腹腔镜子宫全子宫切除术的良性条件：标准技术（图文演示）

LAPAROSCOPIC   TOTAL   HYSTERECTOMY   FOR   BENIGN   CONDITIONS:   STANDARD   TECHNIQUE
Authors
A Wattiez, V Thoma, J Nassif
Abstract
Nowadays, hysterectomy is, after cesarean section, the most common surgical intervention performed in fertile women. Laparoscopic hysterectomy remains a safe and reproducible intervention that should be in any’s gynecologists therapeutic armamentarium.


中文版：腹腔镜子宫全子宫切除术的良性条件：标准技术（中文图文演示）

1. Introduction

▶
Nowadays, hysterectomy is, after cesarean section, the most common surgical intervention performed in fertile women (Cosson et al., 1998 ; Pokras and Hufnagel, 1988). At the beginning of the 1990’s, with the introduction of laparoscopic-assisted hysterectomy that had first been performed in 1989 by Harry Reich, coelioscopy was used to perform hysterectomies (Reich et al., 1989; Reich, 1992). For many reasons such as a very bulky uterus, contraindication of uterine morcellation, the lengthening of the operation time that this technique can generate, and the paucity of experienced trainers, coelioscopy remains poorly diffused (Chapron et al., 1999). Still 60-70% of hysterectomies are performed in open surgery, 20-30% using the vaginal approach, and only 3-5% using laparoscopy (Maresh et al., 2002).

However, we believe that laparoscopic hysterectomy remains a safe and reproducible intervention that should be in any’s gynecologists therapeutic armamentarium (Chapron and Dubuisson, 2000; Wattiez et al., 1996).

2. Anatomy
• Anatomical relationships

A pinpoint knowledge of the anatomical relations between ureter, uterus and uterine artery is essential in order to avoid any injuries.
The ureters enter into the pelvis whilst crossing the iliac vessels. The left ureter crosses the common iliac artery and the right ureter crosses the external iliac artery. At the same level, the ureters are themselves crossed by the lumbo-ovarian ligaments medially on both sides.
During their course behind the ligaments, the ureters are in close contact with the internal iliac vessels and their collaterals. All along the uterine artery is strictly parallel to the ureter. With the exception of overweight patients, they can generally be followed visually during their retroperitoneal course posterior to the ligaments up to their entry into the ureteric canal.
At the level of the ureteric canal, the ureter becomes invisible to the surgeon. It is at this level that it will cross the uterine artery by running underneath it between the parametrium and the paracervix. When they cross one another, ureter and uterine artery remain independent structures and can be easily dissected as long as the dissection plane stays out of the ureteral adventitia. Only the ureteric artery links these two structures and the latter can easily be coagulated and divided.
After leaving the ureteric canal, the ureter runs laterally along the vaginal pouch at a distance of approximately 10-15mm. At this level the ureter lies between the bladder’s internal and external pillars. The ureter then penetrates the vesical wall from externally to medially before joining the bladder.

