Reducing Complications At Laparoscopic Hysterectomy
performed
approximately 300 laparoscopic hysterectomies when, in 1995, I was one of a few surgeons
selected to participate in FDA trials of The RUMI Systemâ Uterine Manipulator and the KOH Colpotomizerä System. This assignment sparked
considerable interest, not only because I have spent several years teaching colleagues how
to avoid the complications associated with laparoscopic hysterectomy, but also because I
have a longstanding interest in outpatient surgery. My focus on limiting physicians'
medicolegal risks and my experience performing laparoscopic hysterectomy and other
advanced endoscopic procedures in free-standing surgicenters keep me on the lookout for
techniques and devices that can reduce the complications, operative time, morbidity, and
costs of laparoscopic hysterectomy.
I
should note that until this point, my technique for laparoscopic hysterectomy usually had
involved placing a moistened sponge stick in the vagina to identify the anterior and
posterior fornices, and thus place laparoscopic colpotomy incisions. Because of the rapid
loss of pneumoperitoneum that followed placement of those incisions, however, the
remainder of the procedure had to be performed vaginally, often under less-than-ideal
visual circumstances. In a majority of cases, the vaginal portion of the hysterectomy
would involve dissection along tissue planes parallel to the laparoscopic portion, but
more medially and closer to the cervix. This resulted in prolonged dissection times,
increased blood loss, and higher costs to the patient and/or her insurance company. In
evaluating the RUMI manipulator and the KOH Colpotomizer, I quickly realized that these
devices made complete laparoscopic dissection of the cervix and vagina much easier,
resulting in greater efflciency and less blood loss while eliminating the difficulties
pertaining to vaginal access.
While
those improvements are welcome, other important efficiency and safety considerations
remain; in this article, I'll discuss how best to address them.
The
two most important steps in using the RUMI manipulator are properly placing it in the
uterine cavity and selecting appropriately sized disposable tips. The modest investment of
time required for these two tasks will yield the dividend of transforming a potentially
difficult procedure into one that generally can be accomplished without undue risk. A
disposable tip that is too long will push the KOH cup away from the cervicovaginal fornix,
thus reducing the value of this device for laparoscopic dissection. A tip that is too
short will not allow proper inflation of the intrauterine balloon, thus resulting in the
device slipping out of the cervix. Because these tips are
rigid and straight, it Is important to dilate the endocervical canal up to 20 French prior
to placing the device.
I
have found it difficult to use a bivalve speculum in placing the KOH cup. Rather, I
recommend the use of a lateral, self-retaining vaginal retractor, with placement of a
single-tooth tenaculum vertically on the anterior cervix. Once it is positioned, the
catheter leading into the uterine cavity (for tubal dye studies) should be closed by
clamping or by placing a small syringe on the end, thus circumventing the risk of air
embolism, which, according to the literature, has resulted in several intraoperative
deaths at hysteroscopy.
In
terms of the KOH Colpotomizer, the obvious advantage is the ability to perform a
completely laparoscopic hysterectomy thanks to the maintenance of pneumoperitoneum. In my
view, however, an equally important benefit is that the significant uterine mobility that
this system and the RUMI manipulator provide facilitates dissection of the ascending
uterine arteries in a manner that reduces the risks of ureteral injury. This enhanced
uterine mobility also speeds uterovesical peritoneal dissection and inferior displacement
of the bladder. Further, the RUMI manipulator allows for significant lateral uterine
displacement, improving visualization and ease of dissection of the uterine vasculature
and broad ligament.
The two most important steps in using the RUMI manipulator are properly placing it in the uterine cavity and selecting appropriately sized disposable tips.
When
using this system for laparoscopic hysterectomy, significant upward traction must be
applied to the cervix and uterus. This places the uterosacral ligaments on stretch, and
delineates the cervicovaginal reflection at its uppermost point. This is crucial, because
the traction enables the surgeon to incise the vagina very near the cervix, thereby
retaining the maximal length of the remaining vaginal canal while allowing the uterosacral
ligaments to be transacted above their insertion point in the vagina. The latter step is
very important, because it reduces the risks of ureteral injury and provides better
vaginal vault support, eliminating the need to place additional sutures through the
uterosacral ligaments and vagina during vault closure.
The
enhanced visualization that the KOH and RUMI systems provide also allows for use of
smaller-diameter access ports, which in turn reduces the risk of anterior abdominal wall
bleeding and the need for fascial closure. A corresponding reduction in postoperative
incisional hernia risk has been reported with use of laparoscopic access ports 5 mm in
diameter or less.1 I use 5-mm ports for most of my surgery. These smaller ports
minimize the risk of trocarrelated injuries, almost 60 percent of which are caused by the
initial incision. Similarly, 50 percent of all intestinal complications of laparoscopy are
related to insertion of the initial sharp trocar. If you can avoid using a sharp trocar,
or can use smaller-diameter trocars, those risks will decline significantly.2
In
summary, by simplifying LH technique and making the procedure safer, The RUMIâ Uterine Manipulator and the KOH
Colpotomizerä System put
advanced laparoscopy within reach of greater numbers of gynecologic surgeons.
REFERENCES
1. Hunt RB, Galen DI, Nezhat C, et al. Laparoscopic complications. Medical Video Productions Video Journal of Ob/Gyn (VJOG). Special edition, November 1995.
2. Galen DI, Jacobson A, Weckstein LN, et al. Radially expandable laparoscopic access device: A controlled comparison of complication rates, effectiveness and cost. Presented at the AAGL 24th annual meeting, Orlando, Fla., 1995.