Anatomy

1. Anatomical relationships
A thorough knowledge of the anatomical relations between the ureter, the uterus, and uterine artery is essential in order to prevent injuries.
The ureters enter the pelvis whilst crossing the iliac vessels. The left ureter crosses the common iliac artery and the right ureter crosses the external iliac artery. At the same level, the ureters are themselves crossed by the lumbo-ovarian ligaments medially on both sides.
During their course behind the ligaments, the ureters are in close contact with the internal iliac vessels and their collaterals. All along, the uterine artery is strictly parallel to the ureter. With the exception of overweight patients, the ureters can generally be followed visually during their retroperitoneal course posterior to the ligaments up to their entry into the ureteric canal.
At the level of the ureteric canal, the ureter becomes invisible to the surgeon. It is at this level that it will cross the uterine artery by running underneath it between the parametrium and the paracervix. When they cross one another, the ureter and the uterine artery remain independent structures. They can be easily dissected as long as the dissection plane stays out of the ureteral adventitia. Only the ureteric artery links these two structures and this artery can be coagulated and divided easily.
After leaving the ureteric canal, the ureter runs laterally along the vaginal pouch at a distance of approximately 10-15mm. At this level, the ureter lies between the bladder's internal and external pillars. The ureter penetrates the vesical wall from externally to medially before joining the bladder.
2. Uterine fixity
1. Round ligament
2. Mesometrium
3. Uterosacral ligament
4. Internal pillars of bladder
5. Paracervix
6. Parametrium

Uterine fixity is ensured by six pairs of visceral ligaments. These ligaments are vessel-supporting structures, made up of densifications of pelvic cellular tissues for which the ligature and the division are indispensable to the mobilization of the uterus. These can be divided into two groups depending on their function and their spatial orientation. The first ones are lateral and follow the terminal branches of the hypogastric artery. The second ones are sagittal and carry the hypogastric plexus nerves.
Lateral ligaments:
- the round ligament extends from the anterior part of the uterine horns, anteriorly to the uterine tubes, up to the labia majora and the mons pubis, whilst crossing the inguinal canal. Generally, a small artery runs along the inferior border of the round ligament.
- the parametrium and the paracervix play a major role in the positioning of the uterus and of the vaginal fornix. Anatomically, they are in perfect continuity. Their splitting is purely theoretical. By definition, the parametria are located above the ureter and contain the uterine artery. Their division leads to the uterine artery loop and frees the uterine isthmus laterally. Their anterior expansion merges with the lateral part of the vesicouterine ligament and covers the retrovesical ureter. The paracervix is situated underneath the ureter and contains the vaginal arteries. It also contains the voluminous nerve and lymph node uterovaginal plexuses.
- superiorly, the mesometrium is part of the broad ligament, a double-layer peritoneal complex stretched in between the lateral borders of the uterus and the lateral walls of the pelvic excavation. In the thickness of these two layers, the vessels and the nerves are contained. The division of the mesometrium frees the body of the uterus. Since the vessels are in contact with the uterus, the division of the mesometrium at a distance of the border of the uterus is bloodless.
Sagittal ligaments:
- vesicouterine ligaments, formerly known as the internal bladder pillars extending from the anterior lateral part of the cervicovaginal junction to the vesical base. Situated above the retrovesical ureter, they extend into the parametria anteriorly.
- uterosacral ligaments extending from the posterior lateral aspect of the cervix and the vaginal fornix, they underlie the rectouterine folds. They run along the lateral aspects of the rectum and delimit the pararectal space medially and disappear onto the presacral fascia opposite S2-S3 sacral vertebras. They contain small vessels but have connective tissue within which nerves of the inferior hypogastric plexus can be found (lateral portion of the uterosacral ligaments). The division of the uterosacral ligaments helps in the lifting up of the uterus during hysterectomy.
3. Vascular supply
1. Ovarian artery
2. Uterine artery
The ovarian artery originates from the anterior surface of the aorta at the level of the L2-L3 intervertebral disc. On the right side, it crosses over the anterior vena cava. On the left side, it crosses over the greater psoas muscle before crossing over the ureter and entering the lumbo-ovarian ligament. Once it reaches the tubal end-portion of the ovary, it splits into 2 branches, one tubal and one ovarian, which often join their respective branches of the uterine artery to form the tubal arcade.
The uterine artery originates from the internal iliac artery (56% of cases) or via a common trunk with the umbilical artery (40% of cases). Three segments can be distinguished:
- parietal segment along the pelvic wall until the ischial spine;
- parametrial segment transversally heading from the pelvic wall to the uterus underneath the broad ligament in the parametrium. It forms a loop which crosses the ureter anteriorly approximately 20mm from the isthmus and 15mm from the vaginal fornix;
- mesometrial segment, proximal to the isthmus; the uterine artery changes its orientation to run upward along the border of the uterus in the mesometrium towards the uterine horn.
At the level of the uterine horn, it runs underneath the round ligament and the tube to split into 2 branches, a tubal branch and an ovarian branch, which join the ovarian branches and form the tubal arcade.
Source: Anatomie opératoire gynécologie & obstétrique. P Kamina, 2000, Editions Maloine.

