Laparoscopic Hysterectomy

Laparoscopic hysterectomy surgery is a type of vaginal hysterectomy that uses a thin, flexible tube called a laparoscope that has a video camera inside of it. The surgeon creates small abdominal incisions in the area of the navel to introduce thin tubes. After that, the uterus is removed in parts either by the vagina or the laparoscope tube.

Why You Need Laparoscopic Hysterectomy

An alternative to the conventional method, laparoscopic hysterectomy provides the potential to remove big uteruses and cancers in addition to the quicker recovery time associated with vaginal hysterectomy.

Types of Laparoscopic Hysterectomy

There are multiple types of laparoscopic hysterectomy – the uterus may be removed entirely or in part, depending on your health condition. The ovaries, fallopian tubes, and cervix may also be removed in some situations. Before surgery, you and your surgeon will go over the suitable options.

1. Total Hysterectomy

The removal of the entire uterus is known as a total hysterectomy. The vagina may be used to remove it. Alternatively, it could be extracted in fragments via tiny incisions made in the abdomen.

2. Hysterectomy Involving Ovarian Excision

The ovaries, fallopian tubes, and uterus are removed during this treatment. The vagina may be used to remove the organs. Alternatively, they might be taken out of the belly through tiny incisions.

3. Laparoscopic Supracervical Hysterectomy (LSH)

The upper portion of the uterus is removed during this treatment. The cervix is not removed; it could shut at the top. This surgery may be done if the cervix is healthy. Little incisions made in the abdomen are used to remove the uterus in segments. This kind of hysterectomy may also involve the removal of the tubes and ovaries.

What Happens During a Hysterectomy?

Your cervix (womb neck) and womb are removed during a complete hysterectomy. Since there is no chance of getting cervical cancer thereafter, a total hysterectomy is typically the better option than a partial hysterectomy.

Procedure of Laparoscopic Hysterectomy

Step 1: Development of the visual field and laparotomy

Depending on the size of the uterus, the surgeon typically makes a midline abdominal incision that is the necessary length. After that, a retractor is used to increase the field of vision and the intestinal tract is pushed into the upper abdomen using two towels dampened with physiological saline.

Step 2: Separate and ligate the circular ligament

Using a Kocher’s forceps, make a ligature in the round ligament 1.5 to 2 cm away from the uterus using 1-0 absorbable suture. Using Kocher’s forceps, the uterine side is clamped, and the round ligament is cut. After making a small upward and downward incision, cut the anterior leaf of the broad ligament across the peritoneal reflection of the vesicouterine.

Step 3: Clamp, cut, and ligate the Fallopian tubes (also known as the infundibulopelvic ligament) and ovarian ligament.

Using Heaney’s and Kocher’s forceps, the ovarian ligament and the Fallopian tubes (also known as the infundibulopelvic ligament) are clamped and cut. Once more, the pelvic side’s edge is ligated.

Step 4:

Step 2 and Step 3 are carried out on the opposite side.

Step 5: Activating the bladder

Tension is increased by applying strong upward traction to the uterus and lifting the incised bladder peritoneal stump with smooth forceps. Using Cooper’s scissors, first the surgeon releases the bladder from its center of the cervix. Next, they use Cooper’s scissors to perform lateral blunt dissection in order to reveal the vesicouterine ligament. The surgeon steers clear of drifting laterally into the bladder pillars, as this could result in problematic bleeding. Small vessels may need hemostasis with a bipolar coagulator at any stage. It is recommended to mobilize the bladder about 1 cm below the cervicovaginal junction. If bleeding occurs, a bipolar coagulator is used to coagulate the bleeding site.

Step 6: The uterine artery, vein, and cardinal ligament should be clamped, cut, and ligated (the first step of parametrial tissue cutting)

To prepare for this step, the surgeon will take hold of the posterior broad ligament with forceps, and use Cooper’s scissors to scrape off the tissues behind it, and then cut down toward the sacrouterine ligament once the posterior broad ligament has thinned. Maintaining the ureter’s distance from the uterine cervix is crucial, particularly in cases of inflammation or endometriotic adhesions in the vicinity of the sacrouterine ligament.

Step 7: Press down on the upper portion of the cardinal ligament and the stump of the uterine artery.

The surgeon will then push down slowly 1.5 to 2 cm along the cervix to the level of the sacrouterine ligament and the vesicouterine ligament. Retracting the uterus strongly upwards to the opposite side, and compressing the cut stump of the cardinal ligament and uterine vessels with gauze. When the 1.5 to 2 cm lower portion of the internal os is clamped and cut, the ureter is further removed from the uterine cervix using this technique.

Step 8: Apply pressure to the uterine artery stump and the upper part of the cardinal ligament.

Gently press down 1.5 to 2 cm down the length of the cervix to where the vesicouterine and sacrouterine ligaments meet. Firmly retract the uterus to the other side, then use gauze to compress the uterine vessels and the cut stump of the cardinal ligament as indicated in. Using this method, the ureter is further extracted from the uterine cervix after the 1.5 to 2 cm lower segment of the internal os is clamped and cut.

Step 9: Third step of parametrial tissue cutting: clamp, cut, and ligate the anterior half of the cardinal ligament and the vesicouterine ligament.

