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Simulation

Total Laparoscopic Hysterectomy

Module

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Objectives

By the end of this unit, you should be able to do the following:

  • Describe the indications for total laparoscopic hysterectomy
  • Explain preoperative planning for total laparoscopic hysterectomy, including options for anesthesia and patient preparation
  • Demonstrate the correct technique to perform a total laparoscopic hysterectomy
  • Describe potential perioperative complications

Evolution of Hysterectomy

  • History
    • 1989: Reich reported the first laparoscopically assisted vaginal hysterectomy
    • 1990s: Hysterectomy was introduced into residency training programs
    • 1989: 600,000 hysterectomies were performed in the United States, of which 70% were total abdominal hysterectomies
    • 2016: 70-80% of hysterectomies were done using minimally invasive techniques
  • The evolution of hysterectomy can be described as starting with traditional abdominal and vaginal routes for hysterectomy:
    • Total abdominal and vaginal hysterectomy (TAH, TVH)
    • Laparoscopic-assisted vaginal hysterectomy, introduced by Harry Reich in late 1980s (LAVH)
    • Laparoscopic supracervical hysterectomy (LSH)
    • Total laparoscopic hysterectomy (TLH)
    • Despite this evolution over the past 20 years, 66% of all hysterectomies still are performed through the abdominal approach

Source: Wu et al, Ob Gyn 2007

Total Laparoscopic Hysterectomy: Advantages

A total laparoscopic hysterectomy:

  • Reduces hospital stay by two days
  • Reduces post-operative recovery by two weeks
  • Can allow for same-day discharge in some clinical scenarios
  • Causes less postoperative pain and discomfort
  • Results in:
    • Less blood loss
    • Substantial financial savings because of lower hospital costs

Disadvantages

Total laparoscopic hysterectomy:

  • Requires increased laparoscopic skills
  • Reduces time for training in vaginal surgery skills
  • Increases:
    • Operative time
    • Procedure cost

Indications

Should be considered when an abdominal hysterectomy is planned for:

  • Pelvic adhesive disease
  • Endometriosis

Should not be used in cases of:

  • Advanced malignancy
  • Large pelvic masses
  • Inadequate visualization because of dense adhesions

A total laparoscopic hysterectomy should not be:

  • Used as a substitute for total vaginal hysterectomy
  • Performed without proper equipment and training

Preparation

  • Check that equipment is available and functioning properly before starting the procedure
  • Position the patient in low lithotomy (See Allen® stirrups in see Fig. 1)*
  • Tuck both arms to sides—see Fig. 1
  • Foley catheter (see Fig. 2)
  • Position dual monitors (see Fig. 3)
  • Check camera resolution
Patient in stirrups.
Figure 1
Foley catheter.
Figure 2
Dual monitors.
Figure 3

*Note: any reference to products in this presentation are made by the authors. ACOG does not promote or endorse any product or company.

The Surgeon

  • Optimizes visualization
  • Requests Trendelenburg position
  • Maintains hemostasis
  • Avoids unnecessary blood loss

Introduction: Anatomic Landmarks

  • Check anatomic landmarks
  • Umbilicus
  • Anterior superior iliac spine
  • Pubic symphysis
  • Aorta
  • Surgical scars

Anatomical landmarks in a female abdomen.

Introduction: Abdominal Vessels

See the blue text to identify these abdominal vessels:

  • Superficial epigastric artery
  • Inferior epigastric artery
  • Superficial circumflex iliac artery
  • Deep circumflex iliac artery
Adominal blood vessels in a female abdomen.

Step 1: Trocar Insertion

  • Insert umbilical trocar through a Hulka or Veress needle or open technique
  • Consider the Palmer point

Trocar insertion points.

Trocar Insertion Techniques

Surgeon entering Veress needle.
Veress needle entry.
Surgeon perfoming optical trocar entry.
Optical trocar entry.
Surgeon performing direct trocar entry.
Direct trocar entry.

Step 2: Lateral Ports

  • Lateral ports: lateral margin of rectus muscle
  • 3-4 fingerbreadths medial to anterior superior iliac spine
  • Transilluminate

Transillumination

Transillumination is the shining of a light through the abdomen to identify abnormalities.