Laparoscopic Hysterectomy

Prof. Arnaud Wattiez

Head of Gynecologic Surgery Department - Strasbourg University

Prof. A. Wattiez

1. Preoperative management
Vaginal touch: once the patient is asleep, clinical examination starts. Vaginal touch is essential as it allows assessment of the size of the uterus, which has a direct impact on port positioning and uterine mobility.

Conventionally, injections of low-weight molecular heparin (LWMH) are begun the evening before the procedure starts. Half of the postoperative prophylactic dose regimen is administered on the eve of the intervention. The prophylactic dose is administered on the evening when the procedure has been performed for a period of 7 to 10 days. The dose regimen and treatment duration will be tailored to the patient’s past medical history and thromboembolic risk factors.
2. Operating room set-up
• Patient
- 2 arms alongside the body to avoid injury of the brachial plexus and ensure better ergonomics for surgeon and assistant alike. Two shoulder supports are placed against the acromia to prevent patient slippage when the patient is placed in Trendelenburg position;
- indwelling bladder catheter (12-14 French);
- ideally the buttocks are placed outside the table; tip of patient’s coccyx resting on the table to facilitate uterine manipulation;
- both legs are half-bent for manipulation purposes;
- patient draped: operative field must include the vaginal route (surgeon should be able to manipulate the uterus without any septic risks).
• Team
1. Surgeon to the patient’s left for a bimanual operation. He/she should stand upright, elbows as closest to the body, the axis of vision should be directed in between the 2 hands. Bent elbows should not exceed 90° to avoid any muscle fatigue.
2. Assistant 1 to the patient’s right, holding the camera with his/her left hand and interacting with the instrument situated in the pelvic trocar in the right iliac fossa.
3. Assistant 2, placed between the patient’s legs; he/she mobilizes the uterus caudally once the uterine manipulator is placed. He/she must be seated so as not to stand in the surgeon’s view and ensure adequate uterine mobilization.
4. Scrub nurse to the surgeon’s left: presence useful when sutures are used.
• Equipment
The operating table equipped with leg holders for stretching of legs, should be lowered as much as possible (about 25 cm in comparison with the height used in conventional surgery).
The low position of the table is required by the raising of the abdominal wall induced by the pneumoperitoneum and Trendelenburg position, combined with the external length of instruments.
1. Monitor to the patient’s right foot
2. Monitor to the patient’s left foot
3. Monitors: one for the surgeon, a second for the 1st assistant and for the 2nd assistant, each assistant in the vision axis.
4. Leg holders
3. Trocar placement
• Landmarks
Distance between the pubis and the umbilicus should be at least 30 cm to accommodate the camera.
Lateral trocars are placed in the middle of the oblique muscles, in compliance with the following landmarks:
- epigastric pedicle: branch of the iliac pedicle, originating from the parietal aspect of the internal inguinal ring, and running superiorly and medially towards the deep surface of the rectus muscle. At umbilical level, it runs deep into the muscle and joins with the internal mammary pedicle, commonly visible laterally to the umbilical artery.
- external edge of the rectus muscle: this border is critical, because the trocar must be placed external to the muscle.
- area of the oblique muscles, forming a triangle laterally to the external edge of the rectus muscle; area of low thickness and poor in muscle fibres.
- anterior superior iliac spine situated about 3 cm laterally to the area of oblique muscles.
A. Optical
The umbilical trocar (optical port) is the first that is placed. Once introduced, the surgeon needs to assess the size of the uterus and control the efficacy of the manipulator. Evaluation of the good accessibility of the adnexa and rectouterine pouch (Douglas’) is also carried out simultaneously. The upper part of the abdominal cavity is routinely explored.
B and C. Operating trocars
Two 5 mm operating trocars are placed laterally.
We prefer using light plastic and disposable trocars. Their main advantage is that they hold still upright in the abdominal wall and permit instrument introduction with the use of one hand only. The trocar valve allows suturing with minimal gas loss/escaping of CO2. High-flow insufflators (20-30 L/min) are essential as they ensure the same quality of vision when leaks occur (during vaginal opening and suturing).
Once operating trocars have been placed laterally, the third operating trocar (D) is introduced. It should not be placed inferiorly to the horizontal position joining the 2 lateral trocars. Ideally, the 3rd trocar may be placed slightly superiorly above this line to allow for better ergonomics. Distance between the operating trocar and the optical trocar should be the longest possible, but never less than 8 cm.
• Variation
In cases of bulky uterus or when distance between the umbilicus and the pubis is short, the umbilical trocar becomes an operating one and another trocar is placed superiorly.
The diameter of the central trocar varies depending on the technique used. A 5 mm trocar is sufficient for techniques using electrocautery and suturing only. 5 mm clips may also be used.
The use of atraumatic forceps or 10 mm clip appliers mandates the use of a 10-12 mm trocar. In case automatic forceps are used, position of the central trocar should be superior to the umbilicus.
4. Devices
• Uterine manipulator
1. Handle
2. Rod handle
3. Bayonet safety device
4. Insert
5. Locking button
6. Handle screw
7. Silicone sealing rings
8. Anatomic blade

