Due to the structural characteristics of the female reproductive tract, there are several methods available to remove the diseased uterus. The traditional surgical approach is to remove the uterus either transabdominally or vaginally. Laparoscopic total hysterectomy means that the ligaments, blood vessels, and vaginal wall around the uterus are severed laparoscopically, the uterus is removed vaginally, and then the vaginal end is sutured again laparoscopically. In addition to total hysterectomy, there are several different types of laparoscopic hysterectomy, including laparoscopic-assisted subtotal hysterectomy (LAVH), laparoscopic subtotal hysterectomy, and laparoscopic intrafascial hysterectomy.
1.Advantageous features of laparoscopic total hysterectomy
Laparoscopic hysterectomy was started in 1989. With the development of various surgical instruments, this procedure has been widely performed. Compared with open total hysterectomy, laparoscopic total hysterectomy has obvious advantages due to the characteristics of minimally invasive surgery, including short hospital stay, mild postoperative pain, quick return to normal life and work, and small abdominal wound.
Although LAVH is easy to perform because of relatively few operations under laparoscopy, the vaginal part of LAVH is very difficult in some difficult cases, such as endometriosis and pelvic adhesions and other diseases that make the uterus not easily pulled down. In such patients, laparoscopic total hysterectomy is relatively easy because it is performed completely laparoscopically.
Compared to abdominal total hysterectomy and negative total hysterectomy, laparoscopic surgery provides a clearer view, and in patients with combined endometriosis and pelvic adhesions, laparoscopic hysterectomy becomes more advantageous when it avoids both the difficulties of negative surgery and the trauma of open surgery, expanding the scope of minimally invasive surgery.
Laparoscopic total hysterectomy can be performed along with laparoscopic surgical treatment of other diseases, such as endometriosis lesion removal, ovarian tumor removal, vaginal stump suspension, laparoscopic pelvic floor defect repair, and bladder neck pubic commissure ligament suspension. Laparoscopic lymph node dissection can also be performed to treat endometrial cancer.
Compared with open total hysterectomy, the incision is smaller, postoperative comorbidities are lower, less postoperative analgesia is required, and the patient can return to normal work and life more quickly. The small incision of laparoscopic surgery is more favorable to obese patients, with clear vision during surgery and avoiding the problem of poor healing caused by large abdominal incisions.
2, laparoscopic, negative, open total hysterectomy selection principles
Laparoscopic, negative and open total hysterectomy, the first two of which are minimally invasive, have much faster recovery than open total hysterectomy, and there is no difference in postoperative recovery between laparoscopic surgery and negative surgery. Nonetheless, laparoscopic total hysterectomy has advantages that cannot be matched by negative hysterectomy, mainly a clear understanding of the pelvic cavity, a clear operative field, and the possibility of dealing with coexisting pelvic lesions at the same time. In complex cases, laparoscopic surgery is much safer than negative surgery. Therefore, for simple total hysterectomy, either negative surgery or laparoscopic surgery can be the preferred procedure. In the case of combined pelvic adhesions, endometriosis and other lesions that require hysterectomy, laparoscopic total hysterectomy should be the preferred procedure. However, both laparoscopic and negative hysterectomy still have their limitations, that is, they cannot complete the hysterectomy of huge uterus or severe pelvic adhesions, and for such patients, they should have sufficient preoperative estimation to choose open surgery, or they should encounter intraoperative difficulties and turn to open surgery.
3. Indications for laparoscopic total hysterectomy
Laparoscopic total hysterectomy can be used for benign lesions of the uterus, such as uterine fibroids, adenomyosis and dysfunctional uterine bleeding, which require hysterectomy, and also for early uterine malignancies, such as carcinoma in situ of the cervix, early endometrial cancer, atypical hyperplasia of the cervical epithelium or endometrium, which are suitable for total hysterectomy.
4.Laparoscopic total hysterectomy method
Laparoscopic total hysterectomy is performed using different energy sources as surgical tools instead of traditional cutting and suturing methods to cut the tissue and stop the bleeding, and finally the uterus is completely excised and removed. Currently, the commonly used energy tools are monopolar electrocoagulation, bipolar electrocoagulation, ultrasonic knife, PK knife (Gaylord, UK), ligation speed (Wiley, USA), and VIO gynecological workstation (ERBE, Germany). Each of these energy tools has its own characteristics and can only be used well if you are familiar with them. Regardless of the energy tool used to remove the uterus, the following steps are required.
4.1 Treatment of the adnexa The intrinsic ovarian ligament, fallopian tube, and round ligament are severed if the patient needs to retain the adnexa, or the pelvic funnel ligament and round ligament if the ovaries do not need to be retained. The pelvic funnel ligament contains ovarian vessels, which can be cut after occluding the vessels with electrocoagulation to stop bleeding, or the peritoneum can be opened at the ovarian tether and the pelvic funnel ligament can be ligated and cut. When dealing with the horn of the uterus, special attention should be paid to the branches of the uterine artery to the ovaries and fallopian tubes and their accompanying veins located therein. The veins are located under the peritoneum and if care is not taken, they can easily tear and cause bleeding. Once bleeding occurs, it is more difficult to stop the bleeding. Therefore, when severing these structures, they can be farther away from the uterine horns so that it is easier to coagulate, close and stop the bleeding.
4.2 Treatment of the broad ligament The anterior and posterior lobes of the peritoneum can be cut together rather than separately when separating the broad ligament. The ureter does not need to be separated either, and is usually not damaged. The incision of the broad ligament should be made away from the uterine wall to avoid touching the superior branches of the uterine artery that run up the lateral wall. If the myoma is located within the broad ligament, the peritoneum of the anterior and posterior lobes of the broad ligament needs to be opened and the peritoneum pushed away against the surface of the myoma to free it so that the ureter is pushed into the pelvic sidewall without injury.
