Overcoming Technical Limits to Laparoscopic Hysterectomy

Reprinted with kind permission from TheTrocar.com Publication Date:: 06/06/2006 Update Date:: 06/06/2006 Introduction The first laparoscopic hysterectomy was performed in 1989 by Henry Reich. Nowadays the laparoscopic hysterectomy for a uterus up to 300 grams, without other pathologies that could limit its mobility or without a poor vaginal access, has to be considered a basic well standardized procedure. However, there are some clinical conditions which can pose limits and can turn laparoscopic hysterectomy in a very challenging procedure. These limits are constituted by: The presence of large uterus over 300 grams (or 12 weeks) with or without a poor vaginal access The presence of adhesions due to previous caesarean sections or previous pelvic surgeries (myomectomies) The presence of pelvic varicosities The presence of other pathologies like endometriosis But these are exactly the clinical conditions which represent the main indications to laparoscopic hysterectomy. In fact these are exactly the situations considered as absolute contraindications to vaginal hysterectomy ( or relative contraindications according to the surgeon's experience)(Doucette RC, 2001; Paparella P, 2004). In practice, it is right in these conditions that the laparoscopic approach can contribute to reduce the number of laparotomic procedures. In the past, the large uterus (> 16 weeks’ gestation) has been listed as a relative contraindication to laparoscopic hysterectomy (De Meus, 1997). However, because of the improvements in laparoscopic techniques and instrumentations in the latest years, clinical feasibility and practicality of laparoscopic surgery to remove enlarged uteri has been demonstrated (Pelosi, 1994; Salmanti, 1999; Wang, 2004). Given that the rationale for the practice of TLH is to convert abdominal hysterectomies into laparoscopic procedures, it seems logic that large uteri in patients with poor vaginal access will be the main indication for laparoscopic hysterectomy. A number of pre-existing clinical conditions generally accepted as contraindications to vaginal hysterectomy will also be associated such as nulliparity or no prior vaginal delivery, previous caesarean or pelvic surgeries, adnexal pathologies, severe endometriosis or requirement of oophorectomy (Unger, 1999). For a skilful laparoscopist, managing a large uterus is both feasible and safe; anyway, very enlarged uteri allow limited access to uterine vascular pedicles depending on size and location of myomas, and may be associated with high risk of complications such as hemorrhage. Other concerns of laparoscopic management of large uteri are the risk of bowel and urinary injury due to poor exposure, difficulty in extracting the uterus and duration of the procedure (Wattiez, 2002). TECHNIQUE Bipolar coagulation forceps, monopolar hook, scissors, grasping forceps, suction-irrigator probe, suturing set and uterine manipulator complete our basic set for hysterectomy. All the instruments are reusable (Table I). The new sealing vessels bipolar systems (Ligasure®, Gyrus® or the BiClamp® ERBE reusable system) could be handy especially in case of varicosities. The patient is placed in the lithotomic position with arms tucked at her side to allow free movements for the surgeons and to avoid brachial plexus injury. The legs are abducted at 90°. The bladder is catheterized and the uterus mobilized by a manipulator (Table II). Uterine Manipulator The role of the uterine manipulator is extremely important in cases of very enlarged uteri. Many functions are required from the uterine manipulators ( whether LAVH or total or supracervical laparoscopic hysterectomy is performed): a) to suitably mobilize the uterus. This is obtained by allowing three kinds of movements : anteversion and retroversion, lateral and, very important for TLH, elevation movements; b) to clearly identify and distend the vaginal fornices to enable a circular section of the vaginal fornices; c) to elevate and define the cervico-vaginal junction to enable a safer dissection of the vesico-uterine fold and fascia; d) to enable the elevation of the uterus upwards in the abdomen, in order to obtain a good visualization of the uterine artery and its removal from the ureter; e) to maintain a regular pneumoperitoneum Standard Technique LH is nowadays a standardized procedures. (Wattiez, 2002; Malzoni, 2004) Lateral suprapubic trocars are inserted higher than usual. Round ligaments and infundibolopelvic or ovarian ligaments are coagulated and dissected with bipolar scissors. The round ligament should be coagulated in its middle part far from the uterine horn. A fenestration is performed, if space allows it, in the posterior leaf of the broad ligament to move the