Total Laparoscopic Hysterectomy Simplified:
A New Technique

By Charles H. Koh, M.D.
Physician Editor

u.gif (1401 bytes)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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)For those reasons, I developed the KOH Colpotomizerš System, which consists of a vaginal extender (KOH Cupš Vaginal Fornices Delineator), and a pneumo-occluder (Colpopneumo Occluderš). I use the system in conjunction with The RUMI System Uterine Manipulator. In this article, I will explain how I employ these devices in a safe, straightforward method for performing laparoscopic hysterectomy.

Getting Ready

15space.gif (44 bytes)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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)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.

simple1.jpg (10068 bytes) By rotating the grip of the RUMI System‚ Uterine Manipulator counter clockwise to retroflex the uterus and then pushing the instrument cephalad, the rim of the KOH Colpotomizerš System becomes easily visible and indicates the area of loose uterovesical peritoneum where the incision to reflect the bladder will begin.

15space.gif (44 bytes)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

15space.gif (44 bytes)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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)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.

simple2.jpg (9706 bytes) 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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)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

15space.gif (44 bytes)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.

simple3.jpg (10087 bytes) At the end of TLH, Dr. Koh prefers to close the vagina with continuous  0-PDS in two layers incorporating the pericervical fascia.

15space.gif (44 bytes)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.

15space.gif (44 bytes)Ureteral safety is another important benefit of the KOH Colpotomizerš 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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)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.

15space.gif (44 bytes)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

15space.gif (44 bytes)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.

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