TLH is the hysterectomy done abdominally laparoscopically.
When the length of vagina is small and uterus is high and immobile or having fibroids ,TLH is the best choice.
Post operative pain is less and formation of granulation tissue is also less because while closing the vault abdominally edges are not everted out. Other great advantage is that posterior vaginal wall is not sacrificed and uterosacrals are not divided so the length of vagina is also maintained and there are less chances of vault prolapse.Patient can be mobilsed as early as possible.
Is the hysterectomy done vaginally.It is a very simple operation.When vaginal space is adequate and uterus is normal sized or bulky and patient does not require BSO then it is best to NDVH.
NDVH is less expensive also.
Some surgeons use vaginal manipulators or colpotmizer, KOH ,RUMI system to demarcate the vagina and to push and rotate the uterus.
Dr Rakesh Sinha uses simple ovum forceps with methylene blue gauge to push the uterus and demarcate the vagina.
Dr Prakash Trivedi uses manipulators.
Whether to inflate the bladder with methylene blue or not ?
Dr Alka Kriplani says that the chances of injury will be more if you inflate it.Do not disturb the normal anatomy,put a simple catheter.
Dr Parveen Bhatia uses two babcock’s forceps on the labia majora to prevent the gas leakage.
Placement of the ports
Dr Prakash Trivedi puts two 10 mm ports , one umbilically and the second 10 mm on the right side near the first one under direct vision.
and two 5 mm ports under direct vision in the iliac fossae lateral to inferior epigastric arteries.
Dr Rakesh Sinha puts a standard 10mm port at the umbilicus and a 5 mm at palmer’s point.He puts the verees needle at palmer’s point and two 5mm ports in the both iliac fossae under direct vision.
One can go for the infundibulopelvic ligament directly.Coagulate and dessicate on both sides if BSO is to be performed.
Posterior peritoneum is opened upto the level of uterosacrals and posterior vaginal wall is not sacrificed.This is the main advantage of TLH.Chances of vault prolapse are also less.
Anterior colpotomy is done with monopolar spatula by pushing the manipulator which was pushed and rotated on each side while dissecting the peritoenum and uterines.Cervix is identified and anterior wall of vagina is separated along with it. Uterus is kept in the vagina so as to prevent the loss of pneumoperitoneum.Vault is closed after removing the uterus and adenexa, taking uterosacrals with figure of 8 stitches.Ideally it should be closed laparoscopically.According to Dr Sunita a beautiful ring is formed when you stitch laparoscopically.She says that the level of vault will be different vaginally and abdominally.If one finds difficuly then he or she can go vaginally for the closure of the vault.
Types of energy sources
Harmonic scalpel (Ethicon )
(When you use simple bipolar there is charring and sticking of the instruments.)
There is less lateral tissue damage.
Great precision near vital structures as it works on lower temperatures.
Risk of injury to the bladder and ureter is less.
that there is always charring , smoke and sticking of the instruments.
Gyrus PK tissue management
So the type of energy source to be used depends on surgeon’s choice and patient’s pocket also.Surgeon must be aware of the energy souce and how to deal with the complications.Sources will continue to improve as the technology is advancing day by day.
TLH is a very good operation in the hands of a skilled surgeon who has performed more than 200 operations .If the uterus is big , immobile , high or having fibroids with less vaginal space then it is the operation of choice. Early ambulation, less post operative pain and less bleeding are its other advantages.Vaginal length is not sacrificed and chances of vault prolapse are also less
- When Uterine Fibroids Become Problematic (everydayhealth.com)