Simulation

Total Laparoscopic Hysterectomy

Simulation

Pre-Simulation

Do a thorough orientation of the room, equipment and simulators; this should take no more than 5-10 minutes
Alternatively, if you want to have the learners build the simulator; this will take 20-30 minutes
Set the stage for the simulation by doing the following:
- Discuss the learning objectives for the day
- Have the learners practice patient counseling by counseling you about the procedures
- Explain that everything should either be verbalized or done as if this was an actual operating room setting

Simulator Assembly

Objective

Create a hysterectomy model for simulation of performing a total laparoscopic hysterectomy (TLH) to achieve the following educational objectives and surgical skills:

Identification of anatomical structures
Knowledge of steps in TLH including dissection of bladder from lower uterine segment, cervix and upper vagina
Flow of operation and assessment of forward planning, time and motion
Knowledge and use of instruments
Use of assistants
Knot tying/ligation

Materials and Preparation

- The TLH bony pelvis (flower pot base) can also be used for the TVH and TAH simulators.
- Both simulators are initially assembled in the same manner.
- The inserts and pelvic floor are slightly different for TVH vs TLH. The TLH model can be modified to change the complexity of the surgical procedure (e.g., enlarged uterus).
- Most of the materials can be reused
- Most of the materials can be substituted for similar products and are easily found.
Completed total laparoscopic hysterectomy simulator.

Figure 1

Figure 2

Figure 3

Pelvis (Figure 1)

Bony pelvis: 1 plastic flower pot (11 in high x 13 in wide): soft enough to cut with garden shears or utility knife (flower pot pelvis is fully reusable). Flowerpot can be ordered online at greenhousemegastore.com.
- 2 to 4 three-quarter inch long flat head #8 wood screws and metal washers
- 1-2 pieces of particle board/ plywood (½ in thick, 8 x 16 in)
- 10 pieces (2.5 - 3 in length) garden wires
- Vulva/ perineum (see also Figure 2.11): Felt fabric (8 x 8 in)
- Awl - to place holes in the flowerpot
- Screwdriver - to screw flower pot to wooden board(s)
- Spray adhesive glue to adhere felt to flower pot Inexpensive pink fabric to line the flowerpot as parietal peritoneum (optional)
- Pelvic floor: 1 inch thick foam (cut to fit the bottom of the flowerpot)
Uterus, Tubes, Ovaries, and Vagina (Figure 2)
- Uterus/cervix (Fig. 2.1): pool noodle cut into shape of uterus (2.5 in x 5 in) (may be used several times)
- Ovaries and utero-ovarian ligament (Fig. 2.2): 2 pieces of 1.5 in diameter foam balls cut into the shape of ovaries (may be used several times); 2 pieces of white yarn (6 in), fold each in half, tie ends together to form loop; sew knotted end to ovary to create ligament
- Fallopian tubes (Fig. 2.3): pink felt fabric (3 in x 0.5 in)
- Vagina (Fig. 2.10): 4-way stretch performance fabric (used for bathing suits and gym outfits- should be thin) (8 in width x ~12 in length) sewn into a 2.5 - 3 in diameter tube
- Vulva/ perineum and bladder (Fig. 2.11): Felt fabric (8 x 8 in for perineum, 2 x 3 in for bladder)
Ligaments (Figure 2)

Note: Err on keeping lengths long as excess can be trimmed later
- Cardinal and uterosacral ligaments (Fig. 2.4): 4 pieces of ½ in white elastic bands (~10 in)
- Round ligaments (Fig. 2.5): 2 pieces of white yarn (16 in)
- Peritoneum (Fig. 2.6): Press'n Seal® wrap
- Areolar tissue (Fig. 2.7): cotton fiber
Vessels (Figure 2)

Note: Err on keeping lengths long as excess can be trimmed later
- Infundibulopelvic ligaments (Fig. 2.8): 2 thick red acrylic yarn (~20-22 in)
- Uterine vessels (Fig. 2.9): 2 pieces of about thick red acrylic yard (~18-20 in)
Additional Equipment (Figure 3)
- 1-2 Vise-Grip tools/ C-clamps (e.g. Quick-Grip Mini Bar clamp)
Assembly time
- Less than one hour, but significantly shorter if multiple simulators made at the same time
Cost
- Approximately $20

Assembly Steps

Materials needed: Plastic flower pot, plywood, flat head screws/washers, garden wire, awl, screwdriver

