Approach to a Total Laparoscopic Hysterectomy Without a Uterine Manipulator and Colpotomy Cup

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is Approach to a Total Laparoscopic Hysterectomy Without a Uterine Manipulator and Colpotomy Cup?
• What are the Risks of Approach to a Total Laparoscopic Hysterectomy Without a Uterine Manipulator and Colpotomy Cup?
• Video Transcript

Video Description

In this video we will describe our step-wise approach and special considerations to completing a total laparoscopic hysterectomy without a uterine manipulator and colpotomy cup. We will review the purpose of a uterine manipulator and colpotomy cup, discuss alternatives to both, and present a case demonstrating our preferred technique. There are many clinical scenarios where it may not be feasible to secure a uterine manipulator and colpotomy cup, therefore the goal of this video is to help general gynecologists gain confidence when approaching these cases, and to reduce unnecessary laparotomies.

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Affiliations

University of Manitoba 

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What is Approach to a Total Laparoscopic Hysterectomy Without a Uterine Manipulator and Colpotomy Cup?

An approach to a total laparoscopic hysterectomy (TLH) without a uterine manipulator and colpotomy cup is a method for removing the uterus laparoscopically without using these common surgical aids. Here’s a breakdown of this specialized technique:

• Lack of Uterine Manipulator: A uterine manipulator typically allows surgeons to reposition the uterus during surgery, improving visibility and control. Without it, surgeons rely on alternative methods, such as external traction and careful instrument placement, to access and stabilize the uterus for dissection.

• Absence of Colpotomy Cup: The colpotomy cup provides a clear demarcation for safely cutting around the cervix and separating the uterus from the vagina. Without it, surgeons must carefully identify the cervicovaginal junction, increasing the need for precise, skillful dissection to avoid damaging nearby structures.

• Alternative Techniques: To compensate, the surgical team may use advanced laparoscopic techniques, such as increased upward traction from an assistant, strategic use of retractors, and careful tissue manipulation, to maintain clear visual and physical control of the uterus and surrounding tissues.

• Benefits and Applications: This approach can be useful in cases where the anatomy makes traditional instruments difficult to use or in patients where the use of manipulators is contraindicated. Surgeons with advanced laparoscopic skills may choose this method to tailor their approach to individual patient needs.

Overall, performing a TLH without a uterine manipulator or colpotomy cup requires high levels of skill, precision, and careful planning, as the surgeon must work within more restricted visualization and control to ensure a safe and successful outcome.

What are the Risks of Approach to a Total Laparoscopic Hysterectomy Without a Uterine Manipulator and Colpotomy Cup?

Video Transcript: Approach to a Total Laparoscopic Hysterectomy Without a Uterine Manipulator and Colpotomy Cup

This video presents an approach to a total laparoscopic hysterectomy without a uterine manipulator and colpotomy cup. There are many scenarios where it may not be feasible to secure a uterine manipulator and colpotomy cup. Some of the most common scenarios are listed here.

In this video, we will describe the purpose of a uterine manipulator and colpotomy cup, discuss alternatives to both, and present a case demonstrating our preferred technique. The overarching goal of this video is to help general gynaecologists gain confidence when approaching these cases and to reduce unnecessary laparotomies. Inability to place a uterine manipulator and colpotomy cup is certainly not a contraindication to a laparoscopic hysterectomy.

The uterine manipulator facilitates anteversion and retroversion and cephalate and lateral excursion of the uterus to complete the case. The colpotomy cup provides a circumferential guide around the cervix to delineate the bladder flap, secure the uterine arteries and complete the colpotomy with minimal vaginal shortening. It also helps to lateralise the uterus, protecting them when the uterine arteries secured and the colpotomy performed.

Here, we present a non-exhaustive list of alternatives to a manipulator and colpotomy cup, some of which have been published in the literature, but many of which are anecdotally described. Alternatives to the uterine manipulator include manipulation of patient position through the bed tilt, cephalad pressure with an instrument or assistant’s hand in the vagina, and manipulation of the uterus from above, using laparoscopic instruments. Delineation of the vaginal fornices can be done with numerous different vaginal instruments, some of which are listed here.

We present a stepwise approach to a total laparoscopic hysterectomy without uterine manipulator and colpotomy. Steps are essentially those of a routine total laparoscopic hysterectomy. However, in our video, we will highlight special considerations along the way to optimise confidence and safety when completing the procedure.

