal surgery, and possible lymphadenectomy for a suspected malignancy. For pelvic organ prolapse, most surgeons perform a laparoscopic total or supracervical hysterectomy with a concomitant sacrocolpopexy, as the distal uterosacral ligaments may not confer adequate apical support postoperatively. A laparoscopic hysterectomy may occur through any of the following approaches: laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic supracervical hysterectomy (LSH), or total laparoscopic hysterectomy (TLH). Any of these approaches can be performed via traditional laparoscopy, single-port laparoscopy, or with the assistance of a robot.

A thorough history and physical should be documented preoperatively, specifically any medical condition that would preclude the use of laparoscopy, such as a ventriculoperitoneal shunt. The patient must be counseled about the anticipated benefits and potential risks of the surgery, including the possibility of conversion to a laparotomy and the possibility of a salpingo-oophorectomy if adhesions or adnexal pathology is suspected. There should be a discussion about the potential need for blood products. A preoperative consultation with an internist and/or anesthesiologist may be deemed appropriate, as well as the ordering of laboratory or imaging studies.

Patients should be provided with a clear explanation of what to expect during their hospitalization, recovery, and return to normal activities. A bowel preparation prior to hysterectomy in case of an unintentional bowel injury is an accepted practice in gynecologic surgery. A sodium phosphate enema is as effective and is associated with fewer adverse effects than an oral preparation.⁶ Preoperative antibiotics should be administered within an hour before incision; a convenient time is just before induction of anesthesia.⁷ Cefazolin (1 g) is most commonly used for antibiotic prophylaxis because of its reasonably long half-life (1.8 hours) and low cost. The dose must be increased (2 g) in morbidly obese patients (BMI greater than 35 or weight greater than 100 kg or 220 lb). For patients with a history of an immediate hypersensitivity reaction to penicillin, an alternative agent can be administered.

Operative Setup

All laparoscopic equipment should be assembled and checked prior to the patient entering the operating room. A preoperative checklist should include ensuring that the carbon dioxide tanks are full and that a spare tank is in the room, assuring that all power sources are connected and appropriate units are switched on, and confirming that basic laparoscopic equipment is available. Basic instrumentation includes electrosurgical monopolar and bipolar instruments, suction irrigator, graspers and needle holders, and uterine manipulator. The laparoscope can be placed in heated sterile water to 120°F to prevent fogging. Depending on the nature of the surgery, ancillary equipment can be available, such as vaginal or rectal probes, a morcellator, cystoscopy equipment, or laparoscopic clip appliers.

The primary surgeon is usually on the patient’s left side. If two monitor screens are available, they should be placed lateral to the legs in direct view of the surgeon standing on the opposite side. The monitors should be placed straight in front of the surgeon at or just below the level of the surgeon’s eyes to prevent neck strain. If only one screen is available, it should be placed between the patient’s legs. To maximize ergonomics of the laparoscopic surgeon, step stools can be placed on either side of the table to ensure that the surgeon is operating with instruments positioned at elbow height.

Patient Positioning and Preparation

Sequential compression devices should be placed and activated prior to anesthetic induction. Once the patient is anesthetized under general anesthesia, an orogastric tube is usually placed to decompress the stomach. The patient should then be positioned by the surgeon in low lithotomy position. Allen™ stirrups are typically utilized. The patient’s heels should be well situated in the stirrup to avoid placing undue pressure on the common peroneal nerve that runs along the popliteal fossa, crossing over the head of the fibula on the lateral knee. The use of Allen stirrups allows transition from a low to high lithotomy position while maintaining sterility. This may be necessary when placing vaginal instruments or when performing any concomitant vaginal surgery. Care must be taken to always return the patient’s legs to a low lithotomy position to avoid hyperflexion of the hips with the possibility of a femoral nerve injury. The arms are tucked on both sides in a neutral position with padding over the ulnar nerve and between any protruding IV tubing. An outstretched arm is at risk of a brachial plexus injury from the surgeon leaning on the arm during the procedure.

The patient’s abdomen is then prepped, followed by the perineum and vagina. A drape is placed to allow access to the vagina. A Foley catheter is placed to decompress the bladder. A uterine manipulator is then placed, preferably with articulating capability. There are many manipulators available, both reusable and disposable. If performing a TLH, a colpotomizer cup should be utilized. If a supracervical hysterectomy is performed, a simple uterine manipulator can suffice. A grounding pad is placed on the patient’s leg for use of monopolar instrumentation.

Entry

The majority of complications associated with laparoscopy occur at the time of entry. There is no clear consensus to the optimal method of entry, although a recent Cochrane review showed that using a closed-entry technique with a Veress needle was associated with an increased incidence of failed entry, extraperitoneal insufflation, and omental injury when compared with an open-entry technique.⁸ There was no difference in the incidence of vascular or visceral injury. Ultimately, choice of laparoscopic entry is usually based on surgeon preference and comfort level.