Figure 4
1. Anterior abdominal wall opening (Fig. 4.1): cut a 10-12 in wide opening on one side of the pot using gardening shears/utility knife. Can use cardboard template.
  - Note: The inner surface of the pelvis may optionally be lined with pink fabric, attached with spray glue, to mimic the parietal peritoneum.
2. Bony pelvis (Fig. 4.2): cut a 5 in diameter wide hole on the bottom of the flower pot (pelvic outlet).
3. To stabilize pelvis (Fig. 4.3): Attach the side of the flowerpot opposite abdominal wall opening with screws and washers on plywood/ particle board.
4. Attachments for ligaments within the pelvis (Fig. 4.4 - 4.5):
  - Make holes with an awl on the posterior part of the flowerpot (opposite from the "abdominal wall opening") to correspond to anatomically correct attachments for infundibulopelvic, round, cardinal and uterosacral ligaments and the uterine arteries.
  - Holes for the round ligament attachments are made on the anterior part of the flower part, at the base of the "abdominal wall opening".
  - Loops of metal garden wire are anchored from these holes to allow for attachment of the above ligaments and vessels.
5. Creation of the pelvic floor (Fig. 4.6): Attach pink felt to outer base of flower pot
  - Secure with round ligament loops anteriorly
  - Spray base with glue and press felt to base (Optional) secure felt further to base with staple gun
6. Creation of vaginal opening (Fig. 4.7): Incise base of pelvic floor (felt) overlying 5 in opening in flower pot in a starburst fashion
Figure 4.1

Figure 4.2

Figure 4.3

Figure 4.4

Figure 4.5

Figure 4.6

Figure 4.7
Materials needed: Pool noodle, 4-way stretch-fabric, and spray adhesive
1. Uterus: cut pool noodle to 4.5-5 in length; shape with serrated knife to form cervix and uterine fundus
2. Vagina: sew the 2 sides of the 4-way stretch-fabric lengthwise to form a tube and then cut into individual pieces (12 in length, 3.5 in width).
3. Attach uterus to vagina:
  1. Place uterus inside vagina (Fig. 5): Place uterus (pool noodle) completely inside the vagina (fabric tube- finished seam side out) letting the fabric tube extend ~1 in beyond the cervix.
  2. Create vagina and vaginal fornix (Fig. 6): fold the vagina (fabric tube) over on itself so that 2/3 of the uterus (pool noodle) is exposed and 1/3 of the uterus (cervix) is covered by 2 layers of fabric tube.
Figure 5

Figure 6
Materials needed: Elastic bands and sutures
1. Attach/stitch cardinal ligaments and uterosacral ligaments (elastic bands (1/2 in x 10 in)) to anatomically correct sites on the uterus/ vagina.
  1. To prevent the uterus (pool noodle) from shredding and to firmly attach ligaments: when stitching, make sure wide, deep bites are taken of the uterus (pool noodle) and the ligaments/ vagina (elastic bands, fabric tube).
  2. The elastic allows for enough stretch when the uterus to is pulled downwards in vaginal hysterectomy or upwards in abdominal hysterectomy. It also simulates well the texture and tangible properties of the real tissue when being cut and suture ligated.
Figure 7
Materials needed: Spray adhesive
1. Invert/fold vaginal fabric back over the uterine fundus (exposed part of pool noodle)
2. Fold back lower portion of vaginal fabric exposing cervix (pool noodle)
3. Spray glue on the cervix portion of pool noodle (Fig. 8)
4. Unfold vaginal tube fabric back over the cervix and firmly adhere to the cervix and tuck excess fabric tube inside the middle of cervix/ cervical canal and secure with glue and wedge of foam (Fig. 9)
5. Fold vaginal tube fabric back down to expose uterine body again
Figure 8

Figure 9
Materials needed: Felt, white yarn, and foam
1. Utero-ovarian ligament: fold white yarn in half, tie ends together to form loop
  1. Ovary: cut foam into ~ 1.5 in ball
2. Attach/suture utero-ovarian ligament to ovary with suture
3. Fallopian tube: cut tube shape out of pink felt
4. Round ligament: tie a knot at one end of thick yarn
5. Attach/suture fallopian tubes and adnexa to the uterus
6. Attach/suture the round ligament (knotted end of thick yarn) to the uterus
Figure 10 - Without vagina attached.

Figure 11 - Anterior view.

