In patients who have had any prior abdominal surgery (cesarean section, appendectomy, etc.), a 3-mm port is placed in the left upper quadrant to insufflate as well as visualize the anterior abdominal wall in order to identify any adhesions that may have formed after the prior surgery. If adhesions are present, then before the umbilical port is placed, two 5-mm left lateral ports are introduced and the anterior abdominal wall adhesions are lysed.
In all patients, an umbilical trocar is placed under direct vision for the 5-mm zero-degree laparoscope, and 5-mm ports (two on my operating side and one for my assistant) are placed lateral to the inferior epigastric vessels on the left and right. These lateral port sites are placed a fist-width apart along the lateral side wall, usually at a level just above the iliac crest. Exact placement is determined by uterine size. Depending on the uterine size, an additional port may be placed below the umbilicus.
When the ovaries are to be removed, both ureters are identified and the infundibulopelvic ligaments are isolated, then coagulated and transected. If there is any question about the path of the ureter and its proximity to the infundibulopelvic ligament or the uterine vasculature – as in the case of endometriosis or broad ligament fibroids – then ureterolysis will be performed.
The broad and round ligaments then are coagulated and transected, and the bladder flap is developed. The creation of the bladder flap is simple unless the patient has undergone multiple cesarean sections and has significant scarring. This dissection must be layer by layer, with the surgeon always working lateral to medial until the vaginal tissues are reached. When in doubt, it is helpful to backfill the bladder with normal saline to more easily identify the bladder margins. This is easily accomplished using a three-way Foley catheter placed at the beginning of the procedure in anticipation of a scarred lower uterine segment.
We then dissect the peritoneum posteriorly as well at the level of the uterosacral ligaments so that the uterine arteries may be isolated bilaterally. This also serves as another relaxing incision keeping the ureter away from our energy sources. At this point, we utilize a reusable bipolar forceps made by Storz (Karl Storz Endoscopy, El Segundo, Calif.) to coagulate the uterine vessels bilaterally and decrease back-bleeding, and I transect the vessels using the Harmonic Ace Shears (Ethicon Endo-Surgery, Somerville, N.J.). I prefer the reusable bipolar forceps over other instruments, and have learned not to overdesiccate the tissues.
It is imperative for the surgeon or the assistant to constantly push the uterus cephalad using the manipulator in order to protect the ureters from thermal damage as well as transection at the time of colpotomy. This should be the responsibility of the surgeon, unless tissue retraction is necessary. In this case, this task can be given to an assistant, but under constant scrutiny.
Once the uterine arteries are secured, the colpotomy is begun anteriorly using the active blade of the Harmonic Ace. Monopolar energy can be used as well, but I find that this results in more bleeding from the cuff, which in turn necessitates the use of bipolar energy to create hemostasis.
The cervix is circumscribed along the colpotomy cup and, once disconnected, is delivered vaginally. To make the colpotomy easier, it is best to thin out the tissue between the cut uterine vessels and the cervix, exposing the cup. This is accomplished by serially clamping and coagulating the soft tissue above the level of the cup, allowing the impression of the cup to be more easily seen, while at the same time always pushing the cup cephalad.
The delivery of the uterus through what appears to be a small colpotomy incision is accomplished by deflating the vaginal occlusion balloon and gently applying traction on the stem, bringing the cervix closer to the introitus. If the uterus is too large to be delivered through the incision, it can be easily morcellated as one would a large uterus during vaginal hysterectomy. To maintain pneumoperitoneum after delivery of the uterus, the uterus can be left in the vagina or, if the Rumi manipulator is used, the balloon can be removed and reinflated in the vagina.
Once hemostasis is adequate, the cuff is closed with three figure-of-eight sutures of O-polydioxanone (PDS). ("Adequate" hemostasis, it must be noted, does not mean complete desiccation of the cuff; it just means no active bleeding. Leaving the cuff a little wet is not a bad thing.) Any dissolvable suture can be used, but I find that PDS slides nicely when used in extracorporeal knot tying. Even if the first knot loosens before the second knot is thrown, it will tighten as the second knot pushes the first toward the tissue. I suture the angles first and then the midline. To lower the risk of posthysterectomy prolapse, I include in my angle sutures the uterosacral ligament, vaginal mucosa, and anterior pericervical fascia. In my experience, inclusion of the vaginal mucosa eliminates the formation of granulation tissue.