Total laparoscopic hysterectomy

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Vessels of the uterus and its appendages, rear...

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Total laparoscopic hysterectomy

TLH

TLH is the hysterectomy done abdominally laparoscopically.

Hysterectomy is the most common gynecological operation performed usually for dysfunctional uterine bleeding , fibroids and a very bad erosion cervix, if woman has completed her family. Medical treatment is tried before operation and in DUB one can always try Mirena IUS.

TLH :

Is the hysterectomy done abdominally laparoscopically.Whole procedure upto the closure of vaginal vault is done laparoscopically.It requires great surgical skill and knowledge of the instruments and  energy sources.

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.

NDVH :

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.

LAHV :

Is laparoscopically assissted vaginal hyterectomy.In this operation cornual structures are dealt abdominally laproscopically.When ahesiolysis is to be performed or oopherectomy is to be performed and surgeon finds difficulty in removing ovaries vaginally or there is a myoma then it is prefered over NDVH.Uterines are not dissected abdominally.Rest of the operation is performed vaginally as in NDVH.

TLH procedure :


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.

first coagulate and dissect the cornual structures, the round ligament , fallopian tube and the ovarian ligament.If one has to perform BSO then some surgeons like Dr Sinha prefer to remove the ovaries later on because they keep on hanging like dog’s ears coming in the way of the operating field.
One can go for the infundibulopelvic ligament directly.Coagulate and dessicate on both sides if BSO is to be performed.
Then go along the round ligament, open the peritoneum upto uterovesical poch,push the bladder down , skeletonize the uterines,coagulate and dissect .Whether to use a simple bipolar or harmonic or ligasure is debatable. It depends on the surgeon’s choice and availability ot the energy sources.Dr Sinha applies a suture after dissecting the uterines as one never knows of the lateral spread and  retraction of the vessels. So one should always be cautious.Dr Sunita Tandulwadkar, Ruby Hall uses simple bipolar as she says that dissection is good with harmonic but vessel gets retracted sometimes.She doesn’t apply a suture.
Dr Trivedi uses Gyrus and Harmonic for the uterines skeletonization and coagulation.

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 )

It is ultrasonic cutting and coagulation device.
advantages are
There is minimal smoke and charring
(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.

Bipolar

It has been used for many years for the dissection and skeletonization of the uterine arteries but greatest disadvantage is

that there is always charring , smoke and sticking of the instruments.

The Ligasure

Combination of pressure and energy is used to create vessel fusion.There is melting of collagen and elastin in the vessel wall and a plastin like seal is formed.Lateral thermal spread is 2mm.There is no sticking and charring.

Gyrus PK tissue management

Provides vapor pulse coagulation (VPC).Produces faster and uniform pulse energy in a controlled manner. Tissues are evenly coagulated.There is minimal thermal spread, less sticking and good haemostasis. It requires its own generator.

Enseal

This electrode is having millions of nano conductive particles each acts like a discrete thermostatic switch to regulate the amount of the current.Less heat is required and there is no charring and sticking.Vessels are fused through compression, protein denaturation and renaturation.

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.

Conclusion

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

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  1. MCQs-Gynaec-1 – ObGyn linked to this post.

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