INTRODUCTION

Thank you for taking the time to reading our site.

As stated before, this site's mission is to help spread the availability of laparoscopic hysterectomy. This page is dedicated to physicians.

For the longest time, open (laparotomy) hysterectomy was the standard of care. In many parts of the world, this is the staple of medical teaching. Residents are usually trained to perform open surgeries. Those who are lucky enough to go through a Minimally Invasive Surgery fellowship are those who eventually venture into laparoscopic hysterectomy.

Again, the aim of this site, and a lot that goes alongside with it, is to empower the general gynecologist to perform laparoscopic hysterectomy. If you know how to do an open hysterectomy, a vaginal hysterectomy and laparoscopic oophorectomy, there is no reason why you do not do Laparoscopic Hysterectomy.

Actually there is one barrier. It is mostly psychological. If your aim is Total Laparoscopic Hysterectomy (TLH), and may be you tried once or twice, or attended a training course, and still see that it is difficult, you are right. This is because, more than anything else, you will need more specialized instruments, as well as the fact that laparoscopic stitching is difficult, and takes a long time to learn.

Then, do not stress yourself out and insist on TLH. Try LAVH; Laparoscopic Assisted Vaginal Hysterectomy. The patient does not care much if she had her vaginal cuff repaired through the vagina or through a very lengthy and complicated laparoscopic procedure. She cares about the fact that she does not have a scar on her abdomen, and the fact that she will be mobile and active much sooner. And you care about the earlier mobilization, less risk of infection, DVT, hospital stay, etc.

So, have an open mind, and join us in this pleasant journey of LAVH.

IMPORTANT

This page will talk about how a generic abdominal hysterectomy is done, the following page talks more about LAVH.

This page is not intended to be a substitute for clinical teaching and hands on experience. 

It is intended for the surgeon who has passed their basic training, is now fully licensed and practicing.

It is not intended to be an education tool on its own, more as a supplement to our clinical hands on teaching.

If you are not comfortable with what we describe here, please do not start any of these procedures on your own.

We do offer hands-on training, if needed.

Hysterectomy 

First, let us agree on what are the tasks needed to perform the surgical procedure of taking the uterus out: Hysterectomy. Whether we take the ovaries or the tubes out at the same time will not change much of what the 'Hysterectomy' part is like.

Pre operative assessment: We assume that you have met with the patient, reviewed all symptoms, had the discussion about different management options and the patient and her surgeon have agreed that hysterectomy is the best option at this point in time.

Consent: As you know, consent is more about the discussion, not the signature. It is making the patient aware of the procedure offered, other alternate procedures to treat her condition and what are the possible consequences if she chooses not to go through with this procedure. Again, you need to discussed with her the most common complications or side effects to the procedure, as well as the most dangerous even if rare.

We will have a sample consent here.
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Have an open mind

All hysterectomies are the same. We need to do the same steps. We may do them in different orders, may be use different tools but at the end, we do the same steps.

And here is why I say you need to have a bit of an open mind.  You have been doing your hysterectomy this way for the longest time. Have you asked yourself why I do it this way? Have you asked yourself what can I change. Should I change?

I work in a hospital with some 12 other gynecologists, which make there at least 15 different ways of doing a hysterectomy. Well, this should not be a problem right? The problem we face is a bit subtle. Everyone has their own way, and everyone likes their own tools and instruments. This ended up with us having a very long list of instruments that need to be prepared, sterilized, counted multiple time before during and after surgeries, that so much time, effort and money is wasted. And all surgeons complain of restricted time availability in OR etc.


To follow, I will talk about the 'standard; hysterectomy, if ever there was such a thing. Each end every gynaecologist will have their own way of doing things. But if we agree on the steps, the tools can easily be interchangeable. From there, we can talk about changing the tools and interchanging the tools. Eventually, laparoscopy instruments can be used to perform needed steps. 

Hysterectomy Steps
Let us review the basic steps of hysterectomy and see how you do it. And can they be done in another way.


Upper pedicles
Round ligament (has a vessel in it): What we usually do is double clamp round ligament, cut and put a transfixion stitch. The stitch may sometimes be kept on a sling and later the ovary of the same side is attached to it for support. We have also seen round ligament stitch being used to support the vaginal angle.


Ovarian Ligament (has a vessel it in) We recommend at least 2 clamps, free tie then transfixion stitch. 


Infundibulopelvic ligament (large vessel that goes retroperitoneal if escapes) The classic teaching is three clamps, cut, followed by a free tie and a transfixion stitch. The issue with the infudibulo pelvic ligament is that the ovarian artery runs through it, and that comes from the Aorta. If it slips and goes retroperitoneal, it will bleed, the bleeding will be heavy, and may be difficult to track up and secure. 