The anterior half of the cardinal ligament and the vesicouterine ligament are the remaining ligaments that adhere to the uterus. The surgeon will check the cervicovaginal junction by placing the right hand against the back of the cervix. If the bladder is not sufficiently mobilized, press down on it again with the left hand and gauze, stopping about 1 cm below the cervicovaginal junction. After that, the anterior portion of the cardinal ligament and the vesicouterine ligament are clamped so that the Heaney’s forceps’ convex surface faces diagonally in front of the uterus. Following the cutting and ligation of the ligaments, the ligature is grasped and drawn back.

Step 10: At the cervicovaginal junction, clamp the vaginal wall.

After determining the boundary by palpating the uterine cervix from the front and back once more, the surgeon will use Heaney’s or right-angle forceps to clamp the vaginal wall. If the rectum sticks to the cervix’s posterior wall and rises when the cervix does too, they will use an electric knife to cut the adhesion at the border, push down slightly, and then clamp the vaginal wall.

Step 11: Opening the vagina

Step 10 is done on the opposite side to open the vagina. An electric knife is used to cut the anterior wall of the cervix, a large piece of gauze is inserted on the posterior side of the uterus, and the bladder is raised using a bladder spatula. Using a long, straight Kocher’s forceps, the surgeon will grab the vaginal wall once the vaginal spase has partially opened and retract the uterine cervix with another long, straight Kocher’s forceps, then incise the vaginal wall all the way around to remove the uterus. Using long, straight Kocher’s forceps, the surgeon will hold the vaginal wall at three or four spots to remove any fluids, and then disinfect.

Step 12: Closing the vagina

First, 1–0 absorbable suture is used to sew the bilateral ends of the vaginal stump, and then continuous suturing is used to suture the remaining portion. To avoid postoperative vaginal stump granulation, the surgeon will use absorbable suture to close the vaginal stump. The detached end of the bladder, the vaginal stump, and Douglas’ peritoneum are interruptedly suture at three sites upon the confirmation of hemostasis.

Step 13: Hemostasis and retroperitoneal closure

Using a Pean’s forceps, the surgeon will grasp the wide ligament incision end, inspect the surgical field, and halt the bleeding. They will use 3-0 synthetic absorbable suture to close the pelvic peritoneum.

How Common Is It To Get Laparoscopic Hysterectomy?

In India, the frequency of hysterectomy procedures was 3.2%; Andhra Pradesh had the highest rate (8.9%), while Assam had the lowest rate (0.9%). India’s rural areas were more prevalent than its metropolitan areas. Most of the female patients had the procedure done at private hospitals. In 126 districts, the prevalence of hysterectomy fell between 3% and 5%, in 47 districts between 5% and 7%, and in 26 districts above 7%.

Why Do I Need a Laparoscopic Hysterectomy?

The majority of patients undergoing a laparoscopic hysterectomy for fibroids or irregular uterine bleeding are eligible for this type of procedure. In some situations, it might not be feasible. For instance, if her uterus is larger than that of a four-month pregnancy, or if she has undergone several lower abdominal surgeries in the past. There are several benefits to laparoscopic hysterectomy compared to standard surgery, such as quicker recuperation and less discomfort, bleeding, and infection risk due to the smaller incisions used.

What Happens After a Hysterectomy?

Following a hysterectomy, vaginal bleeding and discharge are common. This could last up to six weeks, but it will be less discharge than during a period. If you start passing blood clots, feel significant vaginal bleeding, or have a strong-smelling discharge, see your doctor.

How Long Does a Hysterectomy Procedure Last?

The procedure can take one to three hours. The amount of time can vary based on your uterus’s size, the necessity to remove scars from prior surgeries, the removal of other tissue, such as endometrial tissue, and the removal of other organs along with your uterus (such as your ovaries or fallopian tubes).

Risks or Complications of a Laparoscopic Hysterectomy

There may be some risks or complications of a laparoscopic hysterectomy like:

Feeling or becoming ill
Bleeding
Infection at the surgical site or wound an allergic response to a drug, material, or piece of equipment
Causing the scar to herniate
Thromboembolism in veins
Infection in the chest

Death, allergic reactions, and nerve damage are examples of serious consequences. However, deaths are extremely uncommon. Prior to surgery, maintaining good health and fitness lowers the possibility of problems.

Recovering from a Laparoscopic Hysterectomy

Depending on the type of hysterectomy you had, the recovery period could last anywhere from 2 to 6 weeks. Menopause will result from a hysterectomy if your ovaries are also removed. A diminished sex drive may also result from ovarian excision. In that case, your physician might suggest estrogen replacement treatment.

Benefits of Laparoscopic Hysterectomy

Some benefits of laparoscopic hysterectomy are:

Decreased chance of problems such as an abdominal infection
Less postoperative infection due to less vaginal manipulation
Less pain
Quick recovery time
The lengthening of the vagina
Less postoperative prolapse of the vagina
Less enterocele development because of more precise anatomic restoration of the pelvic structures under direct visualization

As an alternative to IV morphine or other prescription opioids that are frequently provided to patients who undergo a conventional hysterectomy, patients can typically use non-narcotic pain relievers if necessary.

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