[Gynecological Laparoscopy] 4K laparoscopic subtotal hysterectomy

Subtotal hysterectomy for women only removes most of the uterine body and only preserves the cervix. It is generally a surgical method for younger women with adenomyosis or uterine fibroids.

After a total hysterectomy, women will no longer have menstruation, and at the same time, normal pregnancy and childbirth will no longer occur.

After uterine surgery, the ovaries can maintain normal endocrine function and do not affect women's sexual life. However, since the female cervix exists, as long as she has a normal sexual life, regular cervical TCT examinations are needed to avoid chronic cervical inflammation or cervical cancer.

In addition, women should also pay attention to keeping the vulva clean and hygienic to reduce the occurrence of vaginal bacterial ascending infection.

Laparoscopic Subhysterectomy (LSH) in 4K Full HD:

LSH refers to a laparoscopic surgery to remove the uterine body while preserving the cervix. It has the advantages of short operation time, less intraoperative bleeding, low postoperative morbidity, and fast recovery. It is currently a surgical method with practical significance in clinical practice.

4K Laparoscopic Subtotal Hysterectomy Precautions

During surgery, care must be taken not to damage the ureter and to minimize blood loss. To this end, the surgeon must be familiar with the local anatomy of the uterus, especially the distribution of blood vessels and the location and direction of the ureter.

Surgical steps

1. In the supine position or lithotomy position, place the uterine lifting device.

2. The treatment above the uterine blood vessels is the same as laparoscopic total hysterectomy.

3. After removing the uterine blood vessels, ligate 3 cervix 1cm below the plane of the uterine isthmus to be resected, and cut it with electrocoagulation scissors above it. The stump can be electrocoagulated with bipolar electrocoagulation forceps. The mucosa of the cervical canal should be electrocautery as much as possible, and be careful not to burn the cannula.

4. Rinse the pelvic cavity and stop bleeding.

5. Reflex the bladder peritoneum to cover the cervix stump and fix it with several stitches. To prevent cervical prolapse, the ends of the round ligament can be sutured to the cervix.

6. Take out the uterine body. Put the large claw forceps through the 10mm cannula sheath, use a cylindrical rotary cutter to crush the tissue, and crush the uterine body into strips and take it out. It is more ideal to use an electric tissue morcellator. If a morcellator is not available, a small incision can be made on the original puncture hole in the abdominal wall to remove the uterine body, or it can be removed through a posterior fornix incision.

7. Flush the abdominal cavity again, suck out the accumulated fluid, exhaust air, remove the trocar sheath and lens, and suture each puncture hole.

Things to note

1. Treatment of appendages: If the patient needs to retain the appendages, cut off the proper ovarian ligament, fallopian tube, and round ligament; if there is no need to preserve the ovary, cut off the infundibular ligament and round ligament of the pelvis. The pelvic infundibular ligament contains ovarian blood vessels. The blood vessels can be closed with electrocoagulation to stop bleeding and then cut. Alternatively, the peritoneum of the ovarian mesentery can be opened first, and the pelvic infundibular ligament can be ligated and then cut. When processing the uterine horn tissue, special attention should be paid to the branches from the uterine artery to the ovary and fallopian tube and its accompanying veins. The veins are located under the peritoneum. If you are not careful, they can easily tear and cause bleeding. Once bleeding occurs, it is difficult to stop the bleeding. Therefore, when cutting these structures, they can be farther away from the uterine horn, so that it is easier to coagulate and close the blood vessels and stop bleeding.

2. Broad ligament treatment: When separating the broad ligament, the peritoneum of the anterior and posterior lobes can be cut together without separating it. The lower edge of the incision can reach the level of the bladder peritoneal reflection. Be careful not to damage the uterine blood vessels. The ureter does not need to be separated and is generally not damaged. The broad ligament incision should be away from the uterine wall to avoid touching the ascending branch of the uterine artery that ascends along the lateral wall of the uterus. If the fibroid is located within the broad ligament, the peritoneum needs to be opened on the front and rear lobes of the broad ligament, and the peritoneum should be pushed away against the surface of the fibroid to free the fibroid, so that the ureter will be pushed to the pelvic side wall without being damaged.

