Laparoscopic total hysterectomy

Abstract

Purpose of the study: To demonstrate the technique of a laparoscopic total hysterectomy as well as to explain how to resolve a difficulty due to bleeding.

Design: Perform step-by-step surgery through a video with narration.

Introduction: Hysterectomy is the most commonly performed surgical procedure in gynecology, in The United States alone more than 500,00 hysterectomies are performed per year. The most common indications for hysterectomy for benign pathology are uterine fibromatosis and abnormal uterine bleeding. The first laparoscopic hysterectomy was described by Reich in 1989 and much progress has been made since that first description in terms of improved technique, development of better instruments, as well as high quality imaging. Less postoperative pain, rapid recovery, lower infection rate and a positive impact on patients' quality of life are some of the benefits of this minimally invasive procedure.

Procedure: In this case we performed a total hysterectomy + bilateral total salpingectomy via laparoscopy in a 44-year-old female patient with colicky lower abdominal pain, menorrhagia and secondary anemia. We started the surgery with access to the abdominal cavity at the umbilical level with open or Hasson technique and then we placed three 5 mm accessory trocars in French triangulation and we also used a 10 mm lens and 30° of vision and a high definition tower. We then performed an inspection of the abdominopelvic cavity and release of the omentum adhesion to the right iliac fossa. Prior to the start of the hysterectomy we identified both ureters and verified the integrity of the cul-de-sac of Douglas. We began the hysterectomy on the left side of the pelvis with coagulation, section and dissection of the round ligament, anterior leaf of the broad ligament, vesicouterine plica, mesosalpinx, utero-ovarian ligament and uterine vascular bundle and for this purpose we used advanced energy device for coagulation and sealing of the structures. Then we proceeded to perform the same maneuvers on the right side of the pelvis where there is bleeding of venous origin at the level of insertion of the right utero-sacral ligament and where we performed clamping maneuvers - aspiration - vision to then perform coagulation and sealing of the bleeding vessel and control the situation. The next step is the cutting of the vagina with monopolar energy in pure cutting mode. The piece is removed and the vaginal vault is closed by means of "X" stitches with an absorbable, synthetic and tennis strength thread of 30 days, 1 gauge.

Conclusion: Laparoscopic hysterectomy is a safe, reproducible procedure and offers patients the advantages of minimally invasive surgery: less postoperative pain, rapid recovery, lower infection rate of the operative site as well as quality of life after surgery.