• Uterine fixity

1. Round ligament
2. Mesometrium
3. Uterosacral ligament
4. Internal pillars of bladder
5. Paracervix
6. Parametrium

Uterine fixity is ensured by six pairs of visceral ligaments. These ligaments are vessel-supporting structures, made up of densifications of pelvic cellular tissues for which the ligature and the division are indispensable to the mobilization of the uterus. These can be divided into two groups depending on their function and their spatial orientation. The first ones are lateral and follow the terminal branches of the hypogastric artery. The second ones are sagittal and carry the hypogastric plexus nerves.
Lateral ligaments:
- the round ligament extends from the anterior part of the uterine horns, anteriorly to the uterine tubes, up to the labia majora and the mons pubis, whilst crossing the inguinal canal. Generally, a small artery runs along the inferior border of the round ligament.
- parametrium and paracervix play a major role in the positioning of the uterus and of the vaginal fornix. Anatomically, they are in perfect continuity. Their splitting is purely theoretical. By definition, the parametria are located above the ureter and contain the uterine artery. Their division leads to that of the uterine artery loop and frees the uterine isthmus laterally. Their anterior expansion merges with the lateral part of the vesicouterine ligament and covers the retrovesical ureter. The paracervix is situated underneath the ureter and contains the vaginal arteries. It also contains the voluminous nerve and lymph node uterovaginal plexuses.
- superiorly, the mesometrium is a part of the large ligament, a double-layer peritoneal complex tensed in between the lateral borders of the uterus and the lateral walls of the pelvic excavation. In the thickness of these two layers, the vessels and the nerves are contained. The division of the mesometrium frees the body of the uterus. The vessels being in contact with the uterus, the division of the mesometrium at a distance of the border of the uterus is bloodless.
Sagittal ligaments:
- vesicouterine ligaments, formerly known as the internal bladder pillars extending from the anterior lateral part of the cervicovaginal junction to the vesical base. Situated above the retrovesical ureter, they extend into the parametria anteriorly.
- uterosacral ligaments extending from the posterior lateral aspect of the cervix and the vaginal fornix, they underlie the rectouterine folds. They run along the lateral aspects of the rectum and delimit the pararectal space medially and disappear onto the presacral fascia opposite S2-S3 sacral vertebras. They contain little vessels but have connective tissue within which nerves of the inferior hypogastric plexus can be found (lateral portion of the uterosacral ligaments). The division of the uterosacral ligaments helps in the rise of the uterus during hysterectomy.

• Vascular supply

1. Ovarian artery
2. Uterine artery
The ovarian artery originates from the anterior surface of the aorta at the level of the L2-L3 intervertebral disc. On the right side, it crosses over the anterior vena cava. On the left side, it crosses over the greater psoas muscle before crossing over the ureter and entering the lumbo-ovarian ligament. Once it reaches the tubal end-portion of the ovary, it splits into 2 branches, one tubal and one ovarian, which often join their respective branches of the uterine artery to form the tubal arcade.
The uterine artery originates from the internal iliac artery (56% of cases) or via a common trunk with the umbilical artery (40% of cases). Three segments can be distinguished:
- parietal segment along the pelvic wall until the ischial spine;
- parametrial segment transversally heading from the pelvic wall to the uterus underneath the broad ligament in the parametrium. It forms a loop that crosses the ureter anteriorly approximately 20mm from the isthmus and 15mm from the vaginal fornix;
- mesometrial segment, proximal to the isthmus; the uterine artery changes orientation to run upward along the border of the uterus in the mesometrium towards the uterine horn.
At the level of the uterine horn, it runs underneath the round ligament and the tube to split into 2 branches, a tubal branch and an ovarian branch, which join the ovarian branches and form the tubal arcade.
Source: Anatomie opératoire gynécologie & obstétrique. P Kamina, 2000, Editions Maloine.

3. Indications and contraindications

▶
Hysterectomy remains the gold standard treatment for a great number of gynaecological conditions. It should be performed only when conventional treatments have failed. The patient’s age and desire for pregnancy are essential factors that determine the treatment. The benefit-risk ratio should be assessed before any intervention, especially in case of benign pathologies.

Indications (Lefebvre et al., 2002)
Benign conditions:
a) Leiomyomas: in cases of fibromas with invalidating symptoms, hysterectomy is the treatment modality once medical treatments have failed.
b) Menometrorrhagia: once a malignant endometrial or cervical pathology has been ruled out, medical treatment is first-line together with hysterectomy. In case of failure, hysterectomy may be carried out, especially in case of secondary anemia.
c) Genital prolapse: in case of prolapse of uterus, hysterectomy may be associated with certain surgical procedures. For instance, in case of sacral promontofixation, hysterectomy helps to reconstruct the vagina and its attachments through reconstruction of the pericervical ring along with adequate traction on the prosthetic material.
d) Endometriosis/adenomyosis: hysterectomy may be the last option in case of major pelvic pain syndrome resistant to treatment and when the patient has no desire for pregnancy.
e) Pelvic pain syndrome: the benefit of hysterectomy is not proven; as a result, it should be performed only in cases of alternative treatment failure and after preliminary consultations with health care professionals (psychologists, physical therapists, and gynecologists). Hysterectomy may be beneficial when pain originates from dysmenorrhea or is associated with major pelvic pain.

