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Total Laparoscopic Hysterectomy- Tips, Tricks & Techniques

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Total Laparoscopic Hysterectomy- Tips, Tricks & Techniques

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Total Laparoscopic Hysterectomy (TLH) - the operative steps made easy with detailed explanation & Tips at various stages of surgery to master it .

Transcrição

  1. 1. TOTAL LAPAROSCOPIC HYSTERECTOMY Tips & Techniques Dr. K. Sendhilkumar, MS,FACS,FICS,DNB (Surg Gastro) Dr. Piyush Patwa, DNB, FMAS, FIAGES Consultant Laparoscopic Surgeon
  2. 2. “THE PAPER”   Reich H, De Caprio J, McGlynn F. Laparoscopic hysterectomy. J Gynaecol Surg. 1989;5:213–6.
  3. 3. WHY LAPAROSCOPY Laparoscopic hysterectomies have been clearly associated with  Relatively lesser blood loss,  Shorter hospital stay,  Speedier return to normal activities – Concept of Day Care surgery  Better cosmesis & patient acceptance  and fewer abdominal wall infections when compared with abdominal hysterectomies.
  4. 4.  The vaginal approach is less expensive, But may be challenging in patients with a history of  1) An adnexal mass,  2) Endometriosis,  3) Pelvic pain, & prior abdominal surgery,  4) In patients with a narrow pubic arch or poor vaginal descent.
  5. 5. POSITIONING OF THE PATIENT  The patient is placed in Trendelenburg position - for better access to the pelvic organs  The patient’s arms are tucked in.  The patient’s legs are flexed at hip & knoee joints & placed in stirrups using caution to prevent compression on the lateral calf and thus peroneal nerve damage.
  6. 6. THE OT SETUP
  7. 7. ANATOMY IN BRIEF
  8. 8. THE UTERINE ARTERY USUALLY ARISES FROM THE ANTERIOR DIVISION OF THE INTERNAL ILIAC ARTERY. IT CROSSES THE URETER ANTERIORLY, REACHING THE UTERUS BY TRAVELING IN THE CARDINAL LIGAMENT. IT TRAVELS THROUGH THE PARAMETRIUM OF THE INFERIOR BROAD LIGAMENT OF THE UTERUS.
  9. 9. URETER  Ureter enters into the pelvis at the bifurcation of the common iliac artery in front of the sacroiliac joint.  To be remembered !! - In the female, the ureter passes above the lateral fornix of the vagina lateral to the supravaginal portion of the cervix and lies below the broad ligament and uterine vessels
  10. 10. LETS DO TLH TOGETHER “STEP BY STEP”
  11. 11. INSERT A VEREES NEEDLE INTO THE PERITONEAL CAVITY.  TIP : - An easy way to confirm intraperitoneal entry is to look for a negative or low pressure reading on the insufflator  TIP :- Use Palmer’s Point ( Left subcostal midclavicular line/perpendicular to skin/stomach should be emptied/?Hepato-Splenomegaly) for Obese patients / patients with previous abdominal surgeries including C-sections.
  12. 12. PORTS PLACEMENT
  13. 13. ONCE INTRAPERITONEAL PRESSURE HAS REACHED TO SET 14 MMHG, INSERT 10MM UMBILICAL /SUPRAUMBILICAL TROCAR  MUST : complete survey of the abdomen to rule out any visceral injury at the time of Verees/trochar entry
  14. 14. MYOMA SCREW
  15. 15.  At Gateway Clinics, we routinely use the myoma screw for uterine manipulation during total laparoscopic hysterectomy.  Others- uterine manipulator/Elevator/Uterine Hitch  REMEMBER its use is avoided in two situations. 1) in endometrial cancer, where peritoneal spread of tumor cells is feared. 2) in patients with pyometra in cervical cancer, where insertion of the screw would lead to spillage of pus into the abdominal cavity.
