Mini lap with elastic retractors in the treatment of fibroids

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Paul Indman, MD: Hi, I am Dr. Paul Indman. We are at the AAGL meeting, World Congress of Minimally Invasive Gynecologic Surgery in Chicago and we are fortunate to have with us Dr. Daniel Tsin, who is Director of Minimally Invasive Surgical Services at Mount Sinai Hospital at Queens. Dr. Tsin, you have a special interest in the small retractors used in mini-laparotomies. As a gynecologic surgeon, I have been thinking about using those, but what is the advantage of that over a traditional metal retractor?

Daniel Tsin, MD: I think that mini-laparotomy has been used by us for many years and tubal ligation is the typical one, but the advantage of the elastic retractor is that it is soft, provides an operative field which is approximately 30% larger than provided by the traditional metal retractors and you have an unobstructed view since metal retractors are not blocking your field. In soft tissue, especially in a mini-laparotomy, when we use the metal retractors, they have a tendency to slip and can produce visceral damage and waste time to apply and re-apply the retractor. So the elastic retractor is like a renewal or rejuvenation of the old-fashioned mini-laparotomy with which we are so familiar from many years ago.

Paul Indman, MD: I have seen people define mini-laparotomy as an incision of any size following a laparoscopy so they do not have to admit defeat. What kinds of incisions are you talking about?

Daniel Tsin, MD: Well, I think that, essentially, I would say mini-laparotomy is an incision that is too small to fit your hand. If you can put your hand inside the abdomen, it is not a mini-laparotomy anymore. So I would say anything from 5 cm and less should be in the concept of mini-laparotomy.

Paul Indman, MD: So what is this hand-assisted laparoscopy? How does that compare?

Daniel Tsin, MD: Hand-assisted laparoscopy is substantially more because I do not know what size hand, mine is more than 5 cm, so hand-assisted laparoscopy is an entirely different approach. It appears to be like mini-laparotomy in the sense that you have this incision to help you and aid you with the surgery, but when we talk about mini-laparotomy, we are talking about substantially smaller incisions.

Paul Indman, MD: What types of procedures will you do through these smaller incisions? Would you do a 10 cm myoma through a 2 cm incision?

Daniel Tsin, MD: Definitely. We have been doing myomectomies, hysterectomies, we have been doing supracervical hysterectomies, we have been doing oophorectomies, I think I mentioned that twice, we have been doing sacropexy with this procedure, so essentially we can do practically every procedure as quickly as you get the proper learning curve. It is substantially faster for people with experience than the laparoscopy learning curve.

Paul Indman, MD: What is the largest size uterus you would do a hysterectomy on with this incision?

Daniel Tsin, MD: I have done hysterectomies in approximately where the uterus is a two finger breadth above the umbilicus.

Paul Indman, MD: Two finger breadths above the umbilicus. How large is the incision?

Daniel Tsin, MD: The incisions are 5 cm.

Paul Indman, MD: Where do you put this incision?

Daniel Tsin, MD: Suprapubic. I usually use Pfannenstiel or a colpotomy-type of incision to do this approach.

Paul Indman, MD: How do you get a uterus that large through? How do you get to the vessels to see what you are doing?

Daniel Tsin, MD: Essentially, we use morcellation, which is surgical morcellation, and we know the pathology, there is a uterine myoma and we use a tenaculum with an injection of vasopressin to give you the points of interest, in some cases it could be the round ligament, and I will do a manual dissection, a manual investigation, by manual I mean fingers only, through the area of the infundibulopelvic in one way and then we gradually work our way through.

Paul Indman, MD: Okay. So typically when we do a hysterectomy, we will, let us say, take the utero-ovarian ligaments or the infundibulopelvic and work our way down and then you have the uterines. So are you just ligating the uterines first? How do you expose the uterines if you still have the broad ligaments intact?

Daniel Tsin, MD: The ideal situation is to deliver the whole uterus out. This has happened in uteri up to 12 week size. When you are talking about a situation of a uterus of the magnitude which I mentioned to you which is almost above the umbilicus, you have to just cut out part of the uterus, making a reduction to allow this exposure.

Paul Indman, MD: Well, that is very interesting. I would like to thank you once more, Dr Tsin, from the AAGL meeting in Chicago. Thank you.

Daniel Tsin, MD: Thank you.