Deep and superficial vessels of the anterior wall.
Image courtesy of Vaman Ghodake, MD, Ghodake Hospital, Sangli, India.

Step 3: Survey

  • Abdominal survey
  • Identify ureters
Pelvis uterus.
Appendix.
Liver edge and gallbladder.
Ureter.
Abdominal ureters.

Images courtesy of Ernest Lockrow, DO.

Step 4: Remember A-B-C

  • A:
    • Identification of anatomy
    • Detachment of adnexa
  • B:
    • Broad ligament
    • Bladder
    • Blood vessels
Uterus and right broad ligament, seen from behind. The broad ligament has been spread out and the ovary drawn downward. Source: Gray, H. (1918). Anatomy of the human body. Lea & Febiger.
  • C:
    • Cardinal ligaments
    • Colpotomy
    • Cuff closure

Step 5 

  • Start with salpingectomy
    • Avoid ovarian vessels
    • Stay at the level of the mesosalpinx, parallel to the fallopian tube
  • Transect the infundibulopelvic ligament
    • Inspect the location of the ureter
    • Desiccate perpendicular to the axis

Cauterize and Transect the Round Ligament

Image courtesy of Ernest Lockrow, DO.

Cauterize the Infundibulopelvic Ligament

Image courtesy of Ernest Lockrow, DO.

Transect the Infundibulopelvic Ligament

Image courtesy of Ernest Lockrow, DO.

Complete Dissection to Round Ligament

 
Image courtesy of Ernest Lockrow, DO.

Identify Ureters Again

 
Image courtesy of Ernest Lockrow, DO.

Make the Bladder Flap Dissection

 
Image courtesy of Ernest Lockrow, DO.

Step 6

  • Transect the uterine vessels Lateralize the cardinals Protect the ureters

Cauterize and Transect the Uterine Vessels

 
Image courtesy of Ernest Lockrow, DO.

Step 7

  • Complete the opposite side in a similar fashion
  • Complete the colpotomy incision

Complete the Colopotomy Incision

 
Image courtesy of Ernest Lockrow, DO.

Cauterize and Transect the Vaginal Artery

 
Image courtesy of Ernest Lockrow, DO.

Step 8

  • Complete the posterior colpotomy preserving the uterosacral ligament support

Complete the Posterior Colpotomy

 
Image courtesy of Ernest Lockrow, DO.

Last Steps

  • Remove the uterus from below or from the umbilical incision with contained in-bag morcellation
  • Close the vaginal cuff from below or laparoscopically
  • Finish with removal of ports
  • Close fascia defects larger than 10 mm

Close the Vaginal Cuff Laparoscopically

 
Image courtesy of Ernest Lockrow, DO.

References

  1. Cheetham, G., & Chivers, G. E. (2005). Professions, competence and informal learning. Edward Elgar Publishing, p. 337.
  2. Eraut, M. (1994). Developing professional knowledge and competence. Psychology Press, p. 124.
  3. Hoffman. B.L., Schorge, J.O., Halverson, L. M., Hamid, C.A., Corton, M.M., & Schaffer, J. I. (2020) Williams Gynecology, 4e. Chapter 44: “Mininally Invasive Surgery,” pp. 873- 906.
  4. Levine, R. L., & Pasic, R. P. (2002). A practical manual of laparoscopy: a clinical cookbook. London: Parthenon. Chapter 11 “Ectopic Pregnancy” Roy G and Luciano A., pp. 157–171.
  5. Reznick, R., Regehr, G., MacRae, H., Martin, J., & McCulloch, W. (1997). Testing technical skill via an innovative “bench station” examination. The American Journal of Surgery, 173(3), pp. 226–230.
  6. Rock, J. A., Jones, H. W., Te Linde, R. W., & Wesley, R. (2008). Te Linde's operative gynecology. Chapter 34: “Ectopic Pregnancy,” pp. 798– 822.

Author

  • Ernest G. Lockrow, DO, FACOG, FACOOG, Professor and Vice Chair of Education, Uniformed Services University Program Director, Minimally Invasive Gynecologic Surgery Fellowship

Developed in association with Advancing Minimally Invasive Gynecology Worldwide.

Reaffirmed February 2021

The CREOG Surgical Skills Task Force created this simulation as part of a standardized surgical skills curriculum for use in training residents in obstetrics and gynecology.