Gynecology
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Avoiding Ureteric Injury during a Total Laparoscopic Hysterectomy

Avoiding Ureteric Injury during a Total Laparoscopic Hysterectomy
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This video discusses the various levels and techniques of ultrasound in the setting of endometriosis and highlights specifics markers of endometriosis to investigate for.

Presented By

 

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Dr. Stephanie Gill
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Dr. Ada Hsieh
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Dr. Joannie Neveu

Affiliations

Memorial University, Newfoundland and Labrador

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What is Avoiding Ureteric Injury during a Total Laparoscopic Hysterectomy?

Avoiding ureteric injury during a total laparoscopic hysterectomy (TLH) is a critical aspect of the procedure, as the ureters run close to the uterus and can be at risk of damage during dissection and removal of the uterus.

  • Techniques to Prevent Injury:

    • Identification and Visualization: The ureters should be identified and their course traced during the procedure, particularly near the pelvic brim and the uterine vessels.
    • Dissection: Careful dissection of the ureters away from the uterine structures, especially when dealing with the uterine artery and ligaments, is crucial to avoid damage.
    • Use of Energy Devices: Cautious use of energy devices such as electrocautery near the ureters helps reduce the risk of thermal injury.

  • Intraoperative Monitoring: Surgeons may use techniques such as cystoscopy or ureteral stents to ensure ureteric integrity during and after the surgery, allowing for early detection of any injury.

Avoiding ureteric injury requires careful planning, thorough anatomical knowledge, and precise surgical techniques to prevent complications and ensure successful outcomes during TLH.

What are the Risks of Avoiding Ureteric Injury during a Total Laparoscopic Hysterectomy?

The risks associated with avoiding ureteric injury during a total laparoscopic hysterectomy (TLH) arise from the proximity of the ureters to critical structures in the pelvis. Key risks include:

  • Incomplete Ureter Identification: Difficulty in identifying the ureters during surgery can increase the risk of accidental damage, especially in patients with distorted anatomy due to previous surgeries, endometriosis, or large fibroids.

  • Thermal Injury: The use of energy devices (e.g., electrocautery) near the ureters can inadvertently cause thermal damage, leading to ureteric stricture or necrosis, which may not be immediately apparent.

  • Delayed Injury Recognition: Ureteric injuries may not be recognized during the surgery, leading to delayed complications such as urinary leakage, infection, or hydronephrosis (swelling of a kidney due to urine buildup).

  • Need for Additional Procedures: If a ureteric injury occurs, further surgical intervention may be necessary to repair the ureter, such as ureteral reimplantation or stenting, increasing recovery time and the risk of complications.

  • Postoperative Complications: Even if ureteric injury is avoided during surgery, there is still a risk of developing strictures or other complications due to manipulation or indirect trauma to the ureter.

Careful surgical planning and techniques are essential to minimizing these risks and ensuring the safety of the patient during TLH.

Video Transcript: Avoiding Ureteric Injury during a Total Laparoscopic Hysterectomy

Avoiding ureteric injury during a total laparoscopic hysterectomy. The objective of this video is to demonstrate a stepwise approach to identifying the ureters and decreasing the risk of ureteric injury. Urinary tract injury during laparoscopic hysterectomy is less than 1%. More specifically, the risk of ureteric injury is up to 0.4%.

 In this video, we will be demonstrating how ureteric injury can be avoided through adequate knowledge and identification of anatomy and meticulous surgical technique. Knowledge of pelvic anatomy is important in order to avoid the common sites of ureteric injury.

The important areas we are going to highlight include, number one, when the ureter courses under the peritoneum on the top of the psoas muscle and enters the pelvis at the bifurcation of the common iliac vessels. This is important when isolating the infundibulopelvic ligament.

Second, the ureter then travels in the medial leaf of the broad ligament, anterior and medial to the internal iliac vessels. This is important when skeletonizing the uterine artery.

Third, the ureter then travels under the uterine artery, approximately 1.5 centimetres lateral to the cervix to finally enter the trigone of the bladder. This is important when performing the colpotomy.

The following six steps will be reviewed to avoid ureteric injury. One, visualise the pelvis and restore the anatomy. Two, open the retroperitoneal space using two different methods, including the safe triangular space and entry through the round ligament.

Three, identify the retroperitoneal structures. Four, isolate the infundibular pelvic ligament. Five, develop the uterovesical space. Six, lateralization of the uterine artery pedicle.

Step one, visualisation of the pelvis. In this case, no anatomy needs to be restored. Step two, opening the retroperitoneal space. To start, we will demonstrate how to enter through the safe triangle. This technique uses monopolar energy or regular scissors. It can be utilised when you want to spare the round ligament, as you would in a nephrectomy.

To avoid tearing tissue, a T incision can be created. Incise the peritoneum immediately inferior and parallel to the round ligament, ensuring superficial use of your energy to only open the posterior leaf.

After repositioning the graspers to maintain traction, create a perpendicular incision to stay parallel to the infundibular pelvic ligament, and avoid vascular injury.

The second technique demonstrates access to the retroperitoneal space through the round ligament, using a bipolar energy source. While being held under tension, the round ligament can be coagulated and transected. A more lateral entry closer to the pelvic sidewall will facilitate visualisation and identification of the anatomy in the retroperitoneal space.

Step three, identifying the retroperitoneal structures. The surgical assistant retracts the medial edge of the peritoneum. This gives exposure to important anatomical structures and provides an additional mechanism of bowel retraction. This avascular space can be cleared using a combination of blunt and electrocautery dissection.

In this space, the important anatomical landmarks to identify include the psoas muscle, the external iliac artery and vein, medially, the internal artery and/or the ureter. After the identification of the ureter and visualisation of vermiculation, proceed with step four, isolation of the infundibular pelvic ligament.

Being the most common site of ureteric injury, the infundibular pelvic ligament should be isolated away from the ureter by creating a window in the posterior leaf of the broad ligament.

Using the Maryland Grasper and your surgical assist for counter traction, the window is opened medial to lateral to avoid inadvertent sidewall vessel injury, and ensure the ureter is well below the surgical field. The infundibular pelvic ligament is then coagulated in a sequential fashion from proximal to distal and transected, leaving the larger portion of the coagulated pedicle in the abdomen.

Step five, develop the uterovesical space. Retracting the bladder caudally by opening the vesicouterine peritoneal fold is an integral part to any hysterectomy. The bladder is grasped and lifted to the anterior abdominal wall, allowing good visualisation of the dissection plane. A combination of blunt and electrocautery dissection is used to mobilise the bladder caudally off the cervix until the pubocervical fascia is visualised.

Step six, lateralize the uterine artery pedicle. Prior to proceeding with the colpotomy, the uterine artery pedicle should be lateralized. This prevents kinking of the ureters while suturing the vault. Furthermore, ureters are more commonly injured while trying to achieve haemostasis. Having the uterine artery pedicle and bladder pillars well dissected allows the surgeon to work with confidence at the level of the vaginal vault.

The uterine artery is coagulated using the energy source in a perpendicular fashion to the vessel. The electrosurgical device is then positioned parallel to the pedicle opposed to the cervix. The tissue is then coagulated and transected.

It may be easier to have the surgical assistant enter the abdomen from the contralateral side. This will allow for the pedicle and potential ureter to fall lateral prior to starting the colpotomy.

This step can also be done from the ipsilateral side by the surgeon using a V technique, as shown here. Using this V technique, the pedicle is slowly lateralized. You can now safely start your colpotomy.

In summary, meticulous surgical technique with a stepwise approach can help decrease the risk of ureteric injury. Thank you for watching this video.