The uterine manipulator permits the following:
- mobilization of the uterus (retraction, lateroversion, anteversion, anteflexion, rotational movements along the instrument axis);
- identification and mobilization of the vaginal fornices;
- patency of the pelvic region during opening of vagina;
- potential aid for morcellation of bulky uterus at the end of intervention;
- mobilization of vaginal cuffs and patency to facilitate vaginal sealing.

Parts constitutive of the manipulator:
- distal tip fixed into the uterus (a screw merely). The screw is chosen depending on the size of the uterus. Tip is mobile, with variable positions (from 0° to 90°, in relation to the shaft of the instrument). Mobilization is granted through manipulation of the main handle.
Placement of the manipulator into the uterus requires dilatation of the cervix up to bougie No. 9.
The instrument is locked using the snap-in mechanism at position 0. The tip is then screwed up to the hilt of the manipulator rod, which is pushed forward into the cervix.
Identification of the vaginal fornices is done with the use of a 360° rotative valve, exposing the whole vaginal circumference. Made of a non-conductive material, it may be exposed to monopolar current without any risk of electric arc. Valves may be of different lengths and widths to adapt to any vaginal conformations. The valve is activated by a handle on the side opposite the main axis. Then the assistant keeps a visual landmark as to the place of the valve. Flexion of the axis combined with rotation movements of the instrument and rotation of the valve contributes to a reduction of ureteral injuries during laparoscopic hysterectomies.
- A patent system made of 3 soft plastic disks: it leaves the vagina free during final manipulations, hence facilitating posterior opening of the vagina
• Trocars/instruments
Download Instrumentation proposal
Introduction of instruments into trocars:
The surgeon to the left holds the instruments introduced into the central, and left operating trocars. The first assistant to the right holds the camera and the instrument introduced into the right trocar. The second assistant is seated between the patient’s legs and mobilizes the uterus with the cannula.
The surgeon uses a bipolar grasper through the left port and scissors through the central trocar. Scissors may be connected to the monopolar generator. The surgeon can use his/her two hands: his/her left hand for manipulation, grasping, and electrocautery; his/her right hand for dissection, mechanical division, and electrocautery.
A grasper is introduced in the right trocar (Manhes grasping forceps) by the assistant.
5. Division/left round ligament
Division of the left round ligament Division of the right round ligament Animation

