"The Texas Approach" To Total Laparoscopic Hysterectomy

Carl F. Giesler, M.D.

ysterectomy is one of the most common surgical procedures performed by gynecologists. The standard approach to the procedure is either abdominal or vaginal removal of the uterus. However, new developments in endoscopic surgery have made the laparoscopic approach a viable alternative for women needing a hysterectomy. While a growing number of gynecologic surgeons have added the skills necessary for laparoscopic hysterectomy to their armamentariums, many of their colleagues have balked at adopting the procedure, citing concerns about excessive operating time, spiraling costs, and frequent complications.

My experience in Houston does not bear out those concerns. Rather, by using a technique that I call "the Texas approach' to total laparoscopic hysterectomy, I have achieved operating times and surgical costs comparable to those for abdominal and vaginal hysterectomies while keeping complications to a minimum. In this article, I'll explain what "the Texas approach" entails.

Attention to Detail: The Key

My surgical results depend on the proper use of both tools and technique. I use a limited number of tools when I perform a laparoscopic hysterectomy. For the pelvic portion of the procedure, I use Allen stirrups, The RUMI Systemâ Uterine Manipulator, and the KOH Colpotomizerä System. The metal cups are used with the UltraCision LaparoSonicâ Coagulation Shears (LCS). I use three I0-mm or 11-mm disposable trocars, a 5-mm disposable trocar, the Carter-Thomasonâ needle, a 0-degree 10-mm laparoscope, the Stryker 3-chip camera, and the LCS. AESOP-2000, the voice-activated robot, replaces a surgical assistant and holds the laparoscope and camera during the procedure. The Tahoe ISN facilitates closure of the vaginal cuff. A surgical glove filled with a wet laparotomy sponge and placed in the vagina allows reestablishment of the pneumoperitoneum after the uterus has been removed; alternatively, one can reinsert the pneumo-occluder. Bipolar coagulation forceps are kept on the field in case there is bleeding.

Successful, efficient laparoscopic hysterectomy requires careful attention to detail right from the start. Proper patient positioning is essential to prevent complications and to facilitate manipulation of the uterus. The Allen stirrups allow the legs to be supported in a physiologic position that permits access to the vagina at the start of the procedure and continued access to the uterine manipulator throughout the remainder of the operation. The thighs are elevated 10 degrees above the horizontal plane and externally rotated 15 degrees to provide adequate access to the vagina. To reduce the risk of compartment syndrome, care is taken to avoid putting pressure on the calves.

The uterus is sounded to determine the correct tip length for the RUMI handle. A 0-Prolene suture is placed through the cervix at the 12:00 position, and a second 0-Prolene suture is placed at the 6:00 position. The RUMI uterine manipulator with the attached KOH Colpotomizer and vaginal occluder then is positioned. The previously placed Prolene sutures are passed through the KOH Colpotomizer and tied to the handle of the RUMI uterine manipulator (which I have modified by creating a hole to accommodate the sutures). This step attaches the instrument securely to the uterus and keeps the colpotomizer attached to the cervix at the cervicovaginal reflection. Next, the balloons on the uterine manipulator and the vaginal occluder are filled with normal saline solution. A Foley catheter is placed in the bladder for the duration of the procedure.

Using "the Texas approach" that he developed, Carl Giesler usually can perform a total laparoscopic hysterectomy with McCall culdoplasty in 60 to 75 minutes.

Readying the Ports

A vertical infraumbilical incision is made with a No. 11 blade. The subcutaneous tissue is spread with a hemostat, and the fascia is grasped with a Kocher clamp and elevated from the patient. Grasping the fascia creates a space free of intestine directly beneath the umbilicus. This short distance allows safe introduction of the Veress needle. After insertion of the Veress needle into the peritoneal cavity, the position of the needle tip is confirmed using the hanging drop technique. Adequate pneumoperitoneum is established. A disposable 10-mm or 11-mm trocar is introduced into the peritoneal cavity. The 10-mm laparoscope is inserted through the trocar sleeve, and the peritoneal cavity is inspected.
The patient is placed in steep Trendelenburg position, and placement of the lateral trocar sites is determined by using the laparoscope to transilluminate the abdominal wall. In most patients, transillumination allows blood vessels to be identified, enabling selection of trocar insertion well away from those vessels. Under direct observation, two 10-mm or 11-mm trocars are introduced lateral to the rectus muscles on either side.

Following introduction of the trocar sleeves, one sleeve is removed and replaced with the Carter-Thomason guide. The Carter-Thomason needle then takes a 0-Vicryl suture through one side of the guide and retrieves it at 180 degrees through the other side. This places the suture directly across the trocar opening, and allows closure of the trocar site at the end of the procedure, thereby preventing hernia formation. The suture is used to fix the trocar sleeve to the abdominal wall for the duration of the procedure. Both 10-mm or 11-mm trocar sites are handled in this fashion. A 5-mm trocar is inserted in the groin on the surgeon's side of the patient to facilitate suturing at the end of the procedure.

