Total Laparoscopic Hysterectomy Part3

Total Laparoscopic Hysterectomy • Identify UV Fold by rotating the Funnel Edge anteriorly. • Mark dissection lines on peritoneum with Bipolar Forceps or gently with Monopolar Scissors. • Dissect on the medial edge of your dissection line, as the lateral edge will be displaced by the CO2 pressure.

UV FOLD LIFTED BY FUNNEL EDGE.

THIS CAN BE USEFUL IN ABDOMINAL OPERATIONS

U / V FOLD

MARK DISSECTION LINES ON ANTERIOR FOLD OF BROAD LIGT FROM UV FOLD UP TO ROUND LIGAMENT WITH MONOPOLAR SCISSORS.

START DISSECTION WITH OVARIAN LIGAMENT AND THEN THE TUBE, WORKING UP TO THE ROUND LIGAMENT AS VESSELS ARE POSTERIORLY PLACED IN THESE STRUCTURES.

DISSECT BROAD LIGAMENT DOWN TO LEVEL OF UTERINE VESSELS. I DO NOT SEPARATE THE LEAVES OF THE BROAD LIGAMENT AS THIS TENDS TO DISTORT THE DISSECTION LINES. YOU WILL COME ACROSS THE UPPER BRANCH OF THE UTERINE ARTERY IN THE BROAD LIGAMENT BEFORE YOU ENCOUNTER THE UTERINE PEDICLE. COAGULATE THIS BRANCH WITH BIPOLAR ENERGY AND DIVIDE IT. USE THE HOOK DISSECTOR TO PULL THE LARGE UTERUS TO EXPOSE THE LATERAL PELVIS.

UTERINE HOOK DISSECTOR

DO THE SAME ON THE OTHER SIDE DOWN TO THE LEVEL OF THE UTERINE VESSELS PEDICLE.

WITH MONOPOLAR ENERGY, COMPLETE THE UV FOLD DISSECTION ON THE FUNNEL EDGE. PUSH THE FOLD DOWNWARDS UNTIL THE VAGINA IS APPARENT. YOU DO NOT HAVE TO UNDERMINE THE BLADDER BASE UNLESS PREVIOUS LSCS.THE FUNNEL EDGE WILL ELEVATE THE VAGINA.

THE UTERINE PEDICLE IS DISPLAYED FROM THE LATERAL EDGE OF THE FUNNEL AS SHOWN.

THE UTERINE PEDICLE IS SECURED WITH A CURVED NEEDLE I VICRYL SUTURE. MAKE SURE THE FUNNEL EDGE IS ANTERIOR. INSERT NEEDLE FROM LATERAL SIDE OF THE FUNNEL EDGE DOWNWARDS.

CURVE NEEDLE AROUND THE UTERINE PEDICLE.

USING SINGH UTERINE ARTERY NEEDLE TO SECURE PEDICLES, INTRODUCED AT SUPRAPUBIS.

NEEDLE PLACEMENT FOR LEFT PEDICLE. RETROVERT UTERUS AND PUSH NEEDLE DOWN TO BLACK MARK.

BLACK MARK

NEEDLE PLACEMENT FOR RIGHT PEDICLE

ANTEVERT UTERUS. NEEDLE TIP SHOULD APPEAR AS SHOWN WITH KNOT ON SUTURE.

PULL ON SUTURE END

SUTURE AROUND LEFT PEDICLE

INTRA CORPORAL TIE.

EXTRA CORPORAL SLIDING KNOT.

After tieing the uterine pedicles, I bipolar medially before dividing the uterine pedicles. If you do not wish to tie your uterine pedicles,you can bipolar them using the edge of the Funnel as your lateral margin. Rotate the funnel edge anteriorly and cauterise the vagina on the funnel edge until the funnel is nearly visible. Rotate the funnel edge laterally to the Right fornix and dissect the Makenrodt ligament on the funnel edge, displacing the uterine pedicle. Cauterise the vagina on the funnel edge until the funnel is visible. Insert bipolar forceps medial to the funnel edge and then cut the vagina with scissors. By using bipolar first before cutting the vagina, you minimise bleeding and bowel damage. I used to use monopolar cautery but find the bipolar and scissors method just as quick. Keep rotating the funnel shaft posteriorly and repeat bipolar and scissors to the uterosacrals and enter the posterior edge. Keep dissecting on the funnel edge and you are well clear of the ureters. Rotate the funnel to the other uterine pedicle and repeat the procedure so the lateral and posterior vaginal vaults are divided.

FOR CO2 LEAKAGE, INSERT THE VAGINAL PLUG ONTO THE FUNNEL AS SHOWN IN THE EARLIER SLIDES. INSERTING A WET PACK INTO THE VAGINA OR LOOSEN THE ORING ON THE SUC AND PULL THE FUNNEL INTO THE VAGINA CAN ALSO HELP. I used to enter the anterior fornix first, but I now find it easier and quicker to enter laterally as soon as the uterine pedicles are displayed laterally. Divide the Macenrodt ligaments down to the vagina and then work posteriorly. The anterior fornix is then divided to free the cervix from the vagina. Remove the funnel shaft by releasing the black or white O Ring. The suture on the cervix will enable extraction of the uterus when you pull out the uterine cannula. Insert the largest Vaginal Probe to maintain pneumoperitoneum so you can suture the vaginal vault. You can leave the uterus in the vaginal vault if you do not want to use a probe.