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SIMPLIFIED TECHNIQUE OF TOTAL
LAPAROSCOPIC HYSTERECTOMY
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Tel:
(0481) 2597399, 2599577, 2595377
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INTRODUCTION
Among the various
techniques employed for performing total hysterectomy "total laparoscopic
hysterectomy" (TLH) is the only "true intrafascial hysterectomy" preserving
the integrity of the endopelvic fascia, avoiding injury to the ligaments
and maintaining the vascularity and innervation of the cellular tissue.
It combines all the advantages of an intrafascial technique such as protection
of bladder and ureter, negligible surgical trauma, low incidence of necrosis
and minimal blood loss. The cardinal step in TLH is upward stretching
of the vagina and cranial displacement of the cervico-vaginal transition.
This cranial displacement permits, apart from protecting the ureters and
bladder, a true intrafascial hysterectomy without destroying the fascia
ring (endopelvic fascia), thereby preventing postoperative enterocele
and prolapse of the vaginal stump. By electrosurgical, bloodless dissection
of ligaments away from the vagina and incision of the vaginal wall at
the cervico-vaginal transition, this intrafasical hysterectomy fully preserves
the integrity of fascial ring without sacrificing the vaginal depth.
The negligible surgical trauma and minimal blood loss offers freedom from postoperative pain and discomfort and shorter recovery time with a hospital stay of less than 24 hours, permitting earlier returning back to normal routines. Until recently, most gynecologists have shied away from performing TLH because of the technical challenges and prolonged operating times that were associated with it earlier. Instead, they had preferred to perform "laparoscopically assisted vaginal hysterectomy" (LAVH), a comparatively inefficient three-part technique composed of an initial laparoscopic phase, followed by a vaginal phase, and, finally, another laparoscopic phase (Koh, 1999). However in recent years of refined technological advancement of instrumentations and equipments the laparoscopic surgeon is able to offer the least morbid, most reliable, comfortable and safe total laparoscopic hysterectomy. The LAVH is a "hybrid surgery" that combines the limitations and disadvantages of both the vaginal hysterectomy and TLH. Moreover the "hybrid" procedure is not a true alternative to time honoured vaginal hysterectomies. Currently the only place for LAVH is when difficulties are encountered at TLH or vaginal hysterectomy (Rajan, 2002).
SIMPLIFIED TECHNIQUE
From our experiences with TLH, we believe that it has the potential to become the method of choice for a great proportion of hysterectomy cases. At the same time, however, wider adoption of TLH would depend on the development of simplified technique that would reduce complications and operative time, and new tools to facilitate the colpotomy portion of the operation.
The key instruments for colpotomy we employ in our armamentarium include the simple vaginal tube (PVC pipe) and the CCL extractor. The vaginal tube has diameter of 4 cms at the inner end and length of 25 cms. The outer end of the vaginal tube is closed with a "flap-valve" that will function as a seal to prevent escape of CO2 and allow introduction of the 10 mm operative instruments such as the claw forceps. The vaginal tube can be tightly inserted into the vagina and by pushing cranially the rim of the tube will correctly occupy the cervico-vaginal transition and elevate the vaginal fornices. Maximal cranial displacement of the vaginal fornix is cardinal in distancing the ureters by nearly 4 cms and thus preventing ureteric damage. By nicely fitting into the cervico-vaginal transition and accommodating the cervix within its cavity the tube allows for safe intrafascial dissection and freeing of the vagina from the bladder and the pelvic ligaments, for the optimal circumferential opening of the vagina. Vaginal tubes of lesser diameters are used when the vagina is narrow or the subject operated is nulliparous. By pushing the tube cephaloid it provides the correct amount of tissue stretching needed for any anatomical surgery. Additionally, the adjoining organs such as the bladder or ureters are moved safely away. Cranial displacement of the uterus and the vaginal fornices eliminates the need for bladder dissection, ensuring the bladder remains neurologically intact.
Prof. R. Rajan, MD