different routes of the Hysterectomy.pdf

Routes of hysterectomy

1. Types of Hysterectomy

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Hysrectomy or removal of uterus is a fairly common
gynecological operation done for a variety of conditios such as
fibroid uterus,AUB,adenomyosis and gynaecological malignancies.
Removal of the body of the uterus with cervix is called total
hysterectomy.
If only body of the uterus is removed and cervix is retained it is
called subtotal hysterectomy(supracervical hysterectomy)
Removal of the uterus with cervix and both tubes and ovaries is
called total abdominal hysterectomy with bilateral salpingo-
oophorectomy.
In cases of malignancies where besides removal of the uterus,
cervix tubes and ovaries ,other structures such as upper vagina ,
parametrial tissue and lymphnodes from pelvis and para-aortic
area are removed is labelled as Radical hysterectomy.

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Indications for hysterectomy
Benign diseases: abnormal bleeding,leiomyoma,adenomyosis,
endometriosis,pelvic organ prolapse,pid,chronic pelvic pain,
pregnancy related conditions

MALIGNANT DISEASE:
CIN,invasive cervical cancer,atypical endometrial hyperplasia,
endometrial cancer,ovarian cancer,fallopian tube cancer,
gestational trophoblastic tumours

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Routes of hysterectomy :
Depending on the expertise of surgeon,size of uterus,underlying
pathology,removal of the uterus can be carried by open
abdominal surgery or by laparoscopic approach or by vaginal
route.

Preoperative investigations:
Before subjecting a patient to any major gynaecological surgery ,
it is necessary to evaluate her fitness to it.
It is decided based on physical examination and preoperative
investigations.

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PREOPERATIVE INVESTIGATIONS:
Complete blood count.this includes haemoglobin assessment
and total & differential leucocyte count.
Urinanalysis.this includes routine and microscopic
urinanalysis.cultural examination is requestioned ,if microscopy
reveals significant number of pus cells (more than 5/ HPF)
or history of urinary tract infection,especially in women with
cystocele ,urinarycomplaints and fistula.
Fasting and postprandial blood sugar estimations.
Kidney function tests-blood urea,serum creatinine and uric acid.
Liver function tests-particularly in women with a history of
jaundice and in all women undergoing cancer surgery.

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Blood tests for HCV,HbsAg,HIV
Serum electrolytes –Na,k,cl,HCO3
Radiograph of the chest,preoperatively especially in cases of
genital cancers for metastasis.
ECG and stress tests whenever indicated.
Intravenous pyelography in case of cancer cervix and urinary
fistulae
BGT
Bleeding time and clotting time

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Pre operative workup-
It is cornerstone for successful surgical outcome
To make the correct diagnosis
To decide on the need for surgery and its correct selection

Investigations to
Confirm the diagnosis
Fitness for anesthesia and surgery
Identify the risk factors ,any abnormal conditions and rectify this
before undertaking surgery.

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CORRECT DIAGNOSIS:
Detailed history and clinical examination can lead to correct
diuagnosis in most cases.history includes the presenting
symptoms,drugs taken any allergy and previous blood
transfusions and surgery.
CLINICAL EXAMINATION:
Apart from abdominal ,speculum and bimanual examination
rule out undetected anemia,thyroid enlargement,breast disease
and cardiovascular examination besides blood pressure.Pap
smear is taken as required.

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INVESTIGATIONS:
These include the following;
Confirmation of clinical diagnosis by ultrasound,CT and MRI.
TO assess the extent of the disease,any anatomical distortion of
bladder,ureter by pelvic tumour and malignancy.
Staging and feasibility of surgery. In Case of uterine fibroids,the
number ,size and location of fibroids decide the type of surgery
appropriate to the case.
Decide on type and route of surgery.

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FITNESS FOR SURGERY:
It is necessary that the woman is fit for surgery,by performing
the following investigations:
Blood pressure checkup
Hb%,WBC count,differential count,BGT.
Routine urine examination for pus cells,sugar and protein.
Kidney function tests.
Liver function tests in cancer surgery.
Thyroid function tests if required.
If any abnormality is detected,the woman is referred to the
appropriate specialist for treatment and the operation is
postponed untilthe women is considered fit.