Middle portion
Broad ligament: needs to be opened anterior and posterior There is no need to use cautery doing this, regular scissors are good enough. There may be some minor capillary bleeding there, though.


Uterine Artery (I suggest skeletonizing it: identify it and remove fascia around it). One clamp, cut and transfixion tie is all that is needed. It is very rare of the uterine artery stitch to slip if taken properly. And because of where it is, and where it comes from, it is easily identified and dealt with if it bleeds. Moreover, if it does bleed, you will see it during the surgery. I have seen gynaecologists place 2 transfixion stitches. 

Do take note of where the ureter is and make sure you are far away enough from it.

Lower Portion

Cardinal Ligament: Fans out to include fascia around lower part of uterus, lateral to cervix and attaches to upper angle of vagina. A couple of clamps here will be all you need to go down enough to reach the area of the lateral fornix. The thing to mention here is, if you do not interfere with the integrity of the cardinal ligament, it is actually the best support to the vaginal vault. Now given that there is no prolapse, and if you do not cut the ligaments attachment to the upper vagina, more so, if you make sure you incorporate it with the vaginal angle stitch, you get excellent support to the vaginal vault after the hysterectomy.


Opening the vagina: You do not need to place a clamp on the vagina beneath the cervix to open the vagina. Some surgeons do. The problem with that, is if you have a deep pelvis and a long cervix, the procedure has become more difficult and more prolonged unnecessarily. Also, doing this, you shorten the vagina by about an inch. I open the vagina with the monopolar cautery. While I am doing that, I use the cutting current. If a bleeding vessel is seen, I easily switch to coagulation and burn the vessel. Long clamps are readily available to catch the cut edge of the vagina, and its angles, and any bleeding vessels as needed.

Avoid injury to urological structures:

Ureter at entry to pelvis: Do not go lateral on abdominal wall, identify ureter before and after clamping.Special care is needed if there is an ovarian cyst and you go lateral and on the lateral pelvic wall. I find it really DIFFICULT to go close to the ureter if you follow these simple steps.. We do not routinely open the peritoneum on the lateral pelvic wall to identify the ureter. We will only do this in selected cases. 

Push bladder well away from front of cervix: This step takes ureter far away from uterine artery proximity. It also takes bladder itself out of the way. It also allows for easier stitching of vaginal cuff. Do move bladder down before tackling the uterine arteries. In an open or vaginal hysterectomy, I use s sponge (4x4 gauze, or abdominal packs, or any similar cotton gauze) open on my finger and gently push the bladder down. I think I have a better feel for the bladder this way. I do not feel comfortable pushing the bladder down with a sponge on a stick. I actually think the sponge on the stick may cause more harm (contrary to what many training programs advise). When you push the bladder, you get some bleeding from the perivesical plexus and the bladder pillar pedicles. Make sure you stop the bleeding as you see it. This can be a nagging nuisance towards the end.


Ureter near Uterine artery-paracolpos: stay close to the uterus as much as you can. Identify the ureter. Skeletonize the ureter and the uterine artery as needed. Pinch ureter, it will contract if healthy. Check it is not dilated if in doubt. 

Possible:

Cytsoscopy at end of procedure. Look for the ureteric orifice, make sure you see the urine jets. You do not need a blue dye to identify it. 

Close vagina.
How to close the vagina? Well, close it the way that leaves no bleeding and gives good support. I like to take a stitch at each angle, and incorporate that with the cardinal ligament as stated above. Now, having taken one of these on each side, all you need is 2-3 figure of eight stitches along the vagina. You may chose to run a locking stitch along the length. There is no real need for a second layer closure. 

Make sure all pedicles are dry


Close up.
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Vaginal Hysterectomy

What do we do different in vaginal hysterectomy? 

I want to say nothing is different. We do the same steps, nearly in the same way. The difference is actually the order in which they are done.

What I do: in Vaginal hysterectomy, we start by opening the vagina. Again, the same way, with cautery. I push the bladder up, then secure the vessels. I then open the posterior peritoneum, and then the anterior. I identify the cardinal ligament, then secure it in 1-2 clamps. Then I skeletonize the uterine artery, secure it, and place a transfixion stitch. Then I clamp and secure the infundibula pelvic ligament-round ligament complex. Then I secure hemostasis and close the vagina (same as above). 

Variations: 

Do you one the peritoneum anterior or posterior first? 
Do you flip the uterus over for the upper pedicles? 

Questions:

Do you close the vagina continuos or figure of eight? One or two layers? 
Do you close visceral peritoneum with vaginal hysterectomy? 
Do you actually close visceral peritoneum in abdominal hysterectomy?
Do you put a vaginal pack in a vaginal hysterectomy with no vaginal repair?
Do you put a vaginal pack in an abdominal hysterectomy?
When do you send your abdominal hysterectomy home? 
When do you send your vaginal hysterectomy home? Why?
How much time do you give your patients off work? Abdominal and vaginal?

