The CCL extractor can be used complementary to vaginal
tube to improve the safety and convenience of certain operative steps.
The alternate instruments that are of equal efficacy are the Clermond
Ferrand uterine manipulator, KOH Colpotomizer and HOHL uterine manipulator.
They have built-in mechanism for uterine manipulation and irrespective
of the instrument that is employed the two safety precautions to be strictly
adhered to are: 1. maximal cranial elevation of the uterus and the vaginal
fornices; and 2. all dissections at the vault to be within the confines
of the rim of the vaginal tube or the cup.
 Even after the
vagina has been dissected the vaginal tube continues to provide a seal,
preventing the intra-abdominal CO2 gas loss through the vagina. Once the
vagina has been completely dissected the uterus can be withdrawn into
the vagina where it continues to act as a seal until completion of laparoscopic
vaginal closure. If the uterus is enlarged it is removed by vaginal morcellation.
Alternatively laparocopic morcellation is performed using Steiner Electormechanical
morcellator, 11 or 15 mm diameter.
 
ADVANTAGE OF TLH
- Total Laparoscopic Hysterectomy is a simple, elegant and less time
consuming "intrafascial hysterectomy".
- It is least traumatic to adjacent pelvic organs and attended with
negligible tissue necrosis, minimal blood loss and no injury to the
uterosacral or paracervical ligaments, and preserves the integrity of
the fascial ring and vaginal length.
- It is highly illustrative with clear demonstration and anatomical
demarcation of all the pelvic structures, such as the bladder, ureters,
rectosigmoid, uterine artery, and the pelvic ligaments.
- Stretching of tissues with significant and meaningful cranial displacement
of the uterus and vaginal fornix provides for forming a surgical platform
protecting the bladder and the ureter without any denervation of the
bladder and pelvic ligaments.
- Unlike vaginal hysterectomy or LAVH all tissues are optimally coagulated
before incision, and hence minimal trauma, clean incision and negligible
blood loss.
- Since it is an intrafasical surgery the integrity of the fascial ring
is preserved with minimal stump necrosis, minimal scarring and with
no risk of vault prolapse or herniation of intra-abdominal contents.
- Since the uterosacrals and paracervical ligaments are not incised
or injured the pelvic blood supply and innervation are unaffected. this
is added assurance against surgery related risk of vault prolapse.
- Since the circumferential vaginal incision is made above the level
of attachment of the paracervical and uterosacral ligaments vault bleeding
and vaginal shortening are avoided.
- Since the central part of vaginal is not closed it functions as nature's
best drain
- No need for pelvic or bladder drainage, and patient is ambulated within
6 hours, encouraged to pass urine, take oral feeds and she is out of
the hospital within 12 - 24 hours of surgery, and back to her routines
immediately thereafter.
PREOPERATIVE PREPARATIONS:
All patients undergoing hysterectomy have a detailed sonographic
evaluation and the following investigations are routinely performed:
- Endovaginal sonographic evaluation of pelvic organs to ensure a precise
- The kidneys, liver and spleen are routinely inspected by abdominal
scan and their normality is ensured.
- Cervical cytology/colposcopy is a routine for exclusion of any cervical
pathology
- Any abdominal scar is critically evaluated for the previous surgery,
nature of scar and presence of hernia.
- Preoperative hematological studies, and medical check-up are completed.
The patients are usually admitted on the day of surgery,
and 5 hours fasting is ensured prior to starting the anaesthesia.
General anaesthesia is preferred for all patients.
for more details do contact Dr R Rajan
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