We present the case of a 31-year-old G0 female with a 17cm Type 0 fibroid that was prolapsing through a fully dilated cervix. This fibroid had a broad fundal stock, as pictured here on MRI. She presented with marked pain, bulk [?] symptoms and abnormal uterine bleeding with a haemoglobin of 60.

She was extensively counselled about her options, including myomectomy for fertility preservation, and she chose to proceed with a total laparoscopic hysterectomy and bilateral salpingectomy. She’s medically optimised with superlight acetate, a blood transfusion, parenteral and oral iron therapy and tranexamic acid preoperatively to achieve the haemoglobin of 107 by the day of her surgery.

The first step of the procedure is to optimise visualisation. We considered the use of lighted ureter stents fairly liberally to improve visualisation of the ureters. Here, the lighted stent is visualised in the left pelvic side wall. Visualisation can be optimised by turning [unclear] positioning, left and right lateral tilt of the operating table, and adhesiolysis of the descending and rectosigmoid colon attachments to the pelvic brim and side [?] wall.

Next, we delineate the borders of the border and vaginal fornices. Here, we suggest routine development of the paracervical spaces for delineation of the lateral borders of the bladder. We also use cystosufflation to confirm the cephalic [?] border of the bladder. This can be particularly helpful in cases with scarring related to prior caesarean sections.

Lastly, a rigid instrument of choice should be introduced into the vaginal fornix. We demonstrate this with the use of a narrow, malleable retractor. The vaginal assistant should be somebody who understands the steps of the procedure well and has experience with vaginal and laparoscopic surgery. Ideally, this is a senior resident, fellow or attending colleague.

The spherical mass of the fibroid is seen here. Without a colpotomy cup to define the uterine isthmus in laterally displaced theatres, this can be more difficult. Here, we secure the vessel at the uterine isthmus, defined by the end of the ring forceps in the lateral vaginal fornix.

We suggest a separate anterior and posterior colpotomy, analogous to the steps of a routine vaginal hysterectomy. This will provide reliable and early access to the correct planes for completion of the colpotomy, which may become more difficult once the peritoneal cavity’s breeched and the peritoneum is potentially compromised, and bleeding can become problematic.

For the anterior and posterior colpotomies, we use a wide and flat metal instrument in the vagina, such as a malleable or right-angle retractor, depending on anatomy. Alternatively, a Breisky retractor can be used. Similar techniques have been employed for colpotomy at the time of Caesarean hysterectomy.

Here, we use monopolar instruments on a rigid metal retractor to initiate the colpotomy. If using ultrasonic energy, it’s critical to avoid contact between the ultrasonic blade and the metal retractor, as even a brief contact can create microfractures in the ultrasonic plate and lead to instrument failure.

Once the anterior and posterior colpotomies have been achieved, the lateral colpotomy can be completed in a connect-the-dots technique. Here, we demonstrate the right lateral colpotomy on ring forceps in the vagina. If the pneumoperitoneum is compromised and visualisation is inadequate, with manual uterine manipulation from below, a gloved sponge can be placed in the vagina to maintain pneumoperitoneum and laparoscopic instruments can be used to provide cephalic [?] traction on the uterus if needed.

In cases with fibroids, there can be significant collateral vascularity of the vagina, and additional measures may need to be taken to achieve optimal haemostasis at the time of colpotomy. Things to consider are systemic tranexamic acid, local vasopressin injected into the upper vagina or uterus, and compressive haemostasis with the sponge if bleeding is encountered, as is seen here.

At this stage of the procedure, the hysterectomy is complete. The cervix, fibroid and uterus were completely detached, and the tissue is safely extracted from the patient. A safe colpotomy had been performed on a fully dilated cervix. The remainder of the case is routine once the colpotomy has been completed. However, it is important to inspect the colpotomy line to rule out inadvertent excursion of the colpotomy line towards the viscera, and confirm that the bowel, bladder and ureters have been respected during this stage of the case.

We close the cuff in the usual fashion, using a Triclosan-coated polydioxanone barbed suture. The patient was discharged the next day with a haemoglobin of 92. She did not require any blood transfusions and is now completely symptom-free.

In summary, we have presented our stepwise approach and special considerations for total laparoscopic hysterectomy, without a uterine manipulator and colpotomy cup through the case of a fully dilated cervix with a large prolapsing fibroid. We hope that this video will provide practical tips and tricks to general gynaecologists to complete these cases safely.