Chapter 14
The Ten Operative Steps
Step 1: Coagulation and cutting of cornual structures (Video 15: Stepwise description of total laparoscopic hysterectomy)
Video 15 Stepwise description of total laparoscopic hysterectomy
Authors’ note: The reader’s attention should now turn to Video 15 which is a total laparoscopic hysterectomy with the ten steps given appropriate titles as the video progresses.
Holding the scissors in the right hand and the bipolar grasper in the left, surgery begins by making the right pedicle fully accessible as a result of the assistant pushing the manipulator’s handle towards the patient’s right thigh with a clockwise twist. Using the bipolar grasper, the round ligament, tube and the ovarian pedicle are coagulated simultaneously 1–1.5 cm away from the uterine cornua. Coagulation is carried out in three adjacent spots so that the cauterized area measures approximately 1.5 cm in diameter. The coagulated area of the pedicle is transected in the middle, thereby ensuring that adequate coagulated pedicle remains on either side to ensure hemostasis.
Care should be taken not to transect the coagulated area more towards the uterus in order to avoid backflow bleeding from the uterine cornua. It is important that the transection be made in small bites in order to avoid bleeding from the inferior margin which may be incompletely coagulated. If there is evidence of incomplete coagulation, that area should be recoagulated before another bite is taken. On occasion, considerable bleeding may come from Samson’s artery in the vicinity of the round ligament. In such instances, it is advisable to irrigate that area with small quantities of saline before recoagulation. The irrigation helps to wash away blood from the bleeding vessel which in turn helps in better identification of the exact bleeding point and penetration of the electricity when reapplied to a clean, albeit bleeding, surface. A common mistake is reapplication of the cautery forceps directly on the bleeding area, thereby coagulating only the surface blood and resulting in a dried coagulum on the forceps blades which then prevents further passage of electrosurgical current to the deeper tissue.
Transection is continued in a downward direction along the lateral border of uterus until the two leaves of the broad ligament are distinctly visible. The ease with which the two leaves are visible as separate anatomic structures depends to a great extent upon the pushing motion and the appropriate fundal rotation provided by the vaginal assistant. If the patient requires salpingo-oophorectomy, the senior author suggests deferral until the end of the operation because, if the infundibulopelvic ligament is transected early on, the tube and the adnexal structures hanging on the sides of the uterus obstruct visualization as surgery progresses.
Because the senior author is of the opinion that the optimal time to remove the adnexa is after the detachment of the uterus from the vagina, the description of this procedure is found in Step 10 (see below).
Step 2: Dissection of the uterovesical peritoneal fold
Once the two leaves of the broad ligament are well visualized, they are further dissected with the bipolar forceps which remains in the left hand. At this juncture, the uterus is placed into a retroverted fashion with the help of the manipulator which has been raised toward the ceiling by the vaginal assistant. The anterior fold of the broad ligament is held with the bipolar forceps and small segments are cauterized sequentially proceeding downward to the level of the uterovesical fold of peritoneum, in a similar manner as is performed in abdominal hysterectomy. When the lower extent is reached, the scissors is first directed towards the midline. It is then continued in a semicircular manner so that the entire bladder peritoneum is detached from the lower uterine segment. Dissection is further continued to the anterior peritoneal leaf of the broad ligament on the contralateral side. As the anatomy varies greatly from patient to patient, it may be useful to continue this peritoneal incision up to the level of the round ligament on the other side after the central bladder peritoneum has been incised. The combination of bipolar cauterization and cutting with scissors is sufficient for satisfactory dissection. One can exactly replicate the technique applied in abdominal hysterectomy. Here, the scissors and the bipolar forceps are used in tandem and in an alternative manner, whereby the scissors tip is used like a forceps to elevate the anterior leaf of peritoneum, while the prongs of the bipolar forceps provide cauterization. After cauterization, the scissors cuts and the bipolar prongs grasp the adjacent peritoneum prior to its being cauterized and cut in a repetitive manner. In this manner, the surgeon does not have to search for the grasping instrument from the trolley to hold the peritoneal edges, thereby prolonging operative time again and again (see Video 15). The dissection of the uterovesical fold is completed when the same process is performed on the left side from the round ligament downwards to the uterovesical fold.