4.3 Bladder peritoneal reflexion In patients without a history of cesarean delivery, the anatomy of the peritoneal reflexion is not altered and the peritoneum is directly cut open and the bladder pushed down. The gap between the bladder and the cervix is very clear and easy to push down. The use of the dome cup to hold up the entire dome makes pushing down the bladder very easy. In general, it is not necessary to push the sides of the cervix too far apart to avoid bleeding. If there is a history of cesarean section, scarring is often formed at the peritoneal reflexion of the bladder and care should be taken not to damage the bladder during separation.
4.4 Treatment of uterine vessels The treatment of uterine vessels is a difficult point in total hysterectomy. If the uterine vessels are not properly treated and bleeding occurs, the operation may be affected or even lead to complications. The main point of the treatment of uterine vessels is to dissect the uterine vessels clearly and then block them close to the uterine side. The common method is to close the vessels by electrocoagulation and then cut them off. The uterine vessels can also be ligated using sutures or blocked using vascular clips. The uterine artery can also be dissected by ligation at the point where it branches off from the internal iliac artery. The uterine artery can be blocked or severed by electrocoagulation by separating the uterine artery retrogradely to the division of the internal iliac artery. The uterine artery can also be isolated from the posterior lobe of the broad ligament, above the ureter, and isolated toward the pelvic wall and blocked.
4.5 Cut of the uterosacral ligament and the main ligament Although there are no large blood vessels in these two ligaments, they are prone to bleeding when cut with scissors only. They are also prone to bleeding when cut with monopolar electrocoagulation. Cutting the ligaments here with an ultrasonic knife will achieve both tissue cutting and good hemostasis. It is important not to extend the incision too far into the cervical tissue and remove too much of it. It is also important not to go too far outward to avoid injuring the ureter and causing more bleeding at the same time. The main and sacral ligaments can also be visibly displayed with the cervical attachment using a lifting cup. Use bipolar electrocoagulation to coagulate and cut off to the vaginal wall exposure.
4.6 Vaginal wall dissection: vaginal wall dissection can be performed with scissors, monopolar electrocoagulation or ultrasonic knife, using various types of dome cups all of which facilitate the display of the cervical-vaginal attachment. The use of one of the dome cups (YSZ-1 uterine lifter) is described here [1].The YSZ-1 uterine lifter consists of three parts: central guide, cervical fixator and dome cup.
The hysterectomy is performed as follows: the assistant first pushes the dome cup up to lift the anterior dome, and then incises the vaginal wall about 1 cm at the upper edge of the dome cup with an ultrasonic knife or electric knife under the microscope, followed by pushing the cervical fixator up while using the cervical support to lift the cervix while the dome cup is backed into the vagina to prevent leakage. The vaginal wall is cut off circumferentially along the gap formed by the edge of the cervical support and the edge of the dome cup, and the cervix is removed intact. The advantage of this type of uterine lift is that the dome cup is located inside the vagina, which prevents the vagina from being cut open afterwards. CO2 gas leakage in the abdominal cavity.
4.7 Vaginal dissection suture The vaginal dissection suture can be done in various ways. Interrupted sutures or continuous interlocking sutures may be used. The knot can be tied intraperitoneally or extraperitoneally and then pushed into the abdominal cavity with a knot pusher.
5.Common complications and management of laparoscopic total hysterectomy
Possible complications of laparoscopic total hysterectomy include intraoperative and postoperative bleeding, intestinal injury, bladder and ureteral injury. The occurrence of complications is mainly related to the difficulty of the operation, the operator’s proficiency and the instruments used.
Bleeding during surgery is mainly due to incomplete closure of blood vessels when cutting off tissue or cutting off tissue and blood vessels that have not yet coagulated and closed. This can be avoided by skilled use of electrocoagulation instruments. At the same time, the location and course of the major vessels should be carefully dissected during surgery, and the vessels should be isolated and then blocked, especially the uterine artery, to avoid intraoperative bleeding. Postoperative bleeding is often associated with incomplete vascular coagulation, postoperative opening of vascular stumps, and also due to poor suture hemostasis. The placement of intraperitoneal drains allows timely detection and management of postoperative bleeding.
Intestinal injury mainly occurs when separating the utero-rectal fossa adhesions, mostly seen in endometriosis, where the lesion causes the utero-rectal fossa adhesions to close, and the intestinal canal adheres to the posterior wall of the uterus and the uterosacral ligament, and improper separation causes sigmoid colon or rectal perforation. Large perforations can be detected microscopically. If the perforation is small and not easily detected, rectal gas injection test can be used to determine: filling the pelvic cavity with water and injecting gas through the anus, if bubbles are seen to overflow from the pelvic water, the diagnosis can be made. Treatment includes microscopic repair, colostomy and second-stage anastomosis.
Urinary tract injury is the most frequent complication during total hysterectomy. It can occur during the procedure, resulting in bladder perforation or ureteral dissection. Vesicovaginal fistula, ureterovaginal fistula, ureterovaginal fistula, and ureteral obstruction resulting in hydronephrosis can also occur postoperatively.
Ureteral anastomosis can be performed during surgery, and bladder perforation can be repaired microscopically, and a catheter or ureter stent can be left in place after surgery. If a vesicovaginal fistula occurs after surgery, it should be treated conservatively first, and the small fistula hole can be healed by keeping the ureter in continuous drainage. If this fails, surgical repair is possible. Ureteral injury causing fistula or obstruction should be promptly treated surgically with ureteral anastomosis or ureteral bladder implantation, both of which can be done laparoscopically.