Pre-invasive pathologies:
- endometrial hyperplasia with atypia;
- cervical carcinoma in situ is not an indication for hysterectomy. However, it may be performed when conization is carried out in diseased portions of the cervix or when the patient desires natural childbirth.
- cervical adenocarcinoma in situ: caution must be taken that there is no invasive lesion associated.

Malignant conditions:
- endometrial cancer and cervical cancer: therapeutic role and staging;
- ovarian cancer and tubal carcinoma: the role of laparoscopy is still debated, apart from staging.

Indications and contraindications to the laparoscopic approach:
Apart from morcellation in cases of malignant pathologies and anesthesia-related contraindications, there is no such contraindication to laparoscopic hysterectomy. Studies undertaken by Wattiez et al. (Wattiez A, Soriano D, Cohen SB, Nervo P, Canis M, Botchorishvili R et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc 2002;9:339-45) have shown that with adequate training, laparoscopic hysterectomy is a safe, effective, and reproducible technique. About 30 laparoscopic hysterectomies are estimated to obtain complication rates and operative times similar to the ones of other approaches. Even a bulky uterus becomes accessible with this approach once a few protocols have been implemented (shifting of ports and use of uterine manipulators) (Wattiez A, Soriano D, Fiaccavento A, Canis M, Botchorishvili R, Pouly J et al. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc 2002;9:125-30).
Nowadays, the main limiting factor is to laparoscopic hysterectomy is assuredly the lack of experience of surgeons.
Nevertheless, following the recommendations of the Cochrane Database Systematic Review of January 2005, vaginal hysterectomy should be performed whenever possible. When the vaginal route fails, the laparoscopic approach precludes laparotomy (Johnson et al., 2005).

4. Preoperative management
Vaginal touch: once the patient is asleep, clinical examination starts. Vaginal touch is essential as it allows assessment of the size of the uterus, which has a direct impact on port positioning and uterine mobility.

Conventionally injections of low-weight molecular heparin (LWMH) are begun the evening before the procedure starts; half of the postoperative prophylactic dose regimen is administered on the eve of the intervention. The prophylactic dose is administered on the evening when the procedure has been performed for a period of 7 to 10 days. The dose regimen and treatment duration will be tailored to the patient’s past medical history and thromboembolic risk factors.

5. Operating room set-up
• Patient

- 2 arms alongside the body to avoid injury of the brachial plexus and ensure better ergonomics for surgeon and assistant alike. Two shoulder supports are placed against the acromia to prevent patient slippage when the patient is placed in Trendelenburg position;
- indwelling bladder catheter (12-14 French);
- ideally the buttocks are placed outside the table; tip of patient’s coccyx resting on the table to facilitate uterine manipulation;
- both legs are half-bent for manipulation purposes;
- patient draped: operative field must include the vaginal route (surgeon should be able to manipulate the uterus without any septic risks).

• Team

1. Surgeon to the patient’s left for a bimanual operation. He/she should stand upright, elbows as closest to the body, the axis of vision should be directed in between the 2 hands. Bent elbows should not exceed 90° to avoid any muscle fatigue.
2. Assistant 1 to the patient’s right, holding the camera with his/her left hand and interacting with the instrument situated in the pelvic trocar in the right iliac fossa.
3. Assistant 2, placed between the patient’s legs; he/she mobilizes the uterus caudally once the uterine manipulator is placed. He/she must be seated so as not to stand in the surgeon’s view and ensure adequate uterine mobilization.
4. Scrub nurse to the surgeon’s left: presence useful when sutures are used.