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Woman on ANY drug needs counselling.any allergy to a particular
drug should be noted.any adverse reaction to blood transfusion
should be noted.
Oral contraceptive pills should be stopped 4 weeks before
surgery.these can cause thromboembolism.warfarin should be
stopped atleast 48-72 hrs before surgery and replaced by heparin
with good monitioring.
Aspirin is also best avoided as it can cause bleeding.Anemia
should be treated and Hb% should be atleast 10 gm%.Any
infection should be cleared with antibiotics.
Smoking and alcohol should be stopped for few days before
surgery.Lithium and tricyclic antideoresseants should also be
stopped.the drugs for diabetes,thyroid drugs and hypertension
should continue.

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THROMBOPROPHYLAXIS:
Prophylactic heparin is needed in a high risk woman for
preventing thromboembolism and it should be continued for a
variable period postoperatively.
CONSENT;
Proper counselling and informed consent should be obtained in
writing.
PREOPERATIVE PREPARATION;
The woman should not take any food or liquid atleast 8-12 hrs
before surgery.
Bowel preparation –advised to take dulcolax or other laxatives.the
vagina is cleaned just before surgery with betadine lotion after the
bladder is catheterized .

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If spinal or epidural anesthesia is employed ,the woman may not
be able to micturate in immediate post operative period and
bladder catheter for 24 hrs postoperatively becomes necessary.
Shaving the part is essential.the area for surgery is cleaned with
chlorhexidine and povidone iodine .The vagina is cleaned with
betadine lotion.the bladder catheter keeps the bladder empty
throughour the procedure ,this avoids injury to the bladder.
ANESTHESIA:depends on the condition of the woman and the
site of incisiosn
ANTIBIOTICS:practice is to start intravenous antibiotics
intraoperatively.In gynaECological surgeries antibiotics are given
just before start of surgery or at the time of induction of
anesthesia.

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Recommended antibiotics:
Cefotoxin 2 gm IV
Cefazolin 1-2 gm IV
For pts. Sensitive to peniciliin
Metrinidazole 1 gm IV
Or clindamycin 900 mg IV

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STEPS OF ABDOMINAL HYSTERECTOMY:
Indwelling catheter for drainage of urine during procedure.
Antiseptic preparation of area of operation.
Choice of anesthesia
Abdominal wall incision;both a transverse suprapubic incision
and vertical midline incision can be used depending on the
underlying disease,size of uterus and previous laparotomy scar.
Inspection and palpation of pelvic organs and exploration of
remaining part of abdomen.Peritoneal washings/ascitic fluid
may be obtained in cases of suspected malignancies.
Packing away of intestines and retracting bladder with help of a
retractor.

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Decision regarding preservation of ovaries:depends on age of
woman ,diagnosis and her desire to preserve ovaries.
Steps-

Clamping of round ligaments and dividing them between two
clamps and suturing the lateral ends with absorbable suture.
Clamping,division and suturing of infundibulopelvic ligaments in
case ovaries are to be removed.in case ovaries are to be
preserved ,clamp is placed close to uterine fundus and ovarian
ligament and the fallopian tubes are divided close to lateral wallof
uterus and stitched.
Opening of utero-vesical fold of peritoneum and displacing
bladderaway from anterior aspect of cervix.
Tying of uterine vessels close to lateral border of uterus.
Division ,tying of mackenrodt’s and uterovesical ligaments close
to lateral margin of cervix.

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11. The uterine vessels are clamped bilaterally. The uterine
vessels are then divided and suture ligated (usually with two
sutures on each side).
12. The exposure of the anterior and posterior vaginal wall just
below the cervix is again checked, and the bladder and rectum
are dissected still more if additional exposure is needed to
safely
clamp across the vagina below the cervix. 13. The remaining
portion of the broad ligament on each side of the cervix is
then clamped, divided, and ligated using a series of clamps
until the cervix is reached, and the broad ligament on each
side has been detached from the lateral cervix and upper
vagina is well exposed.

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With the uterus strongly elevated out of the pelvis, large right
angle clamps areplaced across the vagina just below the cervix-
one from each side with the tips meeting the middle.
15. The vagina is divided with a knife or long heavy curved
scissors above the clamps, and the uterus and cervix are
passed off the operative field.
16. The vaginal apex is closed. Heaney suture ligatures can be
used on each side incorporating the uterosacral and cardinal
ligaments into the cuff for support.
17. The pelvis is irrigated with warm, sterile saline and
hemostasis is checked. The packs and retractors are removed.