ureter laterally and downwards before coagulation of the infundibolo-pelvic or ovarian ligament. The vesico-uterine fold , elevated with endoclinch or Manhes forceps, is incised by endoshears starting from the round ligament: this lateral approach makes the dissection easier in cases of adhesions due to previous Cesarean sections. While pushing on the uterus, the valve of the uterine manipulator highlights the anterior fornix and allows the vesicovaginal dissection plane to be entered. Internal pillars of the bladder are coagulated and sectioned up to the uterine pedicles. Thereafter the uterus is anteverted and anteflexed to show and elevated the uterosacral ligaments. The uterus is pushed upwards into the pelvis and the valves of the uterine manipulator delineate the rectovaginal septum more clearly. The ligaments are intrafascially coagulated and sectioned, so that lateralization of the ureter from the uterus is obtained and ureteral injuries are avoided. The uterine vessels are exposed, skeletonized, and only then coagulated and transected. A coagulation is applied on the ascending branch of the uterine artery to avoid back blood flow. Suture-ligating uterine vessels gives the surgeon a referential lateral landmark beyond which coagulation should occur, but it can be difficult to perform in a narrow space. An intrafascial dissection of the vagina with circular colpotomy is carried out using monopolar hook or scissors. The uterus is removed vaginally. TLH IN CASE OF LARGE UTERI SHOULD BE MODIFIED. (Wattiez, 2002) Poor access and exposure are the main concerns, and can be overcome by few modifications in technique. Preoperative Treatment with GnRH Analogs In most of cases, treatment with GnRH analogs decreases uterine volume, calculated by ultrasonography, by an average of 25%. Although expensive and with adverse symptoms, a 3-month preoperative course of GnRH analogs in women with very enlarged uterus may facilitate (and in some case make it possible) laparoscopic hysterectomy, decreasing uterine size and improving pre-operative Hb levels (Seracchioli, 2003). Trocar Placement and Ergonomics First, trocar insertion sites should be changed. The option of open abdominal entry should be considered to minimize the risk of lacerating the uterus, if it reaches or exceeds the midline. Using the Palmer point to insert the Veress needle could be another option, especially if adhesions are suspected. Video 1 Obviously there is a physical limit to the space of maneuver of our instruments and to the angle of vision represented by the space between the distended abdominal wall and the uterus. The goals are better exposure and handling of the instruments without the hindrance of the uterus. The optic trocar should be placed up to 10 cm above the umbilicus The middle trocar should be placed through the umbilicus or even higher. The other two lateral trocars should be placed according to uterine size and location of myomas. The higher the uterus the higher the ancillary trocars should be inserted, at umbilical line or even some centimeters further up. Therefore instruments that are inserted in lateral trocars will approach the uterine vessels anteriorly and posteriorly to the uterus and above. (Wattiez, 2002). With these modifications, a larger intraperitoneal manipulation space can be achieved. Or alternatively, the left ancillary rocar should be placed lower to reach better the anterior structures and the right ancillary trocar should be placed higher to reach the posterior structures. When the surgeon is working on the left side, he/she uses the bipolar forceps in the left lateral port and the scissors in the midline. The assistant has a grasping forceps to mobilizing the adnexa, showing the operative field or applying traction on the uterus in the opposite direction to allow better exposure of the uterine vessels and cardinal ligaments. On the right side, the surgeon is holding the grasping forceps with the left hand, to allow exposure of the right side and the scissors in the central port. The assistant is using the bipolar forceps. In this way, most of the time, the surgeons do not need to continuously changing instruments during the procedures and all the structures are approached from the best angle. It has to be reminded that the most dangerous times for thermal ureteral injury are during coagulation with bipolar forceps at the right uterosacral and cardinal ligaments (Wattiez, 2002), and coagulation of the right uterine pedicle. Therefore, when coagulation is applied on the right side is preferable that the assistant uses bipolar forceps and approaches the vessels at right angles to the ascending branch. In larger cases, very often only two of the operative instruments are really in action, the central one and