腹腔镜子宫全子宫切除术的良性条件：标准技术（图文演示）

10. Treatment of adnexa
• Total hysterectomy



Non conservative total hysterectomy:
The first assistant should grasp the ovary, and the suspensory ligament of ovary is tracted. The ligament is cauterized and divided proximal to the ovary by the surgeon. Once the vascular pedicle has been divided and before it is completely divided, traction is slackened and hemostasis is achieved. Once division is complete and the ligament has been retracted, hemostasis is controlled. This procedure is performed in the same manner to the right.

• Interadnexal hysterectomy




In case of interadnexal hysterectomy (with preservation of tubes and ovaries), the adnexa may be cauterized and divided proximal to the uterus using successive bipolar cauterization and division.
For an ideal cauterization, it is preferable to set the power to 35 Watts and increase exposure times. The linear graspers are highly indicated. A blue cartridge (size of stapler closed equal to 1.5 mm) should be used. The grasper is ideally introduced through a 12 mm trocar situated centrally and upwards. Generally, one cartridge only suffices to transect the adnexa. Often a residual peritoneal band should be cut to complete division.

11. Bladder dissection

The uterus is pushed cephalad. It is slightly tipped backwards. The surgeon uses a forceps to lever/press down onto the bladder, hereby forming a fold and showing the inferior edge of the bladder (about 1 cm from the junction bladder-uterine isthmus). The vesical fold (inferior edge of the bladder) is grasped by the first assistant, using an atraumatic forceps; then it is tented upwards, showing the dissection plane.
Division should be performed in a plane strictly perpendicular to the uterus whereas the uterus is pushed upwards by the 2nd assistant to avoid any bladder injury.
Combination of this surgical act with traction of the uterus opens up the dissection plane between bladder and vagina as soon as the uterus is opened. Once the dissection plane is created, bladder dissection is continued caudally. The 2 internal bladder pillars (vesicouterine ligaments) are tented by upward traction on the bladder; they are cauterized and divided. This maneuver contributes to place the ureters distally. They run laterally to the internal bladder pillars.

12. Preparation/uterine pedicles
• Dissection of posterior leaflet


Once the adnexa have been treated, uterine pedicles may be approached. Posterior dissection comes first. The uterus is first pushed cephalad and to the right. The first assistant grasps the stump of the left round ligament and lifts it medially. In case of total hysterectomy, traction on the adnexa may be preferred. Traction on the posterior peritoneum is achieved by the surgeon who introduces the bipolar grasper between the posterior peritoneum and the origin of the broad ligament.
Dissection using the grasper is continued towards the left uterosacral ligament proximal to the posterior peritoneum. The left uterosacral ligament is then divided. This step may be easier to perform through anteflexion of the uterus. The uterine artery is visualized, with the vaginal fornix freed of the cardinal ligament (lower portion of the parametrium) posteriorly.
Then the surgeon progresses towards the uterine pedicle anteriorly. The uterus is slightly tipped backwards and pushed upwards. All of the tissue anterior to the uterine pedicle has been cauterized and divided, starting from the internal bladder pillar.
At the end of this operative step, the uterine pedicle protrudes on the lateral surface of the uterine isthmus, between the vaginal fornices anteriorly and posteriorly. As dissection is now complete laterally to the pedicle, the ureter is distal.
The same technique is performed to the right side. The uterus is pushed to the left, and the first assistant traces the uterus to the left following the stump of the round ligament. On this side, instrument angles and movements are often inadequate. Positioning of instruments should be shifted: bipolar cautery is used by the first assistant, scissors are passed through the central trocar and graspers are introduced through the left trocar. The surgeon exerts traction on the uterus by holding the stump of the right round ligament, and the preparation procedure similar to the one done by the surgeon is carried out by the assistant to the left. The surgeon keeps a control on the activation pedal.
Preparation of the two right and left uterine pedicles is now complete. At the end of this operative step, the ureters are at least 4 cm distal from the ascending branch of the uterine artery, where hemostasis is achieved.

A few principles should be observed to avoid ureteral injuries:
- dissection as previously described; uterine vessels should be dissected anteriorly, laterally, and posteriorly;
- cauterization should be performed on the ascending branch of the uterine artery;
- cauterization time should be as limited as possible. Short and repeated cauterization should be preferred to lengthy cauterizations;
- cauterization induces tissue resistance to electric currents, and division should be performed to remove such tissue; cauterization should be carried out on non-cauterized tissue.