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Closure
After the pelvis has been copiously irrigated with warm saline, the
pedicles are inspected carefully to be sure that
hemostasis is present. Electrocautery or suture ligatures with 3-0
absorbable sutures on fine needles are used to
control small bleeders. The location of the ureters, bladder, and major
vessels should be known when placing
these sutures. Common sites of ureteral injury during abdominal
hysterectomy indude the infundibulbpelvic
ligament where the ovarian vessels are ligated, the area of the uterine
artery ligation, and the bladder base.
Distorted anatomy associated with fibrodis, endometriosis, and
malignancy is a signal for special care to avoid
ureteral injury. The pelvis is not reperitonealized, but the rectosigmoid
colon is gently laid over the vaginal culf to
cover this raw surface and minimize the risk of small bowel adhesions.

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MANAGEMENT OF NORMAL OVARIES:
Prophylactic oophorectomy –referring to removal of clinical
normal ovaries at time of hysterectomy.
Bilateral oophorectomy reduces the risk of ovarian cancer and
need for furthaer surgery for benign conditions of ovary,however
the ovaries continue to produce low levels of androgen even after
menopause ,and the psychological effect of oophorectomy on
some women is significant.
Prophylactic oophorectomy is done in women aged 45-65 yrs.
Significant benefits in known BRCA 1,BRCA 2 gene mutation,
stronf family h/o ovarian or breast cancer.
It is recommended not to do oophorectomy in <40 yrs and
oophorectomy ion post menopausal women

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The packs and retractor are removed, the
abdomen checked again for hemostasis, and the omentum
placed anteriorly to minimize the risk of intestinal
adhesions to the abdominal incision. The anterior peritoneum is
closed with delayed absorbable suture, although
some surgeons today feel that it is unnecessary to close the
abdominal peritoneum. The fascial closure should
be commensurate with the patient's risk of infection and hemia,
Generally, a monofilament delayed
absorbable suture such as PDS (Ethicon) on a larger, caved,
lapered needle (CT-1. Ethicon) can be used. If
there is a significant risk of dehiscence secondary to infection,
obesity, or other medical problems, interrupted
sutures or a mass closure technique may be used

22. •The length of postoperative hospitalization has decreased
dramatically in the last 20 years. Athough it was common in the
past for women to remain in the hospital for 7 to 10 days after
abdominal hysterectomy, most patients now discharged home
in 3 or 4 days. This trend toward a shorter hospital stay requires
belter patient education and a reasonable home environment to
which the patient can be safely and comfortably discharged.
The surgeon must also carefully evaluate the patient before
discharge and resist pressure from Insurance companies and
hospital administrators when the patient's condition indicates
that she is not suitable far early discharge

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COMPLICATIONS
Complications from hysterectomy can be diagnosed
intraoperatively or postoperatively. In a thorough review, Hamis
found an overall complication rate of up to 50% associated with
abdominal hysterectomy, but serious complications requiring
reoperation or long-term disability are relatively uncommon..
The most common complications include infection,
hemorrhage, and injuries to adjacent organs .

24. •Several factors have been consistently shown to be associated
with an increased risk of complications due to hysterectomy.
These am increasing age, medical ilness, obesity, and
malignancy. These conditions are beyond the control of the
gynecologic surgeon, but they should be considered in the risk
benefit ratio when considering surgery,.

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VAGINAL HYSTERECTOMY:
Mostly carried out for prolapse of uterus,and is called vaginal
hysterectomy with pelvic floor repair as in the operation
simultaneous repair of anterior vaginal prolapse (cystocele,
urethrocele)and posterior vaginal wall prolapse(rectocele and
enterocele)is carried out.
Vaginal hysterectomy in absence of associated prolapse is known
as non descent vaginal hysterectomy.
STEPS OF VAGINAL HYSTERECTOMY:
Anesthesia
Lithotomy position
Antiseptic preparation
Emptying bladder

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STEPS IN THE PROCEDURE
Vaginal Hysterectomy Bilateral Salpingo-Cophorectomy
1. History and physical exam for assessment of indications for
surgery and appropriateness of patient for surgery, including
medical and anesthesia clearance as needed.
2. Preoperative and examination under anesthesia to document
adequate access to the cervix and apical vaginal structures,
especially the uterosacral ligaments.
3. Careful positioning of the patient in the standard lithotomy
position with the femur vertical and fibula close to the
horizontal plane and oriented toward the opposite shoulder.
Debate and variation exist among experts regarding preparation
of the bladder for surgery. Some surgeons, including the author,
prefer catheter placement prior to surgery. Others prefer leaving
fluid in the bladder in order to alert the surgeon of the presence
of bladder injury

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5. Grasp the cervix firmly, and in cases that do not include an
adequate degree of prolapse, firmly massage the uterosacral
ligaments to establish maximum descent prior to proceeding
6. Grasp the posterior cul-de-sac. With downward traction the
vaginal epithelium and upward traction on the cervix, include the
posterior cul-de-sac and document peritoneal entry
7. Complete circumscription of the vaginal epithelium around
the cervix.
B. Dissect the vesicocervical space, transect the pericervical
ring/supravaginal septum, and dissect the vesicouterine space.
Place a retractor in the anterior dissection to elevate the bladder.