  16. 16.  Inspect the 1) Ureter at the pelvic brim, 2) the infundibulopelvic ligament, 3) Utero-ovarian ligament Tip :- Ligaments Coagulated & incised with combination of Vessel Sealing an Ultrasonic scalpel ( As perfect Haemostasis would be the key to Day care surgery )*
  17. 17. DESSICATION OF THE UTERO- OVARIAN LIGAMENT (TIP: - HUG THE OVARY)
  18. 18. DISSECTION OF THE ROUND LIGAMENT 
  19. 19. TRANSECT THE ROUND LIGAMENT AND SEPARATE THE ANTERIOR & POSTERIOR LEAVES OF THE BROAD LIGAMENT WITH THE HARMONIC SCALPEL FIND THE CORRECT PLANE- THIS IS WHERE THE PERITONEUM SEPARATES EASILY WITH GENTLE MANIPULATION
  20. 20.  Immediately after the round ligament is incised ↓ The uterus, on the myoma screw / uterine manipulator, is pulled cephalad to recreate the “traction-counter-traction” concept of open surgical dissection of the lower uterine segment. ↓ This elevates the uterine arteries along the lower cervix away from the ureters. 
  21. 21. TIP:- THE PARAMETRIAL VENOUS PLEXUS BETWEEN THE OVARY & THE ROUND LIGAMENT COAGULATED WITH VESSEL SEALER & DIVIDED USING HARMONIC SCALPEL
  22. 22. THE VESICOUTERINE PERITONEAL FOLD (UV FOLD) TIP:- LIFT THE BLADDER NICELY
  23. 23. BLADDER MOBILIZATION TIP:- STAY IN THE LOOSE AREOLAR TISSUE PLANE
  24. 24. LIGAMENT CONTINUES ANTERIORLY, THEREBY ENABLING DISSECTION OF THE BLADDER FROM THE LOWER UTERINE SEGMENT. TIP :- HUG THE CERVIX WATCH FOR AIR / BLOOD IN UROBAG !!
  25. 25. PANAROMIC VIEW
  26. 26. SECURE THE UTERINE VESSELS TIPS :- PULLING UTERUS CEPHALAD WITH THE MYOMA SCREW HELPS TO MOVE THE UTERINE VESSELS AWAY FROM THE URETER
  27. 27. IT IS IMPORTANT TO TAKE THE UTERINE VESSELS HIGH AND THEN DISSECT MEDIALLY TO THE UTERINE VESSELS DOWN TO THE CUP. IT AVOIDS URETERAL INJURY AND PROVIDES A HEALTHY UTERINE PEDICLE THAT CAN BE SAFELY DESICCATED FURTHER IN THE EVENT OF BLEEDING WHEN RETRACTED LATERALLY
  28. 28. VESSEL SEALER & HARMONIC JODI (LAPAROSCOPIC VIEW)
  29. 29. VESSEL SEALER & HARMONIC JODI (EXTERNAL VIEW)
  30. 30. TIP :- KEEP SETTING - MIN AT 1 WHILE TACKLING UTERINES
  31. 31. SEPARATE THE UTERUS AND CERVIX FROM THE VAGINAL APEX TIP : DONT TOUCH THE HARMONIC SCALPEL DIRECTLY INTO THE METAL OR CCL BECAUSE THIS MAY RESULT IN FAILURE OF THE DEVICE AND MAY EVEN BREAK THE ACTIVE BLADE
  32. 32. CCL VAGINAL BALL EXTRACTOR
  33. 33. NEARING COMPLETION OF THE COLPOTOMY
  34. 34. PULL THE UTERUS INTO THE VAGINA
  35. 35. TAKE CARE OF BLADDER & RECTUM
  36. 36. VIEW THROUGH VAGINA
  37. 37. DELIVERING THE DELIVERY ORGAN
  38. 38. LOCK THE ESCAPE OF PNEUMO
  39. 39. *TAKE OUT ALL THE SPECIMENS *BRING IN THE SUTURE THROUGH THE VAGINA
  40. 40. VAGINAL VAULT (CUFF) CLOSURE *REMEMBER UTEROSACRALS
  41. 41.  MCCALL CULDOPLASTY THE SUTURES WHEN TIED, THE UTEROSACRAL-CARDINAL LIGAMENTS ARE DRAWN TOWARD THE MIDLINE, THEREBY HELPING TO CLOSE OFF THE CUL-DE-SAC
  42. 42. 1-0 VICRYL SUTURE PROCEEDS IN A RUNNING FASHION, MAKING SURE TO INCLUDE THE VAGINAL MUCOSA
  43. 43. COMPLETION OF VAGINAL VAULT CLOSURE
  44. 44. THE PELVIS IS IRRIGATED & HEMOSTASIS AT ALL SITES SECURED
  45. 45. THE FINAL APPEARANCE

Descrição

Total Laparoscopic Hysterectomy (TLH) - the operative steps made easy with detailed explanation & Tips at various stages of surgery to master it .