the one on the side we are working at : in fact, the controlateral instrument can not pass through the uterus. In order to solve this problem, it should be evaluated the possibility to use five operative trocars using an additional instrument for traction and manipulation so as to have the operating field always accessible with three basic instruments (monopolar scissors, bipolar coagulating forceps and grasping forceps)(Minelli, 2002) 30° Laparoscope It should be remarked that speaking of uterine volume is a little too simplistic: it would be better to precise the uterine shape too. When the transverse diameter of the uterus is relevant we can not see its isthmic part even if we try to strongly push or pull the uterus by means of a uterine manipulator or by grasping forceps. So, a relatively short but large uterus ("pear shaped") may be more challenging than a much bigger one but with an easy access to the main anatomical structures (inverse "pear shaped"). In such cases, as in case of big myomas impeding a correct vision we advice to switch from a 0° to a 30° laparoscope: in this way a simple change of the angle of vision allows to clearly expose the vesicocervical fold of the visceral peritoneum anteriorly, the uterine vessels laterally and the utero-sacral ligaments posteriorly. Drawing strongly the uterus towards one side and using the 30° laparoscope on the opposite side almost always solve any problem of vision, but the fluent and correct use of this endoscope needs a certain time of training. In fact the assistant has to coordinate the usual movement of the camera with the rotation of the endoscope (Minelli,2002). Technical difficulties in the surgical procedure may be greatly increased by the presence of myomas which can encumber depending on their size and localization. In some case, if impeding myomas are encountered in the course of the intervention, it is a matter of surgical judgment to precede the hysterectomy with a myomectomy in order to reduce uterine volume and/or to allow a better vision, for example, of the peritoneal vesicocervical fold. We currently inject a vasoconstrictive agent around myomas, a practice that makes the operative field remarkably bloodless and bloodlessness during both myomectomy and hysterectomy is itself of utmost importance if we want to be highly respectful of anatomy. Use of GnRH analogues could be suggested prior of planned intervention. On other occasions, a strong traction on myomas by grasping forceps is sufficient to obtain a clear view of the operating field. Securing Uterine Vessels and Decreasing the Risk of Hemorrhage The difficult exposure can increase the risk of hemorrhage. The surgeon should be experienced in performing ligation and suturing the uterine artery near its origin from the hypogastric artery. The retroperitoneal approach proposed by Kadar (1994) can be useful to identify the ureter in cases of infiltrating endometriosis of the posterior leaf of the broad ligament, but it is definitively not easy to perform when anatomical exposure is minimal. The retroperitoneum is accessed through the lateral leaf of the broad ligament and the ureter isolated at the pelvic brim. The opening must be larger than in open surgery because more space is needed. At this level, the ureter is easy to visualize by blunt dissection and the pararectal space is opened. The limits of the pararectal space are the ureter medially, the internal iliac artery laterally and by the uterine artery anteriorly. The ureter and the internal iliac artery are then dissected to the origin of the uterine artery, delimiting the pararectal fossa. At this point, the uterine artery is coagulated or a clip is used, previous checking of the ureter. Only at this step the infundibulo-pelvic ligaments or the utero-ovarian ligaments are divided (Volpi, 2002). Large uteri yet have the problem of back blood flow and of bleeding due to tractions on the uterus or ligaments apply to facilitate the exposure. The coagulation of the tube and utero-ovarian vessels and the coagulation of the ascending branch of the uterine artery could decrease the back blood flow. Some authors ( Wang, 2004) have recommended the use of intravenous perfusion (at a rate of 2 mL/min) of 10 Units of oxytocin added to 1000 mL of normal saline to decrease uterine blood perfusion and minimize reflux. Injection of diluted vasopressin around the capsule of a voluminous bleeding myoma can also decreases blood loss and allows a cleaner operating field. Changing Strategies Sometimes, in cases of very large uteri difficult to mobilize or in presence of myomas encumbering the procedure, the routine steps of hysterectomy can not be followed. In these situations, the procedure usually starts anywhere there is a better vision and the structures