1. Laparoscopic Hysterectomy what is the difficulty?
Ayman Shehata MD
Lecturer of Obstetrics and Gynecology
Tanta University
2016

2. Hans Christian Jacobaeus (1879 – 1937)
1910: Swedish internist; first thoracoscopic diagnosis with a cystoscope in a human subject.
Treatment of a patient with tubercular intra-thoracic adhesions.
The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Münchner Medizinischen Wochenschrift, 1911

3. History Bertram Bernheim
1911 : First laparoscopy at Johns Hopkins
12mm proctoscope into epigastric incision for pancreatic cancer
Bernheim called his procedure ‘organoscopy’
Findings confirmed on laparotomy

4. History of Laparoscopy
1920: Zollikofer discovered the benefit of CO2 gas for insufflation
1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum.
After World War II, the development of fiberoptics represented an important step forward for endoscopy
1966: Hopkins rod lens scope & cold light

5. History
1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.

6. History
Since 1989, Harry Reich in Kingston, Pennsylvania described laparoscopic hysterectomy (LH) the laparoscopic assisted vaginal hysterectomy had spread first in the medical centres (LAVH).
In 1993, Semm developed intrafascial laparoscopic supracervical hysterectomy(SLH)
In 2002, Diaz-Arrastia reported the first series of successful robotic laparoscopic hysterectomies.

7. Use of TLH has increased in the last 20 years. TLH accounted for 9
Use of TLH has increased in the last 20 years. TLH accounted for 9.9% of all hysterectomies in 1997 and 11.8% in 2003.

8. Advantages
Vaginal and laparoscopic hysterectomies have been clearly associated with :
Decreased blood loss
Shorter hospital stay
Rapid return to normal activities
Fewer abdominal wall infections
Minimal immune response
Minimal scar tissue formation
Decreased post-operative pain
Reduction in the incidence of post-op ileus

9. Vaginal hysterectomy
In light of these findings, a recent review concluded that vaginal hysterectomy is preferable to abdominal hysterectomy and that a laparoscopic hysterectomy should be attempted when vaginal hysterectomy is not possible.6
The vaginal approach is less expensive, but may be challenging in patients with a history of an adnexal mass, endometriosis, pelvic pain, and prior abdominal surgery, or in patients with a narrow pubic arch or poor vaginal descent.

10. Requirements for successful TLH
Room setup
Positioning
Port sites
Instrumentations
Technique

11. Room setup

12. Radiological unit (optional)
Laparascopic unit
Anaesthetic unit
Laparascopic unit – extra monitors
Instrument table
Electrocautery
Operating table

13. Room setup
Position

14. Port sites in TLH

15. Instruments setup Uterine manipulator Electrosurgical energy source
Stitching instrumentations
Needle holders
Needle grasper
Suture materials
Tissue Morcellators

17. Magneshkar manipulator

18. Marwa Uterine manipulator

19. Electrosurgical units (ESU)

20. Energy sources Electric energy Ultrasonic energy
Monopolar
Bipolar
Ultrasonic energy
Harmonic
Sonosicion
SonoSurg
Advanced vessel sealing devices
Ligasure
Enseal
Thunderbeat

22. Sutures

23. Technique
Danger points

24. Cutting of upper pedicles

25. Cutting of upper pedicles

26. Dissection of bladder flap

27. Dissection of bladder flap

28. Dissection of bladder

29. Uterine artery division

30. Cutting of vaginal edges on colpotomy ring

31. Suturing of vaginal stump

32. Suturing of vaginal stump

34. Practical Tips for successful TLH
Position the patient for both safe access and “surgeon ergonomics”
Port placement in advance
Pelvic anatomy, especially the “danger points” (eg, ureters, ovarian/uterine vasculature, uterosacral ligament)
Principles of open surgical technique
Uterine manipulator to facilitate colpotomy
Electrosurgical instruments
Bladder dissection to minimize the risk of cystotomy and vesicovaginal fistula during colpotomy and vaginal cuff closure
Full thickness healthy bites from cut edge during vaginal cuff closure including Uterosacral Lig .

35. Conclusion
Total laparoscopic hysterectomy is a safe and effective procedure for women needing a hysterectomy.