Laparascopic hysterectomy

THIS IS BASIC KNOWLEDGE REGARDING LAPARASCOPIC HYSTERECTOMY

1. PRESENTED BY: L-NA / HBTU Total Laparoscopic hysterectomy

2. WHAT IS LAPAROSCOPIC ? Laparoscopic is a surgery that uses a thin, lighted tube put through a cut (incision) in the belly to look at the abdominal organs or the female pelvic organs.

3. WHAT IS HYSTERECTOMY ? An operation to remove a woman’s uterus . A woman may have a hysterectomy for different reasons, including : Uterine fibroids that cause pain, bleeding or other problems Uterine prolapse, which is sliding of the uterus from its normal position into the vaginal canal Cancer of the uterus, cervix or ovaries Endometriosis Abnormal vaginal bleeding Chronic pelvic pain Adenomyosis , or a thickening of the uterus

4. WHAT IS TOTAL LAPAROSCOPIC HYSTERECTOMY (TLH) ? Laparoscopic ligation of the ovarian arteries and veins with the removal of the uterus vaginally or abdominally, along with laparoscopic closure of the vaginal cuff . The laparoscope is often reinserted after closure of the vaginal cuff to inspect the abdomen and vaginal cuff for adequate hemostasis at the end of the procedure. This procedure requires adequate uterine descent to safely complete the vaginal portion of the procedure.

5. ADVANTAGES OF TLH ... Visualization of pelvic anatomy and the ability to minimize blood loss is superior with TLH. Substantial and dynamic access to the uterine vessels, vagina and rectum is possible from many angles, especially after introduction of the uterine manipulator in 1995. Reduced short-term morbidity (less blood loss, wound infections and post operative pain), shorter hospital stay and faster resumption of normal activities when compared with abdominal hysterectomy.

6. INDICATION .. Pt with leiomyomata , pelvic organ prolapse and abnormal uterine bleeding. Indicated for resection and debulking of both malignant and premalignant disease, as noted by extensive case series in the gynecologic oncologic literature. Pt with a vaginal hysterectomy which may be difficult. Pt with complicated adhesions, narrow subpubic arch, nulliparous pelvis or leiomyomas whether they are multiple, large or found in the lower uterine segment- laparoscopy can be used to free adhesions and divide the upper pedicles.

7. Operative preparation Anesthesia General anesthetic Position Modified supine with Low lithotomy position with Allen stirrups or knee crutch Prep - Abdominal prep ( chlorhexidine 2%) and vaginal prep ( cetrimide 1%) - Patient is catheterized Draping - Drape sheet under the buttocks (3 layers) - Leggings + 2 layers sheet -LAVH Laparoscopic drape sheet (may have attached leggings )

8. POSITION… Dorsal supine modified lithotomy - arms tucked securely to the patient’s side. Trendelenburg position- during gynecological laparoscopy Modified dorsal lithotomy –placement of the uterine manipulator while the legs are lowered during laparoscopy

9. POSITION OF OT TEAM DURING PROCEDURE

10. INSTRUMENTATION

11. INSTRUMENTS : Laparoscopic basic set or General Adult Set if KIV Open - sponge holder and gallipot for painting - tooth forcep / mchindoe - artery x 2 - lagenback retractor (1 pair) - needle holder - suture scissor - kidney dish as receiver Laparoscopic Instrument Karl Storz (O&G) D&C Set

12. Cont instrumentation .. 1, Laparoscopic Karl Storz Instrument (O&G) - varies needle - Palpation probe - various grasper – atraumatic , maryland or bowel graspers - Needle holder - Trocar with sleeve for port – 10mm x1, 5mm x3 2, D&C Set - used when patient is positioned in the lithotomy position during placement of the uterine manipulator.

13. Cont instrumentation .. 3, single pack -uterine manipulator with black tip (size M) - little wood x 4 -gas tubing -metal suction -traumatic forcep -fascia closure -ratchet handle x 1 - uterine scissor ( kiv ) 4, other supplements - drip set - syringe 10cc - blade 11

14. Cont instrumentation .. Soaking items: telescope 10mm 0 degree

15. Soaking items: telescope 5mm degree Cont instrumentation ..

16. Soaking items: camera head light source Cont instrumentation ..

17. Soaking items: caiman & cable Cont instrumentation ..

18. Cont instrumentation .. Soaking items: maryland dissector bipolar

19. Soaking items: monopolar cable gas connector Cont instrumentation ..

20. Cont instrumentation .. Soaking items: scissor - trocar 5mm / 10mm ( disposible ) - uterine manipulator tip (black) x 2 - thermos - operation light handle ( kiv Open)

21. Cont instrumentation .. Soaking items: hook with diathermy

22. Cont instrumentation .. Soaking items: trocar 5mm ( disposible ) uterine manipulator tip ( black) x 2

23. Cont instrumentation .. Soaking items: thermos operation light handle ( kiv Open)

24. EQUIPMENTS Thunderbeat machine Bipolar setting : 25 Diathermy: Coag : 24, Cutting : 24 Thunderbeat : Seal :3 , Cutting : 3 2. Suction machine 3. Insufflator and Gas Tank pressure : peritoneum 25 – 30 (depends on surgeon) : distended abdomen – reduce to 15 Laparoscopic monitor + light source Caiman machine

25. SUTURE V- Loc , 2-0 ( roundbody ) to close vaginal vault (if available) Ecosorb or Vicryl 2/0 ( roundbody , dyed) - to close umbilical 3. Ecosorb or Vicryl 3/0 (cutting, undyed ) – to close skin (depend on surgeon)

26. DEMONSTRATION ON HANDLING GAS TANK IF EMPTY