Step 3: Dissection of the posterior peritoneum and skeletonization of the uterine vessels
The procedure is then continued on the right side of the posterior leaf of the broad ligament which became apparent in the very early stages of surgery. This leaf is now cut minimally while the vaginal assistant continues pushing the fundus towards the ceiling and each respective side so that the surgeon maintains a clear view of the posterior lateral uterine anatomy. Care should be taken at this stage so that the surgery is confined only to the posterior leaf of the broad ligament. Otherwise, the uterine vein may be severed and bleeding may occur. This part of the operation can only be completed by careful, bite by bite cutting of the posterior leaf of the broad ligament. The posterior leaf of the broad ligament on the right side is then pulled with the bipolar grasper posteriorly and medially while the uterine pedicle is gently pushed anteriorly with help of the closed scissors. By this way a long segment of the uterine vessels is exposed and the ureters fall laterally. The dissection is further continued to transect the posterior peritoneal layer at the level of the uterocervical junction (isthmic region) until one crosses the midline. This step is crucial for proper skeletonization of the uterine vessels and maintaining the ureters lateral and further away from the operative field. If the bleeding from uterine vein should occur, the surgeon must initiate the careful steps of cauterization and recauterization described above for bleeding of Samson’s artery of the round ligament.
At this stage, dissection and cutting the posterior peritoneum also helps the later opening of the vagina posteriorly by making it more visible and accessible. Normally, dissection of the posterior peritoneum is not performed in abdominal hysterectomy, and, as only mechanical clamps are applied to the uterine pedicles, there is no danger from spread of thermal energy in the abdominal technique. However, in laparoscopy the energy source is applied to the uterine pedicle, and thermal spread is likely to the adjacent structures. With the actions suggested above, lateralization of the ureter away from the operative site as described earlier greatly reduces the risk of ureteric damage. As one gains greater familiarity with the techniques described in this publication, the importance of maintaining the uterus pushed cephalad by proper use of the manipulator should never be underestimated, and its value will become obvious.
Step 4: Coagulation and cutting of left cornual structures, posterior peritoneal dissection and skeletonization of the left uterine pedicle
The uterine fundus is now pushed towards the patient’s right side and rotated in an anticlockwise direction by asking the vaginal assistant to push the manipulator handle towards the patient’s left thigh and twist it anticlockwise. When this is finished, the assistant is asked to push the handle towards the floor which elevates the fundus and makes the corneal structures more visible and farther away from the bowel. In this manner, the fundus moves towards the right side of the patient and the left sided structures are made more accessible to the surgeon. The cauterization and cutting of the cornual structures proceeds exactly as performed previously on the right side until the level of the two leaves of the broad ligament. The remaining intact portion of the uterovesical fold, if any, is coagulated and incised to join the previously made line of dissection on the patient’s right side. Similarly, the posterior peritoneum on the left side of the midline is dissected further to join the line of dissection on the posterior peritoneum on the right side. The left uterine pedicle is exposed in a similar manner as that of the right side. Taking the steps described above, the uterus is stripped from its anterior and posterior peritoneal coverings. Of equal importance, the uterine vessels are now clearly visible on both sides after having been stripped of the overlying peritoneum.
