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Laparoscopy and Hysterectomy — 347
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CO2 laser
Suction
irrigator
probe
Bladder
pillars
Uterus
Figure 13.1.8. The bladder pillars are identified and cut close to the cervix with the CO2laser.
Coagulation of
the uterine vessels
Figure 13.1.9. While theureter isobserved,the uterinevesselsare skeletonized, coagulated, and cut.
Coagulation
of the cardinal
ligament
Cut
uterosacral
ligament
Figure 13.1.10. The uterusispulledtotheoppositesidewith a grasping
forceps. The ureter must be observed to ensure that it is not damaged
by the bipolar forceps during coagulation and cutting of the cardinal
ligament.
348 — Farr Nezhat and Jyoti Yadav
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Ureter has been
dissected completely
Figure 13.1.11. The linear stapler is applied across the uterine vessels and cardinal ligament. The ureter is
dissected and held away from the stapler jaws.
Prevention of Enterocoele (Moschcowitz Procedure)
By obliterating the posterior cul-de-sac,this procedure helps prevent enterocele and should be considered, especially in patients
with a deep pelvis. A continuous nonabsorbable or delayed
Anterior culdotomy
incision line by CO
laser
Bladder
Uterus
2
absorbable suture is placed through the various structures of the
posterior cul-de-sac, preventing herniation into the rectovaginal
space. The suture is started laterally over the periureteral area
after the ureter is located. It is passed through the serosa of the
Bladder
Uterus
Ureter
Figure 13.1.12. The uterus is elevated, and as the assistant identifies
the posterior fornix, a laparoscopic posterior culdotomy is done. The
gynecologist must select the correct location so that the rectum is not
involved.
Rectum
Rectum
Posterior culdotomy
incision line by CO
laser
2
Figure 13.1.13. The uterus is mobilized, and as it is pushed down, a
laparoscopic anterior culdotomy is created by using the CO
2
laser.
rectosigmoid colon posteriorly, the contralateral side to include
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the oppositeperiureteral area,andtheanteriorvaginal wall. When
it is tied, the posterior cul-de-sac is obliterated. Injury to the
ureter, rectum, and bladder is avoided by meticulous suturing.
Several variations to the Moschcowitz procedure (e.g., Halban’s
technique) that may be used alternatively have been described in
the literature.
Final Laparoscopic Evaluation
The pelvic and abdominal cavities are evaluated laparoscopically,
irrigated, andcleared of blood clots and debris. The pelvis is filled
with 300 to 500 mL of lactated Ringer’s solution, and the pedicles
and vaginal cuff areinspected for any bleeding with the patient in
reverse Trendelenburg position.[18] Intra-abdominal pressure is
reduced and the pedicles are reinspected to confirm hemostasis.
The vaginal cuff is examined to ensure that no small bowel or
omental tissue is included in its closure. At this point, the fluid
in the pelvis should be clear and a look at the ureters should
confirm normal peristalsis and anatomic integrity. To avoid incisional omental or bowel strangulation after the removal of any
trocars more than 5 mmin size, thefascia is repairedwith delayed
absorbable sutures.[24]
HYSTERECTOMY FOR EXTENSIVE PELVIC
ENDOMETRIOSIS AND ADHESIONS
In women who have extensive endometriosis, the rectosigmoid
colon often is densely adherent to the posterior aspect of the
uterus (Figure 13.1.14). Similarly, if the ovaries are affected by
endometriosis and endometriomas, they may become attached
to the pelvic side wall. To coagulate the uterine artery, it may
be necessary to dissect the pelvic side wall and identify the uterine vessel at its origin from the hypogastric artery. Bipolar forceps, harmonic scalpel, clips, or sutures are used. The rectosigmoid colon is separated from the posterior uterus incrementally,
and the bowel endometriosis is resected or vaporized (Figures
Laparoscopy and Hysterectomy — 349
Figure 13.1.15. The dissection of the rectosigmoid colon is continued.
