2. Total Laparoscopic Hysterectomy
Dr.P.L.KANANI

3. Patient Presentation
A patient in need of a Total Laparoscopic Hysterectomy may present with symptoms such as abdominal pain and abnormal uterine bleeding
Possible causes of these symptoms include Fibroid Uterus, Adenomyosis, Endometrial Polyps, Endometrial Hyperplasia, Endometrial Cancer, and Endometriosis

4. Alternative Treatments
Non-surgical management includes hormonal therapy and NSAIDs
A Dilatation & Curettage and Endometrial ablation can be performed if the patient does not want a hysterectomy
HORMONAL IUCD……
BALLOON THERMAL ABLATION OF ENDOMETRIUM
TCRE …. TO SAVE UTERUS

5. Advantages of the Laparoscopic Technique
A hysterectomy can be completed through open, vaginal, and laparoscopic approaches
Total laparoscopic hysterectomies and vaginal hysterectomies have been found to result in decreased blood loss, shorter hospital and recovery periods, and fewer abdominal wall infections than open hysterectomies
The contraindications for a vaginal hysterectomy include prior abdominal surgery, long and narrow vagina, and endometriosis.

7. Complication of abdominal surgery

8. Patient Positioning
The patient is placed in Trendelenburg position in order to give the surgeon better access to the pelvic organs
The patient’s arms are secured against their body
The patient’s legs are bent and placed in stirrups using caution to prevent compression on the lateral calf and thus peroneal nerve damage

9. Operating Room Set Up
The anesthesiologist is located at the patient’s head
The surgeon stands on the left side of the patient.
There are assistants to the right of the patient and between the patient’s legs.
The scrub nurse is located to the left of the patient near the surgeon
Monitors are placed around the room so that each member of the operating team has a direct view of the video feed

10. Operating Room Set Up

11. Instruments 0° laparoscope Uterine manipulator with colpotomy ring
mm trocars
Insufflator
Harmonic Scalpel
Grasping Forceps
Endostitch Suturing Device
Lapra Ty’s
Myoma scruwe

12. Trocar Placement
A Total Laparoscopic Hysterectomy typically uses three 11 mm trocars and an optional fourth 11 mm trocar.
The optical trocar is placed at the umbilicus.
Two operating trocars are placed lateral and inferior to the optical trocar within the oblique muscles.
A fourth operating trocar may be placed in the midline, inferior to optical trocar. This trocar allows for the placement of a bowel retractor which may be needed in obese patients who can not tolerate steep Trendelenburg positioning.

13. Trocar entery. Primary and secondary trocar entery
Direct trocar entery
Verries needle insufflation fby PTE
Palmer point entery
Safty trocar entry
Endotip trocar entery
secondary
entry always UV of PT

14. Pelvic Cavity Prior to Surgery

15. Procedure Outline
Dissection of the Utero-Ovarian Ligaments and Fallopian Tubes (left 9:00, right 15:00)
Dissection of the Round Ligament (left 10:00, right 16:50)
Dissection of the Anterior Leaf of the Broad Ligament and the Endopelvic Fascia (17:30)
Dissection of Cardinal Ligaments (left 29:30, right 37:00)
Separation of the Uterus from the Vagina (46:15)
Removal of the Uterus and closure of the Vaginal Cuff (1:03:30)

16. Utero-Ovarian Ligament and Fallopian Tube Dissection
The Utero-Ovarian Ligament and Fallopian Tube are bilaterally dissected with the Harmonic Scalpel during the same step
The dissection is carried out along the medial border of the ovary in order to prevent damage to the uterine veins
The uterine manipulator is used to push the uterus upward and to the contralateral side

17. CORNUAL LIGAMENT CUTTING WITH DISSECTER /COVIDIAN VESSAL SEALER

18. SALPINGECTOMY WITH DISSECTER /COVIDIAN VESSAL SEALER

19. Broad Ligament Dissection
The Broad Ligament is dissected with the Harmonic Scalpel in order to mobilize the bladder off of the anterior wall of the uterus
This dissection is carried out in the plane between the Anterior and Posterior Leaves of the Broad Ligament
Care must be taken to avoid damage to the bladder during this step
Adipose tissue indicates the location of the bladder and should not be dissected

20. Broad Ligament Dissection

21. BLADDER DISSECTION DISSECTER /COVIDIAN VESSAL SEALER

22. Cardinal Ligament Dissection
The Cardinal Ligament is initially coagulated medially in order to control back bleeding from the Uterine Artery
The Cardinal Ligament is dissected with the Harmonic Scalpel along the border of the uterus with each cut being more medial than the next. This is done to prevent damage to the ureters
The uterine manipulator is used to push the uterus to the contralateral side

23. Cardinal Ligament Dissection

24. Vault Cutting DISSECTER /COVIDIAN NIEF

25. Separation of the Uterus and Vagina
At this point in the procedure, the uterus should have a whitish appearance due to lack of blood supply
The Uterus is separated from the Vagina by cutting along the colpotomy ring with the Harmonic Scalpel
The Harmonic Scalpel is used as a blade in this step
After complete separation, the uterus is removed through the vagina

26. Separation of the Uterus and Vagina

27. Closure of the Vaginal Cuff
The Vaginal Cuff is closed with the Endostitch Suturing Device and Lapra Ty’s
Irrigation is performed after closure of the Vaginal Cuff to check for bleeding

28. CLOSURE OF VAGINAL CUFF

29. Pelvic Cavity After Surgery

30. MORCELLATION OF SPECEMEN LEPROSCOPY & VAGINAL

31. TLH IN PREVIOUS lSCS, LAPROTOMY,

32. TLH IN ENDOMETRIOSIS

33. TLH IN PREVIOUS TWO LSCS

35. TLH IN SEVERE OBESE PATIENT

36. TLH IN MULTIPLE FIBROIDS

37. TLH IN C/O 32 WKS SIZE UTERUS

38. Post Operative Care
Patients typically go home the day of the surgery or the following morning
Patients are told to rest and relax
Patients normally resume their normal activities 2 – 3 weeks after the surgery

39. TROCAR INJURY, BLADDER INJURY,
VACULLAR INJURY, RECTAL INJURY, SEVRE ADHESION SEPRATION,

40. BLADER INJARY

41. URETER INJURY

42. RECTER INJURY

43. Complications
Injuries may occur during a Total Laparoscopic Hysterectomy at two points:
During trocar placement
During dissection of the ligaments attaching the Uterus to the Pelvic Cavity

44. Complications (continued)
During placement of the optical trocar, the surgeon must be aware of and avoid the Aorta and Vena Cava which are deep to the umbilicus. This is more of a concern with thin patients.
During placement of the operating trocars, the surgeon must be aware of and avoid the Inferior Epigastric Arteries.

45. Complications (continued)
Within the Pelvic cavity, the surgeon must be aware of three structures:
Colon – is located posterior to the uterus and may be perforated by the surgical instruments
Bladder – is located anterior to the uterus and may be damaged during mobilization. A fistula may form between the bladder and vagina if it is not completely mobilized off of the uterus
Ureters – most often damaged during dissection of the cardinal ligaments and at the pelvic brim

46. Thank You