Step 5: Bladder dissection
In this step, the uterine manipulator is rotated 180° inside the uterine cavity by opening the ratcheted lock, pulling it out slightly and then rotating it in an anticlockwise direction by 180°, after which it is relocked by reclamping the two handles. In this manner, when the manipulator handle is lifted towards the ceiling and the manipulator is simultaneously pushed cephalad, the uterus becomes retroverted with its anterior surface, isthmus and cervix visualized prominently and clearly. The guard of the manipulator is easily appreciated through the upper vaginal wall and serves as a landmark to differentiate the bladder and the upper vagina. The limits of the bladder tissue can be demarcated by gently moving the uterine manipulator in a forward and backward motion (see Video 15). The bladder is held with the bipolar grasper forceps and gently pulled anteriorly in order to see a ‘frost’ of loose areolar tissue between the bladder and the pubocervical fascia. One can easily dissect this loose areolar tissue with the scissors without damaging the bladder. Visualization of the manipulator’s guard, which is now situated at the level of the external cervical os, makes the anterior vaginal fornix prominent, thus differentiating the inferior cervical limit and the superior portion of the anterior vaginal wall. The location of this easily visible guard also helps in identifying the extent of the bladder dissection, such that if the bladder is seen as pushed below the guard’s bulge, an adequate bladder dissection has been accomplished. It is best to initiate the bladder dissection in the midline except in patients with a prior cesarean delivery scar when it is advisable to start laterally anterior to the uterine pedicle. Usually the bladder is dissected very well in the midline, but one must cauterize the bladder pillars laterally on both sides and transect them in order to displace the bladder downwards. The manipulator guard helps in identifying the bladder pillars and the extent of the lateral dissection by making the lateral fornices prominent. One can come across troublesome bleeding from the delicate veins beneath the lateral aspect of the bladder. If this occurs, it should be controlled by irrigating the area and giving the only short bursts of bipolar energy rather than a continuous energy flow to obtain coagulation. This procedure should be exactly similar in nature to that described earlier in the operation for small vessel bleeding at the cornu and the uterine vein.
The dissection of the bladder, along with that of the posterior peritoneum and cephalad pushing of the uterine fundus up into the abdomen with the manipulator, all help in skeletonization of the long segments of the uterine pedicles (almost 4–5 cm) on both sides. This step increases the distance between the point of the uterine pedicle coagulation to the wall of the ureter from 1.5 to 4.5 or 5 cm, thereby effectively reducing the incidence of potential ureteric injury dramatically.
Step 6: Coagulation of uterine vessels
Continuing the steps described above for the skeletonization process allows the uterine vessels to be visualized in considerably greater length. Because it is easier to skeletonize the uterine pedicle on the right side than on the left, the right side is cauterized first. The site of cauterization should be close to the insertion of the uterine vessels into the uterus. As sufficient length of uterine vessels is now available, these vessels can be cauterized at three adjacent points (similar to the technique described in Step 1). The completeness of cauterization is identified by either the disappearance of bubbles or the hearing of the auto-stop sound on the machine. Once this is achieved, the pedicle is cut in small bites in the center of the coagulated area in order to obtain safe pedicle length on the uterine wall and the pedicle stump. After the uterine vessels are coagulated and cut, the dissection is carried further downward but medial to the uterine pedicles to create a plane anteriorly within the pubo-cervico-vesical fascia (similar to the intrafascial technique of hysterectomy) and facilitate further downward movement of the bladder anteriorly. This step helps in dissecting the bladder pillars on the left and skeletonization of the remaining left sided uterine pedicle.
After the extension of this plane on the left side, the bladder pillars can be superficially coagulated and pushed downward with the tip of the blunt bipolar grasper forceps (see Video 15). At this juncture, the uterine manipulator is opened and slightly withdrawn and rotated clockwise to its original position (its tips now are facing the ceiling). By pushing the manipulator handle towards the patient’s left thigh and rotating it in an anticlockwise direction, the uterine fundus is deviated to the right side and axially rotated anteriorly. This maneuver makes the skeletonized left uterine pedicle more accessible for coagulation and cutting. However, if the uterus is large, bulky or the pedicle is somewhat obscure, it is useful to elevate the handle to the ceiling at the same time that the other motions are instituted, thereby once again making the uterine pedicle more easily accessible. After proper visualization, the uterine vessels on the left side are coagulated and cut in a similar manner as was performed on the right.