are approachable. Dividing one ligament, freeing an infraligamentous myoma from the surrounding peritoneum, cutting an utero-sacral ligament allow to slowly gain space and mobility. Sometimes it is impossible to completely prepare one side: the surgeon will often switch from one side to the other, from the anterior to the posterior aspect, always working where there is a good vision, step by step until a better mobilization is achieved. Morcellation Enlarged uteri require significantly more morcellation than smaller uteri. Morcellation can be performed either vaginally or with a laparoscopic knife. The laparoscopic knife can be of advantage in nulliparous patients or in patients with very narrow vagina. A not complete hemisection is performed, followed by further hemisection of the two halves. In any case the uterus is at the end removed vaginally. Surgeons experienced with vaginal surgery could find easier (and less time consuming) the vaginal morcellation, bearing in mind the risk of vaginal and rectal injuries. Usually a combined use of Lash intramyometrial coring (Lash, 1941), bisection, wedge morcellation and myomectomy (Magos,1996; Reiffenstuhl, 1996) is required in all patients. Whatever technique the surgeon is using, surrounding tissue (vaginal wall, rectum and bladder) should be protected with retractors throughout the procedure (Drawing 4). It has to be stressed that vaginal morcellation after laparoscopic hysterectomy could be more difficult than after vaginal hysterectomy. In fact, an extraperitoneal dissection of the cul-de-sac of Douglas and the section of the uterosacral ligaments improve access to the enlarged uterus with poor uterine descent. On the other hand, the laparoscopic intrafascial circular colpotomy allow a narrower passage for the uterus. Bisection The cervix is grasped with two tenaculums on both sides and a scalpel is used to bisect the uterus in an antero-posterior direction towards the fundus (Magos, 1996) The bisection usually in carried out along the posterior uterine wall: the continuous repositioning of the tenaculums close to the upper part of the incision combined with the rotation of the proximal part towards the pubic arch help the progression to the fundus. When the fundus has been reached or the further posterior bisection is difficult, the uterus is repositioned in the correct orientation and the bivalving continues anteriorly in a similar way. Sometime one half of the uterus is delivered through the vagina followed by the other half. Coring Coring is performed with some of the smaller uteri. Grasping the cervix with a Museux or Collin forceps and apply a strong traction, a circumferential incision is made at the level of the uterine isthmus approximately 5mm into the corpus of the uterus. A central core of tissue which includes the uterine cavity and the surrounding myometrium is then excised by progressively undercutting the serosal surface of the uterine corpus towards the fundus. This process is facilitated by applying strong tractions on the cervix at the beginning, by moving the grasping forceps inwards as the coring proceeds ( to apply better traction and to avoid lacerations of the tissue) and elevating the serosal part of the dissection with grasping forceps. The coring allows a thinning of the uterus which is at the end inverted at the fundus and delivered through the vagina. When dealing with bigger uteri, the coring is usually limited to a deep cervical amputation. Myomectomy This is usually combined with the other techniques. Smaller myomas are simply removed, once their capsule has been opened, by applying a rotating traction with a Bernard forceps. Larger myomas are removed in smaller pieces after bisection or situ morcellation. To avoid a sudden re-ascending of the uterus which can be dangerous because of the almost blind grasping of the uterus inside the abdomen, a tenaculum is always holding the residual uterine bulk. As soon as myomectomy has been completed and further descend of the uterus can be obtained, bisection starts again. Wedge Morcellation Whenever, despite cervical amputation, bisection, myomectomy, no further descensus of the uterus is possible, wedge morcellation becomes handy. The uterus is firmly grasped with tenaculums or short Bernard forceps and a sharp excision with scissors or scalpel delivers pieces of the specimen. When a sufficient reduction of the uterine bulk has been gained, a further bisection allows the delivery of the uterus through the vagina. MASSIVE UTERI - High Epigastric Port Placement In case of very large uteri (>1500 to 2400-3050 grams) especially with large central myomas impeding the view to a central 10 mm telescope, benefit was found with high epigastric port placement (Lee, 2001). After obtaining a