Pelosi minilaparotomy hysterectomy: Effective alternative to laparoscopy and laparotomy
This new modality—useful for normal, large, and fibroid-ridden uteri—combines the technical benefits of standard laparotomy with the convalescent advantages of laparoscopic surgery.
Exteriorize the uterus. Next, bring the uterus and the adnexa above the abdominal wall in order to perform as much of the hysterectomy extracorporeally as possible. Pass the uterus or adnexa through the incision with the upward assistance of the uterine manipulator, then divide the upper uterine attachments (FIGURE 4A).
Increase exposure. You can achieve additional uterine elevation and targeted exposure in several ways. For example, a strong traction suture can be placed in the uterine fundus, left long, and secured with a clamp. To achieve uterine elevation, place long clamps lateral to the corpus. Another effective approach is to place a heavy tenaculum on the uterine fundus.
When lateral exposure is limited, divide the proximal adnexal pedicles and round ligaments to begin the operation, and remove the adnexa separately following the completion of the hysterectomy.
Divide the uterine vessels through the small incision using clamping, division, and ligation. Unless you intend to preserve the cervix, mobilize the bladder to the level of the anterior vaginal fornix. Inward pressure on the uterine manipulator provides additional elevation of the lower uterine vasculature and the cardinal and uterosacral ligaments as these structures are ligated and divided. Amputate the uterine specimen from the vaginal cuff using the uterine manipulator to guide the vaginal circumcision (FIGURE 4B). Close the vaginal cuff using standard closure.
If the cervix is to be preserved, amputate the uterus supracervically following division of the uterine vessels. Then suture the cervical stump in the traditional fashion. Upward elevation of the cervix using the uterine manipulator expedites this step.
Complete the procedure. Once the surgery is completed, remove the retractor, hooking the bottom ring by inserting a finger into it and pulling it up and out of the incision (FIGURE 4C). Closing a cruciate incision is faster and requires less exposure than closing a mini-Pfannenstiel incision. Eliminate the possibility of postoperative wound hematoma or seroma formation by applying a vertical pressure dressing over the incision (FIGURE 4D). Remove the dressing 24 hours later.
FIGURE 4 Hysterectomy for the normal to moderately enlarged uterus
A. Exteriorize the uterus as much as possible with both upward assistance of the manipulator and uterine fundal elevation (using clamps lateral to the uterus, a heavy tenaculum, or a traction suture). Then conduct a standard hysterectomy.
FIGURE 4 Hysterectomy for the normal to moderately enlarged uterus
B. Separate the uterus from the vagina using the manipulator to guide the vaginal circumcision. (If the cervix is to be preserved, a supracervical amputation is performed instead.)
FIGURE 4 Hysterectomy for the normal to moderately enlarged uterus
C. After completing the surgery, remove the retractor from the incision.
FIGURE 4 Hysterectomy for the normal to moderately enlarged uterus
D. Apply a vertical pressure dressing over the incision.
Variations for abnormal uteri
The large fibroid uterus: Begin with the dominant myoma. A large fibroid uterus can be easily removed with our minilaparotomy technique using 3 basic steps:
- Reduce size by selective myomectomy.
- Deliver the debulked uterus through the abdominal incision.
- Perform extracorporeal hysterectomy.
First, you must conduct a thorough assessment of the number, size, and location of the myomas. Begin the myomectomy on the largest tumor of those closest to the minilaparotomy incision. (Minimize bleeding by injecting diluted vasopressin subserosally prior to the procedure.)
Incise the uterine serosa, myometrium, and pseudocapsule of the myoma via scalpel or Bovie electrocautery until the whorly appearance of the myoma is apparent. Next, grasp the myoma with claw-toothed forceps to stabilize it and place it under traction. Then, using a combination of sharp and digital dissection, develop a plane of dissection between the fibroid and the myometrium (FIGURE 5A).
After securing the dominant myoma, deliver it through the abdominal incision. If the myoma is too large to be removed intact from the abdominal cavity, morcellate it using a scalpel or scissors (FIGURE 5B). Then continue systematic removal of the remaining myomas using the same approach. It is not necessary to remove all myomas—the goal of this process is merely to permit delivery of the uterine body for subsequent hysterectomy.
Once the uterus is debulked, deliver it through the abdominal incision. Hysterectomy then is easily completed (FIGURE 5C).
The ‘solid’ uterus: In situ supracervical hysterectomy and uterine morcellation.
Very large uteri are sometimes homogeneous and solid in nature, possessing few or no individual myomas. This so-called cannonball fibroid uterus is the most challenging type of uterus to remove. The selective-myomectomy approach cannot be used because of the potential for massive bleeding and the technical anatomical difficulties that arise when operating through such a small abdominal incision.