Ever asked yourself why?

LAPAROSCOPIC HYSTERECTOMY MADE EASY

I will try to walk you through the steps of a laparoscopic hysterectomy. There is no fancy equipment needed. There is no need to prove anything. Slowly and surely, steadily and securely , if you go through these steps, the uterus will be free to come out. You will not need much in terms of laparoscopic instrumentation or technique. There is the assumption, however, that you are a fully trained gynecologist who understands what the steps are, is capable of performing an abdominal and a vaginal hysterectomy, and that you know how to prevent, identify and deal with complications of a hysterectomy. Even if this means opening up for an abdominal hysterectomy. By time, you will open less and less, as you learn how to deal with these complications through the scope. Actually, you should have less and less complications !

Hospital

Once you have been through all the getting ready business for hysterectomy, you will make arrangements to have your patient booked in the hospital. The hospital needs to be prepared with adequate laparoscopic instruments and equipment (light source, C02 source, etc). It makes your life much easier if the OR nurses are trained in assisting with laparoscopic cases.  The OR must also be equipped with tools needed for a conversion to laparotomy if needed. This, among other things, means that there is the option for the patient to be admitted overnight.

An assistant trained and versed in laparoscopic assisting is an asset and will make your procedure easy or difficult. Make sure to communicate and talk to them about your preferences as this may be different from one surgeon to the other. 

I prefer to book time a bit over what I think I will need. After having done a few, you will get a feel of how much time it takes you from the time the patient comes in to the room, till she is out of the OR. You will be surprised how much time is wasted getting the instruments ready and counting, setting up, etc.

The last time I checked, from the total time allocated to me for a case, I use about 40% of the time for the operation (skin to skin, so to speak)  and about half the time is spent doing everything else. There is always time needed between cases to clean the room, bring in new sets of instruments, washroom brakes for staff, etc.


Position and OR table

During the procedure you will need to put the patient in a steep Trendlenberg position. She must be medically fit for that, and the anesthetist must be comfortable with that as well. Having said that, you can understand that the patient will be under a general intubation anasthesia, and will be ventilated. If at all in doubt, make sure that anasethesia are aware of her before hand, or would see her before the day of the procedure. The worst that can happen is having her cancelled the day of the surgery, when everything has been prepared and set up to go.

I prefer an operative table that has adjustable stirrups. When performing the laparoscopic part, it is best to have the patients legs lowered down and nearly flat (non flexed) hip joint. This will allow you to move your laparoscopic instruments as needed. When you have the leg high up, like with a D&C position (Dorsal Lithotomy), the legs can sometimes be in the way.

When performing the vaginal part, you will need her in the Dorsal Lithotomy position. If your leg stirrups are not adjustable, you should have the patient in a happy medium position before you start. The best position is something that you will find out works best with your technique. It is advised that you adjust the patient yourself before you start the procedure, especially if the other staff members have not done this before. You will show them what you want and teach them the new techniques.

The patient needs to come all the way down till she overhangs the bed. You need at least one inch of 'overhanging'. If not, and when you are trying the vaginal part, the self retaining speculum will fall and hit your foot, or it may hit the bottom of the table and will not give you good access. 

If you will be moving the legs, please make sure that the patient's hands are protected. Standard OR gel pads should be wrapped around the arms and hands for protection. 

I like to use the lap-table on the leg stand of the OR table, as in standard vaginal surgery. 

Arms in: I prefer to have both arms tucked in by the side of the patient. Having the arms abducted will restrict your comfort area and might restrict you from moving to a better angle. Hyper abducting the arms for your comfort may lead to brachial plexus nerve injury.

Mayo Stand on assistant's side: Helps with suction, parking tools, and to help assistant relax their left arm while they are holding the camera for along time.

Procedure:

​The patient has been put to sleep, in position, prepped and draped, instruments counted, ...etc: we are ready to go. 

Sequence:To save time, I start by the umbilical stab. Go ahead and do your standard 10 mm skin incision. Pass the Veruss needle through, attach the gas and while you wait of to reach 15 mm of pressure, attach the light cable, the camera, and the bipolar or other energy device. You may attach suction-irrigation, etc.

NOW: I  put the vaginal speculum: View the cervix, grasp the anterior lip of the cervix, insert uterine manipulator, take speculum out. Keep a Foley catheter with a bag draining.Change your gloves.

Gas pressure reached? Close the valve on the Veruss needle. Pull it out. Put the 10 mm tracer through, attach camera and look inside. Make sure you are in peritoneal cavity, connect gas source again. Clean the camera, put antifoam, white balance, focus, etc. Do your routine check, no injury, other pathology, etc. 

