Laporoscopic Hysterectomy

Question 1

Advantages of laporoscopic hysterectomy over abdominal hysterectomy

Answer 1

• Decreased blood loss
• Shorter hospital stay
• Lower risk of infection
• Speedier return to normal activities

Question 2

What does laporoscopic supracervical hysterectomy often leave behind?

Answer 2

A “cervical stump”

This stump is still hormonally responsive, and may continue to bleed and carry a risk for cervical cancer

This is not left behind in a total laporoscopic hysterectomy

Question 3

Positioning a patient for laporoscopic hysterectomy

Answer 3

• Dorsal lithotomy position
• Pneumoboots in place
• Arms tucked in at sides

Question 4

Kocher clamp

Answer 4

Question 5

Veres needle

Answer 5

Question 6

Port placement for laporoscopic hysterectomy

Answer 6

• Initial incision: 5mm incision at deepest part of umbilicus
• Optical trocars: 2 mm medial and 2mm above the anterior, superior iliac spine on each side, one 5 mm and one 12 mm
• Additional trocar: placed approximately 8 cm above the left optical trocar

Question 7

How do you confirm entry into the peritoneum during laporoscopic port placement?

Answer 7

By observing a negative pressure reading on the insufflator attached to the veres needle

Question 8

What abdominal pressure is reached prior to inserting optical equipment for laporoscopy?

Answer 8

15 mmHg

Question 9

Once ports are set up and the anatomy has been surveyed, what is the first step in total laporoscopic hysterectomy?

Answer 9

Dessicating the IP ligaments and associated ovarian arteries and veins.

The parametrial veins, which run between the IP ligament and round ligament, should also be desiccated at this time.

Question 10

Harmonic scalpel

Answer 10

Question 11

Mobilizing the bladder

Answer 11

• Transect the round ligament
• Separate the anterior and posterior leaflets of the broad ligament
• Identify the vesicouterine peritoneal fold and continue the dissection anteriorly, thereby mobilizing the bladder off the lower uterine segment
• STAY in loose areolar tissue (there may be scar present here if patient had previous C section)
• Reevaluation of the route of dissection is advised if fat is encountered because the fat belongs to the bladder; this may indicate that the dissection is moving too close to the bladder.

Question 12

In the context of hysterectomy, fat belongs to. . .

Answer 12

. . . the bladder

If you see fat, there is probably bladder behind it, so do NOT dissect it.

Question 13

Avoiding the ureters

Answer 13

• IDENTIFY THEM at the start of the surgery, or earliest possible opportunity
• Push the uterus cephalad when interacting with uterine vessels – this separates the uterine vessels from the ureters.

Question 14

How do you know that a vessel is fully dessicated and ready to be cut?

Answer 14

It will not produce any more bubbles when dessicated

Question 15

Once the uterine and ovarian vessels have been safely dessicated and cut, what is the next step in hysterectomy?

Answer 15

Separating the uterus and cervix from the vagina.

For this step, it helps to push the uterine manipulator into the fornices of the cervix so they can be visualized from inside the abdominal cavity.

Question 16

Maintaining pneumoperitoneum while suturing the vagina back together

Answer 16

Can be accomplished by. . . leaving the uterus in the vaginal canal as a plug until you are done fixing up the peritoneal cavity.