13.1.15, 13.1.16). The high-power ultrapulse CO2laser is very
precise, and with a penetration of only 100 μm, the possibility
of delayed bowel necrosis is very low. The CO
laser is an excel-
2
lent instrument for the treatment of endometriosis. Hemostasis not obtained with the CO
laser is controlled with cautious
2
application of thebipolarelectrocoagulator. Endometriosis of the
rectum, rectovaginal septum, and uterosacral ligament is treated
by vaporization, excision, or a combination of the two, and the
posterior cul-de-sac is freed (Figures 13.1.17, 13.1.18). Bipolar
forceps are used to achieve hemostasis. If the endometriosis has
penetrated deeply to the bowel muscularis or mucosa and has
caused a stricture requiring anterior or complete resection and
repair, this procedure is done after the hysterectomy.
The hysterectomy starts with coagulation and transection of
the round ligament close to the pelvic side wall (Figure 13.1.19).
The peritoneum is opened, and the pelvic side wall is dissected
and developed. This technique allows excellent visualization of
retroperitoneal major vessels and ureter (Figure 13.1.20).
The bladder serosa is injected with lactated Ringer’s solution. The bladder flap is developed with the CO
laser or any
2
cutting device. After division of scar tissue in the vesicouterine
fold, the suction–irrigator probe is used for blunt dissection and
Figure 13.1.14. The rectosigmoid colon is attached to the posterior aspect of the uterus with dense adhesions
and endometriosis. Using the hydrodissection probe and CO
colon is separated from the uterus.
laser,the adhesions arelysed and the rectosigmoid
2
350 — Farr Nezhat and Jyoti Yadav
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Figure 13.1.16. The rectum, theback ofthe cervix, and the uterosacralligaments are dissected.
Right ovary
with endometriosis
and severe adhesions
mobilization of the bladder. The infundibulopelvic ligaments are
desiccated and transected (Figure 13.1.21).
The uterine vessels are coagulated close to the hypogastric artery (Figures 13.1.22, 13.1.23) and retracted medially and
removedfromtheureter. Theanteriorparametrium is transected.
The ureters are freed from the peritoneum andskeletonizeddown
to thebladder with the suction–irrigator probe and the laser,harmonic scalpel, scissors, or electric knife.
At the level of the cardinal ligaments, the ureter and the
descending branches ofthe uterine artery are close toone another
and to the cervix. Therefore, cardinal ligament dissection must
be precise to prevent bleeding and ureteral injury. The LigaSure device is 10 mm and the linear stapler is 12 mm wide,
which considering the short distance between the cervix and
the ureter, increases the risk of ureteral injury with these instruments. Using contralateral retraction of the uterus, the cardinal
ligament is dissected to identify tissue planes, vessels, and the
ureter (Figure 13.1.24). Once the ureter is displaced laterally, the
cardinal ligament tissue closest to the cervix is coagulated and
transected. The bladder pillars are transected close to the cervix
(Figure 13.1.25).
After the uterosacral ligamentsaredissected,folded wet gauze
in a sponge forceps or the tip of a right-angle Heaney retractor
is used to mark the anterior or posterior vaginal fornix. The
vaginal wall is tented and transected horizontally with a laser or
electrode (Figures 13.1.26, 13.1.27). Bipolar electrocoagulation
may be used tocontrol bleeding. The remainderof the procedure
is done vaginally.
Figure 13.1.17. The rectosigmoid colon is freed from the posterior aspect of the uterus and cervix.
hypogastric artery
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External iliac
artery
External iliac
vein
Laparoscopy and Hysterectomy — 351
Obliterated
Round ligament
Figure 13.1.18. While the uterus is pulled to the right, the left round ligament is coagulated close to the pelvic
side wall.
Developing the paravesical space
Obliterated
hypogastric artery
Figure 13.1.19. The hydrodissection probe is used as a backstop for the CO2laser to develop the paravesical
space. The gynecologist must be careful to avoid injury to the major pelvic side wall vessels and the ureter.