Cauterization and division of the left round ligament:
The 2nd assistant retracts the uterus to the right without any anteflexion, and with the utmost traction. The first assistant grasps the left round ligament at its corneal origin and traction is exerted rightwards and cephalad. A triangle is formed, bordered by the round ligament cranially, by the iliac vessels laterally, and by the adnexal vein medially. Tension on the left round ligament exposes the central portion of the triangle made of the 2 juxtaposed anterior and posterior peritoneal layers of the broad ligament. This area becomes gray because of CO2 and the presence of an empty space beneath the posterior layer of the broad ligament. The surgeon must cauterize the left round ligament in the centre of the triangle. In this way, he/she keeps away from the adnexal vein, thereby limiting the risks of bleeding. Successively using cauterization and division, the left round ligament is fully divided. Occasionally the presence of a small artery running posterior to the ligament may be noted. It should be also carefully cauterized.
6. Opening of vesicouterine space
• Opening of vesicouterine space
Video Animation

Once the round ligament has been divided, the vesicouterine space is opened. The uterus is then pushed cephalad. Caudal traction is exerted on the stump of the left round ligament by the first assistant to provide clear and free access to the vesicouterine space. The surgeon uses the tip of the instrument introduced and passed underneath the anterior peritoneal layer to lift it up. Close contact must be kept as it aids in dissecting the vesicouterine space. The anterior leaflet of the broad ligament is progressively cauterized medially paying attention not to injure the bladder. Peritoneal capillaries are also cauterized. Once the posterior attachments of the anterior leaflet of the broad ligament have been freed, the anterior leaflet is divided using either the cold blade of scissors or monopolar cautery. Such dissection should be discontinued about 1 cm from the midline.
• Fenestration/broad ligaments
Video Animation

Fenestration of the right and left broad ligaments is created by the surgeon.
While maintaining the uterus in the same position, thereby tenting the left adnexa, the posterior layer of the broad ligament is progressively freed using the divergent movements of the 2 instruments (scissors medially and bipolar grasper to the left) held by the surgeon. Capillaries of the broad ligament should be carefully cauterized. The posterior layer should be opened, where it looks gray, testifying to the absence of small bowel posteriorly to it. The window in the peritoneal layer is created through simple collapse or division using monopolar cautery. Once the window has been created, it is enlarged using divergent traction exerted by the 2 instruments held by the surgeon.
Traction is exerted towards different directions depending on the type of hysterectomy.
In case of interadnexal hysterectomy, traction is exerted on uterosacral ligaments (craniocaudal direction). In case of total hysterectomy with adnexectomy or non conservative hysterectomy, traction is exerted on the suspensory ligament of ovary (medial lateral direction).
Fenestration is a critical step. Once the window has been created, the ureter can be found on the lateral aspect of the window (against the pelvic wall). At this stage in the procedure, the uterus is pushed cranially and to the left. The same procedure is then performed to the right.
7. Treatment of adnexa
• Total hysterectomy
Video Animation

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
Video Animation

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.
8. Bladder dissection
Video Animation

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.
9. Preparation/uterine pedicles
• Dissection of posterior leaflet
Video Animation

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
Video Animation

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.
10. 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.
11. 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.
12. Indications and Contraindications
Apart from morcellation in cases of malignant pathologies and anesthesia-related contraindications, there is no such contraindication to laparoscopic hysterectomy. Studies undertaken by Wattiez et al. (Wattiez A, Soriano D, Cohen SB, Nervo P, Canis M, Botchorishvili R et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc 2002;9:339-45) have shown that with adequate training, laparoscopic hysterectomy is a safe, effective, and reproducible technique. About 30 laparoscopic hysterectomies are estimated to obtain complication rates and operative times similar to the ones of other approaches. Even a bulky uterus becomes accessible with this approach once a few protocols have been implemented (shifting of ports and use of uterine manipulators) (Wattiez A, Soriano D, Fiaccavento A, Canis M, Botchorishvili R, Pouly J et al. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc 2002;9:125-30).