3. Bladder-peritoneal reflection: For patients without a history of cesarean section, the anatomy of the peritoneal reflection remains unchanged. Simply cut the peritoneum and push the bladder down. The gap between the bladder and cervix is very clear and easy to push down. Use the dome cup to hold up the entire dome, making it easy to push down the bladder. Generally speaking, the two sides of the cervix should not be pushed too far apart to avoid bleeding. If there is a history of cesarean section, scars often form at the peritoneal reflex of the bladder, so care should be taken not to damage the bladder during separation.

4. Treatment of uterine blood vessels The treatment of uterine blood vessels is the difficulty of total hysterectomy. If the uterine blood vessels are not handled properly and cause bleeding, it will affect the operation and even lead to complications. The key point of treating uterine blood vessels is to dissect the uterine blood vessels clearly and then block them close to the uterus. The commonly used method is to close the blood vessel with electrocoagulation and then cut it. Sutures can also be used to ligate the uterine blood vessels, or vascular clips can be used to block them. The uterine artery can also be ligated and cut off where it branches from the internal iliac artery. The key point of this method is to incise the peritoneum between the circular ligament and the fallopian tube, separate the loose connective tissue inside, and separate it downward along the surface of the ureter. The uterine artery can be identified at the entrance of the ureteral tunnel.The uterine artery is separated retrogradely to the branch of the internal iliac artery, and the uterine artery can be blocked or severed by electrocoagulation. It can also be incised from the posterior lobe of the broad ligament and above the ureter, and separated toward the pelvic wall to find the uterine artery and block it.

5. Cutting off the uterosacral ligament and cardinal ligament. Although there are no large blood vessels in these two ligaments, it is easy to bleed just by cutting them with scissors. The use of monopolar electrocoagulation to cut is also prone to bleeding. Using an ultrasonic scalpel to cut off the ligament here will achieve both tissue cutting and good hemostasis. It is worth noting that you should not extend the incision into the cervical tissue or remove too much cervical tissue. It should not be too far to the outside, so as not to damage the ureter and cause more bleeding. The attachment of the main and sacral ligaments to the cervix can also be clearly displayed using the cup. Use bipolar electrocoagulation to coagulate and cut to expose the vaginal wall.

6. Vaginal wall cutting: Vaginal wall cutting can be performed with scissors, monopolar electrocoagulation or ultrasonic scalpel. The use of various types of dome cups is beneficial to displaying the connection between the cervix and vagina. Here we introduce the usage of one of the dome cups (YSZ-1 type uterine lifting device) [1]. The YSZ-1 uterine lifting device consists of three parts: a central guide rod, a cervical fixator, and a dome cup.

1. Treatment of appendages: If the patient needs to retain the appendages, cut off the proper ovarian ligament, fallopian tube, and round ligament; if there is no need to preserve the ovary, cut off the infundibular ligament and round ligament of the pelvis. The pelvic infundibular ligament contains ovarian blood vessels. The blood vessels can be closed with electrocoagulation to stop bleeding and then cut. Alternatively, the peritoneum of the ovarian mesentery can be opened first, and the pelvic infundibular ligament can be ligated and then cut. When processing the uterine horn tissue, special attention should be paid to the branches from the uterine artery to the ovary and fallopian tube and its accompanying veins. The veins are located under the peritoneum. If you are not careful, they can easily tear and cause bleeding. Once bleeding occurs, it is difficult to stop the bleeding. Therefore, when cutting these structures, they can be farther away from the uterine horn, so that it is easier to coagulate and close the blood vessels and stop bleeding.