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there is no compelling reason to complete entry into the anterior
cul-de-sac at this point
unless specifically desired.
9. Identify, clamp, transect, and ligate the uterosacral ligament
pedicle separately. This pedicle wil be used in cuff closure
10. Identify, clamp, transect, and ligate the
cardinal/pubocervical ligament pedicle.

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. Identify, clamp, transect, and ligate the uterine
vasculature.Identify and enter the anterior cul-de-sac if not
already accomplished.
13. Clamp and ligate the lower portion of the broad ligament
(often including the ascending portion of
the uterine vasculature) including the anterior and posterior
peritoneum
14. Deliver the fundus of the uterus posteriorly. An alternative is
to deliver the fundus of the uterus anteriorly,however, posterior
delivery is usually the more effiicent method .

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16. Identify, clamp, and transect the adnexal pedicle (fallopian
tube, round ligament, and utero
ovarian ligament) to remove the uterus
17. If adnexectomy is desired, identify and divide the round
igament to begin the process. Then
identify, clamp, divide, and ligate the mesovarium
18. Identify, clamp, divide, and ligate the infundibulopelvic
ligament to complete the removal of the
adnexa
19. Carefully inspect all pedicles for hemostasis.

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20. Irigate the surgical field.
21. If appropriate, perform one of the variations of culidoplasty (eg,
McCall) incorporating the
uterosacral ligaments into the cuff to help prevent future prolapse.
22. Perform cystourethroscopy to document bladder and ureteral
integrity.
23. Perform cuff closure. Several variations exist. Most surgeons
prefer interrupted sutures rather
than a running closure because of potential hematoma or
abscess formation
24. Vaginal packing is optional. It is not necessary in the absence
of concomitant pelvic reconstructive surgery

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BEST SURGICAL PRACTICES
Randomized controlled trials have demonstrated that women
treated by vaginal hysterectomy experience lower morbidity,
less pain, rapid recovery, and a rapid retum to normal activities
compared with abdominal, endoscopio, or laparoscopicaly
aassisted vaginal hysterectomy.Little evidence is available to
compare robolic and vaginal surgeries.
Using guidelines to determine the route of hysterectomy
adopted by the National Guideline Clearinghouse, and with
maximum development of surgical technique, it is feasible to
perform 90% of hysterectomies for

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benign disease indications via the vaginal route.
Following the National Guideline Clearinghouse guidelines for
selecting the route of hysterectomy, even for a resident training
environment, has been shown to decrease the number of
abdominal and consequently endoscopic hysterectomies.
To minimize bladder and rectal injuries, the anterior and
posterior peritoneum should always be entered under direct
vison
The risk of ureteral injury can be minimized by retracting the
bladder anteriorly at all times aller completion of the dissection
of the vesicocervical and vesicouterine spaces and dividing the
cardinal ligament before cutting. damping, or suturing in the
anterolateral area above the cervix

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The only vascular pedicle above the uterine vessels contains the
round ligament, utero-ovarian ligament, and fallopian tube.
These structures can generally be clamped in a single pedicle.
Transvaginal removal of the ovaries at the time of vaginal
hysterectomy should be technically feasible in more than 90%
of patients.
Following vaginal hysterectomy, the presence of preexisting
pelvic support defects should be carefully evaluated and
repaired if present. The vaginal vault should always be
resuspended to the uterosacral ligaments.

