Laparoscopic Hysterectomy what is the difficulty? Ayman Shehata MD Lecturer of Obstetrics and Gynecology Tanta University 2016

Hans Christian Jacobaeus (1879 – 1937) 1910: Swedish internist; first thoracoscopic diagnosis with a cystoscope in a human subject. Treatment of a patient with tubercular intra-thoracic adhesions. The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Münchner Medizinischen Wochenschrift, 1911

History Bertram Bernheim 1911 : First laparoscopy at Johns Hopkins 12mm proctoscope into epigastric incision for pancreatic cancer Bernheim called his procedure ‘organoscopy’ Findings confirmed on laparotomy

History of Laparoscopy 1920: Zollikofer discovered the benefit of CO2 gas for insufflation 1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum. After World War II, the development of fiberoptics represented an important step forward for endoscopy 1966: Hopkins rod lens scope & cold light

History 1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.

History Since 1989, Harry Reich in Kingston, Pennsylvania described laparoscopic hysterectomy (LH) the laparoscopic assisted vaginal hysterectomy had spread first in the medical centres (LAVH). In 1993, Semm developed intrafascial laparoscopic supracervical hysterectomy(SLH) In 2002, Diaz-Arrastia reported the first series of successful robotic laparoscopic hysterectomies.

Use of TLH has increased in the last 20 years. TLH accounted for 9 Use of TLH has increased in the last 20 years. TLH accounted for 9.9% of all hysterectomies in 1997 and 11.8% in 2003.

Advantages Vaginal and laparoscopic hysterectomies have been clearly associated with : Decreased blood loss Shorter hospital stay Rapid return to normal activities Fewer abdominal wall infections Minimal immune response Minimal scar tissue formation Decreased post-operative pain Reduction in the incidence of post-op ileus

Vaginal hysterectomy In light of these findings, a recent review concluded that vaginal hysterectomy is preferable to abdominal hysterectomy and that a laparoscopic hysterectomy should be attempted when vaginal hysterectomy is not possible.6 The vaginal approach is less expensive, but may be challenging in patients with a history of an adnexal mass, endometriosis, pelvic pain, and prior abdominal surgery, or in patients with a narrow pubic arch or poor vaginal descent.

Requirements for successful TLH Room setup Positioning Port sites Instrumentations Technique

Room setup

Radiological unit (optional) Laparascopic unit Anaesthetic unit Laparascopic unit – extra monitors Instrument table Electrocautery Operating table

Room setup Position

Port sites in TLH

Instruments setup Uterine manipulator Electrosurgical energy source Stitching instrumentations Needle holders Needle grasper Suture materials Tissue Morcellators

Magneshkar manipulator

Marwa Uterine manipulator

Electrosurgical units (ESU)

Energy sources Electric energy Ultrasonic energy Monopolar Bipolar Ultrasonic energy Harmonic Sonosicion SonoSurg Advanced vessel sealing devices Ligasure Enseal Thunderbeat

Sutures

Technique Danger points

Cutting of upper pedicles

Cutting of upper pedicles

Dissection of bladder flap

Dissection of bladder flap

Dissection of bladder

Uterine artery division

Cutting of vaginal edges on colpotomy ring

Suturing of vaginal stump

Suturing of vaginal stump

Practical Tips for successful TLH Position the patient for both safe access and “surgeon ergonomics” Port placement in advance Pelvic anatomy, especially the “danger points” (eg, ureters, ovarian/uterine vasculature, uterosacral ligament) Principles of open surgical technique Uterine manipulator to facilitate colpotomy Electrosurgical instruments Bladder dissection to minimize the risk of cystotomy and vesicovaginal fistula during colpotomy and vaginal cuff closure Full thickness healthy bites from cut edge during vaginal cuff closure including Uterosacral Lig .

Conclusion Total laparoscopic hysterectomy is a safe and effective procedure for women needing a hysterectomy.