Total Laparoscopic Hysterectomy (TLH) - the operative steps made easy with detailed explanation & Tips at various stages of surgery to master it .

1. TOTAL
LAPAROSCOPIC
HYSTERECTOMY
Tips & Techniques
Dr. K. Sendhilkumar, MS,FACS,FICS,DNB (Surg Gastro)
Dr. Piyush Patwa, DNB, FMAS, FIAGES
Consultant Laparoscopic Surgeon

2. “THE PAPER”
 Reich H, De Caprio J, McGlynn F. Laparoscopic
hysterectomy. J Gynaecol Surg. 1989;5:213–6.

3. WHY LAPAROSCOPY
Laparoscopic hysterectomies have been clearly
associated with
 Relatively lesser blood loss,
 Shorter hospital stay,
 Speedier return to normal activities – Concept of
Day Care surgery
 Better cosmesis & patient acceptance
 and fewer abdominal wall infections when
compared with abdominal hysterectomies.

4.  The vaginal approach is less expensive,
But may be challenging in patients with a history
of
 1) An adnexal mass,
 2) Endometriosis,
 3) Pelvic pain, & prior abdominal surgery,
 4) In patients with a narrow pubic arch or poor
vaginal descent.

5. POSITIONING OF THE PATIENT
 The patient is placed in Trendelenburg position - for
better access to the pelvic organs
 The patient’s arms are tucked in.
 The patient’s legs are flexed at hip & knoee joints &
placed in stirrups using caution to prevent compression
on the lateral calf and thus peroneal nerve damage.

7. THE OT SETUP

8. ANATOMY IN BRIEF

9. THE UTERINE ARTERY USUALLY ARISES FROM THE
ANTERIOR DIVISION OF THE INTERNAL ILIAC ARTERY.
IT CROSSES THE URETER ANTERIORLY, REACHING
THE UTERUS BY TRAVELING IN THE CARDINAL LIGAMENT.
IT TRAVELS THROUGH THE PARAMETRIUM OF THE
INFERIOR BROAD LIGAMENT OF THE UTERUS.

11. URETER
 Ureter enters into the pelvis at the bifurcation of the common
iliac artery in front of the sacroiliac joint.
 To be remembered !! - In the female, the ureter passes above
the lateral fornix of the vagina lateral to the supravaginal
portion of the cervix and lies below the broad ligament and
uterine vessels

13. LETS DO TLH TOGETHER
“STEP BY STEP”

14. INSERT A VEREES NEEDLE INTO
THE PERITONEAL CAVITY.
 TIP : - An easy way to confirm intraperitoneal
entry is to look for a negative or low pressure
reading on the insufflator
 TIP :- Use Palmer’s Point ( Left subcostal
midclavicular line/perpendicular to skin/stomach
should be emptied/?Hepato-Splenomegaly) for
Obese patients / patients with previous
abdominal surgeries including C-sections.

16. PORTS PLACEMENT

17. ONCE INTRAPERITONEAL PRESSURE HAS
REACHED TO SET 14 MMHG, INSERT 10MM
UMBILICAL /SUPRAUMBILICAL TROCAR
 MUST : complete survey of the abdomen to rule
out any visceral injury at the time of
Verees/trochar entry

19. MYOMA SCREW

20.  At Gateway Clinics, we routinely use the myoma
screw for uterine manipulation during total
laparoscopic hysterectomy.
 Others- uterine manipulator/Elevator/Uterine
Hitch
 REMEMBER its use is avoided in two situations.
1) in endometrial cancer, where peritoneal
spread of tumor cells is feared.
2) in patients with pyometra in cervical cancer,
where insertion of the screw would lead to
spillage of pus into the abdominal cavity.