37. •LAPAROSCOPIC HYSTERECTOMY

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Choice of approach:
Abdominal,vaginal ,laparoscopic,laparposcopically assisted
vaginal hysterectomy
Abdominal route is common,but vaginal nand laparoscopic are
associated with fewer complications,shorter hospital stay,rapid
recovery.
Pts. With gynecological malignancy are operated on with an
abdominal incision.
Large uterus –abdominal hysterectomy(larger than 12 weeks)
Cervical fibroids,unknown adnexal mass,extensive pelvic
endometriosis,adhesion from prior surgery : abdominal

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Subtotal versus total hysterectomy for benign conditions:
The routine practice of removing the cervix at the time of
hysterectomy for benign disease is being challenged as many
traditional surgical procedures are being modified to
accommodate minimally invasive techniques.
Total lap hysterectomy has been associated with increased risk
of ureteral and bladder injury so that lap supracervical
hysterectomy has been introduced to avoid these complications.
The introduction of powered laparoscopic tissue morcellator
has allowed to perform supracervicalhysterectomy efficeientlty.

40. •The term laparoscopic hysterectomy includes a family of
procedures that vary in degree to which the procedure is
performed laparoscopicaly. This ranges from treatment of
andometriosis or adhesiolysis and division of ovarian
vasculature to completion of the entire procedure
laparoscopically, including cuff closure. In 2000, detailed
classification system for total and supracervical Hysterectomy
was given.

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The American Association of Gynecologic Laparoscopists
Classification System Lapar Hysterectomy
TYPE DESCRIPTION
Laparoscopic preparation for vaginal hysterectomy, induding
diagnostic only, treatment of intraperitoneal disease and/or
adhesiolysis
Laparoscopic occlusion and division of ovarian pedicle, unilateral or
bilateral, and dissection up to but not including the uterine artery
Type + ocdusion and division of the uterine artery, unilateral or
bilateral
Type II+ dissection of a portion but not all of the cardinal-uterosacral
ligament complex, unilatera or bilateral
Type III complete transection of the cardinal-uterosacral ligament
complex, unilateral or bilateral, with or without entry into the vagina

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The American Association of Gynecologic Laparoscopists
Classification System for Laparoscopic Supracervical
Hysterectomy
TYPE DESCRIPTION
LSHI Laparoscopic occlusion and division of ovarian pedicle,
unilateral or bilateral; ocdusion and
division of the superior branches of the uterine vessels above
the level of the intemal os; with or without dissedlion but not
occlusion of the main uterine artery, unilateral or bilateral
LSHII Type LSHI+ occlusion but not division of the main uterine
artery, unilateral or bilateral
LSH Type LSM division mum uenine anery, unilaterat or bilaterat
Types LSHI through LSH are further divided into subgroups,
based on treatment of the cervical stump, including (A) without
excision or ablation of the cervical canal: (B) with ablation of the
cervical canel; and (C) with excision of the cervical canal

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Advantages and Disadvantages of Laparoscopic Hysterectomy
The decision for appropriateness of hysterectomy a therapeutic
Intervention is the regardless of the approach being considered,
although the access for hysterectomy is generally a function of
patient pathology and surgeon skill and preference A 2006
Cochrane database systematic review induding over 3.600
patients in 27
randomized studies pointed to significant advantages of
laparoscopic hysterectomy (LH) over abdominal hysterectomy
(AH), Induding less blood loss, fewer wound infections or fevers,
smaler indsions with lese pain, shorter hospital stay, and
speedler recovery However, LH was associated with longer
operating time and greater likelihood of urinary tract injuries.

44. •The eVALuate trial is one of the largest randomized trials
comparing different approaches to hysterectomy. Condusions
pointed to LH as being associated with less pain, quicker
recovery, and better quality of Ife compared with AH but as
taking longer to performs. The roport also concluded that total
vaginal hysterectomy (TVH) was the profiored approach, when
possible, as it offond similar benefits as LH with lass const and
shorter operating times

45. •While TVH may be the preferred hysterectomy route for a variety
of reasons, there are definitely pelients in whom this approach is
less than ideal. Specifically, a laparoscopic approach may be
lavored in patients who are morbidy obese, who have a
constricted poivic anatomy, who have no uterine descensus, or
who have known or suspected concomitant pelvic disease (eg.
adhesions, enciometriosis, etc) Indeed, there are few
contraindications to laparoscopic hysterectomy

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are relative contraindications related to the patients
comorbidites. Including deficiencies in main physiologic
functions and elevated body mass index. These would indude
the following
Medical conditions that would limit preumoperitoneum,
adequate ventilation, or Trendelenburg positioning jeg. morbid
obesity, increased intracranial pressure, ventriculoperitoneall
shunt, or pulmonary hypertension,
hemorrhagic shock) Severe abdominal or pelvic adhesive
disease or other conditions that preclude safe entry or adequate
operating space (eg, advanced pregnancy, bulky uterine or
fibroid size that precludes access to uterine vessels)
Malignancy or other tumors in which a large specimen needs to
be removed intact (eg, ovarian cancer, dermoid, leiomyoma with
necrotic degeneration or other findings suspicious for
leiomyosarcoma