Nowadays, the main limiting factor to laparoscopic hysterectomy is assuredly the lack of experience of surgeons.
Nevertheless, following the recommendations of the Cochrane Database Systematic Review of January 2005, vaginal hysterectomy should be performed whenever possible. When the vaginal route fails, the laparoscopic approach precludes laparotomy (Johnson et al., 2005).
13. 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.

Vaginal Hysterectomy

Dr. Henri Clavé

Gynecologic surgeon - Clinique St George, Nice (France)

Dr. H. Clavé

1. Patient preparation and positioning
After a preoperative betadine shower, voluntary emptying of the bladder, and premedication, the patient is placed in a dorsal lithotomy position. The hips and knees are flexed with the calves in boot supports. No shaving is performed and no bladder catheter drainage is used. The operator sits on an elevated stool with an operative assistant standing on either side. There is no need for an additional scrub nurse.
2. The instrument table
Video Photo

Only half a dozen basic instruments are laid out on the instrument table:
- a short-handled scalpel with #11 blade,
- an 8-inch fine-toothed dissecting forceps,
- a pair of 8-inch Mayo scissors,
- a single-toothed bullet forceps (as a Pozzi forceps for example),
- an 8-inch needle holder,
- a set of handheld vaginal retractors (Breisky) and a weighted vaginal speculum,
- a thermal hemostatic clamp (Ligasure™ open curved jaws),
- a Yankauer suction cannula and tubing,
- vaginal packing, 10 Ray-tec sponges,
- cups, two 20cm³ syringes with 22G needles for complementary local anesthesia.
3. Pudendal block
Video Illustration

For local anesthesia, we combine a pudendal anesthetic with a paracervical block.

The following solution is used for local anesthesia: 30mL of ropicavaine (Naporin®) 7.5‰, combined with clonidine (Catapressan®) at a ratio of 1 µg/kg to prolong the effect for a period of at least 12 hours.

For the pudendal anesthetic, 10mL of this solution are injected in the vicinity of the Alcok's canal on either side near the ischium, using a 100mL long 22G cannula with a 20mL syringe.
The needle is positioned 3cm laterally to the vulva and towards the inner side of the ischial tubercle. Two fingers of the contralateral hand are placed in the vagina to control this procedure. Prior to injecting the anesthetic, a brief aspiration is carried out with the tip of the syringe to ensure that no vessel has been punctured.

For the paracervical block, the remaining 10mL are injected paracervically in a 5 o'clock and in a 7 o'clock position. This anesthesia covers the entire paracervical area of the hypogastric plexus. This injection is carried out submucosally. It has an additional beneficial vasoconstrictive effect (in contrast to Xylocaine, which has a vasodilatative effect).
4. General principles
The standard sequence of operative steps for vaginal hysterectomy is performed. However, three basic concepts must be followed:
- never use more than two instruments at a time in the vagina in addition to retractors:
  - the bullet forceps
  - and the LigaSure™ vessel-sealing device;
- hemostasis should always be performed as close as possible to the center of the vaginal canal by applying the LigaSure™ in direct contact with the uterine edge and by taking advantage of the concavity or convexity of the instrument;
- no traction should be applied in an effort to exteriorize the uterus to perform the procedure outside of the vagina. This is to prevent pain from nociceptive reflex arcs and untimely pedicular bleeding.
5. Pericervical incision
Video Illustration

A solution of adrenaline (1/4mg) in 40mL of saline is infused in the frontal part of the vagina in order to reduce vaginal bleeding and improve visibility.
Pericervical circumcision is performed with the scalpel blade.
6. Division of supravaginal septum
Video Illustration

The tenaculum is used to draw the uterine cervix downward and the anterior vaginal margin is elevated with toothed forceps while the bladder is retracted anteriorly and internally. Dissection of the vesicovaginal plane should be neither too high (risk of bladder perforation) nor too low (risk of penetration into the uterine isthmus).
A vaginal retractor now rolls back the vesicouterine septum until the reflection of the peritoneum in the anterior cul-de-sac.
7. Opening of Douglas' pouch
Video Illustration