TLH Texas Style

After I place the trocar sleeves, I'm ready to perform the hysterectomy. I use the LCS, which allows me to both coagulate and cut, eliminating multiple instrument changes. With the power setting at 5, the infundibulopelvic ligament is coapted, coagulated, and cut just lateral to the ovary. If the ovary is to be preserved, the utero-ovarian ligament is coapted, coagulated, and cut just medial to the ovary. I try to avoid placing excessive tension on the tissue while coagulating with the LCS, since too much tension will result in inadequate coagulation and lead to bleeding from the pedicle surfaces.

The mesosalpinx, round ligament, and broad ligament are progressively coapted, coagulated, and cut using the same technique. While these tissues are being coagulated and cut, the assistant surgeon provides exposure by placing the free ovary and Fallopian tube or free uterine horn on traction. I then use my free hand to push the RUMI manipulator into the pelvis, rotating the uterus to provide optimal exposure. Pushing the uterus into the pelvis separates the uterine vessels from the ureter, providing an additional margin of safety. The point of incision when cutting the broad ligament with the LCS is 1 cm to 2 cm away from the wall of the uterus, thus ensuring that the tortuous plexus of vessels along the side of the uterus are not cut tangentially, and that excessive bleeding does not occur.

At this time, the anterior peritoneum over the lower uterine segment is opened to the opposite side. With the RUMI pushing the uterus into the pelvis, the KOH cervical cup becomes apparent through the tissue. I use the blunt edge of the LCS to achieve tissue blanching over the edge of the collar. Once the anterior colpotomy is achieved, the colpotomy incision is extended in either direction using the blunt tip. Care is taken not to put too much pressure on the collar with the LCS, since this could take the LCS out of harmonics, necessitating use of a second LCS to complete the procedure.

The uterosacral ligaments are identified posteriorly and are coapted, coagulated, and cut. Pushing on the RUMI uterine manipulator and anteverting the uterus make this step extremely easy. The KOH cervical cup again is readily visualized through the tissue, and the posterior colpotomy is achieved in a fashion similar to that of the anterior colpotomy.

At this point, I control the uterine vessels on my side of the uterus. I use the LCS at a
power setting of 3 to coapt and coagulate the vessels in two adjacent spots near where the anterior and posterior colpotomy incisions approach one another. I then cut the intervening tissue to finish the merger of the anterior and posterior colpotomy incisions on one side. The opposite side is managed similarly, completing the hysterectomy from above.

The assistant surgeon places the LCS on his or her side of the uterus, while I control the power to the LCS. Since I am in charge of the robot holding the laparoscope and camera, I also control the field of view on the opposite side, and the assistant surgeon becomes an extension of my hands. Employing the assistant surgeon in this fashion improves the efficiency of the procedure and decreases the awkwardness associated with reaching across the patient to achieve proper placement.

Using the RUMI manipulator to push the uterus into the pelvis separates the uterine vessels from the ureter, providing an extra margin of safety.

Some surgeons may feel uncomfortable using the LCS to control the uterine vessels. If so, once the anterior and posterior colpotomies have been created, it is a simple matter to return to the vaginal approach and place clamps across the uterine vessels from below. This usually requires placement of only one or two clamps on either side. The vaginal cuff then may be closed in the same way normally used to complete a vaginal hysterectomy, and the laparoscopically assisted vaginal hysterectomy (LAVH) would be finished. Once familiarity with the instrumentation is achieved, an LAVH performed in this fashion usually is accomplished in less than one hour. Completion of the LAVH requires confirmation of hemostasis in the pelvis after closure of the vaginal apex, irrigation and removal of residual blood clots, and removal of the trocar sleeves, with closure of the lateral 10-mm or 11-mm trocar port incisions using the previously placed sutures.

I prefer to complete the hysterectomy laparoscopically. After the uterus has been completely separated from the vagina, the vaginal occluder is deflated and the uterus is removed. At this point, the value of suturing the RUMI uterine manipulator to the cervix becomes readily apparent. Thanks to this step, the uterus is not dislodged from the manipulator and lost in the abdominal cavity. After the uterus is removed, pneumoperitoneum must be re-established. This is accomplished by using a wet laparotomy sponge placed inside a surgical glove. (Again, however, one instead can reinsert the pneumo-occluder at this point.) The laparotomy sponge is moistened to improve its malleability and to facilitate occlusion of the vagina.

Once the pneumoperitoneum is re-established, extensive irrigation is used to demonstrate adequate hemostasis. Capillary oozing at the vaginal cuff occasionally is observed; if this occurs, the bipolar coagulating forceps is used to control the bleeding. When hemostasis is deemed adequate, the vaginal apex is dosed with three figure-of-eight sutures using the Tahoe ISN. 2-0 Monocryl provides sufficient strength and dissolution time to allow the vaginal apex to heal.