352 — Farr Nezhat and Jyoti Yadav
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Uterine artery
Hypogastric
Left ureter
Developing the
vesicovaginal space
Bladder
artery
Figure 13.1.20. The anterior leaf of the left broad ligament is dissected with hydrodissection and the CO2laser
to develop the vesicovaginal space.
Infundibulopelvic
ligament
Hypogastric
artery
Left ureter
Figure 13.1.21. The left infundibulopelvic ligament is coagulated close to the ovary with bipolar forceps.
Laparoscopy and Hysterectomy — 353
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Obliterated
hypogastric artery
Uterine
vessels
Hypogastric
artery
Left ureter
Figure 13.1.22. The paravesical space is developed, and the uterine vessels are identified. The uterine artery at
its origin from the hypogastric artery is coagulated with bipolar forceps. The ureter is observed, and excessive
heat is avoided to prevent ureteral injury.
HYSTERECTOMY FOR LARGE MYOMAS
The safety of the laparoscopic approach to hysterectomy for large
myomatous uteri has been demonstrated in numerous studies.
Both Wattiez et al. [25] and Seracchioli [26] et al. reported on
laparoscopic hysterectomies for uteri weighing more than 500 g,
with comparable complication rates and operating times and
shorter convalescence versus the abdominal approach.
The following factorsmustbe considered in selecting patients
for this procedure:
1. The patient must have adequate hemoglobin and hematocrit
to decrease the possibility of transfusion.
2. Gonadotropin-releasing hormone (GnRH) analogues are
advisable if the uterus is more than18 weeks’ gestational size.
3. The primary trocar should beinserted between theumbilicus
and thexiphoidiftheuterusismorethan18weeks’gestational
size. The secondary trocars should be placed nearer to the
umbilicus than usual.
A uterus more than 16 weeks’ gestational size with multiple
large leiomyomas is more difficult to manipulate laparoscopically. Three and, at times, four secondary trocars are introduced
to provide adequate traction to the uterus if the anatomy is distorted, and ureteral dissection may be recommended in this situation. Although it is possible to completely dissect the uterus
Left ureter
Cardinal ligament
Figure 13.1.23. While the uterus is pulled to the right, bipolar forceps
are used to coagulate the cardinal ligaments close to the cervix. The
ureter is distanced from the bipolar forceps.
Figure 13.1.24. The cardinal ligament is dissected with the CO2laser.
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Left bladder pillar
Right angle retractor
in anterior fornix
CO2 laser
Figure 13.1.26. An assistant places a right-angle Heaney retractor in
the anterior fornix, and the CO
culdotomy.
laser is used to create an anterior
2
Figure 13.1.25. The vesicocervical fascia (bladder pillars) is dissected
close to the cervix with the CO
laser.
2
laparoscopically, it takes longer and a combination of laparoscopic and vaginal approaches is preferred. If there is a large pedunculated leiomyoma interfering with theexposure and laparoscopicmanipulation,myomectomyisdonefirst.Thelaparoscopic
approach is continued until the cardinal ligaments are reached,
and the remaining portion of the procedure is completed vaginally. After the uterosacral and cardinal ligaments are ligated and
cut vaginally, the uterus is morcellated and removed vaginally.
TOTAL LAPAROSCOPIC HYSTERECTOMY
TLH is a technically challenging procedure. Proficiency andcomfort with this procedure require years of experience. In the largest
series of total laparoscopic hysterectomies by Wattiez et al. [27],
comprising 1647 cases over 10 years, the average operating time
was 102.5 minutes, with an average uterine weight of 235 g and a
3.4% major complication rate.
If TLH is planned, two 4 × 4wetspongesareplacedina
surgical latex glove and inserted into the vagina to prevent loss
of pneumoperitoneum. When contralateral traction is applied to
the uterus, the vaginal wall surrounding the cervix is outlined,
coagulated with the unipolar scissors or bipolar forceps, and cut
circumferentially until the cervix is separated (Figure 13.1.28).