21.  Inspect the 1) Ureter at the pelvic brim,
2) the infundibulopelvic ligament,
3) Utero-ovarian ligament
Tip :- Ligaments Coagulated & incised with
combination of Vessel Sealing an Ultrasonic
scalpel ( As perfect Haemostasis would be the
key to Day care surgery )*

22. DESSICATION OF THE UTERO-
OVARIAN LIGAMENT (TIP: - HUG
THE OVARY)

23. DISSECTION OF THE ROUND
LIGAMENT

24. TRANSECT THE ROUND LIGAMENT AND SEPARATE THE
ANTERIOR & POSTERIOR LEAVES OF THE BROAD LIGAMENT
WITH THE HARMONIC SCALPEL
FIND THE CORRECT PLANE- THIS IS WHERE THE PERITONEUM
SEPARATES EASILY WITH GENTLE MANIPULATION

25.  Immediately after the round ligament is incised
↓
The uterus, on the myoma screw / uterine
manipulator, is pulled cephalad to recreate the
“traction-counter-traction” concept of open
surgical dissection of the lower uterine segment.
↓
This elevates the uterine arteries along the lower
cervix away from the ureters.

26. TIP:- THE PARAMETRIAL VENOUS PLEXUS BETWEEN
THE OVARY & THE ROUND LIGAMENT COAGULATED
WITH VESSEL SEALER & DIVIDED USING HARMONIC
SCALPEL

27. THE VESICOUTERINE PERITONEAL
FOLD
(UV FOLD)
TIP:- LIFT THE BLADDER NICELY

28. BLADDER MOBILIZATION
TIP:- STAY IN THE LOOSE AREOLAR TISSUE
PLANE

29. LIGAMENT CONTINUES ANTERIORLY, THEREBY ENABLING
DISSECTION OF THE BLADDER FROM THE LOWER UTERINE
SEGMENT.
TIP :- HUG THE CERVIX
WATCH FOR AIR / BLOOD IN UROBAG !!

30. PANAROMIC VIEW

31. SECURE THE UTERINE VESSELS
TIPS :- PULLING UTERUS CEPHALAD WITH THE
MYOMA SCREW HELPS TO MOVE THE UTERINE
VESSELS AWAY FROM THE URETER

32. IT IS IMPORTANT TO TAKE THE UTERINE VESSELS HIGH AND THEN
DISSECT MEDIALLY TO THE UTERINE VESSELS DOWN TO THE CUP.
IT AVOIDS URETERAL INJURY AND PROVIDES A HEALTHY UTERINE
PEDICLE THAT CAN BE SAFELY DESICCATED FURTHER IN THE
EVENT OF BLEEDING WHEN RETRACTED LATERALLY

33. VESSEL SEALER & HARMONIC
JODI
(LAPAROSCOPIC VIEW)

34. VESSEL SEALER & HARMONIC JODI
(EXTERNAL VIEW)

35. TIP :- KEEP SETTING - MIN AT 1 WHILE
TACKLING UTERINES

36. SEPARATE THE UTERUS AND CERVIX
FROM THE VAGINAL APEX
TIP : DONT TOUCH THE HARMONIC SCALPEL DIRECTLY INTO
THE METAL OR CCL BECAUSE THIS MAY RESULT IN FAILURE OF
THE DEVICE AND MAY EVEN BREAK THE ACTIVE BLADE

38. CCL VAGINAL BALL EXTRACTOR

39. NEARING COMPLETION OF THE
COLPOTOMY

40. PULL THE UTERUS INTO THE
VAGINA

41. TAKE CARE OF BLADDER &
RECTUM

42. VIEW THROUGH VAGINA

43. DELIVERING THE DELIVERY ORGAN

44. LOCK THE ESCAPE OF PNEUMO

45. *TAKE OUT ALL THE SPECIMENS
*BRING IN THE SUTURE THROUGH THE
VAGINA

46. VAGINAL VAULT (CUFF) CLOSURE
*REMEMBER UTEROSACRALS

47. MCCALL CULDOPLASTY
THE SUTURES WHEN TIED, THE UTEROSACRAL-CARDINAL
LIGAMENTS ARE DRAWN TOWARD THE MIDLINE, THEREBY
HELPING TO CLOSE OFF THE CUL-DE-SAC

48. 1-0 VICRYL SUTURE PROCEEDS IN A RUNNING
FASHION, MAKING SURE TO INCLUDE THE VAGINAL
MUCOSA

49. COMPLETION OF VAGINAL VAULT
CLOSURE

50. THE PELVIS IS IRRIGATED &
HEMOSTASIS AT ALL SITES
SECURED

51. THE FINAL APPEARANCE