Ports: I use three. Rarely a fourth may be added.The first is the umbilical port, a standard 10 mm port for the camera, light and gas. The second and third I put in the left lower quadrant LLQ, about 12-15 cm apart. I like to have one of them more medial and the other lateral in relation to each other. This gives more flexibility in moving tools and instruments intraperitoneal without causing issues outside the abdomen. Rarely, you may need a 4th RLQ port. 

Role of surgeon and assistant: As you can guess, the assistant hold the camera in the left hand. The assistants right hand may be used to hold a uterine manipulator to push the uterus up, down and sideways. The surgeons will use both hands, and each is manipulating the  instruments that go through ports 2 and 3. Really rarely do we need a fourth port, the assistants hold an instruments through it, typically to push the bowel, or rarely the uterus.

Hysterectomy

Upper pedicle:

Use the same steps that you would do to perform the 'standard hysterectomy' to perform your laparoscopic hysterectomy. For every clamp you used, you will need to use an 'energy' device, to coagulate the vessel in the pedicle and stop it from bleeding. start by the Round Ligament, make sure it is dry and cut through it. Open the broad ligament as usual. 

Infundibulopelvic and ovarian ligaments: I use three bites of the energy device and cut between the medial two and the proximal one as usual. 

Tubes: This is not the time or the place to talk about taking the tubes out or leaving them in, the evidence in relation to cancer, ovarian malfunction, etc is to be consulted somewhere else. We are only talking about the technical part of performing the surgery. Make sure you are aware of the latest recommendations and that you have had a discussion with the patient and have reached a decision. 


Now that you have secured all the upper pedicles,  the upper part of the uterus is free. 

Uterines: 

Skeletonize the uterine arteries. Coagulate and cut them, well close to the body of the uterus and near the isthmus. At this point I usually then turn the uterus side ways, and upwards into the pelvis. This way the uterine artery is on top of the uterus and well away from the ureter. I then take another go at the uterine, and cut flush with the uterus. If you go low enough, you are at the level of the cardinals.

We are done now through the scope. Time to go vaginal

Close the gas valve on the 10 mm port. Pull the light and camera out of the abdomen, put the camera on the Mayo stand, secure and away from patient and paper. Open the gas valve to release the pressure on a 5 mm port. Tell the team you are going vaginal. At this point, you need to attach the cautery to work on the vaginal end (unipolar- do note we have not used it till now). Attach the suction.

Now you need to have a seat, remove the uterine manipulator. Insert the self retaining weighted posterior vaginal wall retractor in place. Grasp both the anterior and posterior cervical lips. 

Open the vagina: I inject 10 mL of Xylocaine with 1% adrenaline in the cervix, all round, for the vasoconstrictive effect. The cervix blanches (talk to anasthesia). Then I open the vagina, all round the cervix, the same way I would do during an abdominal hysterectomy: with cutting unipolar cautery. Some coag cautery may be needed for complete hemostasis. 

Now, push the bladder up, make sure you are in the right plane. I do this, again, using a small piece of gauze (4x4 inches) on my index finger. Some hemostasis my be needed. How far do we go up? I push the bladder up till I see the peritoneum. You can chose to open it now, or later. Then I open the posterior peritoneum at the Douglas Pouch, I use Metz for that. Make sure you have had all the pneumoperitoneum gas evacuated before you open the peritoneum vaginally, or you are in for an unpleasant surprise.

Identify the uteroscral ligament, cauterize and cut them.


Lower Pedicles:

Now secure the cardinal ligaments with a clamp, cut and place a stitch, the same way you would during an abdominal or a vaginal hysterectomy. You may need another go at the uterosacrals. 

Basically, the uterus is free now and you can take it out. 

Close the vagina:  

Now, as in the abdominal hysterectomy, take an angle stitch, secure it to the anterior and posterior walls of the vagina, and make sure you incorporate the cardinal ligaments with you. After doing this on both side, you only need to close the vagina with 2-3 figure of eight stitches.Do you close the peritoneum during an abdominal hysterectomy?

Now, change your gloves, if you will. Close the open gas valve on the 5 mm port, open the closed gas valve on the 100 mm port, put the scope in and have a look.


Closing:

Check all pedicles, make sure there is no bleeding. Suction irrigation can be done to clear clots and make sure there are no bleeding vessels.  Make sure the edge of the vagina is not oozing. 

Check the ureter on the side wall of the pelvis, if you do not see it peristalsing do a cystoscope and check the urine jets. 

Remove your instruments, release the gas, close the skin, thank everyone and go have a coffee.  You just did an LAVH.