The tenaculum is then applied to the lower lip of the cervix, which is drawn anteriorly.
The posterior vaginal incision is dissected with toothed forceps. It is sharply incised with scissors until the peritoneal reflection of the rectouterine pouch (Douglas' pouch) is opened.
A weighted vaginal speculum is introduced. Now the paracervical tissues can be palpated bi-digitally.
If there are intestinal adhesions, they can be taken down.
8. Division of sacrouterine ligaments

The LigaSure™ device is applied to the exposed structures either as one large bite or as a series of small successive bites.
As a result, the uterosacral ligaments are divided. It usually increases mobility greatly.
9. Lateral cervical hemostasis (vessel sealing)
Video Illustration

Hemostasis of cervicovaginal pedicles should be performed below and medial to the hook holding the uterine artery to prevent ureteral damage. Visualization for clamp application is facilitated by the anterior retractor, which keeps the bladder out of the way. Each successive hemostatic bite should stay in direct contact with the cervix.
10. From a pear-shaped uterus to an apple-shaped uterus
Video Illustration

Once pericervical hemostasis has been completed, the cervix is the focus of an operation carried out through the vagina.
The pear-shaped uterus is difficult to mobilize either laterally or using rotation.
Amputation of the cervix transforms the uterus from a pear shape into an apple shape.
The uterus is then easier to rotate using a successive application of clamps without any excessive downward traction.
11. Cervical amputation
Video Illustration

Transection of the cervix with a cold blade is easy to perform.
Your assistants should be asked to protect the vaginal wall from the blade using Breisky valves.
A strand of vaginal packing is placed underneath the isthmus to keep bowel loops out of the operative field and at a safe distance from the hemostatic instrument.
Reflected light off of the white gauze also improves illumination of the depths of the operative field.
12. Opening up the front of the peritoneum
Video Illustration

The vesicoperitoneal reflection is now very easy to find. It is simpler to open up the front of the peritoneum. A retractor is placed beneath the bladder to protect it.
At this stage, it is easy to see the anterior and posterior folds of the broad ligament laterally to the isthmus.
We know that the vessels are inside of this broad ligament.
13. Hemostasis of uterine pedicles
Video Illustration

The tenaculum is reapplied to the transected edge of the isthmus on the side where the LigaSure™ device is to be applied.
Slight medial traction on the isthmus is applied while the subvesical retractor is tented laterally to keep the angle of the ureter at a safe distance.
The LigaSure™ device is applied along the axis of the vaginal canal, parallel to the uterine isthmus.
Do not place the LigaSure™ device as a Heaney clamp at 45 or 90 degrees to prevent thermal heat damage to the ureter.
14. Cheek-to-cheek application
Video Illustration

The curve of the LigaSure™ device is applied to the curve of the uterine wall in a ''cheek-to-cheek'' fashion.
15. Division of adnexa
Video Illustration

The LigaSure™ device is now applied in one or several bites at the level of the uterine horns. Either the concave or convex aspect of the uterine clamp is applied, making sure it properly adapts to the anatomy.
The adnexa are divided in close contact with the uterus, high in the center of the axis of the vaginal canal.
The uterus should not be exteriorized to the level of the vulva during the hemostasis.
If need be for visibility purposes, the uterus can be bisected or morcellated to allow for hemostasis of the pedicles without traction.
The operator should always be able to see the tip of the LigaSure™ device and make sure that the intestinal loops are well displaced by the gauze packing.
16. Adnexectomy
It is much easier to perform adnexal resection with the LigaSure™ device than with a clamping and ligature technique.
First, the round ligaments are cauterized and divided, as close as possible to the pelvic sidewall.
A tenaculum is applied to the uterine horns to draw them away from the pelvic sidewall and towards the center of the axis of the vaginal canal, well away from the infundibulopelvic ligament and the ureter, which remain alongside the sidewall.
The ovary and tubal mesentery are grasped with a ring forceps.
Hemostasis of the infundibulopelvic pedicle is performed with the LigaSure™ device in one or several applications.
Do not forget to place the gauze to push the bowels away.
This hemostasis is much more reliable than the one achieved with suture ligatures as long as it is not performed under traction.
17. Closure of vaginal cuff
Video Illustration