Transcrição

  1. 1. TOTAL LAPAROSCOPIC HYSTERECTOMY Tips & Techniques Dr. K. Sendhilkumar, MS,FACS,FICS,DNB (Surg Gastro) Dr. Piyush Patwa, DNB, FMAS, FIAGES Consultant Laparoscopic Surgeon
  2. 2. “THE PAPER”   Reich H, De Caprio J, McGlynn F. Laparoscopic hysterectomy. J Gynaecol Surg. 1989;5:213–6.
  3. 3. WHY LAPAROSCOPY Laparoscopic hysterectomies have been clearly associated with  Relatively lesser blood loss,  Shorter hospital stay,  Speedier return to normal activities – Concept of Day Care surgery  Better cosmesis & patient acceptance  and fewer abdominal wall infections when compared with abdominal hysterectomies.
  4. 4.  The vaginal approach is less expensive, But may be challenging in patients with a history of  1) An adnexal mass,  2) Endometriosis,  3) Pelvic pain, & prior abdominal surgery,  4) In patients with a narrow pubic arch or poor vaginal descent.
  5. 5. POSITIONING OF THE PATIENT  The patient is placed in Trendelenburg position - for better access to the pelvic organs  The patient’s arms are tucked in.  The patient’s legs are flexed at hip & knoee joints & placed in stirrups using caution to prevent compression on the lateral calf and thus peroneal nerve damage.
  6. 6. THE OT SETUP
  7. 7. ANATOMY IN BRIEF
  8. 8. THE UTERINE ARTERY USUALLY ARISES FROM THE ANTERIOR DIVISION OF THE INTERNAL ILIAC ARTERY. IT CROSSES THE URETER ANTERIORLY, REACHING THE UTERUS BY TRAVELING IN THE CARDINAL LIGAMENT. IT TRAVELS THROUGH THE PARAMETRIUM OF THE INFERIOR BROAD LIGAMENT OF THE UTERUS.
  9. 9. URETER  Ureter enters into the pelvis at the bifurcation of the common iliac artery in front of the sacroiliac joint.  To be remembered !! - In the female, the ureter passes above the lateral fornix of the vagina lateral to the supravaginal portion of the cervix and lies below the broad ligament and uterine vessels
  10. 10. LETS DO TLH TOGETHER “STEP BY STEP”
  11. 11. INSERT A VEREES NEEDLE INTO THE PERITONEAL CAVITY.  TIP : - An easy way to confirm intraperitoneal entry is to look for a negative or low pressure reading on the insufflator  TIP :- Use Palmer’s Point ( Left subcostal midclavicular line/perpendicular to skin/stomach should be emptied/?Hepato-Splenomegaly) for Obese patients / patients with previous abdominal surgeries including C-sections.
  12. 12. PORTS PLACEMENT
  13. 13. ONCE INTRAPERITONEAL PRESSURE HAS REACHED TO SET 14 MMHG, INSERT 10MM UMBILICAL /SUPRAUMBILICAL TROCAR  MUST : complete survey of the abdomen to rule out any visceral injury at the time of Verees/trochar entry
  14. 14. MYOMA SCREW
  15. 15.  At Gateway Clinics, we routinely use the myoma screw for uterine manipulation during total laparoscopic hysterectomy.  Others- uterine manipulator/Elevator/Uterine Hitch  REMEMBER its use is avoided in two situations. 1) in endometrial cancer, where peritoneal spread of tumor cells is feared. 2) in patients with pyometra in cervical cancer, where insertion of the screw would lead to spillage of pus into the abdominal cavity.