Knowledge of anterior abdominal wall anatomy is essential to laparoscopic trocar placement. The umbilicus is at the L3–L4 level, and the aortic bifurcation is at the L4–L5 level. Most surgeons prefer the umbilicus for laparoscopic entry, whether using a closed- or open-entry technique. The umbilicus is devoid of subcutaneous fat and represents a fusion of the three fascial layers: external oblique, internal oblique, and transversalis. The goal of umbilical entry is to enter the peritoneal cavity without injuring the underlying omentum, bowel, and aortic and inferior vena cava bifurcations. Caution must be exercised in thin patients, as the great vessels may be within centimeters of the umbilicus. Additionally, if the patient is prematurely in the Trendelenburg position, the angle of the sacrum and great vessels are rotated anteriorly, making these structures more prone to injury.

Most laparoscopic entries can be achieved through the umbilicus. Situations in which an umbilical entry may be risky or difficult include suspected adhesions, a prior umbilical or ventral hernia repair with mesh, pregnancy, or a large pelvic mass suspicious of malignancy. An alternative site to the umbilicus for laparoscopy entry is in the left upper quadrant at Palmer’s point. Palmer’s point is located 3 cm below the left costal margin in the midclavicular line. Underlying structures at this level include the stomach, spleen, left lobe of the liver, pancreas, and transverse colon.

Accessory ports should be placed lateral to the epigastric vessels. Incisions are made along Langer’s lines that are the lines of skin tension. Lateral ports should be placed medial and superior to the anterior superior iliac spine to avoid the ilioinguinal and iliohypogastric nerves that run along the lateral border of the psoas muscle. The inferior epigastric artery originates from the external iliac artery and passes medially to the inguinal ligament. The inferior epigastric artery runs with two veins. Cadaver studies show that the inferior epigastric vessels are 2.6 to 5.5 cm lateral to the midline.⁹ Thus, placement of lateral trocars should be at least 6 cm lateral to the midline. The inferior epigastric vessels can sometimes be seen lateral to the medial umbilical ligament, which is seen as a prominent peritoneal fold on either side of the midline. A suprapubic port should be placed above the upper margin of the bladder, which is usually about one-third of the distance between the pubic symphysis and umbilicus.

Steps of Laparoscopic Hysterectomy

Once the uterine manipulator and trocars are in place, the patient is placed in the Trendelenburg position. Usually 30° to 45° of Trendelenburg is sufficient to allow the bowel to move out of the pelvis. The bowel can be gently grasped and retracted cephalad to the pelvic brim. The colon can be further mobilized cephalad by lysing the congenital adhesions of the rectosigmoid colon to the pelvic brim, otherwise known as the white line of Toldt. A 0° 10 mm laparoscope is usually satisfactory to perform any laparoscopic hysterectomy. If the uterus is large or bulky, an angled laparoscope, such as 30°, may be utilized. The basic steps in a laparoscopic hysterectomy are essentially the same as in an open hysterectomy.

1. 
   

   Dividing the round ligament: The round ligament is first secured and divided on one side (usually the left as the primary surgeon is on the left side of the patient; Figure 31-1). To avoid bleeding, the round ligament should be taken lateral to the varicose vessels in the broad ligament (Figure 31-2).

   
   
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   Developing the bladder flap: Once the round ligament is divided, the uterus is retroverted using the uterine manipulator. A peritoneal incision is made in the anterior leaf of the broad ligament toward the level of the colpotomizer cup, and then toward the contralateral round ligament (Figures 31-3 and 31-4). It is essential to elevate the peritoneum anteriorly while making this incision to protect underlying structures and vessels (Figure 31-5). Once this incision is made, the bladder is carefully mobilized off the cervix and vagina. The bladder is lifted anteriorly to provide adequate countertraction. The surgical assistant can place traction on the uterus to keep it retroverted. Once endopelvic fascia is identified, this is the correct vesicouterine plane (Figure 31-6). Lateral dissection should be avoided to minimize bleeding from the uterine vessels (Figure 31-7).

   
   
3. 
   

   Securing the cornual pedicles: Whether performing a salpingo-oophorectomy or conserving the ovary, it is helpful to create a window in the posterior leaf of the broad ligament. A small incision can be made in the peritoneum, and then widened bluntly. Creating a window will help skeletonize the utero-ovarian ligament or infundibulopelvic ligament, and ensure that the ureter is not included when securing these pedicles (Figures 31-8 and 31-9). Once this window is made, the fallopian tube and utero-ovarian ligament can then be sealed and divided (Figures 31-10 and 31-11). It is essential to avoid the uterine cornua when ligating these pedicles, as this can cause significant bleeding. If performing a salpingo-oophorectomy, it may still be helpful to divide the fallopian tube and utero-ovarian ligament first, and then come back for the infundibulopelvic ligament. If the adnexa remains with the uterine specimen, it may impair exposure during the rest of the hysterectomy.