• Equipment

The operating table equipped with leg holders for stretching of legs, should be lowered as much as possible (about 25 cm in comparison with the height used in conventional surgery).
The low position of the table is required by the raising of the abdominal wall induced by the pneumoperitoneum and Trendelenburg position, combined with the external length of instruments.
1. Monitor to the patient’s right foot
2. Monitor to the patient’s left foot
3. Monitors: one for the surgeon, a second for the 1st assistant and for the 2nd assistant, each assistant in the vision axis.
4. Leg holders

6. Trocar placement
• Landmarks


▶
Distance between the pubis and the umbilicus should be at least 30 cm to accommodate the camera.
Lateral trocars are placed in the middle of the oblique muscles, in compliance with the following landmarks:
- epigastric pedicle: branch of the iliac pedicle, originating from the parietal aspect of the internal inguinal ring, and running superiorly and medially towards the deep surface of the rectus muscle. At umbilical level, it runs deep into the muscle and joins with the internal mammary pedicle, commonly visible laterally to the umbilical artery.
- external edge of the rectus muscle: this border is critical, because the trocar must be placed external to the muscle.
- area of the oblique muscles, forming a triangle laterally to the external edge of the rectus muscle; area of low thickness and poor in muscle fibres.
- anterior superior iliac spine situated about 3 cm laterally to the area of oblique muscles.
A. Optical
The umbilical trocar (optical port) is the first that is placed. Once introduced, the surgeon needs to assess the size of the uterus and control the efficacy of the manipulator. Evaluation of the good accessibility of the adnexa and rectouterine pouch (Douglas’) is also carried out simultaneously. The upper part of the abdominal cavity is routinely explored.
B and C. Operating trocars
Two 5 mm operating trocars are placed laterally.
We prefer using light plastic and disposable trocars. Their main advantage is that they hold still upright in the abdominal wall and permit instrument introduction with the use of one hand only. The trocar valve allows suturing with minimal gas loss/escaping of CO2. High-flow insufflators (20-30 L/min) are essential as they ensure the same quality of vision when leaks occur (during vaginal opening and suturing).
Once operating trocars have been placed laterally, the third operating trocar (D) is introduced. It should not be placed inferiorly to the horizontal position joining the 2 lateral trocars. Ideally, the 3rd trocar may be placed slightly superiorly above this line to allow for better ergonomics. Distance between the operating trocar and the optical trocar should be the longest possible, but never less than 8 cm.

• Variation

In cases of bulky uterus or when distance between the umbilicus and the pubis is short, the umbilical trocar becomes an operating one and another trocar is placed superiorly.
The diameter of the central trocar varies depending on the technique used. A 5 mm trocar is sufficient for techniques using electrocautery and suturing only. 5 mm clips may also be used.
The use of atraumatic forceps or 10 mm clip appliers mandates the use of a 10-12 mm trocar. In case automatic forceps are used, position of the central trocar should be superior to the umbilicus.

7. Instruments
• Uterine manipulator

1. Handle
2. Rod handle
3. Bayonet safety device
4. Insert
5. Locking button
6. Handle screw
7. Silicone sealing rings
8. Anatomic blade

The uterine manipulator permits the following:
- mobilization of the uterus (retraction, lateroversion, anteversion, anteflexion, rotational movements along the instrument axis);
- identification and mobilization of the vaginal fornices;
- patency of the pelvic region during opening of vagina;
- potential aid for morcellation of bulky uterus at the end of intervention;
- mobilization of vaginal cuffs and patency to facilitate vaginal sealing.

Parts constitutive of the manipulator:
- distal tip fixed into the uterus (a screw merely). The screw is chosen depending on the size of the uterus. Tip is mobile, with variable positions (from 0° to 90°, in relation to the shaft of the instrument). Mobilization is granted through manipulation of the main handle.
Placement of the manipulator into the uterus requires dilatation of the cervix up to bougie No. 9.
The instrument is locked using the snap-in mechanism at position 0. The tip is then screwed up to the hilt of the manipulator rod, which is pushed forward into the cervix.
Identification of the vaginal fornices is done with the use of a 360° rotative valve, exposing the whole vaginal circumference. Made of a non-conductive material, it may be exposed to monopolar current without any risk of electric arc. Valves may be of different lengths and widths to adapt to any vaginal conformations. The valve is activated by a handle on the side opposite the main axis. Then the assistant keeps a visual landmark as to the place of the valve. Flexion of the axis combined with rotation movements of the instrument and rotation of the valve contributes to a reduction of ureteral injuries during laparoscopic hysterectomies.
- A patent system made of 3 soft plastic disks: it leaves the vagina free during final manipulations, hence facilitating posterior opening of the vagina