Figure 12 - Posterior view.
Materials needed: Thick dark red yarn and thick bright red yarn
1. Uterine vessels: fold 1 piece of dark red yarn in half
2. Attach/suture the uterine vessels (mid portion of dark red yarn) to the anatomically correct site on the uterus
3. Attach infundibulopelvic ligament to ovary by looping bright red yarn through the utero-ovarian ligament
Figure 13 - Anterior view.

Figure 14 - Close up of adnexa.

If needed, steps can be reshuffled here.
Materials needed: Felt fabric, cotton fibers, and spray adhesive
1. Vesicouterine space/areolar tissue: spray glue over the anterior lower uterine segment and upper vagina and place thin layer of cotton fibers. (Fig. 15)
  - Of note, apply only a very small amount of spray glue
2. Bladder: spray over the thin cotton fibers and place felt fabric (bladder) over the lower 4/5th of the cotton fibers, i.e. make sure there is some cotton fibers that are not covered by the top of the bladder so that the vesicouterine space may be entered more easily. (Fig. 16)
  - Of note, apply only a very small amount of spray glue
Figure 15

Figure 16
Materials needed: Press 'N' Seal® wrap and cotton fibers
1. Place a thin layer of cotton fiber over the posterior lower uterine segment/ upper vagina.
  - Note: This will ease vaginal entry into the posterior cul-de-sac during the procedure.
2. Place the uterus so that the posterior uterus/ vagina (with the thin layer of cotton fiber) is facing up with the ligaments, adnexa, and vessels spread out in anatomically correct position.
3. Carefully place a piece of Press 'N' Seal® wrap (sticky side down) over the entire uterus/ ligaments/ adnexa and press the Press 'N' Seal® around the uterus/ ligaments/ adnexa (without adhering the Press'n Seal to the work surface).
  - Note: Make sure the >Press 'N' Seal® covers at least 1/2 the length of the vagina
4. Carefully flip the entire structure over so that the anterior uterus and bladder/ ligaments/ adnexa with the Press 'N' Seal® is now facing up (Fig. 17).
5. Place a second piece of Press 'N' Seal® ;wrap (sticky side down) over the entire anterior uterus/ligaments/adnexa so that the ligaments, vessels and uterus are sealed within the 2 layers of the wrap. (Fig.18).
  - Note: Make sure the round ligaments are wrapped separately from the adnexa to allow the rounds to be attached anteriorly to the bony pelvis later.
6. Press 'N' Seal® can be trimmed if needed. (Fig 16).
7. The uterus is now encased within the broad ligament. (Press 'N' Seal®).
Figure 17

Figure 18
Materials needed: Complete uterus with vagina, ligaments and adnexa, and bony pelvis
1. Attach the uterus, ligaments, and vessels by tying the ligaments and vessels to the anatomically correct sites (garden wire loops) in the bony pelvis.
Figure 19
Materials needed: Complete uterus with vagina, ligaments and adnexa, and bony pelvis
1. Pelvic floor: cut a circular piece of foam large enough to cover the base of the flower pot and cut a 2.5 - 3 in diameter circular opening in the middle (Fig. 20)
2. Place the uterus/ vagina through the opening in the circular foam so that the uterus and proximal vagina is just above the foam and the distal vagina is below the foam, exiting through the pelvic outlet (hole in the bottom of flower pot) (Fig. 21)
Figure 20

Figure 21
Materials needed: uterus within bony pelvis
1. Through the felt pelvic floor opening, grasp the distal vagina from the attached uterus (Fig. 22)
2. Secure vagina to introitus: attach/ suture the distal vagina to the vaginal/pelvic floor opening (felt fabric) with stitches placed circumferentially (Fig. 23)
  1. To alter the extent of uterine descensus, more or less vaginal length can be made by altering where it is attached to the introitus.
3. Use C-clamps to clamp the simulator to a table to facilitate performance of TLH
Figure 22