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On the other hand, there are recognizable challenges to
performing laparoscopic opic hysterectonty, including the
following
Reduced range of motion through laparoscopic ports and with
conventional (straight) laparoscopic instruments
resulting in reduced dextertty Reduced field of view in which
only the tissues actively bg manipulated are generally seen by
the surgeon.
Reduced depth perception in converting a 3D surgical field to a
2D video imag
Reduced haptics and difficulty in assessing degree of force
needed or being applied to issues

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STEPS IN THE PROCEDURE
Laparoscopic Hysterectomy
Place the patient in lithotomy position, and perform tit test to
ensure stability on table Drape into sterile lleld, uterine
manipulator, colpotomy ring, pneumoperitoneum ooduder
(depending on procedure), and Foley catheter
Peritoneal insufflation and port placement depending on size of
uterus
Identification of anatomic landmarks including urelers,
uterosacral ligaments, bladder edge, and colpatomy ring
Coagulate and transect proximal fallopian tube(s) and utaro-
ovarian Igament(s) to separate adnexal
structures from uterine Corpus

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Coagulate and transect round ligament and dissect broad
ligament to the level of the uterine isthmus.
Create bladder flap and skeletonize uterine vessels
For supracervical hysterectomy
Coagulale uterine vessels at the level of the uterine isthmus
Amputate the uterus from the cervix at the level of the isthmus.
For total laparoscopic hysterectomy

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Coagulate uterine vessels at the level of the coipatomy ring
Transect cardinal ligament and amputate the uterus and cervix
from the vaginal apex, using colpolamy ring as a guide, with
monopolar continuous (cutting) current
Isolate, coagulate, and transect infundibulopelvic ligaments (if
salpingo-oophorectomy is desired)
Coagulate and transend mesosalpinx (if only salpingectomy is
desired). Renove adriexol tissue intact and uterus (with
morcellation, if indicated).
Close the vaginal cuff incorporating the uterosacral ligaments.
Secure hemssasis and dose trocar sites in usual fashion

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CONCLUSIONS
Alter performing the first total laparoscopic hysterectomy, Harry
Reich envisioned its role as decreasing the need for abdominal
hysterectomy by "avoiding the increased morbidity associated
with abdominal surgery while retaining the surgical advantages
of the abdominal approach. Not only did his words ring true, his
efforts launched an era of advanced laparoscopic gynecologic
surgery enjoyed today. Indeed, lapamscopy simultaneously
provides superior exposure to the adnexa and upper abdomen,
which is not available to the vagine surgeon, but simultaneously
avoids a large sodomnal wall incision, thus reducing the
associated nak of infection, postoperative pain, and hemia.
Thus, with appropriate training, skill, and experience, the
surgeon performing laparoscopic hysterectomy enjoys vision
and acness advantages that are superior to abdominal
hysterectomy while retaining the decreased morbidity of the
vaginal approach.

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BEST SURGICAL PRACTICES
The choice of access for and type of hysterectomy should be
based on the patient's anatomy and pathology Supracervical
hysterectomy should not be performed simply because of the
surgeon's lack of comfort with removing the cervix, Instead,
assistance from more skilled surgeons should be sought.
The patient should be counseled thoroughly regarding
anticipated outcomes, poterital complications, preoperative
preparation, and postoperative care. Risks and benefits of using
energy-based instruments and morceliators should be included
in the informed consent process. Discuss alternatives for
morcellation or laparotomy

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Preprocedure optimization of comorbidiles, especially
cardiovascular, should be coordinated with the anesthesia laam
to minimize medical complications
An appropriate uterine manipulator and vaginal formix
delineator should be used for total laparoscopic
hysterectomy to improve procedural ergonomics and decrease
complications.
Anatomy should be respected. Clearly idently ureters, bladder,
and other anatomic landmarks Isolate or skeletonize vessels to
be coagulated
Understand the electrosurgical and mechanical characteristics
of energy-based Instruments you are using, and
apply these principles to minimize undesired themel tissue
effects.
Prevent or minimae bleeding as much as possible during
laparoscopic hysterectomy Blood absorbs light and hinders full
visualization by decreasing light intensity in the surgical field.

54. •Thankyou