• Trocars/instruments

Introduction of instruments into trocars:
The surgeon to the left holds the instruments introduced into the central, and left operating trocars. The first assistant to the right holds the camera and the instrument introduced into the right trocar. The second assistant is seated between the patient’s legs and mobilizes the uterus with the cannula.
The surgeon uses a bipolar grasper through the left port and scissors through the central trocar. Scissors may be connected to the monopolar generator. The surgeon can use his/her two hands: his/her left hand for manipulation, grasping, and electrocautery; his/her right hand for dissection, mechanical division, and electrocautery.
A grasper is introduced in the right trocar (Manhes grasping forceps) by the assistant.

8. Division/left round ligament

Cauterization and division of the left round ligament:
The 2nd assistant retracts the uterus to the right without any anteflexion, and with the utmost traction. The first assistant grasps the left round ligament at its corneal origin and traction is exerted rightwards and cephalad. A triangle is formed, bordered by the round ligament cranially, by the iliac vessels laterally, and by the adnexal vein medially. Tension on the left round ligament exposes the central portion of the triangle made of the 2 juxtaposed anterior and posterior peritoneal layers of the broad ligament. This area becomes gray because of CO2 and the presence of an empty space beneath the posterior layer of the broad ligament. The surgeon must cauterize the left round ligament in the centre of the triangle. In this way, he/she keeps away from the adnexal vein, thereby limiting the risks of bleeding. Successively using cauterization and division, the left round ligament is fully divided. Occasionally the presence of a small artery running posterior to the ligament may be noted. It should be also carefully cauterized.

9. Opening of vesicouterine space
• Opening of vesicouterine space

Once the round ligament has been divided, the vesicouterine space is opened. The uterus is then pushed cephalad. Caudal traction is exerted on the stump of the left round ligament by the first assistant to provide clear and free access to the vesicouterine space. The surgeon uses the tip of the instrument introduced and passed underneath the anterior peritoneal layer to lift it up. Close contact must be kept as it aids in dissecting the vesicouterine space. The anterior leaflet of the broad ligament is progressively cauterized medially paying attention not to injure the bladder. Peritoneal capillaries are also cauterized. Once the posterior attachments of the anterior leaflet of the broad ligament have been freed, the anterior leaflet is divided using either the cold blade of scissors or monopolar cautery. Such dissection should be discontinued about 1 cm from the midline.

• Fenestration/broad ligaments



Fenestration of the right and left broad ligaments is created by the surgeon.
While maintaining the uterus in the same position, thereby tenting the left adnexa, the posterior layer of the broad ligament is progressively freed using the divergent movements of the 2 instruments (scissors medially and bipolar grasper to the left) held by the surgeon. Capillaries of the broad ligament should be carefully cauterized. The posterior layer should be opened, where it looks gray, testifying to the absence of small bowel posteriorly to it. The window in the peritoneal layer is created through simple collapse or division using monopolar cautery. Once the window has been created, it is enlarged using divergent traction exerted by the 2 instruments held by the surgeon.
Traction is exerted towards different directions depending on the type of hysterectomy.
In case of interadnexal hysterectomy, traction is exerted on uterosacral ligaments (craniocaudal direction). In case of total hysterectomy with adnexectomy or non conservative hysterectomy, traction is exerted on the suspensory ligament of ovary (medial lateral direction).
Fenestration is a critical step. Once the window has been created, the ureter can be found on the lateral aspect of the window (against the pelvic wall). At this stage in the procedure, the uterus is pushed cranially and to the left. The same procedure is then performed to the right.