Total Laparoscopic Hysterectomy Simplified:
A New Technique
By Charles H. Koh, M.D.
Physician Editor
ntil recently, most gynecologists have shied away from performing total
laparoscopic hysterectomy (TLH) because of the technical challenges and prolonged
operating times that are associated with it. Instead, they have 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.
From my earliest experiences with TLH, I have believed that
it has the potential to become the method of choice for a great proportion of hysterectomy
cases, particularly in those situations - such as when the pubic angle is narrow, the
vagina small, or the uterus high and immobile - in which LAVH has a reduced chance of
success. At the same time, however, I realized that wider adoption of TLH would depend on
the development of new tools to facilitate the colpotomy portion of the operation, and on
the introduction of a simplified technique that would reduce complications and operative
time.
For those reasons, I developed the KOH Colpotomizerä System, which consists of a vaginal
extender (KOH Cupä Vaginal
Fornices Delineator), and a pneumo-occluder (Colpopneumo Occluderä). I use the system in conjunction with
The RUMI Systemâ Uterine
Manipulator. In this article, I will explain how I employ these devices in a safe,
straightforward method for performing laparoscopic hysterectomy.
Getting Ready
I
position the patient in a laparoscopic lithotomy position, with aseptic prepping and
draping. After dilating the cervix to Hegar 8, I sound the uterus to measure its length,
and then select a RUMI disposable tip less than or equal to the length I have sounded. If
the uterine length falls between tip sizes, I choose the smaller-sized tip. A longer tip
will hit the uterine fundus, preventing the KOH cup from fitting.
Cup
selection comes next, and is a critical part of the procedure. A poorly fitting cup can
undermine the prospects for a successfully completed operation. I select the appropriate
cup by visually comparing the cervix to the cups, which come in small, medium, and large
sizes. The cup selected should just cover the whole cervix. If the cup is too large, it
will pull the ureters toward the colpotomy incision.
After
connecting the disposable tip to the RUMI uterine manipulator, I fit the pneumo-occluder
over the tip and shaft of the RUMI, and then fit the KOH cup over the tip. Using lateral
or upper and lower vaginal refractors, I place a tenaculum on the anterior cervix and pull
it down. Next, I apply surgical jelly to the RUMI tip and insert it in the cervical os.
The posterior retractor is now removed, as well as the interior one. With the labia spread
apart by an assistant, the tip is inserted into the uterus and the cup placed in the
vagina. The presence of upper and lower refractors at this point reduces the space
available for introduction of the cup. At this point, while releasing the first tenaculum,
I introduce a second tenaculum through the fenestration of the cup to catch the cervix. I
push the RUMI tip further into the uterus to engage the cup around the cervix and against
the fornix by pushing the RUMI cephalad, with countertraction provided by the second
tenaculum. Since the cervix has already been dilated, this part of the procedure proceeds
smoothly. In patients with a more relaxed vagina, it may be possible to leave one
retractor in the vagina during this process of introduction, vut usually it is better to
have no retractors.
 |
By rotating the grip of the RUMI Systemâ Uterine Manipulator counter clockwise to retroflex the uterus and then pushing the instrument cephalad, the rim of the KOH Colpotomizerä System becomes easily visible and indicates the area of loose uterovesical peritoneum where the incision to reflect the bladder will begin. |
I
inflate the uterine balloon with 5 cc of water, and then insert a three-way Foley catheter
for bladder drainage. Later, I will use the catheter to fill the bladder with dilute
methylene blue to indicate its position and confirm that it is intact. Finally, I inflate
the pneumo-occluder with 60 to 100 cc of saline.
TLH, Step by Step
In
addition to the 10-mm umbilical port, I use three secondary 5-mm ports. My arsenal of
instruments includes reusable graspers, Kleppinger bipolar forceps, scissors, a needle
holder, and a unipolar hook electrode. To ensure that I have placed the colpotomy system
correctly, I anteflex and retroflex the RUMI tip and palpate the rim of the cup with a
grasper, visually identifying the bulge. I then begin operative laparoscopy.
I
first desiccate the tubo-ovarian pedicle with bipolar forceps and divide it. I then
desiccate and divide the round ligament, and open the parametrium bilaterally.
To
highlight the anterior fornix, I push the cup up firmly. At the level of the fornix, I
incise the uterovesical peritoneum and dissect the bladder down to expose 1 cm to 2 cm of
the anterior vagina. If done correctly, this should not produce bleeding. I then incise
the anterior fornix, using the unipolar hook electrode at 90 watts of unmodulated current.