An appropriately positioned KOH cervical cup minimizes the risk of bladder injury by clearly identifying the cervicovaginal reflection.

Many patients develop an enterocele after hysterectomy. To avoid this, I place a high McCall suture, using 0-Ethibond through both uterosacral ligaments and the posterior vaginal apex.

At this point, I have essentially completed the total laparoscopic hysterectomy. I irrigate the pelvis to remove residual blood clots and irrigation fluid. I inspect all pedicles for adequate hemostasis. I remove the trocar sleeves and release the pneumoperitoneum. I tie the previously placed sutures across the lateral trocar sites by elevating the abdominal wall while tying the suture. This theoretically prevents any tissue from being caught between the loop of suture and the peritoneum on the inside of the abdomen.

Reduced Operating Time

Using the technique described above, I usually am able to perform a total laparoscopic hysterectomy with a McCall culdoplasty - including suturing the vagina closed and using laparoscopic suturing techniques for the McCall suture - in 60 minutes to 75 minutes. I did not have such relatively brief operative times when I first performed TLH, however. My initial surgical times ranged between 120 minutes and 150 minutes. Applying the suturing techniques that I employ in laparoscopic Burch bladder suspensions was the first step I took to reduce my surgical time. These techniques provide the best outcome for my patients. To develop and maintain my suturing skills, I suture endoscopically every chance I get. Continued practice and use of the Tahoe ISN have helped me shorten my surgical time significantly.

I believe that the techniques I have described in this article will allow most laparoscopic surgeons to reach operating times of 60 minutes or less for LAVH. This is very competitive with the operative times for other hysterectomy methods. By honing his or her suturing skills, a surgeon can complete total laparoscopic hysterectomy in the same amount of time.

Complications on the Wane

Beyond lengthy operative times, another criticism aimed at laparoscopic hysterectomy relates to the number of complications associated with the procedure. As with any new procedure (the first laparoscopic hysterectomy was performed by Harry Reich in 1989), complications are related to the learning curve of the surgeon. Over the years, as more and more laparoscopic hysterectomies have been performed, common potential complications have been identified, and ways to avoid them have been established.

In contrast, the numerous safety benefits associated with performing TLH with the devices described above are gaining increased recognition among gynecologists. An appropriately positioned KOH cervical cup minimizes the risk of inadvertent injury to the bladder by clearly identifying the cervicovaginal reflection. Because the RUMI uterine manipulator pushes the uterus into the pelvis, the ureter is separated from the uterine vessels, and is less likely to be injured when those vessels are coagulated. Also, because the LCS uses ultrasonic energy to coagulate tissue - with mechanical energy active only at the point of application - remote injury from this energy source is very rare. Injuries to bowel and blood vessels during laparoscopic procedures always are possible, but they can occur during vaginal and abdominal procedures, as well. Again, these types of injuries relate more to the experience and skill of the surgeon than to the approach. When performed by experienced laparoscopic surgeons, the complication rates for laparoscopic hysterectomy are similar to the rates for abdominal and vaginal procedures.

The Cost Factor

The final criticism of laparoscopic hysterectomy is that it costs significantly more than the standard approaches. This notion must be evaluated carefully, however, with care taken to ensure that cost figures from different institutions reflect equivalent services. Since hospitals often are reimbursed for the procedure performed and not for the actual cost entailed in that procedure, accurate cornparisons are difficult. Also, because of contractual commitments to third-party payers, the per-case reimbursement that a hospital receives for a given procedure often will vary widely. Since the major surgical cost in any hospital is operating room time, any technique that can reduce OR time is going to make a surgical procedure cost-effective.

As I noted earlier, the procedure that I have described here has reduced my operating time for total laparoscopic hysterectomy to the same amount of time I take to perform a vaginal or abdominal hysterectomy. Further, my use of many reusable endoscopic instruments and a minimum of disposable instruments has allowed me to keep the cost of the procedure on par with that of vaginal and abdominal hysterectomies. I believe that my approach can be reproduced by other surgeons with similar results. Therefore, I also believe that cost is not going to remain an obstacle to wider adoption of total laparoscopic hysterectomy.

My experience with more than 250 laparoscopic hysterectomies over the past six years has shaped my technique. TLH constitutes a safe, efficient surgical procedure for my patients. Moreover, this procedure has been associated with minimal complications. By careful evaluation of new technology and judicious selection of the reusable endoscopic instrumentation now available, I have achieved a cost-effective laparoscopic hysterectomy. I believe that my colleagues can also achieve favorable results using "the Texas approach' to laparoscopic hysterectomy.

The author gratefully acknowledges the contributions of his associate, Larry Myers, MD., the co-developer of 'the Texas approach" to laparoscopic hysterectomy.

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