Step 7: Dissection of posterior parametrium
The uterus is acutely anteverted by moving the manipulator handle to the floor as much as possible while, at the same time pushing the manipulator itself towards the ceiling. Also at the same time, the handle is further rotated anticlockwise, so as to facilitate the cauterization of the parametrium medial and posterior to the transected left uterine pedicle. The plane of dissection is identified by the prominence of the manipulator’s guard situated at the left lateral vaginal fornix. Further dissection is continued posteriorly along the lower part of the uterus and cervix; in this manner, the uterosacral and McEnrodt’s ligaments can be dissected but not transacted, allowing them to slide downward as the uterus is pushed upward by the manipulator. This latter activity progressively thins out the posterior vaginal fornix so that posterior colpotomy will be easier. After these actions are completed the fundus of the uterus is further deviated to the patient’s left side and the manipulator is progressively pushed up and rotated clockwise making the right side vaginal fornix more prominent. A similar dissection can then be carried out on the patient’s right side by which the Mackenrodts and uterosacral ligaments on the right side are allowed to slide down after being dissected and not transacted.
To repeat, the vaginal tube is shaved so that it is thinner at the time that colpotomy is to be performed. A common mistake is to perform colpotomy immediately after the desiccation of the uterine vessels at which time the upper vaginal tube is still thick, especially in its posterior aspect. When this occurs, especially when monopolar current is used to make the incision, brisk bleeding often follows, so much so that the operative field is temporarily obscured. In the abdominal hysterectomy, on the other hand, the transection and ligation of the Mackenrodt and uterosacral ligaments avoids this issue. The senior author cautions novice surgeons to pay special attention to the step of thinning out the posterior vaginal wall prior to its incision. It is important to remember that by this time the blades of the bipolar forceps may become covered with coagulated and carbonized blood, and be less able to fully grasp and coagulate the tissue. Should this occur, the bipolar forceps can be removed and easily cleaned with a sterile toothbrush which is kept in readiness on the instrument trolley.
Similar to the manner in which these tissues are treated in an abdominal hysterectomy, whereby a clamp is followed by tissue division and ligation, the bipolar cautery forceps is used to desiccate the tissues immediately lateral to the cervix at a level above the vaginal vault but medial to the uterine vessels. Here the tissue is coagulated first and then cut. By doing this in a careful and stepwise manner, a small border of tissue remains on the uterus, but the majority of the desiccated tissue falls laterally. The effect is absolutely equal to that produced in an abdominal hysterectomy. As noted above there is no clear division of the uterosacral ligaments per se, and they remain attached to the vaginal cuff where they help in future vault support.
Step 8: Colpotomy
A posterior colpotomy incision is initiated on the patient’s right side at a level below the cervix where, when the uterus is pushed upward by manipulator, the guard is easily visible. Even though this initial incision is small, it is likely to result in a loss of pneumoperitoneum. Accordingly, the uterine manipulator is removed at this point in time and replaced by the vaginal delineator tube. After removal of the uterine manipulator, additional stabilization and manipulation of the uterus is accomplished by inserting the myoma screw from the uppermost ancillary port. At this point, the bipolar forceps and scissors are alternatively passed through the lower ancillary port. The myoma screw is fixed at the level of the isthmus posteriolaterally on the right side. The vaginal tube then is pushed upward while its handle is pushed downward to the floor and towards the patient’s right thigh. This maneuver helps in stretching the vaginal tube and assisting with visualization as the colpotomy proceeds by cutting with scissors as the vaginal tube is appropriately manipulated to facilitate exposure (see Video 15). As the vagina has been made thinner by the earlier dissection, no modality other than the bipolar energy source is required to accomplish the complete colpotomy. Minimal bipolar energy is preferable at this point for a number of reasons including less secondary hemorrhage, tissue necrosis and possible postoperative dehiscence of vaginal vault. (The senior author has never seen this latter complication in his years of his practice using this technique.) As the colpotomy is being completed, one should be careful not to forcibly pull the myoma screw because of the risk of tearing the remaining upper part of the vagina and causing brisk bleeding. In the event that it becomes difficult to visualize the left lateral aspect of the colpotomy before it is coagulated and incised, the assistant can take advantage of the 30° telescope and put that area in focus by rotating the angle of the scope, keeping the camera head steady. It is axiomatic that the moment the colpotomy has been completed, the uterus is completely detached from the vagina.
Until this point in the operation, it is only necessary to use two instruments: the bipolar grasping forceps in the left hand and the scissors in the right. This minimalistic technique saves a great deal of time that could be lost in changing instruments. The insertion of the myoma screw represents the first time an additional instrument has come into the picture.