Figure 23

Room Preparation

Materials needed: Simulator, C-clamp, table, and drape
- The TLH simulator can be set up in any room with a table which allows for it to be placed at the appropriate height for the surgeon to sit or stand for the TLH
- There should be at least one assistant for the TLH but it is ideal if there are two assistants
- Place a drape across the TLH simulator to cover the opening of the flower pot
Figure 24
Answers to Common Questions
- The purpose of this simulator is to familiarize the learners with the common steps of an abdominal hysterectomy
- Remember that this is a simulation, nothing can be as exact as real-life
- Reiterate what is important as the learners goes through the steps of the procedures from start to finish so that they are more familiar with the steps when they actually do these procedures in the operating room
Common Pitfalls to Monitor
- Do not put too much cotton material when using the Press 'N' Seal® as it can prevent proper adherence
- Do not spray too much glue when attaching the bladder for the TLH model
Vaginal hysterectomy operating room tray:
- Tenaculums (Schroeder Single Tooth, Jacobs, etc)
- Clamps (Heaney, Kelly, straight, curve etc.)
- Scalpel
- Needle driver
- Forceps (Russian, Debakey, etc.)
- Vaginal retractors
- Weighted speculum
- Scissors
- Sutures
Figure 25
1. Time out
2. SCDs/DVT prophylaxis
3. Single dose antibiotic prophylaxis
4. Position
5. Hair clipping
6. Exam under anesthesia
7. Choose abdominal incision
8. Prep: Vagina/Perineum with antiseptic solution
9. Place Foley
10. Prep: Abdomen
11. Place sterile drape

Procedure

Enter abdomen, abdominal exploration.
Place self-retaining retractor.
Pack bowel.
Grasp round ligaments and uteroovarian ligaments with large clamp (i.e., Kelly).
A 0 delayed absorbable suture is placed under the round ligament half way between the uterus and pelvic sidewall. A second suture is placed 1 cm medial to the first suture. These sutures are tied. The round ligament is held taut and divided between the two sutures.
The retroperitoneal space is opened, and the external iliac artery is identified. The ureter should be identified crossing the pelvic brim at the Bifurcation of the common iliac artery.
If the ovaries are to be taken: A window is made in the peritoneum between the ureter and the ovarian vessels. The IP is doubly clamped (tonsil, unless significant edema/inflammation may use heavy clamp such as Heaney) and ligated with a free tie, then a transfixion suture
If the ovaries are to be left in place: A window is made in the peritoneum between the uterus and ovary below the fallopian tube. The pedicle is then clamped (Heaney/Kocher), ligated, free tied and suture ligated.
The bladder is dissected off the anterior cervix: the peritoneum is divided inferior to its attachment to the lower uterine segment. Metzenbaum scissors are used to develop a plane between the bladder and the anterior cervix.
The uterine artery and vein are skeletonized, and clamped with a heavy curved clamp (Heaney/Zeppelin/Masterson), the vessels are cut and doubly ligated.
Confirm separation of rectum from cervix (blunt dissection is generally enough).
Lift the uterus on tension, Clamp remaining portion of broad ligament with straight Heaney/zeppelin clamps, then cut with knife in sequential fashion and suture ligate.
Clamp across the vagina below the cervix using two large Zeppelin clamps that meet each other in the middle. (The clamps should include the base of the cardinal ligaments laterally, the uterosacral ligament posteriorly, the vaginal wall anteriorly and posteriorly.) A knife or Jorgenson scissors are used to cut the vagina from the cervix.
Anchor this portion of the vagina with a figure of eight in the midline. Then Heaney ligate under each clamp. Make sure to include the uterosacral ligament posteriorly and cardinal ligament laterally.
Close the reminder of the vagina with figure of eight sutures.
Irrigate the pelvis.
Inspect the pedicles for hemostasis. Use electrocautery or suture ligatures for small bleeders.
Remove all packing.
Replace omentum anteriorly and consider closure of the peritoneum.
Close fascia- running or mass closure if needed.
Close skin with absorbable suture or staples.
Leave Indwelling catheter until patient mobile.
Oral intake may start as tolerated.

Competency Assessment

The resident is able to demonstrate appropriate pre-operative assessment and planning including the selection of antibiotics and DVT prophylaxis. The resident performs a time out, positions the patient properly and requests the appropriate instruments and suture. The resident demonstrates appropriate tissue handling and flow of the procedure including choosing the most appropriate incision and retractors. In addition, the resident should be able to identify the ureters, perform a bladder dissection, maintain hemostasis and anticipate potential complications. The resident should be able provide postoperative care including thromboembolic prophylaxis and management of medical co-morbidities.

Contributing Authors

Johns Hopkins University School of Medicine Department of Gynecology and Obstetrics

Kristiina Altman, MD
Dayna Burrell, MD
Grace Chen, MD
Betty Chou, MD
Tola Fashokun, MD

Total Laparoscopic Hysterectomy

Simulation

Pre-Simulation

Simulator Assembly

Objective

Materials and Preparation

Assembly Steps

Room Preparation

Procedure

Competency Assessment

Contributing Authors

Please Confirm