The specimen is pulled to mid-vagina but not removed, to preserve pneumoperitoneum. Alternatively, a colpotomizer, several
of which are available on the market, may be used to delineate
the vaginal cuff. This allows the cervix to be circumscribed at a
higher level while preserving the uterosacral–cardinal ligament
complex and has been referred to in the literature as total laparoscopic intrafascial hysterectomy (TLIH).[28] The vaginal cuff is
Right angle retractor
in posterior fornix
Figure 13.1.27. A right-angle Heaney retractor helps identify the site for a posterior culdotomy. The CO2laser
cuts the remainder of the uterosacral and cardinal ligaments.
Laparoscopy and Hysterectomy — 355
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Left cardinal-
uterosacral
ligament
complex
Figure 13.1.28. After anterior culdotomy and posterior culdotomy are achieved, the remainder of the cardinal
and uterosacral ligaments on each side is dissected. The cervix is amputated from the vagina. The uterus is
removed.
irrigated and inspected for active bleeding. Once hemostasis is
achieved, vaginal angles are sutured to the adjacent cardinal and
uterosacral ligaments; care is taken to avoid the ureters. The rest of
the vaginal cuff is closed with polydioxanone(PDS)orpolyglactin
(Vicryl) suture on a straight or curved needle using the extracorporeal or intracorporeal knot-tying technique (Figures 13.1.29,
13.1.30). Endoscopic suturing is difficultand time consuming for
an unskilled surgeon, and the cuff closure should be done vaginally in such cases. Thermal electrocoagulation or a harmonic
device should be used cautiously at the vaginal cuff to prevent
tissue necrosis and subsequent breakdown if sutures are placed
in nonviable tissue.
Left cardinal-uterosacral
ligaments
Because of theclose proximity of thebladder, ureters, rectum,
and uterine arteries to one another, the most difficult aspect of
TLH involves ligation andtransection of theuterosacral–cardinal
ligament. An expert laparoscopist will be able to place adequate
traction on the uterus to avoid injury to these pelvic structures;
however, concomitant pelvic disease may distort the anatomy.
A rectum that is adherent to the posterior cul-de-sac may be
thought to be a thickened uterosacral ligament. A ureter may
be mistaken for pelvic vasculature in the case of extensive pelvic
adhesions or an anomalous renal system. In contrast, employing a vaginal approach when ligating the uterosacral–cardinal
ligament complex affords the laparoscopist the benefit of tactile
Figure 13.1.29. After the uterus is removed, two sponges are placed in a surgical glove and left inside the vagina
to prevent the loss of pneumoperitoneum. The vaginal angles are sutured to the uterosacral–cardinal ligament
complex, and the cuff is closed with 0 Vicryl laparoscopic sutures and intracorporeal or extracorporeal knot
tying.
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(0.4% to 1.4%), menstrual bleeding (25%), and vaginal discharge (10%).[35] Approximately 22% of patients require a second procedure for persistent symptoms following supracervical hysterectomy.[36] The uterus is morcellated and removed
through a 10- to 20-mm trocar with an electric morcellator. The
cervical stump is closed with interrupted absorbable sutures and
covered with peritoneum sewn transversely with either continuous or interrupted sutures. Peritoneal washing and inspection of
the pelvis and abdomen are done at the end of the procedure.
If the vagina was not entered, there are fewer sexual restric-
tions. These patients are advised of the continued risk of cervical
neoplasia and the need for annual examinations and Papanicolaou smears.
Figure 13.1.30. The vaginalcuffisrepaired laparoscopically. Theround
ligaments and upper portion of the broad ligaments have been cut and
suture ligated.
inspection of the cervix and vagina, using hands instead of endoscopic instruments. In doing so, the bladder, ureters, and other
pelvic structures can be felt more confidently to avoid injury.