  16. 16.  Inspect the 1) Ureter at the pelvic brim, 2) the infundibulopelvic ligament, 3) Utero-ovarian ligament Tip :- Ligaments Coagulated & incised with combination of Vessel Sealing an Ultrasonic scalpel ( As perfect Haemostasis would be the key to Day care surgery )*
  17. 17. DESSICATION OF THE UTERO- OVARIAN LIGAMENT (TIP: - HUG THE OVARY)
  18. 18. DISSECTION OF THE ROUND LIGAMENT 
  19. 19. TRANSECT THE ROUND LIGAMENT AND SEPARATE THE ANTERIOR & POSTERIOR LEAVES OF THE BROAD LIGAMENT WITH THE HARMONIC SCALPEL FIND THE CORRECT PLANE- THIS IS WHERE THE PERITONEUM SEPARATES EASILY WITH GENTLE MANIPULATION
  20. 20.  Immediately after the round ligament is incised ↓ The uterus, on the myoma screw / uterine manipulator, is pulled cephalad to recreate the “traction-counter-traction” concept of open surgical dissection of the lower uterine segment. ↓ This elevates the uterine arteries along the lower cervix away from the ureters. 
  21. 21. TIP:- THE PARAMETRIAL VENOUS PLEXUS BETWEEN THE OVARY & THE ROUND LIGAMENT COAGULATED WITH VESSEL SEALER & DIVIDED USING HARMONIC SCALPEL
  22. 22. THE VESICOUTERINE PERITONEAL FOLD (UV FOLD) TIP:- LIFT THE BLADDER NICELY
  23. 23. BLADDER MOBILIZATION TIP:- STAY IN THE LOOSE AREOLAR TISSUE PLANE
  24. 24. LIGAMENT CONTINUES ANTERIORLY, THEREBY ENABLING DISSECTION OF THE BLADDER FROM THE LOWER UTERINE SEGMENT. TIP :- HUG THE CERVIX WATCH FOR AIR / BLOOD IN UROBAG !!
  25. 25. PANAROMIC VIEW
  26. 26. SECURE THE UTERINE VESSELS TIPS :- PULLING UTERUS CEPHALAD WITH THE MYOMA SCREW HELPS TO MOVE THE UTERINE VESSELS AWAY FROM THE URETER
  27. 27. IT IS IMPORTANT TO TAKE THE UTERINE VESSELS HIGH AND THEN DISSECT MEDIALLY TO THE UTERINE VESSELS DOWN TO THE CUP. IT AVOIDS URETERAL INJURY AND PROVIDES A HEALTHY UTERINE PEDICLE THAT CAN BE SAFELY DESICCATED FURTHER IN THE EVENT OF BLEEDING WHEN RETRACTED LATERALLY
  28. 28. VESSEL SEALER & HARMONIC JODI (LAPAROSCOPIC VIEW)
  29. 29. VESSEL SEALER & HARMONIC JODI (EXTERNAL VIEW)
  30. 30. TIP :- KEEP SETTING - MIN AT 1 WHILE TACKLING UTERINES
  31. 31. SEPARATE THE UTERUS AND CERVIX FROM THE VAGINAL APEX TIP : DONT TOUCH THE HARMONIC SCALPEL DIRECTLY INTO THE METAL OR CCL BECAUSE THIS MAY RESULT IN FAILURE OF THE DEVICE AND MAY EVEN BREAK THE ACTIVE BLADE
  32. 32. CCL VAGINAL BALL EXTRACTOR
  33. 33. NEARING COMPLETION OF THE COLPOTOMY
  34. 34. PULL THE UTERUS INTO THE VAGINA
  35. 35. TAKE CARE OF BLADDER & RECTUM
  36. 36. VIEW THROUGH VAGINA
  37. 37. DELIVERING THE DELIVERY ORGAN
  38. 38. LOCK THE ESCAPE OF PNEUMO
  39. 39. *TAKE OUT ALL THE SPECIMENS *BRING IN THE SUTURE THROUGH THE VAGINA
  40. 40. VAGINAL VAULT (CUFF) CLOSURE *REMEMBER UTEROSACRALS
  41. 41.  MCCALL CULDOPLASTY THE SUTURES WHEN TIED, THE UTEROSACRAL-CARDINAL LIGAMENTS ARE DRAWN TOWARD THE MIDLINE, THEREBY HELPING TO CLOSE OFF THE CUL-DE-SAC
  42. 42. 1-0 VICRYL SUTURE PROCEEDS IN A RUNNING FASHION, MAKING SURE TO INCLUDE THE VAGINAL MUCOSA
  43. 43. COMPLETION OF VAGINAL VAULT CLOSURE
  44. 44. THE PELVIS IS IRRIGATED & HEMOSTASIS AT ALL SITES SECURED
  45. 45. THE FINAL APPEARANCE

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