   
   
4. 
   

   Skeletonization of uterine vessels: The posterior leaf of the broad ligament is dissected to the uterosacral ligament at the level of the colpotomizer cup (Figures 31-12 and 31-13). This dissection skeletonizes the uterine artery at the level of the internal cervical os, allowing the uterine artery to be secured without including the posterior peritoneum. Isolating the uterine artery in this fashion minimizes bleeding when the uterine artery is divided. In addition, dissecting the posterior leaf of the broad ligament increases the distance to the ureter that runs in the medial leaf of the posterior broad ligament. The uterine artery can then be further skeletonized using a similar technique in open surgery: the areolar tissue is divided and then retracted caudad (Figures 31-14 and 31-15).

   
   
5. 
   

   Securing the uterine artery: Once the uterine artery is skeletonized at the level of the internal cervical os, it can be sealed and divided with a bipolar instrument or vessel-sealing device (Figure 31-16). It is essential to bounce off the cervix similar to using a curved Heaney clamp during a laparotomy. This ensures that the medial branches of the uterine artery are secured. If the uterine vessel is large, a grasper can first be used to compress the vessel so that the vessel-sealing device can be applied to the entire pedicle (Figure 31-17). The uterine vessels are coagulated multiple times to shrink the pedicle, and then divided (Figures 31-18 and 31-19). The uterine manipulator should be pushed cephalad to increase the distance between the uterine artery and the ureter. If performing a TLH, the uterine artery pedicles are then dissected and dropped to below the level of the colpotomizer cup (Figures 31-20 and 31-21). This ensures that the endopelvic fascia is cleared when making a colpotomy.

   
   
6. 
   

   Colpotomy: If performing a TLH, the colpotomy can be facilitated with the use of a colpotomizer cup. If a colpotomizer cup cannot fit into the vagina, a Breisky–Navratil vaginal retractor or bulb syringe can be used to distend the vagina and delineate the cervicovaginal junction. A colpotomy can be started either posteriorly or anteriorly using monopolar energy or a laparoscopic scalpel (Figures 31-22 and 31-23). If utilizing monopolar energy, it is essential to use pure cutting current and fast decisive strokes with the monopolar instrument to minimize lateral thermal spread (Figure 31-24). Excessive control of hemostasis with electrosurgery should be avoided to reduce thermal trauma to the vagina. Unnecessary thermal spread to the vaginal cuff can contribute to decreased wound healing and potentially increase the risk of vaginal cuff dehiscence. The colpotomy can then be carried around circumferentially using the colpotomizer cup as a guide (Figure 31-25). The surgical assistant can provide countertraction on the uterus to delineate the edge of the cup. Once the colpotomy is completed, the uterine specimen can be removed through the vagina. If the specimen is too large, it can be debulked with a morcellator to a size that will fit through the vagina.

   
   

   If performing a supracervical hysterectomy, the uterus is amputated at the level of the internal cervical os. An anatomic landmark is the level of the uterosacral ligaments and their attachment to the uterus. The uterus can be amputated with a monopolar instrument, a monopolar loop, or a cold knife (Figures 31-26 and 31-27). The uterine manipulator must be removed, and a grasper can be used to elevate the cervix away from the bowel posteriorly.

   
   
7. 
   

   Closure of the vaginal cuff: Once the colpotomy is completed, hemostasis can be achieved with suturing the vaginal cuff. This minimizes thermal trauma to the vaginal cuff and promotes wound healing. The bilateral vaginal angles can be sutured using a monofilament delayed absorbable suture (such as PDS or Maxon) on a CT-1 or GS-21 needle to ensure an adequate bite of tissue. These can be sutured in a modified Richardson fashion, incorporating the uterosacral ligament (Figures 31-28 to 31-31). The vaginal angle sutures can be retracted out of the lateral ports for traction (Figure 31-32). The vaginal cuff can then be sutured in a transverse fashion using interrupted or figure of eight sutures, a continuous running suture, or a barbed suture. Sutures can be tied down using intracorporeal or extracorporeal knot tying, or with a Lapra-Ty^® device. They should be spaced approximately 1 cm apart, ensuring 1 cm of endopelvic fascia on either side (Figures 31-33 and 31-34). The vaginal mucosa should be included in each suture, which can decrease the risk of exposed granulation tissue leading to vaginal bleeding postoperatively.

   
   

   If performing a LSH, the cervical stump should be oversewn to cover the raw surface (Figure 31-35). In addition, if the patient has any postoperative complaints of bleeding, silver nitrate or another hemostatic agent can be applied into the cervical canal in the office without fear of injuring the bowel or other internal structures.