SUPRACERVICAL (SUBTOTAL)
LAPAROSCOPIC HYSTERECTOMY
Supracervical hysterectomyisrequested by patients andpreferred
by some gynecologists who believe that the cervix affects sexuality and orgasm and helps provide better vaginal support. A comparison [29] of the risks and benefits of subtotal hysterectomy
with those of total hysterectomy in women at low risk for cervical cancer revealed the following operative complication rates
and ranges for total abdominal hysterectomy and subtotal hysterectomy, respectively: infection 3% (3% to 20%) and 1.4% (1%
to 5%), hemorrhage 2% (2% to 15.4%) and 2% (0.7% to 4%),
adjacent organ injury 1% (0.7% to 2%) and 0.7% (0.6% to 1%).
The study design was a decision analysis and concluded that proposed benefits from subtotal hysterectomy had not been proven.
More recent reports by Munro [30] and Learmen et al. [31] were
also unable to demonstrate any significant difference in shortand long-term outcomes between supracervical hysterectomy
and total abdominal hysterectomy. The procedure may be performed laparoscopically, and the specimen is morcellated before
removal from the peritoneal cavity through a small abdominal
incision. An electric morcellator is recommended for this purpose
(e.g., 15-, 20-, and 25-mm morcellators by Gynecare [Johnson &
Johnson] and Semm [WISAP]). A comparison among laparoscopic supracervical hysterectomy (LSH), LAVH, and TLH failed
to demonstrate any clear benefit with LSH.[32–34]
The uterine vessels are coagulated and cut at the level of the
cardinal ligaments above the uterosacral ligaments. The uterus
is retracted, and its lower segment is amputated with scissors, a
unipolar endoscopic electrode, or laser. After the uterus is transected from the cervix, the uterine manipulator is removed vaginally, the cervical stump is irrigated, and hemostasis is achieved.
The endocervical epithelium lining the cervical canal is vaporized or coagulated with the laser or electrosurgery. The rest
of the endocervical canal is ablated vaginally or laparoscopically to reduce the risk of intraepithelial cervical neoplasia
CLASSIC INTRAFASCIAL SUPRACERVICAL
HYSTERECTOMY
Semm [37] described coring the cervix intrafascially without
colpotomy by using a calibrated resection tool (CURT) that
removes the transformation zone to prevent the subsequent
potential development of cervical carcinoma (Figures 13.1.31–
13.1.34). The pelvic floor support is maintained, the ureters are
not jeopardized, and sexual function is not compromised. Semm
suggested that the classic intrafascial supracervical hysterectomy
(CISH) technique should replace total hysterectomy in 80% of
patients.[38] It preserves the blood supply to the lower pelvis
and prevents subsequent uterine prolapse. Mettler and coworkers [39] described an approach for doing endoscopic intrafascial
supracervical hysterectomy using a serrated-edged macromorcellator. When the endoscopic approach for dissection and uterine extraction was used with the morcellator, a colpotomy was
avoided.Another modification involvednearly complete excision
(95%) of the endocervical mucosa with the calibrated resection
instrument. Maintaining the cardinal ligaments provides support to the cervical stump, and the risks of hemorrhage and genitourinary complications are reduced by avoiding dissection of
the parametrium at the level of the endocervix.
An evaluation of the efficacy of CISH was ascertained in 90
patients.[40] No major complications occurred, even in women
who hadlarge myomas. The average operating time was 170minutes, blood loss was lower than that from conventional hysterectomy, and no procedure was converted to a laparotomy. Kim and
coauthors [41] comparedCISH with TLH and LAVH. They found
among three groups that CISH resulted in lowest blood loss and
the fewest complications and suggested that CISH was preferable
for patients with myomas.
COMPARISON OF OUTCOMES FOR VAGINAL,
ABDOMINAL, AND LAPAROSCOPIC
HYSTERECTOMIES
There is ample evidence in the literature that laparoscopic hysterectomy compares favorably with abdominal hysterectomy,
offering reduced morbidity, expense, and discomfort.[42–44] In
a multicenter randomized comparison of 34 women undergoing
LAVH and 31 women undergoing abdominal hysterectomy [45],
although the mean operating time was significantly longer for
LAVH (179.8 vs. 146 minutes), LAVH required a considerably
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