2. Broad ligament treatment: When separating the broad ligament, the peritoneum of the anterior and posterior lobes can be cut together without separating it. The lower edge of the incision can reach the level of the bladder peritoneal reflection. Be careful not to damage the uterine blood vessels. The ureter does not need to be separated and is generally not damaged. The broad ligament incision should be away from the uterine wall to avoid touching the ascending branch of the uterine artery that ascends along the lateral wall of the uterus. If the fibroid is located within the broad ligament, the peritoneum needs to be opened on the front and rear lobes of the broad ligament, and the peritoneum should be pushed away against the surface of the fibroid to free the fibroid, so that the ureter will be pushed to the pelvic side wall without being damaged.

3. Bladder-peritoneal reflection: For patients without a history of cesarean section, the anatomy of the peritoneal reflection remains unchanged. Simply cut the peritoneum and push the bladder down. The gap between the bladder and cervix is very clear and easy to push down. Use the dome cup to hold up the entire dome, making it easy to push down the bladder. Generally speaking, the two sides of the cervix should not be pushed too far apart to avoid bleeding. If there is a history of cesarean section, scars often form at the peritoneal reflex of the bladder, so care should be taken not to damage the bladder during separation.

4. Treatment of uterine blood vessels The treatment of uterine blood vessels is the difficulty of total hysterectomy. If the uterine blood vessels are not handled properly and cause bleeding, it will affect the operation and even lead to complications. The key point of treating uterine blood vessels is to dissect the uterine blood vessels clearly and then block them close to the uterus. The commonly used method is to close the blood vessel with electrocoagulation and then cut it. Sutures can also be used to ligate the uterine blood vessels, or vascular clips can be used to block them. The uterine artery can also be ligated and cut off where it branches from the internal iliac artery. The key point of this method is to incise the peritoneum between the circular ligament and the fallopian tube, separate the loose connective tissue inside, and separate it downward along the surface of the ureter. The uterine artery can be identified at the entrance of the ureteral tunnel.The uterine artery is separated retrogradely to the branch of the internal iliac artery, and the uterine artery can be blocked or severed by electrocoagulation. It can also be incised from the posterior lobe of the broad ligament and above the ureter, and separated toward the pelvic wall to find the uterine artery and block it.

5. Cutting off the uterosacral ligament and cardinal ligament. Although there are no large blood vessels in these two ligaments, it is easy to bleed just by cutting them with scissors. The use of monopolar electrocoagulation to cut is also prone to bleeding. Using an ultrasonic scalpel to cut off the ligament here will achieve both tissue cutting and good hemostasis. It is worth noting that you should not extend the incision into the cervical tissue or remove too much cervical tissue. It should not be too far to the outside, so as not to damage the ureter and cause more bleeding. The attachment of the main and sacral ligaments to the cervix can also be clearly displayed using the cup. Use bipolar electrocoagulation to coagulate and cut to expose the vaginal wall.

6. Vaginal wall cutting: Vaginal wall cutting can be performed with scissors, monopolar electrocoagulation or ultrasonic scalpel. The use of various types of dome cups is beneficial to displaying the connection between the cervix and vagina. Here we introduce the usage of one of the dome cups (YSZ-1 type uterine lifting device) [1]. The YSZ-1 uterine lifting device consists of three parts: a central guide rod, a cervical fixator, and a dome cup.

4K Full HD Laparoscopic Hysterectomy Complications Management

1. Bleeding: When dealing with the round ligament of the uterus, the proper ligament of the ovary, and the fallopian tube, the broken ends are not sutured tightly or the knot slips, causing bleeding, so double ligation is appropriate. When cutting off the uterine arteries and veins, the tissues surrounding the uterine arteries and veins should be separated as much as possible, the blood vessels should be clearly identified, and the clamps should be clamped close to the uterus and ligated firmly. When pushing down on the bladder, it is necessary to distinguish the layers. Too shallow or too deep will cause bleeding.

2. Injury to adjacent organs: Because subtotal hysterectomy is often used when the adhesions between the uterus and pelvic organs are obvious, especially when the bladder, rectum, and cervix are densely adhered, the anatomical layers are not clear, and injuries to the bladder, rectum, and ureters are prone to occur. Once it occurs, it should be repaired immediately.