Step 9: Specimen retrieval
In general, a uterus up to 12 weeks size can be removed through the colpotomy incision with minimal manipulation in a multiparous patient who has previously delivered vaginally. In contrast, when the uterus is more than 12 weeks size, in nulliparous patients with normal size uteri, and in those who have not delivered vaginally, uterine removal requires vaginal mechanical morcellation or abdominal electronic morcellation.
After detaching the uterus from the vagina, the myoma screw is left in situ and the cervix is pushed downwards through the colpotomy incision into the vagina using the screw to initiate the downward motion. Then the vaginal tube is removed. Next the abdomen is deflated and the vaginal assistant begins removal of the specimen using tenaculum or vulsellum. If the abdomen is not deflated at this stage, there is a risk of gas, blood and/or abdominal fluid being splashed onto the assistant’s face. Care should be taken to put the light source on the standby mode, as a risk of thermal damage to the bowel remains if contact is made with the tip of the telescope in a deflated abdomen.
When the uterus is greater than 12 weeks size, the specimen can be retrieved vaginally by holding the cervix with two vulselli and retracting the anterior and posterior vagina with two specula. This type of retrieval requires a mechanical morcellation with a coring technique, whereby constant traction is provided by the two vulselli and the specimen is cored out with the help of the blade making deep concentric incisions, while protecting the bladder and the vaginal walls with the help of the specula anteriorly and posteriorly (Video 8: Uterine morcellation through the vaginal route). In this manner, the specimen becomes narrow, elongated and tubular, thus effectively reducing the diameter for easy removal. The operating surgeon should be patient in order to increase the likelihood of having a successful outcome. One should not bisect the specimen for its retrieval, as the superior margin of the vaginal cuff has a narrow and fixed diameter. By bisecting the uterus and pulling it down, the size and diameter of the upper part of the specimen does not diminish, and a constant pull through the narrow upper vaginal cuff may cause laceration and tears into the lateral fornices and/or the bladder. Occasionally the pressure of the uterus onto the bladder may irritate the mucosal lining and cause some degree of hematuria which should not be worrisome in the majority of instances. If, on the other hand, bleeding or frank hematuria occurs early in the operation or is persistent at the time of the attempt at specimen retrieval, appropriate investigations are warranted.
If the operating surgeon is not comfortable or well versed with the technique of vaginal retrieval of a larger specimen, in situations of a narrow postmenopausal, nulliparous vagina, in severely obese patients with long narrow vaginas, and when the patient has never delivered vaginally in spite of one or more cesarean sections, the specimen may be retrieved abdominally using the electronic morcellator through an extension of the right lower ancillary port. The preference and type of morcellator selected is within the purview of the operating surgeon. The senior author prefers a morcellator with a reusable 15 mm blade. In his experience, it is relatively easy to morcellate the complete uterine specimen compared with attempting to morcellate a myoma specimen. During this procedure, the principles of morcellation technique should be followed carefully to avoid accidental injury to the other abdominal structures. After completion of the morcellation, a layered closure of the morcellator port is useful to avoid a Spigelian hernia.
Based on an FDA analysis of currently available data if laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s long-term survival. While the specific estimate of this risk may not be known with certainty, the FDA believes that the risk is higher than previously understood. Few authors morcellate the uterine specimen in a large specimen bag to prevent the risk of spread of cancer. In senior authors experience these specimen bags require further improvement in the design. The FDA recommended the following new contraindications:
- Laparoscopic power morcellators are contraindicated for removal of uterine tissue containing suspected fibroids in patients who are peri- or postmenopausal, or are candidates for en bloc tissue removal, for example through the vagina or mini-laparotomy incision. (Note: These groups of women represent the majority of women with fibroids who undergo hysterectomy and myomectomy.)
- Laparoscopic power morcellators are contraindicated in gynecologic surgery in which the tissue to be morcellated is known or suspected to contain malignancy.
- The FDA warns that uterine tissue may contain unsuspected cancer. The use of laparoscopic power morcellators during fibroid surgery may spread cancer, and decrease the long-term survival of patients. This information should be shared with patients when considering surgery with the use of these devices.
