Since the operation begins with trocars placed through the abdominal wall, it is necessary to know what blood vessels must be avoided both in the abdominal wall and in the pelvis and abdomen (Fig. 11.1).

Patients who have had abdominal operations, especially when a midline incision extends to or is above the umbilicus, may have adhesions. A left upper-quadrant primary entry should be considered. Palmer’s point was described as 3 cm caudad to the costal margin in the midclavicular line (Fig. 11.2). At the University of Arizona, we have placed the Veress needle between the cartilage of the 6th and 7th ribs and the trocar just under the costal margin since 1992. We do so because the peritoneum is attached to the undersurface of the ribs and it will not “tent up” in front of the needle causing extraperitoneal insufflation. The diaphragm begins 3 cm cephalad to the Veress needle. This is especially important for the obese patient.

Body mass index (BMI) is an anatomic consideration. Women with a BMI of 35 to 40 may need to have the trocar sites placed more cephalad (Fig. 11.3). Women with a BMI of over 40 should be considered candidates for robotic assisted surgery because it is difficult to perform a paraaortic node dissection with standard laparoscopy on these patients.

For a description of the pelvic and paraaortic lymph node anatomy, see Chapters 9, Open Surgery for Apparent Early-Stage Endometrial Cancer, and 12, Robotic Extrafascial Hysterectomy.

See Chapter 9, Open Surgery for Apparent Early-Stage Endometrial Cancer.

The legs are in stirrups that support the entire leg. Compression devices are on the legs. The arms are tucked. An orogastric tube is usually placed to empty the stomach of gas and liquid.

The patient will be in steep Trendelenburg, so a device to keep patients from sliding is important.

Laparoscopic hysterectomy can be a total laparoscopic procedure with the uterus completely detached, pulled through the vagina, and the cuff sewed through the laparoscope.

At the University of Arizona, we prefer a laparoscopic-assisted vaginal hysterectomy (LAVH BSO) with the vaginal incision made with a knife and the uterus removed. The uterosacral and cardinal ligaments are ligated and tied together in the midline when the vagina is closed.

The technique of LAVH BSO has several advantages: it avoids the use of electrical energy on the cuff and we have had no vaginal dehiscences in our patients; the use of vaginal retractors makes delivery of an enlarged uterus easier; the vaginal apex is supported by suturing the uterosacral and cardinal ligaments in the midline; and it provides excellent training in vaginal surgery for the residency program.