pneumoperitoneum by Veress needle inserted at the umbilicus or at the Palmer point, a 10 mm cannula is placed 5 cm above the upper margin of the palpable uterus. This port is now used to insert under vision the lateral epigastic 10 mm cannula site for the laparoscope from 3 to 7 cm in the bilateral subcostal regions; during the procedure this central port will be used for retraction and manipulation. On both sides, two 5 mm accessory ports are placed lateral to inferior epigastric vessels at level of the umbilicus and left suprapubic area. On each side, section of the round ligament, infundibolopelvic or ovarian ligament, dissection of the vesicouterine peritoneal fold and coagulation and division of the uterine artery were achieved. The surgeon moves to the side where is inserted the laparoscope. Hand-assisted Laparoscopy An alternative to this seven port technique could be the hand-assisted laparoscopy (Pelosi, 1999) which may be faster and cost-effective, but it requires an incision the width of the surgeon’s hand. A transverse lower abdominal incision is made and an air-sealing hand access system is mounted. Manual countertraction is effective in facilitating exposure and laparoscopic bipolar coagulation and division of vascular pedicles. Morcellation is carried out through the laparotomic incision. Supracervical Hysterectomy In other cases, it could be easier to perform first a supracervical hysterectomy, followed by laparoscopic or better vaginal trachelectomy (Nimaroff, 1996). ENDOMETRIOSIS Endometriosis, especially in cases of deep infiltrating disease, needs a surgeon well trained in the treatment of this difficult pathology. Moreover endometriosis is a contraindication to supracervical hysterectomy, because of the common involvement of the cul-de-sac and uterosacral ligaments. In case of deep infiltrating disease the surgery should be aggressive given that a good cytoreduction seems to guarantee better results in the long term. The complete removal of the lesions will reduce the risk of recurrences, and the persistence of pain symptoms. (Reich H, 2004) Hysterectomy by itself is not enough to guarantee the complete resolution of symptoms related to endometriosis. In case of severe adhesions with anatomical distortion or in case of rectovaginal septum endometriosis, we advice to approach the lesion laterally and retroperitoneally, starting very high in healthy tissue, opening the peritoneum at the level of the pelvic brim, isolating and lateralizing the retroperitoneal structures: ureter, hypogastric artery, uterine artery, utero-sacral ligament , freeing them from all the endometriotic and fibrotic tissue; pushing medially the rectum and preparing bilaterally the pararectal fossae. All the peritoneal tissue of the posterior leaf of the broad ligament involved with endometriosis should be removed. When the lesion infiltrating the pouch of Douglas and the rectovaginal space is well defined laterally, it is possible to remove the pathology from the back of the uterus and vagina and from the anterior wall of the rectum following different approaches: Starting to dissect the lesion firstly from the back of the uterus and vagina and after from the anterior wall of the rectum (as proposed by Redwine,2001 ) Starting to dissect the lesion firstly from the rectum and after from the uterus and vagina (as proposed by Koninckx, 1994) Dividing the endometriotic tissue and opening the Douglas pouch with the complete restoration of the rectovaginal space and after removing the endometriotic tissue both from rectum and from uterus and vagina.(as proposed by Koh, 2002). All these three different approaches are acceptable for removing the lesion, and we believe that it is possible to choose one of these techniques according to the anatomical conditions or to surgical preference. PELVIC VARICOSITIES The presence of pelvic varicosities can make the coagulation of the vessels more difficult to control with bipolar energy, leading to unexpected bleedings. Venous vessels have very thin and fragile walls and can be easily broken with mechanical shocks tractions or with the fast increasing of temperature during bipolar coagulation. Pelvic varicosities are frequent in case of large uteri due to the increasing need of blood supply?. To prevent bleeding from pelvic varicosities the surgeon should: Avoid a complete skeletonising of the uterine vessels Start to apply coagulation higher on the ascending branch of the uterine vessels to avoid back flow. It could be useful to coagulate the vessel bundles on both sides before start to cut them to reduce the uterine vascularisation. Try to obtain a complete grasping of the vessel bundle, also with the help of a grasping forceps. At the beginning of the coagulation avoid a too tight compression