- Carefully consider all the available treatment options for women with uterine fibroids.
- Thoroughly discuss the benefits and risks of all treatments with patients. Be certain to inform the small group of patients for whom laparoscopic power morcellation may be an acceptable therapeutic option that their fibroid(s) may contain unexpected cancerous tissue and that laparoscopic power morcellation may spread the cancer, significantly worsening their prognosis. This population might include some younger women who want to maintain their fertility or women not yet perimenopausal who wish to keep their uterus after being informed of the risks. (FDA. Laparoscopic Uterine Power Morcellation in Hysterectomy & Myomectomy: FDA Safety Communication Updated, Recommendation for health providers, November 24, 2014)
Step 10: Closure of the vaginal vault
The senior author prefers to close the vagina laparoscopically for the following reasons:
- While suturing the vaginal cuff laparoscopically, the surgeon can observe it distinctly and differentiate it from the bladder tissue, a procedure which may be exceedingly difficult using the vaginal approach.
- Laparoscopically, it is easy to suture the full thickness of the vaginal vault including the mucosa and, at the same time, the uterosacral ligaments can be anchored to it.
- Laparoscopically, it is easy to identify the angles of the vaginal vault so that one can suture them correctly without damaging the uterine pedicles situated just adjacent to the vaginal vault.
- Laparoscopically, it is easy to identify the vaginal edges which may have retracted somewhat after the colpotomy has been completed. In contrast, this is difficult with the vaginal approach where the surgeon cannot see the bladder and tends to take larger and less definitive bites. Such sutures may compromise the bladder, the uterine pedicles and/or the ureter.
- In a well versed surgeon’s hands it takes less time for closure of the vaginal vault laparoscopically than would be required to change the patient’s position and that of the operating table to accomplish closure via the vaginal vault.
The preferred suture material is a 20–30 cm polyglactin delayed absorbable on a half circle round body #1 needle (Universal code 2347). The suture is introduced through the right lower ancillary port, and the needle holder remains in that port. As described, the 2 ´ 4 tooth grasper is used to assist in the suturing process. The suturing begins at the left vaginal angle, and the closure is performed with a simple continuous suture proceeding from left to right. Use of a continuous suture allows a certain degree of traction to be exerted if necessary prior to tying the knot. A surgeon’s knot is tied at the right vaginal angle. Due care is required to avoid penetration of the uterine pedicle at the vaginal angles. The uterosacral stumps and posterior peritoneum are also incorporated in the vaginal closure. The vaginal closure may not be air tight as long as hemostasis is satisfactory. Peritonealization of the cuff is not mandatory and is not used in the senior author’s practice. The peritoneal edges fall together after the gas is removed from the abdominal cavity.
Immediately after tying the surgeon’s knot, it is preferable to remove the needle from the abdominal cavity and announce this fact to all team members. Although the needle is removed, the laparoscope remains in place. A generous saline irrigation is performed through the lower ancillary port to ensure that hemostasis is secure. At this juncture, the surgeon must confirm the normal vital patient parameters with the anesthesiologist, as some anesthesiologists prefer to operate with a lower but stable blood pressure (hypotensive anesthesia) which then will rise at the termination of the procedure. An unexpected rise could cause bleeding in an otherwise dry pelvis.
Before deflating the abdomen, it is advisable to re-inspect the uterine pedicles and upper abdomen. This is to confirm that no inadvertent injury has involved upper abdominal structures.
The procedure is concluded with removal of all ports under direct vision and restoration of the patient’s horizontal position. The port sites are closed as per the prevalent practice of the surgeon. Before the patient’s position is changed, however, it is advisable to perform gentle vaginal examination to check for bleeding from the vault edges or lacerated vaginal walls as well as to make sure that no foreign bodies, i.e. gauze, remain in the vagina. At this point, the patient’s legs can be removed from the stirrups and gently placed on the table which now can be returned to the flat position. A final check is made on the catheter to ensure that the urine is flowing and the bag to ensure that the urine is clear.