Challenges in total laparoscopic hysterectomy: Severe adhesions
Success is likely if you are 1) proactive and 2) meticulous about abdominal entry, and if you manage adhesions strategically. Two experts offer tips and techniques.
When dissection becomes unproductive in one area, switch to another; dissection planes frequently open and demonstrate the relationships between pelvic structures and loops of bowel.8
Occasionally, the visceral peritoneum of the bowel is breached during adhesiolysis. If the mucosa and muscularis remain intact, denuded serosa need not be repaired. Surgical repair is necessary if mucosa is exposed, or perforation may occur.
Because most ObGyn residency programs offer limited training in management of bowel injuries, intraoperative consultation with a general surgeon may be indicated if more than a simple repair is required.8
CASE RESOLVED
You perform total laparoscopic hysterectomy and find multiple adhesions in the right lower quadrant, adjacent to the area of trocar insertion. Small intestine is adherent to the right lateral pelvic wall; sigmoid colon is adherent to the left pelvic wall; and the anterior fundus is adherent to the bladder peritoneal reflection, with the adhesions extending on either side to include the round ligaments.
You begin adhesiolysis in the right lower quadrant to optimize trocar movement. You transect the round ligaments in the mid-position, with dissection extended retroperitoneally on either side to the midline of the lower uterine segment; this opens access to the ascending branch of the uterine vessels. You dissect the intestine free of either pelvic sidewall along the line of demarcation.
Total blood loss is less than 25 mL. The patient is discharged 6 hours after surgery.