Entry into the vagina is confirmed by visualizing the cup. Next, I extend the incision
laterally, stopping short of the uterine vessels, which are desiccated at a later stage of
the operation. Bipolar dissection helps to control cuff bleeders. It is of utmost
importance to push the RUMI uterine manipulator strongly cephalad at this point,
stretching the vagina and thus distancing the incision from the ureter.
 |
After retroverting the uterus and pushing the colpotomizer against the uterine cervix, an anterior colpotomy is made over the rim of the device. The tension provided by the colpotomizer allows an accurate incision into the anterior fornix. This incision is extended laterally short of the vagina on both sides. |
Next,
by rotating the handle of the RUMI clockwise, I anteflex the uterus acutely. I make the
posterior colpotomy incision at the rim of the cup, sparing most of the uterosacral
ligament where it inserts into the posterior fornix. I then move the RUMI handle to expose
the right vaginal fornix and uterine vessels, all the while maintaining good pressure on
the RUMI manipulator. Using an ammeter to monitor tissue desiccation, I coapt and
desiccate the right uterine vessels above the cup rim. I always check to make sure that I
have completely coapted and desiccated both the uterine vein and artery. I then rotate the
uterus to the right pelvis and proceed to coapt and desiccate the left uterine vessels.
The distance between the area of desiccation and the ureter is at least 2 cm. To create
even greater distance, I push the cup up against the fornix, thereby lengthening the
vagina and pushing the vessels upward.
Using
the unipolar hook, I divide the uterine vessels. I also divide the lateral vaginal fornix
on the left and right sides to complete the colpotomy incision. During this critical stage
of the operation, pneumoperitoneum is maintained by the pneumo-occluder. As a result, the
anatomy is clearly visible, and hemostasis is unhurried and thorough.
Once
my work is completed, I deflate the pneumo-occluder and gently pull the RUMI handle to
deliver the uterus into the vagina. The uterus may be left in the vagina to maintain
pneumoperitoneum, or it may be removed. I then replace and reinflate the pneumo-occluder
in the vagina.
I
close the vagina by continuous suture of the vault, using O-Prolene on a CT1 needle d by
two Laparoties or by three interrupted mattress sutures incorporating the vaginal angles
and the central vagina using 0-Vicryl. I close the vault laparoscopically, avoiding the
bladder and ureter. As an alternative for those who are not yet proficient with
laparoscopic suturing, the vaginal cuff can be easily closed vaginally with a continuous
suture. This is a rapid, five-minute procedure; the beauty of it is that, because the
uterosacral ligaments are not divided, one does not have to make a special effort to
incorporate them. Therefore, simple vault closure is all that is necessary. After vault
closure, a laparoscopic McCall using O-Prolene or Ethibond can be easily accomplished
where indicated.
Weighing the Benefits
The
KOH cup is the key to successful use of this technique. It provides a distinct landmark
that is both visible and palpable. The presence of the colpotomizer ensures that
dissection of the vagina and parametrium is accurate and does not proceed more caudally
than is necessary - a frequent error given the unusual angled view of the pelvis at
laparoscopy, and given the inability of some surgeons to palpate where the cervix ends, as
at laparotomy. The Colpotomizer prevents overdissection of the bladder and parametrial
tissues, thus avoiding troublesome bleeding and saving time.
 |
At the end of TLH, Dr. Koh prefers to close the vagina with continuous 0-PDS in two layers incorporating the pericervical fascia. |
The
large uterus is hard to elevate and maneuver. However, after uterine and ovarian pedicle
vessels are desiccated, it is possible to morcellate a fibroid, thus allowing the
manipulator to mobilize the smaller uterine mass. The landmarks mentioned in this article
then become evident, and the laparoscopic technique begins to follow that employed for a
uterus of normal size.
Ureteral
safety is another important benefit of the KOH Colpotomizerä System. By pushing the vaginal fornices and the lateral overlying
uterine vessels upward, vessel desiccation and colpotomy occur more than 2 cm from the
ureters. In the early days of TLH, the ureters were dissected and exposed, and lighted
stents were used. Now ureteral dissection is unnecessary, in my opinion, if the simplified
TLH technique and instruments described above are employed. The cup operates as a
backstop, facilitating easy circumferential colpotomy, while the occluder prevents gas
loss during this critical phase of the procedure.
In
the vast majority of cases, I have achieved operating times of 50 to 75 minutes. Even when
I combine TLH with other operative procedures, such as enterolysis, adhesiolysis,
colposuspension, enterocele repair, or sacrocolpopexy, I achieve reasonable operating
times.
Maximization
of vaginal length is another benefit of the procedure just described. Postoperatively, the
average vagina is 10.5 cm in length. By comparison, anterior and posterior colpotomy as
performed in a typical LAVH are achieved by tenting the vagina with sponge forceps,
resulting in a loss of 2 cm to 3 cm of vaginal length.
Further,
preservation of the uterosacral ligaments at TLH is time-saving and may maintain vaginal
innervation. In LAVH, division of the uterosacral ligaments requires subsequent
reattachment, which, with the shortened vaginal length, necessitates operating in close
proximity to the ureters and bladder. Another benefit of TLH is that laparoscopic closure
of the vaginal vault is achieved without inversion; as a result, postoperative granulation
has been infrequent and inconsequential. Pubocervical and Denonvilliers' fascia are
readily and safely incorporated in the vault closure, resulting in improved closure and
support.
In Summary
With
the development of the surgical tools and simplified technique described above, the
average gynecologist can add to his or her armamentarium a safe, readily mastered,
time-efficient hysterectomy technique that offers the prospect of consistently good
outcomes.