Laparoscopic total hysterectomy still not routinely chosen Operative description and available instruments

Abstract

Hysterectomy is the most common gynecological surgical intervention; therefore, there are many technical variations in different healthcare systems around the world. We aimed to review, step by step, the technique of laparoscopic hysterectomy as well as to present the available variety of surgical instruments impartially so that the operative team can decide in an informed manner the model and characteristics of the equipment used. The surgical technique is presented based on the experience of the authors, focusing mainly on intraoperative recommendation and suggestions. Advantages and disadvantages of the available instruments are also extensively detailed. Surgical positioning, as well as inserting the uterine manipulator are essential steps. The open technique is used to create pneumoperitoneum. The utero-ovarian ligament or the infundibulopelvic ligament is identified, coagulated and cut. The round ligament is incised, entering the space between the two layers of the broad ligament and advancing caudally in this space, which, if correctly identified, should be avascular. The uterine vessels located on the posterior sheet of the broad ligament are dissected and coagulated. The vaginal wall is sectioned with the help of the manipulator’s cap, making it easier to expose the insertion line of the vagina on the cervix. The uterus is removed through the vagina or through a trans-parietal incision. Thereafter, the vagina is sutured using separate Vicryl sutures. Between 2011 and 2016, laparoscopic hysterectomy had an increasing trend all over Europe. With a reported percentage of 3%, Romania ranks last in hysterectomies performed laparoscopically. The laparoscopic approach offers the advantages of minimal invasiveness: less pain, faster recovery and early social reintegration; therefore, this trend of improvement should become more accepted.

A novel approach to minimally invasive hysterectomy without the use of a uterine manipulator: Kamran’s TLH technique

“…Various TLH approaches have been described for both benign and malignant gynaecological diseases. These techniques are dependent on the use of uterine manipulator or vaginal tubes [3]. However, only few reports has described TLH approach without utilising either vaginal or uterine assistant [4,5].…”

A novel approach to minimally invasive hysterectomy without the use of a uterine manipulator: Kamran’s TLH

“…Various TLH approaches has been described for both begin and malignant gynaecological diseases. Almost all of those techniques are dependent on the use of uterine manipulator or vaginal tubes [3]. Also, uterine manipulators are reported to offer the easiest way to manoeuvre the uterus [4].…”