Presentation on theme: "Total Laparoscopic Hysterectomy"— Presentation transcript:
1Total Laparoscopic Hysterectomy Andrew DoeringMinimally Invasive Surgery LabUniversity of Kentucky
2Patient PresentationA patient in need of a Total Laparoscopic Hysterectomy may present with symptoms such as abdominal pain and abnormal uterine bleedingPossible causes of these symptoms include Fibroid Uterus, Adenomyosis, Endometrial Polyps, Endometrial Hyperplasia, Endometrial Cancer, and Endometriosis
3Alternative Treatments Non-surgical management includes hormonal therapy and NSAIDsA Dilatation & Curettage and Endometrial ablation can be performed if the patient does not want a hysterectomy
4Advantages of the Laparoscopic Technique A hysterectomy can be completed through open, vaginal, and laparoscopic approachesTotal laparoscopic hysterectomies and vaginal hysterectomies have been found to result in decreased blood loss, shorter hospital and recovery periods, and fewer abdominal wall infections than open hysterectomiesThe contraindications for a vaginal hysterectomy include prior abdominal surgery, long and narrow vagina, and endometriosis.
5Female Pelvic AnatomyThe uterus is located posterior and rostral to the bladder, typically in an anteverted positionThe broad ligament of the uterus is composed of an anterior and posterior leaf and connects the sides of the uterus to the pelvic cavityThe ureters enter the pelvic cavity by crossing anterior to the iliac vesselsWithin the pelvic cavity, the ureters travel within the cardinal ligament beneath the uterine arteries to reach the bladder
8Patient PositioningThe patient is placed in Trendelenburg position in order to give the surgeon better access to the pelvic organsThe patient’s arms are secured against their bodyThe patient’s legs are bent and placed in stirrups using caution to prevent compression on the lateral calf and thus peroneal nerve damage
9Operating Room Set UpThe anesthesiologist is located at the patient’s headThe surgeon stands on the left side of the patient.There are assistants to the right of the patient and between the patient’s legs.The scrub nurse is located to the left of the patient near the surgeonMonitors are placed around the room so that each member of the operating team has a direct view of the video feed
11Trocar PlacementA Total Laparoscopic Hysterectomy typically uses three 11 mm trocars and an optional fourth 11 mm trocar.The optical trocar is placed at the umbilicus.Two operating trocars are placed lateral and inferior to the optical trocar within the oblique muscles.A fourth operating trocar may be placed in the midline, inferior to optical trocar. This trocar allows for the placement of a bowel retractor which may be needed in obese patients who can not tolerate steep Trendelenburg positioning.
15Procedure OutlineDissection of the Utero-Ovarian Ligaments and Fallopian Tubes (left 9:00, right 15:00)Dissection of the Round Ligament (left 10:00, right 16:50)Dissection of the Anterior Leaf of the Broad Ligament and the Endopelvic Fascia (17:30)Dissection of Cardinal Ligaments (left 29:30, right 37:00)Separation of the Uterus from the Vagina (46:15)Removal of the Uterus and closure of the Vaginal Cuff (1:03:30)
16Utero-Ovarian Ligament and Fallopian Tube Dissection The Utero-Ovarian Ligament and Fallopian Tube are bilaterally dissected with the Harmonic Scalpel during the same stepThe dissection is carried out along the medial border of the ovary in order to prevent damage to the uterine veinsThe uterine manipulator is used to push the uterus upward and to the contralateral side
20Broad Ligament Dissection The Broad Ligament is dissected with the Harmonic Scalpel in order to mobilize the bladder off of the anterior wall of the uterusThis dissection is carried out in the plane between the Anterior and Posterior Leaves of the Broad LigamentCare must be taken to avoid damage to the bladder during this stepAdipose tissue indicates the location of the bladder and should not be dissected
22Cardinal Ligament Dissection The Cardinal Ligament is initially coagulated medially in order to control back bleeding from the Uterine ArteryThe Cardinal Ligament is dissected with the Harmonic Scalpel along the border of the uterus with each cut being more medial than the next. This is done to prevent damage to the uretersThe uterine manipulator is used to push the uterus to the contralateral side
24Separation of the Uterus and Vagina At this point in the procedure, the uterus should have a whitish appearance due to lack of blood supplyThe Uterus is separated from the Vagina by cutting along the colpotomy ring with the Harmonic ScalpelThe Harmonic Scalpel is used as a blade in this stepAfter complete separation, the uterus is removed through the vagina
29ComplicationsInjuries may occur during a Total Laparoscopic Hysterectomy at two points:During trocar placementDuring dissection of the ligaments attaching the Uterus to the Pelvic Cavity
30Complications (continued) During placement of the optical trocar, the surgeon must be aware of and avoid the Aorta and Vena Cava which are deep to the umbilicus. This is more of a concern with thin patients.During placement of the operating trocars, the surgeon must be aware of and avoid the Inferior Epigastric Arteries.
31Complications (continued) Within the Pelvic cavity, the surgeon must be aware of three structures:Colon – is located posterior to the uterus and may be perforated by the surgical instrumentsBladder – is located anterior to the uterus and may be damaged during mobilization. A fistula may form between the bladder and vagina if it is not completely mobilized off of the uterusUreters – most often damaged during dissection of the cardinal ligaments and at the pelvic brim
32Post Operative CarePatients typically go home the day of the surgery or the following morningPatients are told to rest and relaxPatients normally resume their normal activities 2 – 3 weeks after the surgery