• Division of uterine artery



Technically for the left arterial pedicle, the uterus is tracted to the right by the assistant whereas the cannula is pushed strongly cephalad and to the right. At the level of its ascending branch the uterine pedicle is fully grasped by the surgeon’s bipolar forceps through the left lateral port.
Global cauterization is achieved, and the surgeon also insists on the superficial layers, which are incised using scissors. The pedicle is progressively divided. Veins of the periarterial uterine plexus are perfectly cauterized, and the artery is cauterized and divided.
Dissection is continued anteriorly and posteriorly in order to lower the pedicle just beneath the margin of the vaginal fornix. This is purely a case in point of intrafascial hysterectomy.
The remaining elements of the cardinal ligament are cauterized and divided at this stage.
The same technique is performed for the right pedicle. For the safety of the ureter, the bipolar grasper should be in the hands of the assistant. The pedicle should be divided with a right angle at the level of its ascending portion, hence reducing any ureteral damage. The surgeon does always keep a control on the activation pedal.
Other technique ligature-division:
Control of uterine pedicles can also be achieved through ligatures or clip application. With ligatures, it is not necessary to dissect the artery completely.
Once the pedicle has been dissected as previously described, a polyglactin 0 suture mounted on a curved 30 mm needle is achieved. The thread should be thrown anteriorly to posteriorly into the left pedicle, and posteriorly to anteriorly into the right pedicle.
The needle should be passed through from the angle of dissected vaginal portion anteriorly to posteriorly not to take too much of vagina posteriorly to vessels. If not, it would necessitate thread cutting during progression within the fascial planes.
Clip application requires dissection of the artery on all its aspects.
Two options are available: either stay proximal to the ascending branch or move laterally when the artery runs distal from the uterus.
At the level of the ascending branch, repeated cauterizations of the veins running peripheral to the artery should be performed. Then repeated divisions should be done in order to expose the artery and clip it.
Laterally to the uterus, vein and artery are more easily cleavable. Dissection should be conducted with the least cauterization because of the proximity of the ureter.
In all cases, clip closure should be achieved under visual guidance. The artery should be divided partially only to check that clip application is effective.

13. Opening and division of vagina



At this stage in the procedure, the uterus is no longer vascularized and turns white. The 360° valve of the manipulator shows that uterine pedicles are dissected more caudally than vaginal fornices.
The sealed device is introduced into the vagina. The 3 disks of the device should be inside the vagina. The vagina should be opened over 360° by the surgeon. The more the vagina is opened, the more the 2nd assistant loses control of the uterus with the cannula. Theoretically it is easier to start at the posterior surface of the uterus. The 2nd assistant performs anteversion combined with anteflexion of the uterus. The posterior fornix forms a bulge, which is easy to open using monopolar cautery via the left trocar. Monopolar cautery is used to safely divide the anterior, left lateral, and posterior portions of the fornix. The 2nd assistant exposes the fornix to division, rotating the valve in the same direction as division. Rotation of the valve should be carried out before the surgeon completes division until the angle of the valve. Contrarily, should the valve move away from the fornix, it would enter the abdominal cavity.

14. Hysterectomy and vaginal closure
• Extraction of specimen

Once the uterus has been freed, 2 options are left for the surgeon:
- either the size of the uterus is regular and its extraction is easy through colpotomy. The 2nd assistant places the uterus into the vagina, hence the patency of the pneumoperitoneum is established and the vaginal cuffs are mobilized for closure.
- or on the contrary the uterus should be first morcellated, then removed. In this case, the procedure ends using the vaginal route. The uterus is then bisected or intramyometrial coring for uterine volume reduction may also be carried out.

• Closure of vagina

Closure may be performed either using the vaginal route or laparoscopically. In the former case, a glove filled up with packs is placed in the vagina to maintain the pneumoperitoneum.
When laparoscopy is used for vaginal closure, a polyglactin suture 0 or 1.0 mounted on a curved 30 mm needle is used. Introduced through the left trocar, the needle is righted before the needle holder can grasp it for driving. The needle is driven by the surgeon through the superior margin of the vagina medially to the colpotomy. Then the vaginal margin is held as the needle makes a half rotation cranially. The assistant mobilizes the posterior margin and the needle is driven through it.
It is critical to completely transfix the vagina for complete hemostasis. A figure of eight stitch is performed by the surgeon. Removal of the thread is carried out fairly easily. A half hitch knot is performed to the right and to the left. Two figure of eight sutures are thrown and tied to each side of the colpotomy and in the middle of it. A third stitch is thrown at the anterior posterior fascia and uterosacral ligaments. The last stitch is essential as it helps recreate the pericervical ring.
Removal of uterus or intravaginal glove permits control of patency. In a few cases, a mere central stitch may be needed to achieve vaginal closure.
Lavage of the operating field completes the procedure. Bipolar cautery may be used to control bleedings at the vaginal section. Ureters may then be controlled.

15. Conclusion

The operative protocols described here show that laparoscopic hysterectomy is reproducible and can be performed safely. In the light of the new surgical laparoscopic techniques recently developed, better instruments will be available shortly, and these techniques will become safer and quicker to perform.
Introduced in 1989, it is only in 1995 with the introduction of the uterine manipulator that laparoscopic hysterectomy has become a well standardized and easily reproducible surgical procedure.
Integration of and compliance with the technical principles described allow to reproduce laparoscopic hysterectomy safely and with fully acceptable operative times.
Even if at present the laparoscopic approach may not be considered a first-line option, it should be part of the therapeutic armamentarium for the pelvic surgeon.

16. Reference

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