of the vessel bundle to prevent the rupture of a varicous veins. It is also possible to apply a suture preventively, but sometime, especially in case of very large uteri, suturing can be difficult due to lack of space. In any case it is possible to apply a suture later, in case of uncontrolled haemorrhage, provided a prompt grasping of the bleeding vessels. In case of bleeding we advise to immediately clamp the bleeding vessel with a grasping forceps. Whether the grasping forceps is not quickly available, apply a momentary pressure with any kind of instrument while waiting for the grasping forceps. You can aspirate the blood and once the bleeding has completely stopped, you can coagulate or apply a suture. This is of paramount importance in laparoscopic surgery where also a little bleeding, if not immediately controlled, can reduce the vision. HYSTERECTOMY IN PATIENTS WITH SEVERE ADHESIONS AND AFTER MULTIPLE CAESAREAN SECTIONS One or more previous caesarean sections can cause thick adhesions at the level of the vesico uterine fold. In these cases the dissection of the bladder from the cervix can be difficult posing the first at high risk of perforation. A safer approach is from the lateral part of the cervix. In this area the adhesions are less dense and firm and the bladder is not on direct contact with the cervix. This space was firstly described by S. Sheth (1995;1999) as the utero-cervical broad ligament space for the vaginal approach to hysterectomy in uteri with previous caesarean sections. This anatomic space was described by Sheth as follows: The anterior wall consist medially of the under surface of the bladder and laterally of the anterior leaf of the broad ligament. The posterior all consist of the utero-cervical surface as it slopes toward the utero-cervical border. Medially the space ends where the bladder comes in close contact with the utero-cervical surface thickening at the level of the bladder pillars. This anatomical space has been demonstrated by Magnetic Resonance Imaging that at the isthmic level through different planes shows a distinct vacant space medial to the line joining the maximally bulging uterus above and the cervix below with its continuity medially between the utero-cervical surface and the bladder until they come intimately close to each other in the midline. This surgical window allows a safe sharp dissection also through laparoscopy, starting from both sides going medially as far as to put in evidence the connective tissue of the pericervical ring. Then the dissection can be prolonged towards the medial portion of the vesico-uterine space where the adhesions between the bladder and the cervix are thicker in case of previous C-Section. Filling the bladder with saline or methilen blue is of no utility. Inadvertent lesions of the bladder will be immediately recognized because the catheter bag will be filled with the gas of pneumoperitoneum. Unintentional bladder injury can be easily repaired by laparoscopy. In case of adhesions so thick that the dissection could be too difficult, it is possible to perform firstly a supracervical hysterectomy and after to remove the cervix starting from the posterior fornix. Previous caesarean sections and previous surgeries like myomectomies or endometriosis can cause adhesions with the bowel or with the abdominal wall. In case of uterine ventrofixation the dissection starts from the fundus of the uterus trying to reach the Retzius space. At this moment it is possible to start with the usual steps of hysterectomy. The harmonic scalpel can be useful in case of adhesions with omentum or bowel. Bipolar coagulation or monopolar cutting and coagulation do not work well in presence of tissues with a high electrical impendence like fat tissue. Conclusions Caution must be used in evaluating data presented in literature concerning complications rate and limit to feasibility: results can be biased by the fact that most reports on laparoscopic hysterectomies include some of the most skilled and experienced laparoscopists in the world. Nevertheless, despite some authors' conclusion (De Meeus, 1997) that uterine volume limits laparoscopic hysterectomy, we believe that laparoscopic hysterectomy can be performed safely and effectively in almost any patients when the surgical team is sufficiently trained and experienced in managing complications. In our opinion LH will become standard treatment for benign uterine diseases and it certainly can be considered substitutive to the laparotomic approach almost every time vaginal hysterectomy is not advisable. References: References 1. De Meeus JB, Magnin G. Indications of laparoscopic hysterectomy. Eur J Obstet Gynecol Reprod Biol 1997; 74: 49-52. (Medline) 2. 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