After extraction of the intact or morcellated uterus, hemostatic completeness must be confirmed:
a freshly placed gauze mesh must remain white.
Colpopexy is performed if necessary by means of a suture approximation of the uterosacral ligaments.
The vagina is closed with a running suture of 0 absorbable monofilament. This suture ligature includes the anterior and posterior walls of the vagina as well as the peritoneal edges to avoid any hidden bleeding into the potential space between these two layers, and to achieve a vaginal scar which is supple, linear, and free of induration or granulations.
18. Conclusion

Minimally invasive vaginal hysterectomy with vessel sealing is an easier¹, safer^2,7, quicker^1,2,3,4,5,6 technique, and no major difference in costs⁴ than the conventional vaginal hysterectomy. These benefits guarantee a more widespread use of this technique.

1. Eur J Obstet Gynecol Reprod Biol. 2009 Nov;147(1):86-90. doi: 10.1016/j.ejogrb.2009.07.011. Epub 2009 Sep 2.
Efficacy of using electrosurgical bipolar vessel sealing during vaginal hysterectomy in patients with different degrees of operative difficulty: a randomised controlled trial.
Elhao M1, Abdallah K, Serag I, El-Laithy M, Agur W.

2. Eur J Obstet Gynecol Reprod Biol. 2009 Oct;146(2):200-3. doi: 10.1016/j.ejogrb.2009.03.014. Epub 2009 Apr 19.
Randomized study of bipolar vessel sealing system versus conventional suture ligature for vaginal hysterectomy.
Silva-Filho AL1, Rodrigues AM, Vale de Castro Monteiro M, da Rosa DG, Pereira e Silva YM, Werneck RA, Bavoso N, Triginelli SA.

3. Arch Gynecol Obstet. 2013 Nov;288(5):1067-74. doi: 10.1007/s00404-013-2857-1. Epub 2013 Apr 27.
LigaSure vessel sealing system in vaginal hysterectomy: safety, efficacy and limitations.
Gizzo S1, Burul G, Di Gangi S, Lamparelli L, Saccardi C, Nardelli GB, D'Antona D

4. BJOG. 2012 Nov;119(12):1473-82. doi: 10.1111/j.1471-0528.2012.03484.x. Epub 2012 Aug 24.
Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for vaginal hysterectomy: a randomised controlled trial.
Lakeman MM1, The S, Schellart RP, Dietz V, ter Haar JF, Thurkow A, Scholten PC, Dijkgraaf MG, Roovers JP.

5. BJOG. 2005 Mar;112(3):329-33.
Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomised controlled trial.
Hefni MA1, Bhaumik J, El-Toukhy T, Kho P, Wong I, Abdel-Razik T, Davies AE.

6. Int J Gynaecol Obstet. 2005 Dec;91(3):243-5. Epub 2005 Oct 21.
Electrosurgical bipolar vessel sealing during vaginal hysterectomy.
Cronjé HS1, de Coning EC.

How to check suspected calcified vessel	How to avoid traction during sealing	How to minimize Tissue blanching	How to dissect planes and create windows

Avoiding compromised seals low	How to avoid incorrect tissue placement	How to create a tissue window	How to open tissue planes

How to use grasping capabilities	How to grasp and seal thick tissue	LigaSure™ 5mm Surgical Techniques	How to seal without cutting

How to seal with cutting	How to dissect with the LigaSure™ Advance device	How to double seal by overlapping	How to double seal on the same seal surface

How to avoid compromised seal
Always refer to the instructions for use included with the product for complete instructions, indications, contraindications, warnings, and precautions. © 2015 Medtronic. All rights reserved. Medtronic, Medtronic logo and Further, Together are trademarks of Medtronic. All other brands are trademarks of a Medtronic company.

Hysterectomy

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